Percutaneous Coronary Intervention For Acute Coronary Syndrome Research Articles

Efficacy and safety of bivalirudin for percutaneous coronary intervention in acute coronary syndromes: a meta-analysis of randomized-controlled trials.

The efficacy and safety of bivalirudin in patients undergoing percutaneous coronary intervention (PCI) for treatment of acute coronary syndromes (ACS) remains controversial despite recent evidence from large randomized-controlled trials (RCTs). Thus, this systematic review and meta-analysis sought to investigate the efficacy and safety of bivalirudin as compared to heparin in patients with ACS undergoing PCI. Medline/PubMed, Cochrane Central Register of Controlled Trials, and Clinical Trials.gov databases were searched for RCTs. Primary endpoint was MACE consisting of all-cause death, myocardial infarction, and stroke within 30 days. Secondary endpoints were components of the primary endpoint and stent thrombosis. The primary safety endpoint was major bleeding. We identified 12 RCTs comprising 33,844 patients. Between bivalirudin and heparin, there were no significant differences for MACE (OR 1.06; 95% CI 0.96-1.17; p = 0.24), death, myocardial infarction, and stent thrombosis. Similar results were seen following stratification by use of glycoprotein inhibitors (GPI). Major bleeding trended to be less frequent in patients treated with bivalirudin. However, no safety benefit for bivalirudin was seen when use of GPI was balanced between groups (OR 0.88; 95% CI 0.67-1.16; p = 0.35; p for heterogeneity < 0.01). Compared with heparin, bivalirudin was associated with a similar incidence of ischemic events following PCI for ACS. An association of bivalirudin with decreased bleeding was not seen with balanced use of GPI.

Gender is Not a Predictor of Mortality or Major Adverse Cardiovascular Events in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndromes

Historically, studies of percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) have reported worse outcomes for women. We sought to determine if contemporary PCI techniques eliminate gender differences in PCI outcomes. This was a retrospective study of 4,776 consecutive patients who underwent PCI for acute coronary syndromes between January 2008 and July 2015. Primary outcomes studied were major adverse cardiovascular events (MACE) and death at 1year. Percutaneous coronary intervention success was similar in men and women (97.8% v 97.7%, p=0.76). There was no significant gender difference in the number of vessels attempted (1.14 vs 1.12, p=0.25), mean number of lesions treated (1.34 vs 1.32, p=0.21) or the mean number of stents used (1.32 vs 1.30, p=0.31). There was equivalent use of drug eluting stents (38.2% vs 38.3%, p=0.94). Women with ST-elevation myocardial infarction STEMI had longer median symptom-to-door time (111 vs 90 mins, p=0.0411) but there was no gender difference in door-to-balloon time or symptom-to-balloon time. There was no significant difference in percentages of women and men <75years treated with prasugrel or ticagrelor (11.1% vs 13.4%, p=0.092). Unadjusted 1-year mortality was 6.4% for women and 4% for men (p=0.0012), but on multivariate analysis, female sex was not a predictor of death. There was no significant gender difference in the overall incidence of unadjusted 1-year MACE (11.6% vs 10.8%, p=0.434). When contemporary PCI techniques are applied equally to men and women with ACS there is no gender difference in mortality or MACE at 1year.

In-Hospital Outcomes of Dual Loading Antiplatelet Therapy in Patients 75Years and Older With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention: Findings From the CCC-ACS (Improving Care for Cardiovascular Disease in China-Acute Coronary Syndrome) Project.

