Months Of Percutaneous Coronary Intervention Research Articles

Randomized evaluation of 5-month Ticagrelor monotherapy after 1-month dual-antiplatelet therapy in patients with acute coronary syndrome treated with drug-coated balloons: REC-CAGEFREE II trial rationale and design

BackgroundPatients treated with drug-coated balloons (DCB) have the theoretical advantage of adopting a low-intensity antiplatelet regimen due to the absence of struts and polymers. Nevertheless, the optimal antiplatelet strategy for patients undergoing DCB-only treatment remains a topic of debate and has not been investigated in randomized trials.MethodsThe REC-CAGEFREE II is an investigator-initiated, prospective, open-label, multi-center, randomized, non-inferiority trial aimed to enroll 1908 patients from ≥ 40 interventional cardiology centers in China to evaluate the non-inferiority of an antiplatelet regimen consisting of Aspirin plus Ticagrelor for one month, followed by five months Ticagrelor monotherapy, and then Aspirin monotherapy for six months (Experimental group) compared to the conventional treatment of Aspirin plus Ticagrelor for 12 months (Reference group) in patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI) using paclitaxel-coated balloons (DCB) exclusively. Participants will be randomly assigned to the Experimental or Reference group in a 1:1 ratio. The randomization will be stratified based on the center and the type of lesion being treated (De novo or in-stent restenosis). The primary endpoint is net adverse clinical events (NACE) within 12 months of PCI, which includes the composite of all-cause death, any stroke, any myocardial infarction, any revascularization and Bleeding Academic Research Consortium (BARC) defined type 3 or 5 bleeding. The secondary endpoint, any ischemic and bleeding event, which includes all-cause death, any stroke, MI, BARC-defined type 3 bleeding, any revascularization, and BARC-defined type 2 bleeding events, will be treated as having hierarchical clinical importance in the above order and analyzed using the win ratio method.DiscussionThe ongoing REC-CAGEFREE II trial aims to assess the efficacy and safety of a low-intensity antiplatelet approach among ACS patients with DCB. If non-inferiority is shown, the novel antiplatelet approach could provide an alternative treatment for ACS patients with DCB.Trial registrationClinicalTrials.gov identifier: NCT04971356.

Effects of using primary percutaneous coronary interventions on the incidence of new-onset atrial fibrillation following an acute myocardial infarction.

Acute ST-segment elevation myocardial infarction (STEMI) and new-onset atrial fibrillation (AF) are associated with increased risk of mortality. This study aimed to determine the proportion of patients who go on to develop new-onset a AF after undergoing a primary or delayed percutaneous coronary intervention (PCI) for an acute STEMI and to explore possible risk factors. One hundred and fifty-fourpatients who underwent PCI after STEMI were included in the study. Patient characteristics, baseline blood tests and cardiac parameters, type of PCI, and incidence of new-onset AF within 3 months of PCI were recorded and analyzed. Fifteendeveloped new-onset AF following the PCI, and 139 patients maintained a sinus rhythm. Univariate analysis showed significant differences between the two patient groups in terms of age, nature of the PCI (primary vs. delayed), left atrial diameter, and left ventricular diastolic dysfunction (p < .05). Age (odds ratio [OR] = 1.065, 95% confidence interval [CI]: 1.007-1.127, p < .05) and left atrial diameter (OR = 1.165, 95% CI: 1.008-1.347, p < .05), were independent predictors of new-onset AF after PCI. Primary PCI (OR = 0.232, 95% CI: 0.066-0.814, p < .05) was an independent protective factor. Age and left atrial diameter were independent risk factors of new-onset AF in patients undergoing a PCI following an acute myocardial infarction, while primary PCI was a protective factor. This discovery can help reduce mortality rate, improve long-term prognosis, and provide a theoretical basis for the prevention of new-onset AF.

Comparison of 6-Month and Prolonged Dual Antiplatelet Therapy after Percutaneous Coronary Intervention with Biodegradable Polymer Everolimus-Eluting Stent.