BackgroundElderly patients with acute coronary syndrome (ACS) are at high risk for ischemic and bleeding events. This study aimed to evaluate the clinical effectiveness and safety of dual loading antiplatelet therapy for patients 75 years and older undergoing percutaneous coronary intervention for ACS.Methods and ResultsThe Improving Care for Cardiovascular Disease in China‐ACS project was a collaborative study of the American Heart Association and Chinese Society of Cardiology. A total of 5887 patients 75 years and older with ACS who had percutaneous coronary intervention and received dual antiplatelet therapy with aspirin and P2Y12 inhibitors (clopidogrel or ticagrelor) between November 2014 and June 2017 were enrolled. The primary effectiveness and safety outcomes were in‐hospital major adverse cardiovascular events and major bleeding. Hazard ratios (HRs) of in‐hospital outcomes with different loading statuses of antiplatelet therapy were estimated using Cox proportional hazard models with multivariate adjustment. A propensity score–matched analysis was also conducted. Compared with patients receiving a dual nonloading dose, patients taking a dual loading dose had increased risks of both major adverse cardiovascular events (HR, 1.66, 95% confidence interval, 1.13–2.44; [P=0.010]) and major bleeding (HR, 2.34, 95% confidence interval, 1.75–3.13; [P<0.001]). Among 3284 propensity score–matched patients, a dual loading dose was associated with a 1.36‐fold risk of major adverse cardiovascular events (HR, 1.36; 95% confidence interval, 0.88–2.11 [P=0.168]) and a 2.08‐fold risk of major bleeding (HR, 2.08; 95% confidence interval, 1.47–2.93 [P<0.001]).ConclusionsA dual loading dose of antiplatelet therapy was associated with increased major bleeding risk but not with decreased major adverse cardiovascular events risk among patients 75 years and older undergoing percutaneous coronary intervention for ACS in China.Clinical Trial Registration URL: http://www.ClinicalTrials.gov. Unique identifier: NCT02306616.

ADVANCIS Score Predicts Acute Kidney Injury After Percutaneous Coronary Intervention for Acute Coronary Syndrome.

Acute kidney injury (AKI), a common and crucial complication of acute coronary syndrome (ACS) after receiving percutaneous coronary intervention (PCI), is associated with increased mortality and adverse outcomes. This study aimed to develop and validate a risk prediction model for incident AKI after PCI for ACS. We included 82,186 patients admitted for ACS and receiving PCI between 1997 and 2011 from the Taiwan National Health Insurance Research Database and randomly divided them into a training cohort (n = 57,630) and validation cohort (n = 24,656) for risk model development and validation, respectively. Risk factor analysis revealed that age, diabetes mellitus, ventilator use, prior AKI, number of intervened vessels, chronic kidney disease (CKD), intra-aortic balloon pump (IABP) use, cardiogenic shock, female sex, prior stroke, peripheral arterial disease, hypertension, and heart failure were significant risk factors for incident AKI after PCI for ACS. The reduced model, ADVANCIS, comprised 8 clinical parameters (age, diabetes mellitus, ventilator use, prior AKI, number of intervened vessels, CKD, IABP use, cardiogenic shock), with a score scale ranging from 0 to 22, and performed comparably with the full model (area under the receiver operating characteristic curve, 87.4% vs 87.9%). An ADVANCIS score of ≥6 was associated with higher in-hospital mortality risk. In conclusion, the ADVANCIS score is a novel, simple, robust tool for predicting the risk of incident AKI after PCI for ACS, and it can aid in risk stratification to monitor patient care.

Prognostic value of incomplete revascularization after PCI following acute coronary syndrome. Focus on CKD patients

The residual SYNTAX Score (rSS) is an angiographic score that assesses residual coronary artery disease (CAD) after percutaneous coronary intervention (PCI). Residual CAD has been associated with worsened prognosis in patients undergoing PCI for acute coronary syndromes (ACS). The association between kidney function with rSS has not been investigated in patients with ACS. In ACS, we sought to determine whether chronic kidney disease (CKD) patients exhibit more incomplete revascularization as assessed by rSS following stage revascularization procedures by PCI. We evaluated the impact of incomplete revascularization on the occurrence of major cardiovascular events (MACE) Eight hundred and thirty-one ACS patients undergoing PCI were divided into 3 subgroups according to their estimated Glomerular Filtration Rate (eGFR) levels: 695 patients with eGFR ≥ 60 ml/min/1,73 m 2 , 108 patients with eGFR < 60–30 ml/min/1,73 m 2 and 28 patients with eGFR < 30 ml/min/1.73 m 2 . Initial SS and rSS for each patient after stage revascularization were calculated. Compared with those with preserved eGFR, CKD patients had significantly higher all-cause and cardiovascular mortality (3.6% vs. 11.1% vs. 25%, P < 0.0001 and 1.6% vs. 6.5% vs. 10.7%, P < 0.0001, respectively), MACE (12% vs. 25.9% vs. 35.7%, P < 0.0001). Patients with rSS > 8 had higher all cause and cardiovascular mortality (13% vs. 3.4%, P < 0.0001 and 8% vs. 1.2%, P < 0.0001 respectively), and MACE (25.9% vs. 11.8%, P < 0.0001) than those with rSS ≤ 8. Multivariate analysis identified rSS > 8 as an independent predictive factor of cardiac death (hazard ratio (HR): 3.38, 95% confidence interval: 1.28 to 8.93; P = 0.014) and MACE (HR: 1.63, 95% confidence interval: 1.08 to 2.46; P = 0.02). CKD is an independent predictive factor of rSS > 8 (HR: 1.65, 95% confidence interval: 1.01 to 2.71; P = 0.048) ( Table 1 , Fig. 1 ). In ACS, CKD is predictive of incomplete revascularization which is a strong predictor of adverse cardiovascular outcomes including cardiac death and MACE.

Perforated balloon technique: A simple and handy technique to combat no‐reflow phenomenon in coronary system

Examining the efficacy and outcomes of intracoronary (IC) instillation of adenosine using a novel perforated balloon technique (PBT) to combat no-reflow phenomenon during percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Occurrence of no-reflow during PCI is a serious adverse prognostic event and inability to re-establish better flow is associated with poor outcomes. Several pharmacological and non-pharmacological interventions have been used to treat this situation. This series describes the use of PBT for IC adenosine administration and its effects on outcomes during real world interventional practice. Subjects comprised of 24 patients with ACS (out of a total of 1,634 patients undergoing PCI between January 2016 and June 2017) in whom we used PBT for IC administration of adenosine to treat coronary no-reflow. PBT for IC adenosine instillation was used in 24 (1.5%) of 1,634 patients undergoing PCI. TIMI grade III flow was established in 21 patients (87.5%). In two patients (8.3%) TIMI grade II flow was established and in one patient (4.2%) we were unsuccessful. We demonstrate the safety and efficacy of a novel strategy for adenosine instillation in the distal coronary bed, the PBT. This technique enables rapid and cost-effective treatment of no-reflow phenomenon during PCI for ACS.

Impact of nonfasting triglycerides/high-density lipoprotein cholesterol ratio on secondary prevention in patients treated with statins

BackgroundSome studies have demonstrated that low-density lipoprotein cholesterol (LDL-C) lowering therapy is one of the most important strategies to prevent coronary artery disease. Also, serum triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C) are recognized as independent risk factors of cardiovascular diseases. The aim of this study was to investigate whether the nonfasting TG/HDL-C ratio could affect the incidence of cardiovascular events after percutaneous coronary intervention (PCI) even in patients treated with statins. Methods and resultsOne thousand one hundred seventy consecutive patients were enrolled, all of whom underwent successful PCI for acute coronary syndrome or stable angina and continued statin treatments after PCI. They were equally divided into three groups on the basis of a nonfasting TG/HDL-C ratio 3 months after PCI. Among these groups, the incidence of major adverse cardiac events (MACE) was measured during a maximum of 5 years after PCI. MACE was defined as cardiac death, nonfatal myocardial infarction, revascularization due to new stenosis or restenosis. Kaplan–Meier analysis demonstrated that patients with higher TG/HDL-C ratio had a significantly higher incidence of MACE than other groups (p<0.001). In addition, Cox proportional hazards regression analysis indicated that the nonfasting TG/HDL-C ratio was significantly correlated with the incidence of MACE. ConclusionThe nonfasting TG/HDL-C ratio was a valuable predictor of cardiovascular events after PCI in patients treated with statins.

Ninety-Day Readmission and Long-Term Mortality in Medicare Patients (≥65 Years) Treated With Ticagrelor Versus Prasugrel After Percutaneous Coronary Intervention (from the Blue Cross Blue Shield of Michigan Cardiovascular Consortium)