Background The optimal duration of dual antiplatelet therapy (DAPT) after biodegradable-polymer (BP) everolimus-eluting stent (EES) implantation remains uncertain. Methods This study analyzed 793 patients who underwent percutaneous coronary intervention (PCI) with BP-EES in 10 cardiovascular centers in Korea between July 2016 and January 2018. Using the prescription data at 6 months post-PCI, we divided these patients into two groups, namely, short-DAPT and prolonged-DAPT groups, which underwent DAPT for 6 and > 6 months of PCI, respectively. The primary endpoint, which included mortality, myocardial infarction, or target-vessel revascularization at 2 years, was compared by propensity score (PS) matching between the two groups. Results Out of the 793 patients, 283 matched pairs were identified by PS matching. Out of this matched population, 405 (71.6%) patients had an acute coronary syndrome. The primary endpoint did not differ in 2 years between the short-DAPT and prolonged-DAPT groups (7.5% vs. 8.3%; hazard ratio, 0.87; 95% confidential interval, 0.47–1.60; P = 0.648). Likewise, no difference was found regarding mortality, cardiac mortality, myocardial infarction, target-lesion failure, target-vessel failure, and bleeding events defined by the Bleeding Academic Research Consortium and Thrombolysis In the Myocardial Infarction classification. Meanwhile, one patient in the short-DAPT group had definite stent thrombosis at 364 days post-PCI. Subgroup analysis showed that several anatomical and procedural factors were not significantly related to DAPT duration. Most patients (77.4%) in both groups were prescribed clopidogrel at discharge. Conclusions In real-world patients undergoing PCI with BP-EES, the ischemic and bleeding endpoints demonstrated no difference between 6-month and prolonged (>6 months) DAPT.

Abstract 10602: Baseline Clinical and Genetic Data Based Machine Learning Predictions of 1-Year Ischemic Outcomes Following Percutaneous Coronary Intervention

Background: Ischemic event rates are low after percutaneous coronary intervention (PCI), conversely second generation P2Y12 inhibitors increase bleeding therefore identifying patients at risk to enable precision in prescribing dual anti-platelet therapy (DAPT) is of clinical interest. Prior machine-learning predictive analyses have been limited by use of older generation stents and lack of genetic data. We utilized clinical and genetic data of patients with new generation stents enrolled in TAILOR-PCI, a 40-center international trial to predict ischemic events after PCI. Methods: There were 4398 eligible post PCI patients with acute coronary syndromes or stable coronary artery disease who were randomly split into training (n=3299) and validation (n=1099) cohorts. The primary endpoint comprising of cardiovascular death, myocardial infarction, stroke, or stent thrombosis within 12 months of PCI was predicted with patient characteristics prior to hospital discharge. First, random forests were used for feature selection with 1,000 bootstraps comprising equal numbers of those with and without ischemic events to minimize the bias of sample imbalance. Features were selected by a consensus on variable-importance over bootstraps. Second, using these features in the training cohort, support vector machines (SVM) with a polynomial kernel was trained with repeated 5-fold cross validation to choose a model with highest area under the receiver operating characteristic curve (AUC) which was then used to predict ischemic events in the validation cohort. Results: The primary endpoint occurred in 2.4% of patients. Using 89 clinical and genetic variables in the random-forest feature selection step, variable importance-based consensus identified 50 top predictors. These 50 predictors achieved AUC=0.703 in the SVM training cohort and AUC=0.744 (specificity=0.84; sensitivity =0.43) in the SVM validation cohort. Conclusions: Machine learning methods using baseline clinical and genetic data enables prediction of infrequent ischemic events in post PCI patients receiving new generation stents. The role of such artificial intelligence algorithms in individualization of DAPT by identifying high or low risk patients needs to be explored.

Glycated Hemoglobin and short-term Prognosis in Patients with Acute Coronary Syndrome with Diabetes Mellitus: A Prospective Cohort Study

Background: Data on the association between glycemic control after percutaneous coronary intervention (PCI) and clinical outcomes are limited and controversial in diabetic patients. Objective:The aim of the study was to assess the impact of good glycaemic control on three months clinical outcomes in diabetic acute coronary syndrome (ACS) patients undergoing PCI, from a Bangladesh health service perspective. Materials and methods:This prospective cohort study which was conducted in UCC, BSMMU included 346 consecutive diabetic ACS patients who underwent PCI at department of cardiology, BSMMU. Diabetic patients were categorized into two groups based on their 3 months HbA1c levels: 169 (48.84%) diabetics with good glycaemic control (HbA1c &lt; 7%) and 177 (51.16%) diabetics with poor glycaemic control (HbA1c ≥7%).The outcome was major adverse cardiovascular events (MACEs), defined as cardiac death, myocardial infarction (MI), definite stent thrombosis, target vessel revascularization and stroke. Results: At 3 months follow up, patients with poor glycaemic control had a significantly higher incidence of MI (6.2% vs 1.2%; p=0.021). No other adverse events were found significantly different between the groups at 3 months of PCI. Conclusion:Good glycaemic control to obtain HbA1c level &lt;7% in diabetic ACS patients undergoing coronary artery stenting may be beneficial in reducing the risk of MACEs and improvement of clinical outcome after PCI during 3 months follow up.&#x0D; University Heart Journal Vol. 17, No. 2, Jul 2021; 108-113