Ticagrelor and prasugrel were found to be superior to clopidogrel for the treatment of acute coronary syndrome (ACS) after percutaneous coronary intervention (PCI); however, the comparative effectiveness of these 2 drugs remains unknown. We compared postdischarge outcomes among older patients treated with ticagrelor versus prasugrel after PCI for ACS. We linked clinical data from PCIs performed in older patients (age ≥65) for ACS at 47 Michigan hospitals to Medicare fee-for-service claims from January 1, 2013, to December 31, 2014, to ascertain rates of 90-day readmission and long-term mortality. We used propensity score matching to adjust for the nonrandom use of ticagrelor and prasugrel at discharge. Logistic regression and Cox proportional hazards models were used to compare rates of 90-day readmission and long-term mortality, respectively. Patients discharged on ticagrelor (n = 1,243) were more frequently older, female, had a history of cerebrovascular disease, and presented with ST- or non-ST-elevation myocardial infarction compared with prasugrel (n = 1,014). After matching (n = 756 per group), there were no significant differences in the rates of 90-day readmission (16.7% ticagrelor vs 14.6% prasugrel; adjusted odds ratio 1.15, 95% confidence interval 0.86 to 1.55, p = 0.35) or 1-year mortality (5.4% ticagrelor vs 3.7% prasugrel; hazard ratio 1.3, 95% confidence interval 0.8 to 2.2, p = 0.31). In conclusion, we found no significant differences in the rates of 90-day readmission or long-term mortality between older patients treated with ticagrelor and patients treated with prasugrel after PCI for ACS. In the absence of randomized data to the contrary, these 2 treatments appear similarly effective.

Fractional flow reserve (FFR)-based therapy in patients presenting with acute coronary syndrome: Current data and everyday practice.

Fractional flow reserve (FFR) is an evidence-based diagnostic tool of physiological significance of coronary artery stenosis in patients with stable coronary artery disease (CAD). Due to microvascular dysfunction in acute coronary syndrome (ACS), information obtained from FFR assessment could be less reliable and, thus, its clinical role remains controversial. Indeed, results of currently published studies are essentially discrepant. Only a few randomized clinical trials have been performed showing the efficacy of FFR-guided percutaneous coronary intervention in ACS. Consequently, its role in acute scenarios remains substantially understudied. Herein, is presented the current state of knowledge re-garding FFR use in ACS setting. (Cardiol J 2017; 24, 4: 426-435).

25 Thirty day readmission rates for patients undergoing percutaneous coronary intervention

IntroductionReadmission following a percutaneous coronary intervention (PCI) procedure is undesirable, being associated with patient morbidity and financial penalties. US data suggest 30 day readmission rates of approximately 10%, however little...

Pre-Procedural Blood Glucose Level and Contrast-Induced Nephropathy after Percutaneous Coronary Intervention in Non Diabetic Patients with Acute Coronary Syndrome

Background: Contrast induced nephropathy (CIN) is not an uncommon complication of percutaneous coronary intervention (PCI) and it is more in diabetic patients. But we do not know the incidence and consequences of CIN of patients with high blood sugar but not known diabetic. We planned to find the relationship between level of admission blood glucose and contrast induced nephropathy after PCI in Acute Coronary Syndrome (ACS) in non-diabetic patients.Methods: This prospective observational study was conducted in National Institute of Cardiovascular Diseases, Dhaka from January 2012 to June 2012. Total 120 patients were observed in two groups, group-I non-diabetic with normal blood glucose (?7.8 mmol/L) and group-II non-diabetic with high blood glucose (?7.8 mmol/L).Results: Results show increase in serum creatinine (0.1mg/dl vs. 0.3 mg/dl) and decrease in creatinine clearance rate (12.9 ml/min vs. 6.0ml/min) was more in hyperglycemic than normoglycemic. When most common definition of contrast induced nephropathy was used, the incidence of CIN was 24% in high blood glucose group and 4% in normal blood glucose group (p=0.004). The higher the admission blood glucose level there is more incidence of contrast induced nephropathy. Multivariate analysis of factors associated with CIN shows that patients with high blood glucose (&gt;7.8 mmol/l) and &gt; 150 ml of contrast exposure are independent predictors of contrast induced nephropathy. The patients subjected to PCI having high blood glucose were at 6 times higher risk of developing CIN than normal blood glucose and use of contrast &gt;150 ml were more than 2 times higher risk of developing CIN.Conclusion: Patients with high blood sugar on admission of ACS patients have more chance of developing CIN after PCI.Cardiovasc. j. 2017; 9(2): 106-115

Intra vascular ultrasound findings in drug eluting stent restenosis following emergent PCI for acute coronary syndrome – Gender based analysis