Abstract 13029: Sonothrombolysis Improves Left Atrial Pressure and Volume in Patients With ST Elevation Acute Myocardial Infarction

Introduction: Preclinical studies in ST elevation myocardial infarction (STEMI) indicate that high mechanical index impulses guided with transthoracic diagnostic ultrasound associated with intravenously administered microbubbles results in the dissolution of the thrombus (sonothrombolysis), improving coronary microcirculation and epicardial coronary recanalization rate. Hypothesis: Left atrial (LA) echocardiographic parameters are compromised in STEMI and can be accurately measured by two-dimensional echocardiography. To study the effect of sonotrombolysis on the LA pressure and volume we propose our study. Methods: A total of 100 patients were randomized, 50 for the control group and 50 for the therapy group. Echocardiographic analysis of LA pressure and volume were performed immediately before and after percutaneous coronary intervention (PCI), 72 hours, 1 month and 6 months of follow-up. LA pressure was classified in normal or elevated, depending on the grade of left ventricular diastolic disfunction (DD): normal diastolic function and DD grade 1 have normal LA pressure, and DD grades 2 and 3 have elevated LA pressure, according to the American and European guideline. LA volume was evaluated by Simpson method and indexed to the body surface area. Results: The LA pressure and volume had lower values in the therapy group after 6 months of PCI. The comparison of LA pressure between the therapy and control groups respectively was: before PCI (72% vs. 70% normal; 28% vs. 30% elevated; p=0.826), after PCI (68% vs. 65% normal; 32% vs. 35% elevated; p=0.777), 72 hours (75% vs. 62% normal; 25% vs. 38% elevated; p=0.147), 1 month (68% vs. 52% normal; 32% vs. 48% elevated; p=0.123) and 6 months (84% vs. 64% normal; 16% vs. 36% elevated; p=0.035). The comparison of LA volumes between the therapy and control groups respectively was: before PCI (19.0±6.2 vs. 22.4±9.8 ml/m 2 ; p=0.061), after PCI (22.8±7.9 vs. 24.4±12.1 ml/m 2 ; p=0.469), 72 hours (25.9±8.5 vs. 26.4±12.7 ml/m 2 ; p=0.815), 1 month (27.2±8.3 vs. 29.1±13.1 ml/m 2 ; p=0.410) and 6 months (26.7±7.5 vs. 33.1±14.9 ml/m 2 ; p=0.013). Conclusions: The use of sonothrombolysis as adjuvant therapy in STEMI patients results in better values of LA pressure and volume, demonstrating the benefit of using this new therapy.

Abstract 15502: Clinical Outcomes in Patients Undergoing Non-cardiac Surgery Within 1 Year of Pci

Introduction: Perioperative cardiovascular events are an important cause of morbidity and mortality associated with non-cardiac surgery (NCS), especially in patients with recent percutaneous coronary intervention (PCI) who require dual antiplatelet therapy. Objective: To illustrate the types and timing of different noncardiac surgeries occurring within 1 year of PCI, and to evaluate the risk of thrombotic and bleeding events according to perioperative antiplatelet management. Methods: All patients undergoing NCS within 1 year of PCI at a tertiary-care center between 2011 and 2018 were included. The primary outcome was major adverse cardiac events (MACE; composite of death, myocardial infarction, stent thrombosis or target vessel revascularization). The key secondary outcome was major bleeding, defined as ≥2 units of blood transfusion. All outcomes were evaluated at 30 days after NCS. Results: A total of 1092 NCS (corresponding to 747 patients) were included and classified by surgical risk (low: 50.9%, intermediate: 38.4%, high: 10.7%) and priority (elective: 88.5%, urgent/emergent: 11.5%). High-risk and urgent/emergent surgeries tended to occur earlier post-PCI compared to low-risk and elective ones ( Figure-A ). The incidence of MACE and bleeding was time-dependent, with an increased risk in surgeries occurring in the first 6 months post-PCI ( Figure-B ). Perioperative antiplatelet cessation occurred in 487 (44.6%) NCS and was more likely for intermediate-risk procedures and after 6 months of PCI. There was no significant association between antiplatelet cessation and cardiac events. Conclusions: Among patients undergoing NCS within 1 year of PCI, the perioperative risk of MACE is inversely related to time from PCI. Preoperative interruption of antiplatelet therapy was observed in less than half of all cases and was not associated with an increased risk of cardiac events.

Cancer treatment resumption in patients with new-generation drug-eluting stents.

Percutaneous coronary intervention (PCI) with new-generation drug-eluting stents (DESs) may provide survival benefits to the cancer population undergoing PCI by expediting cancer treatment due to improved safety profile. We aimed to assess the safety of starting or resuming cancer treatment within 6 months of DES placement. We also compared the impact of different DES types on the overall survival (OS) in cancer patients and to identify a safe threshold for dual antiplatelet therapy (DAPT) discontinuation. Cancer patients at our institution undergoing PCI with DES from December 2014 to June 2017 were included. Baseline demographics, DAPT duration, malignancy type, stage, and treatment were retrospectively analyzed. Univariate Cox regression was used to pinpoint baseline characteristics that correlated with OS. Survivorship was determined by Kaplan-Meier analysis, and the log-rank test was used to compare OS among DES types. Seventy-five patients were included. Of these, 45 had biodegradable polymer DES (Synergy) and 30 patients had durable polymer DES (Resolute Integrity, Xience, Ion, or Promus). Mean duration of follow-up was 1367 ± 334 days. There were two minor bleeding complications. No statistically significant differences in OS were found among different stent brands. Discontinuation of aspirin, early P2Y12 inhibitor discontinuation, and advanced cancer were significantly associated with OS. DAPT discontinuation <6 months after PCI was not associated with stent thrombosis or in-stent restenosis. There were two major adverse cardiac events: one in-stent restenosis while on DAPT for >12 months (attributed to radiation-induced heart disease) and one myocardial infarction and death. Of patients who resumed or started cancer treatment (chemotherapy, radiation therapy, or surgery) after PCI, all but one did so within 6 months of PCI, and most of them as early as 2 weeks. Patients may resume cancer treatment <6 months after PCI. We suggest that DAPT may be safely interrupted as early as 6 months, but additional longitudinal studies are needed.

High low-density lipoprotein cholesterol as an independent risk factor for coronary restenosis in hemodialysis patients undergoing percutaneous coronary interventions.

HD patients have been reported to have a higher risk of restenosis after percutaneous coronary intervention (PCI). The aim of this study was to investigate the risk factors of coronary restenosis in HD patients. We enrolled 54 HD patients (mean age: 66.5 ± 10.1 years; 72.2% men; mean HD duration: 3.7 years), who received PCI and follow-up coronary angiography. Of the patients, 22 (40.7%) had restenosis within 3 to 12 months of PCI. Univariate logistic analysis showed low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio, LDL-C, non-HDL-C, and history of major adverse cardiovascular events were significantly associated with coronary restenosis (OR]: 1.89, 1.27, 1.22, and 5.79, respectively). Multivariate analysis showed that LDL-C was significantly associated with coronary restenosis (OR: 1.43). These data suggest that LDL-C is an independent risk factor for coronary restenosis in HD patients undergoing PCI, and strict lipid management may be required.

Quality of life at six months after primary percutaneous coronary intervention performed at a predominantly rural population

Background: HRQL is important in improving the quality of patient care. However, there is a paucity of data from low-income and middle-income countries (LMIC). Differences in socio-demographics and socio-cultural contexts may influence HRQOL. Therefore, this research was designed with the aim to explore the HRQOL in patients after Percutaneous Coronary Intervention (PCI).Objective: The goal of the study was to evaluate the quality of life after six months of Percutaneous Coronary Intervention using HeartQol questionnaire at a tertiary care hospital in Pakistan.Method: This was a Cross-sectional, descriptive study. Patients between the ages of 20-60 years who underwent primary Percutaneous Coronary Intervention at least 6 months ago were inducted in the study. Coronary angiography was performed mostly through radial as preferred route. Data was collected using a structured questionnaire covering demographic characteristics, predisposing risk factors, procedural details, and quality of life. Heart related Quality of life was assessed using HeartQol questionnaire. Collected data was analyzed using SPSS v.21.Results: A total of 241 patients participated in the study. Mean age of the patients was 53.37±11.07 years. On analysis of quality of life at six months, the median (IQR) HeartQol score was 31 (37-23) with majority of the patients, 84.22% (203) fall under the excellent score (&gt;20).Conclusion: It is of enormous prognostic importance that the quality of life of patient is assessed on a regular basis after PCI. Our study shows that the majority of patients had improved quality of life at six months of PCI. Majority of patients were not bothered by mild symptoms. Further investigation needs to be done to validate these results.