BackgroundOptimal stent deployment attaining larger lumen area with image guidance (IVUS/OCT) may reduce the risk of re-stenosis. However imaging based optimization is often not performed in emergency procedures. We planned to prospectively evaluate intra vascular ultrasound (IVUS) findings in patients with in stent restenosis (ISR) who underwent emergency PCI for ACS. MethodsTo find out the intra vascular ultrasound findings in drug eluting stent restenosis (DES-ISR). We enrolled consecutive patients with DES-ISR who had index PCI for ACS (NSTEMI/STEMI). IVUS analysis of individual lesions was performed for sub optimal stent deployment. ResultsOf the 1823 patients who had ACS PCI during the 5-year period, 172 patients {74 (9.4%) females and 88 males (8.4%)} had ISR. Eighty-two lesions in women were compared with 84 ISR lesions men. Baseline characteristics were similar except for presence of diabetes mellitus and multivessel disease. Females had more focal ISR (48 focal, 34 diffuse) compared to males (23 focal, 61 diffuse) (P<0.001). The prevalence {38(46%) females and 33(39%)} and IVUS pattern of different mechanical factors (MF) with suboptimal stent deployment was not different between both sexes (P=0.2). ConclusionsThe occurrence of ISR was higher in women. Women had higher TLR and lower mean vessel size. In 46% of women and 39% men, a mechanical factor with sub optimal stent deployment was found. Longer stented length, diffuse disease, calcification and Type B/C lesion type were associated with under expanded and undersized stents.

TRENDS IN INCIDENCE AND MORTALITY ASSOCIATED WITH ACUTE KIDNEY INJURY IN PATIENTS UNDERGOING PCI FOR ACUTE CORONARY SYNDROME

Background: Acute kidney injury (AKI) is associated with high morbidity in patients undergoing percutaneous coronary intervention (PCI), particularly in acute coronary syndrome (ACS). We sought to examine the incidence and outcomes of AKI in ACS PCI patients from a large tertiary center and to

Comparison of Safety and Efficacy of Unfractionated Heparin Versus Bivalirudin in Patients Undergoing Percutaneous Coronary Intervention

Anti-platelet and anti-coagulant adjunctive therapies are associated with a clinically significant increased risk of major bleeding. We retrospectively assessed in-hospital major adverse clinical events (MACE) and major bleeding in patients undergoing percutaneous coronary intervention (PCI) who received either unfractionated heparin (UFH) or bivalirudin. Consecutive patients undergoing PCI for acute coronary syndrome (ACS) at Fremantle Hospital from August 2008 to December 2013 were identified. Patients received dual antiplatelet therapy (DAPT), with either UFH (50-100IU/kg) or bivalirudin (bolus 0.75mg/kg and infusion 1.75mg/kg/hr). Adjunctive glycoprotein IIb/IIIa (GPIIbIIIa) antagonist use was at the operator's discretion. In-hospital events were identified from case notes and PCI database review. Of 3371 patients identified, 1740 received UFH and 1631 received bivalirudin. The two groups were similar with respect to age, 62.5 SD 12.1 yrs vs. 62.8 SD 12.2 yrs, (p=0.575) female gender, 24% vs. 26% (p=0.10), current smokers, 66% vs. 70% (p=0.53), diabetes, 25% vs. 26% (p=0.62) and the use of DAPT (p=ns). Presentation with ST-segment-elevation myocardial infarction (STEMI) was significantly higher in the UFH group (28% vs. 19%, p<0.001). The use of transfemoral arterial access was similar (93% UFH vs. 92% bivalirudin) (p=0.41). More patients received GPIIb/IIIa antagonist in the UFH group (30% vs. 3%; p <0.001). There was no difference in pre-discharge acute stent thrombosis (<24hours) occurring in 1.0% with UFH vs. 0.5% with bivalirudin (p=0.20). The equipoise on the outcomes of stent thrombosis persisted after multivariate adjustment for difference in rates of STEMI. In-hospital BARC Type 1-3 major bleeding occurred in 3.7% in the UFH group vs. 2.9% in the bivalirudin group (p=0.20). Unfractionated heparin compared with bivalirudin was not associated with a higher incidence of in-hospital MACE or major bleeding in a cohort with overall high rates of transfemoral access, despite significantly higher use of GPIIb/IIIa antagonists in the UFH group.

Outcomes of Middle Eastern Patients Undergoing Percutaneous Coronary Intervention: The Primary Analysis of the First Jordanian PCI Registry.