Risks of noncardiac surgery early after percutaneous coronary intervention

BackgroundPrior registry data suggest that 4%-20% of patients require noncardiac surgery (NCS) within 2 years of percutaneous coronary intervention (PCI). Contemporary data on NCS after PCI in the United States among women and men are limited. We determined the rate of early hospital readmission for NCS and associated outcomes in a large cohort of patients who underwent PCI in the United States. MethodsAdults undergoing PCI between January 1 and June 30, 2014, were identified from the Nationwide Readmission Database. Patients readmitted for NCS within 6 months of PCI were identified. Outcomes of interest were in-hospital death, myocardial infarction (MI), and bleeding defined by International Classification of Diseases, Ninth Revision, codes. ResultsAmong 221,379 patients who underwent PCI and survived to hospital discharge, 3.5% (n = 7,696) were readmitted for NCS within 6 months post-PCI, and 41% of these hospitalizations were elective. Early NCS was complicated by MI in 4.7% of cases, and 21% of perioperative MIs were fatal. Bleeding was recorded in 32.0% of patients. All-cause mortality occurred in 4.4% of patients (n = 339) readmitted for surgery. The risk of death or MI was greatest when NCS was performed within the first month after PCI. ConclusionsDespite clear guidelines to avoid surgery early after PCI, NCS was performed in 1 of every 29 patients with recent PCI, corresponding to as many as ~30,000 patients each year nationwide. Surgical mortality and perioperative MI were high in this setting. Strategies to minimize perioperative thrombotic and bleeding risks during readmission for NCS after PCI are necessary.

Randomized evaluation of ticagrelor monotherapy after 3-month dual-antiplatelet therapy in patients with acute coronary syndrome treated with new-generation sirolimus-eluting stents: TICO trial rationale and design

BackgroundTicagrelor monotherapy after short-term dual-antiplatelet therapy (DAPT) may optimize ischemic and bleeding risks, particularly for acute coronary syndrome (ACS) patients, because its strategy is less potent than ticagrelor-based DAPT but more potent than aspirin or clopidogrel monotherapy. MethodsThe TICO randomized open-label trial will evaluate whether ticagrelor monotherapy following 3-month DAPT is superior to 12-month ticagrelor-based DAPT in terms of net adverse clinical events (NACE) including efficacy and safety in ACS patients treated with ultrathin bioresorbable polymer sirolimus-eluting stents (BP-SES). Patients undergoing BP-SES implantation for ACS treatment will be randomized in a 1:1 fashion to the (1) ticagrelor monotherapy group after 3-month DAPT; or the (2) 12-month DAPT group. The primary endpoint is NACE within 12 months of percutaneous coronary intervention, which includes major adverse cardiac and cerebrovascular events (MACCE) plus major bleeding as defined by Thrombolysis in Myocardial Infarction. MACCE includes the composite of all-cause death, myocardial infarction, stent thrombosis, stroke, and target vessel revascularization. Secondary endpoints included each component of the primary endpoint. ConclusionsThe TICO trial is an ongoing trial evaluating the efficacy and safety of ticagrelor monotherapy following 3-month DAPT exclusively in ACS patients treated with uniform BP-SES. It may provide novel insights regarding the need for adjusted use of DAPT for rebalancing risk–benefit in current practice and changing from the conventional concept of aspirin maintenance to a ticagrelor-based regimen in the management of ACS.

Relationship between thrombus age in aspirated coronary material and mid-term major adverse cardiac and cerebrovascular events in patients with acute myocardial infarction

Background and aimsRecent studies have shown that coronary thrombus histopathology is associated with impaired myocardial reperfusion and poor clinical outcome in patients with acute myocardial infarction (AMI). We sought to investigate the age of thrombi aspirated during percutaneous coronary intervention (PCI) in patients with AMI and evaluate the relationship between histopathologic findings and major adverse cardiac and cerebrovascular events (MACCEs) defined as all-cause death, stroke, or myocardial infarction within 6 months of PCI. MethodsIn this prospective 2-center observational study, coronary material was obtained during PCI from 305 patients with AMI within 24 h of symptom onset. Thrombi were morphologically classified as either only fresh or older (lytic changes or organization). ResultsMACCE occurred in 38 (12.5%) patients. Only fresh thrombi were observed in 114 (37%) of 305 patients; older thrombi were identified in 191 (63%). The rate of MACCE was significantly higher among patients with older thrombus (p = 0.011). Multivariate analysis also showed the presence of older thrombus [odds ratio (OR) 3.03, 95% confidence interval (CI) 1.122–9.522] is an independent predictor of MACCE within 6 months of PCI, as well as age (OR 1.051, 95% CI 1.013–1.094) and creatine kinase concentration (OR 1.025, 95% CI 1.013–1.037). The prevalence of slow flow or distal embolization during PCI and peak creatine kinase concentration were significantly higher in the older thrombus group (p < 0.05, respectively). ConclusionsOlder thrombus found in aspirated coronary material is associated with impaired myocardial reperfusion and is an independent predictor of mid-term MACCE in patients with AMI.

Multisite Investigation of Outcomes With Implementation of CYP2C19 Genotype-Guided Antiplatelet Therapy After Percutaneous Coronary Intervention

ObjectivesThis multicenter pragmatic investigation assessed outcomes following clinical implementation of CYP2C19 genotype–guided antiplatelet therapy after percutaneous coronary intervention (PCI). BackgroundCYP2C19 loss-of-function alleles impair clopidogrel effectiveness after PCI. MethodsAfter clinical genotyping, each institution recommended alternative antiplatelet therapy (prasugrel, ticagrelor) in PCI patients with a loss-of-function allele. Major adverse cardiovascular events (defined as myocardial infarction, stroke, or death) within 12 months of PCI were compared between patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy. Risk was also compared between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy. Cox regression was performed, adjusting for group differences with inverse probability of treatment weights. ResultsAmong 1,815 patients, 572 (31.5%) had a loss-of-function allele. The risk for major adverse cardiovascular events was significantly higher in patients with a loss-of-function allele prescribed clopidogrel versus alternative therapy (23.4 vs. 8.7 per 100 patient-years; adjusted hazard ratio: 2.26; 95% confidence interval: 1.18 to 4.32; p = 0.013). Similar results were observed among 1,210 patients with acute coronary syndromes at the time of PCI (adjusted hazard ratio: 2.87; 95% confidence interval: 1.35 to 6.09; p = 0.013). There was no difference in major adverse cardiovascular events between patients without a loss-of-function allele and loss-of-function allele carriers prescribed alternative therapy (adjusted hazard ratio: 1.14; 95% confidence interval: 0.69 to 1.88; p = 0.60). ConclusionsThese data from real-world observations demonstrate a higher risk for cardiovascular events in patients with a CYP2C19 loss-of-function allele if clopidogrel versus alternative therapy is prescribed. A future randomized study of genotype-guided antiplatelet therapy may be of value.

The detection of viable myocardium by low-dose dobutamine stress speckle tracking echocardiography in patients with old myocardial infarction.

To explore the significance and value of speckle-tracking echocardiography (STE) associated with low-dose dobutamine stress echocardiography (LDDSE) for the detection of viable myocardium (VM) in patients with old myocardial infarction (OMI). We performed STE with LDDSE in 33 hospitalized patients with OMI and left ventricular systolic dysfunction. QLAB software was used to analyze strain (S) and strain rate (Sr). Percutaneous coronary intervention (PCI) was subsequently performed. The movement of each wall segment was observed by routine echocardiography before and after 1, 3, and 6 months of PCI, and improvement was regarded as the gold standard for diagnosing VM. Compared with semi-quantitative wall-motion analysis combined with LDDSE, the sensitivity, specificity, and accuracy of c-STE (combining the three directions of S and Sr) at LDDSE were 91.6%, 79.5%, and 87.5%, respectively (p < 0.02). Among the deformation parameters, longitudinal strain (LS) and longitudinal strain rate (LSr) had the highest sensitivity, specificity, and accuracy. Upon combining LS and LSr at LDDSE to parallel tests, the sensitivity, specificity, and accuracy were 91.7%, 90%, and 90.6%, respectively. Compared with baseline, LVEF after PCI increased from 43.3% ± 2.6% to 47.3% ± 2.9% (p < 0.001). Global strain at LDDSE is superior to semi-quantitative wall-motion analysis with LDDSE for the assessment of VM. When the multivariable analysis and the parallel tests are combined, LS combined with LSr can be considered an independent predictor of VM. LVEF is improved after PCI in patients with VM and OMI. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:545-554, 2016.

Association of Coronary Stent Indication With Postoperative Outcomes Following Noncardiac Surgery.

Current guidelines for delaying surgery after coronary stent placement are based on stent type. However, the indication for the stent may be an important risk factor for postoperative major adverse cardiac events (MACE). To determine whether the clinical indication for a coronary stent is associated with postoperative MACE. Retrospective cohort study in patients at US Veterans Affairs hospitals who had a coronary stent placed between January 1, 2000, and December 31, 2010, and underwent noncardiac surgery within the following 24 months. The association between the indication for stent and postoperative MACE rates was examined using logistic regression to control for patient and procedure factors. Three subgroups of stent indication were examined: (1) myocardial infarction (MI); (2) unstable angina; and (3) revascularization not associated with acute coronary syndrome (non-ACS). Composite 30-day postoperative MACE rates including all-cause mortality, MI, or revascularization. Among 26 661 patients (median [IQR] age, 68 [61.0-76.0] years; 98.4% male; 88.1% white) who underwent 41 815 surgical procedures within 24 months following coronary stent placement, the stent indication was MI in 32.8% of the procedures, unstable angina in 33.8%, and non-ACS in 33.4%. Postoperative MACE rates were significantly higher in the MI group (7.5%) compared with the unstable angina (2.7%) and non-ACS (2.6%) groups (P < .001). When surgery was performed within 3 months of percutaneous coronary intervention, adjusted odds of MACE were significantly higher in the MI group compared with the non-ACS group (odds ratio [OR] = 5.25; 95% CI, 4.08-6.75). This risk decreased over time, although it remained significantly higher at 12 to 24 months from percutaneous coronary intervention (OR = 1.95; 95% CI, 1.58-2.40). The adjusted odds of MACE for the unstable angina group were similar to those for the non-ACS group when surgery was performed within 3 months (OR = 1.11; 95% CI, 0.80-1.53) or between 12 and 24 months (OR = 1.08; 95% CI, 0.86-1.37) from stent placement. Stent type was not significantly associated with MACE regardless of indication. Surgery in patients with a coronary stent placed for MI was associated with increased postoperative MACE rates compared with other stent indications. The risk declined over time from PCI, and delaying surgery up to 6 months in this cohort of patients with stents may be important regardless of stent type.