Aim:This is a prospective multicenter registry designed to evaluate the incidence of adverse cardiovascular events in Middle Eastern patients undergoing percutaneous coronary interventions (PCI). The registry was also designed to determine the predictors of poor outcomes in such patients.Methods and Results:We enrolled 2426 consecutive patients who underwent PCI at 12 tertiary care centers in Jordan between January 2013 and February 2014. A case report form was used to record data prospectively at hospital admission, discharge, and 12 months of follow-up. Mean age was 56 ± 11 years, females comprised 21% of the study patients, 62% had hypertension, 53% were diabetics, and 57% were cigarette smokers. Most patients (77%) underwent PCI for acute coronary syndrome. In-hospital and 1-year mortality rates were 0.78% and 1.94%, respectively. Definite or probable stent thrombosis occurred in 9 patients (0.37%) during hospitalization and in 47 (1.94%) at 1 year. Rates of target vessel repeat PCI and coronary artery bypass graft surgery at 1 year were 3.4% and 0.6%, respectively. The multivariate analysis revealed that cardiogenic shock, congestive heart failure, ST-segment deviation, diabetes, and major bleeding were significantly associated with higher risk of 1-year mortality.Conclusions:In this first large Jordanian registry of Middle Eastern patients undergoing PCI, patients treated were relatively young age population with low in-hospital and 1-year adverse cardiovascular events. Certain clinical features were associated with worse outcomes and may warrant aggressive therapeutic strategies.

Aortic Dissection after Percutaneous Coronary Intervention for Acute Coronary Syndrome: An Outcomes-Based Study from the Nationwide Inpatient Sample Database

Introduction: Aortic dissection is a rare complication of Percutaneous Coronary Intervention (PCI) for Acute Coronary Syndrome (ACS), but is associated with mortality rates of up to 20%. This study assessed the demographic and clinical profile of a large cohort of patients undergoing PCI for ACS to assess patient and clinical risk factors that may predispose to the development of aortic dissection. Methods: The Nationwide Inpatient Sample (NIS) database (2001-2011) was used to abstract admission data on patients undergoing PCI for ACS. Results: 777,595 patients underwent PCI and 380 (0.05%) developed aortic dissection. Patients who developed aortic dissection were more often older (68 vs. 64 years), female (47.4% vs. 33.8%), insured through Medicare (56.2% vs. 50.7%), Medicaid (7.9% vs. 5.3%) or uninsured/self-pay (6.3% vs. 4.7%), p < 0.05. Patients with aortic dissection had a higher rate of ventricular fibrillation (6.3% vs. 1.8%), cerebrovascular accident (2.4% vs. 0.4%), longer lengths of hospitalization (9 days vs. 3 days), as well as higher mortality (13.2% vs. 1.4%), p < 0.001. Multivariate analysis identified female gender, Hispanic race, uninsured/self-pay, fluid and electrolyte disorders, and peripheral vascular disease (PVD) as independent risk factors for aortic dissection after PCI. Conclusion: Aortic dissection is a rare complication of PCI, which occurs more often in older patients with Medicare insurance status. Hispanics, females, uninsured patients and those with PVD are at the highest risk of aortic dissection. Clinicians should be more cognizant of patients at increased risk of developing PCI in order to institute earlier screening in high-risk patients.

Long-term outcomes in patients with acute coronary syndromes related to prolonging dual antiplatelet therapy more than 12 months after coronary stenting.

To assess the impact of stent type on the risk of death or myocardial infarction (MI) related to dual antiplatelet therapy (DAPT) more than 12 months (prolonged DAPT) versus 12 or less months after PCI for an acute coronary syndrome (ACS). The recent DAPT study reported lower recurrent ischemic events from prolonged DAPT in patients treated with PCI for an ACS, but was underpowered to determine the impact of stent type. We determined clinical outcomes after PCI for an ACS (median follow-up: DES = 26 months, BMS = 46 months) in 18,484 patients in the Veterans Affairs system treated with first generation drug-eluting stents (DES) or bare-metal stents (BMS). We used landmark analyses starting 1 year after the index PCI to assess the risk of prolonged DAPT on the primary endpoint of death or MI. Multivariable and propensity models adjusted for confounding. There was a significant interaction between stent type and prolonged DAPT for death and MI (P = 0.0036), death (P = 0.054), and major bleeding (P = 0.0013). Patients treated with prolonged DAPT had lower risks of death or MI (HR = 0.71, 95% CI = 0.61, 0.82) and death (HR = 0.74, 95%CI = 0.62, 0.89) with DES, but not BMS, and higher risks of major bleeding, particularly with BMS (HR = 1.67, P < 0.001) than DES (HR = 1.24, p = 0.01). Prolonging DAPT more than 12 months after PCI for ACS only associated with a lower risk of ischemic events in the 1-4 years after PCI in those receiving first generation DES. Stent type may influence the benefit of prolonged DAPT. © 2016 Wiley Periodicals, Inc.

Usefulness of Post-coronary Dilation to Prevent Recurrent Myocardial Infarction in Patients Treated With Percutaneous Coronary Intervention for Acute Coronary Syndrome (from the BASE ACS Trial)

Stent underexpansion is associated with worse outcome after stent implantation. Whether post-dilation (PD) improves outcome in patients with acute coronary syndrome (ACS) remains unclear. We performed post hoc analysis of outcome in patients from the BASE ACS (A prospective randomized comparison of titanium-nitride-oxide-coated bioactive stents with everolimus-eluting stents in acute coronary syndrome) trial who underwent PD versus those who did not. The BASE ACS trial randomized 827 patients (1:1) with ACS to receive either titanium-nitride-oxide-coated bioactive stents or everolimus-eluting stents. The primary end point was major adverse cardiac events (MACE): a composite of cardiac death, nonfatal myocardial infarction (MI), or ischemia-driven target lesion revascularization. Follow-up was planned at 12months and yearly thereafter for up to 7years. Of 827 patients enrolled in the BASE ACS trial, 357 (43.2%) underwent PD. Median follow-up duration was 5years. Patients who underwent PD had less frequent nonfatal MI events at long-term follow-up, compared with those who did not (4.5% vs 8.5%, respectively, p= 0.02). The rates of MACE (15.7% vs 15.1%, respectively, p= 0.81), and the other endpoints, were not significantly different (p >0.5 for all). The results were consistent in propensity score-matched analysis (270 pairs). In patients treated with bioactive stents, those who underwent PD had a trend for a fewer nonfatal MI events (p= 0.076). Comparably, in patients treated with everolimus-eluting stents, MACE and all the individual end points were comparable (p >0.5 for all). In conclusion, patients treated with early percutaneous coronary intervention for ACS who underwent PD had less frequent nonfatal MI events at long-term follow-up, compared with those who did not; MACE rates were not significantly different.

TCT-116 Elective Use of Intra-Aortic Balloon Pump For High-Risk Percutaneous Coronary Intervention For ACS: Meta-Analysis of RCT’s

Intra-aortic balloon pump (IABP) plays a major role in the treatment of cardiogenic shock complicating acute coronary syndromes (ACS) in high-risk patients. The usefullness of IABP as prophylaxis in among those patients is yet not clear. We aimed to evaluate the safety and efficacy of prophylatic

Impact of Preexisting Vascular Disease on the Outcome of Patients With Acute Coronary Syndrome: Insights From the Comparison of Bioactive Stent to the Everolimus-Eluting Stent in Acute Coronary Syndrome Trial.

The Comparison of Bioactive-Stent to the Everolimus-Eluting Stent in Acute Coronary Syndrome (BASE-ACS) trial demonstrated an outcome of titanium-nitride-oxide-coated bioactive stents (BAS) non-inferior to everolimus-eluting stents (EES) in patients presenting with acute coronary syndrome (ACS). We performed a post hoc analysis of the BASE-ACS trial in patients with, versus those without, preexisting vascular disease. We randomized 827 patients (1:1) presenting with ACS to receive either BAS or EES. The primary end point was major adverse cardiac events (MACE): a composite of cardiac death, non-fatal myocardial infarction (MI), or ischemia-driven target lesion revascularization (TLR). A total of 169 (20.4%) patients had preexisting vascular disease. Median follow-up was 5.0 years. The incidence of MACE was higher in patients with, versus those without, preexisting vascular disease (22.5% vs 13.5%, respectively, P = .004). This was driven by more frequent cardiac death and non-fatal MI (5.9% vs 2.4% and 11.8% vs 5.5%, P = .02 and P = .003, respectively). The rates of ischemia-driven TLR were comparable ( P > .05). All events were comparable between the 2 matched-pair subgroups ( P > .05 for all). In patients treated with early percutaneous coronary intervention for ACS, the long-term outcome was worse in patients with, versus those without, preexisting vascular disease.