Gastroscopy-related adverse cardiac events and bleeding complications among patients treated with coronary stents and dual antiplatelet therapy.

Background and study aims: Dual antiplatelet therapy (DAPT) is recommended following percutaneous coronary intervention (PCI) with drug-eluting stent (DES). DAPT is a risk factor for gastrointestinal bleeding. We aimed to quantify (1) the rate of gastroscopy within 12 months after PCI, (2) the rate of adverse cardiac events and gastroscopy-related bleeding complications within 30 days of gastroscopy, and (3) the association between antiplatelet therapy and these events. Patients and methods: Patients receiving gastroscopy within 12 months of PCI were identified and two nested case-control analyses were performed within the PCI cohort by linking Danish medical registries. Cases were patients with adverse cardiac events (cardiac death, myocardial infarction, or stent thrombosis) or hemostatic intervention. In both studies, controls were patients with gastroscopy including biopsy without adverse cardiac events and hemostatic intervention, respectively. Medical records were reviewed to obtain information on exposure to DAPT. Results: We identified 22 654 PCI patients of whom 1497 patients (6.6 %) underwent gastroscopy. Twenty-two patients (1.5 %) suffered an adverse cardiac event, 93 patients (6.2 %) received hemostatic intervention during or within 30 days of the index gastroscopy. Interrupting DAPT was associated with a 3.46 times higher risk of adverse cardiac events (95 %CI 0.49 – 24.7). Discontinuation of one antiplatelet agent did not increase the risk (OR 0.65, 95 %CI 0.17 – 2.47). No hemostatic interventions were caused by endoscopic complications. Conclusion: Gastroscopy can be safely performed in PCI patients treated with DES and single antiplatelet therapy while interruption of DAPT may be associated with an increased risk of adverse cardiac events.

Abstract 153: Stress Testing Following PCI in the VA Health Care System: Insights from the VA CART Program

Background: Use of stress testing following percutaneous coronary intervention (PCI) is common in community practice with 60% of patients undergoing stress testing within 24 months of PCI. Rates of stress testing following PCI within integrated and salaried healthcare systems like the VA are unknown. Methods: Using national data from the VA Clinical Assessment Reporting and Tracking (CART) Program, we evaluated all VA patients who had PCI from October 2007-September 2011. We assessed the proportion of patients undergoing stress testing, stress test type, and timing of stress testing in the 2 years following PCI. To be consistent with prior studies, we excluded stress tests performed within 60 days of PCI as these may reflect assessment of residual ischemia in anticipation of staged procedures. Timing of follow-up stress testing was determined from 30-day incremental windows of follow-up. Results: Overall, 7,145 of 21,635 patients (33.0%) had a stress test performed within 2 years of PCI. The vast majority of stress tests following PCI were performed with nuclear imaging (80.8%). Treadmill stress ECG without imaging represented 15.2% of stress tests and stress echo 3.9%. Patients undergoing stress testing in follow-up were younger (63.4 vs 65.7 years, P&lt;.001) and less likely to have comorbid congestive heart failure (21.8% vs 25.1%, P&lt;.001) or chronic obstructive pulmonary disease (23.2% vs 25.5%, P&lt;.001). In 30-day incremental windows of follow-up, first stress tests were most commonly performed in the 60-90 days following PCI (Figure). Conclusions: About 1 in 3 patients had a stress test performed in the 2 years following PCI in the VA. This rate is nearly half that reported from prior studies of community practice. Further study is needed to understand if this represents underuse of stress testing in VA or overuse in fee-for-service care.

Outcomes of Percutaneous Coronary Intervention in a Nonagenarian Population

Background: Australia has an ageing population and there is a paucity of evidence guiding the management of coronary artery disease in the very elderly. Traditionally these patients have been managed non-invasively due to potential for high complication rates and perceived futility.Methods: A retrospective study was conducted examining medical records of nonagenarians presenting to a tertiary hospital who underwent percutaneous coronary intervention (PCI) between 2004 and 2012. Clinical and procedural characteristics, in-hospital complications, mortality at 30 days and six months, median survival and residential status were assessed.Results: A total of 22 nonagenarians (range 90–96 years; 13 female; 20 community based, mean GFR 34 mL/min) underwent PCI. Twenty patients were acutely unstable including eight ST elevation myocardial infarctions (four in cardiogenic shock). Procedural details: femoral access: 21; multivessel disease: 18; mean stents per patient: 2.1; drug eluting stent use: 11; procedural success: 21 (95%). Three patients required blood transfusions peri-procedurally (one related to vascular access). No patient required dialysis. Survival at 30 days and six months was 90.9% (n = 20) and 81.8% (n = 18) respectively. Median survival was 2.8 years post procedure (age and gender matched expected survival 4.3 years). Two patients died within three days of PCI; both had cardiogenic shock on presentation; and two patients died within three months (myeloma; intracranial haemorrhage). Two patients moved from community to residential care within six months of PCI.Conclusion: In nonagenarians selected for invasive management, PCI was performed safely with acceptable survival outcomes. The majority of patients continued living at home post hospitalisation. Background: Australia has an ageing population and there is a paucity of evidence guiding the management of coronary artery disease in the very elderly. Traditionally these patients have been managed non-invasively due to potential for high complication rates and perceived futility. Methods: A retrospective study was conducted examining medical records of nonagenarians presenting to a tertiary hospital who underwent percutaneous coronary intervention (PCI) between 2004 and 2012. Clinical and procedural characteristics, in-hospital complications, mortality at 30 days and six months, median survival and residential status were assessed. Results: A total of 22 nonagenarians (range 90–96 years; 13 female; 20 community based, mean GFR 34 mL/min) underwent PCI. Twenty patients were acutely unstable including eight ST elevation myocardial infarctions (four in cardiogenic shock). Procedural details: femoral access: 21; multivessel disease: 18; mean stents per patient: 2.1; drug eluting stent use: 11; procedural success: 21 (95%). Three patients required blood transfusions peri-procedurally (one related to vascular access). No patient required dialysis. Survival at 30 days and six months was 90.9% (n = 20) and 81.8% (n = 18) respectively. Median survival was 2.8 years post procedure (age and gender matched expected survival 4.3 years). Two patients died within three days of PCI; both had cardiogenic shock on presentation; and two patients died within three months (myeloma; intracranial haemorrhage). Two patients moved from community to residential care within six months of PCI. Conclusion: In nonagenarians selected for invasive management, PCI was performed safely with acceptable survival outcomes. The majority of patients continued living at home post hospitalisation.

Relationship between clopidogrel-induced platelet P2Y12 inhibition and stent thrombosis or myocardial infarction after percutaneous coronary intervention—A case-control study

Insufficient platelet inhibition is a major determinant of stent thrombosis (STh), although the etiology is multifactorial. On-clopidogrel platelet reactivity was investigated in patients with previous angiographically confirmed STh, myocardial infarction (MI), and controls. Using the Swedish Coronary Angiography and Angioplasty Registry, we identified patients with angiographically confirmed STh (n = 48) or MI (n = 30) while on dual antiplatelet therapy within 6 months of percutaneous coronary intervention (PCI) and matched control patients (n = 78). On-clopidogrel platelet reactivity was measured with VerifyNow P2Y12 and vasodilator-stimulated phosphoprotein (VASP) phosphorylation assay. The mean P2Y12 reaction units (PRU) was higher (246.8 ± 75.9 vs 200.0 ± 82.7, P = .001) in STh patients compared with controls. The optimal cutoff for STh was 222 PRU or higher (area under the curve 0.69, P < .0001) in a receiver operating characteristics (ROC) analysis. The cutoff level resulted in 70.2% sensitivity and 67.3% specificity. There was no significant difference in mean PRU but a higher device-reported percent inhibition (45.1 ± 23.8 vs 32.1 ± 23.2, P = .04) in patients with MI compared with controls. Results with the VASP phosphorylation assay were not related to the occurrence of STh or MI. STh was associated with high on-clopidogrel platelet reactivity measured with VerifyNow (cutoff level of PRU ≥222) but spontaneous MI in stented patients on clopidogrel treatment was not. There was, however, a substantial overlap in on-clopidogrel platelet reactivity between patients with and without on-treatment STh questioning the clinical use of platelet function testing to identify patients at high risk for STh.