PCI Therapy Research Articles

A new risk score predicting 1- and 5-year mortality following acute myocardial infarction: Soroka Acute Myocardial Infarction (SAMI) Project

BackgroundRisk stratification of patients following acute myocardial infarction (AMI), in order to identify patients whose clinical outcomes can be improved through specific medical interventions, is needed. ObjectivesDevelopment and validation of a prognostic tool comprising a variety of non-cardiovascular co-morbidities, to predict mortality of hospital survivors after AMI. MethodsThe study cohort included 2773 consecutive patients with AMI who were discharged live from the Soroka University Medical Center between 2002 and 2004. Two-thirds were used obtain the model (training set) and one-third to validate it (validation set). Data were collected from the hospital's routine computerized information systems. The primary outcome was post-discharge 1-year all-cause mortality. The weight of each variable in the final score was computed based on the odds ratio values of the multivariate model. Additionally, the ability of the index to predict 5-year mortality was assessed. ResultsThese are comprised of the following parameters: 4 points — age >75years, abnormal echocardiography findings; 3 points — at least one of following: gastro-intestinal hemorrhage, COPD, malignancy, alcohol or drug addiction, neurological disorders, psychiatric disorders; 2 points — no echocardiography results, renal diseases, anemia, hyponatremia; −3 points for PCI or thrombolytic therapy; −6 points — CABG; −2 points — obesity. The c-statistics for 1-year all-cause mortality were 0.86 and 0.83 in the training and validation sets, respectively. The c-statistics for 5-year mortality was 0.858 for both sets combined. ConclusionsThe new score is a simple robust tool for predicting mortality in patients discharged alive following AMI.

IVUS Guided Management of Angiographic Intermediate Coronary Lesions: Long-Term Outcome After Stratification to PCI, CABG or Medical Therapy

IVUS Guided Management of Angiographic Intermediate Coronary Lesions: Long-Term Outcome After Stratification to PCI, CABG or Medical Therapy

11C-meta-hydroxyephedrine defects persist despite functional improvement in hibernating myocardium

BackgroundRegional cardiac sympathetic nerve dysfunction develops in hibernating myocardium and may play a role in its association with sudden cardiac death. Interventions to improve cardiac function (i.e., revascularization) improve survival, but the potential reversibility of sympathetic nerve dysfunction remains unclear. Methods and ResultsPigs (n = 11) were chronically instrumented with a proximal left anterior descending coronary artery (LAD) stenosis to produce hibernating myocardium. Prior to therapeutic interventions, there was LAD occlusion with collateral-dependent myocardium, reduced regional function (echocardiographic LAD wall-thickening 23% ± 4% vs 83% ± 6% in Remote, P < .001), and large defects in 11C-meta-hydroxyephedrine (HED) PET (48% ± 4% of LV area, 26% ± 2% integrated reduction). Successful PCI or pravastatin therapy improved regional (LAD wall-thickening 23% ± 4% to 42% ± 6%, P < .05) and global LV function (fractional shortening 24% ± 2% to 31% ± 2%, P < .01), but did not alter regional HED uptake, retention, defect size, or defect severity. ConclusionsDespite significant functional improvement of hibernating myocardium as a result of PCI or pravastatin therapy, there were no changes in HED defect size or severity. Thus, inhomogeneity in myocardial sympathetic innervation persisted, and the lack of plasticity suggests that even in the absence of significant infarction, structural rather than functional defects are responsible for reduced myocardial norepinephrine uptake in chronic ischemic heart disease.

Quality of Life Outcomes in Chronic Stable Angina Patients Treated with PCI or Medical Therapy

was associated with higher mortality. Unadjusted, each 0.5mm step increase in V1 ST level was associated with ∼25% increase in 30-day mortality and this was true for patients with and patients without V3 ST depression. The odds ratio for mortality was 1.21 (95% confidence interval 1.07–1.37) after adjusting for infero-lateral ST elevation and clinical factors and 1.24 (95% confidence interval 1.09–1.40) if also adjusted to V3 ST level. In contrast lead V1 ST depression was not associated with mortality after adjustment for V3 ST level. V1 ST elevation ≥1mm, analyzed dichotomously in all patients, was significantly associated with higher mortality (28% higher unadjusted, 51% higher adjusted to V3 ST level, and 35% higher adjusted to ECG and clinical factors). Resolution of V1 ST elevation ≥1mm 60min after fibrinolysis was associated with lower mortality (5.5% vs 10.8%, P= 0.0012). Conclusion: V1 ST elevation identifies higher risk patients with inferior AMI. doi:10.1016/j.hlc.2009.05.276

Advances in Antiplatelet Therapy for ACS and PCI

Platelet activation and thrombin formation play significant roles in the pathophysiology of acute coronary syndrome. To overcome this pathophysiology, antiplatelet agents are utilized to decrease platelet aggregation and anticoagulants to decrease thrombin formation. Current antiplatelet agents are designed to inhibit various mediators of platelet activation, such as thromboxane A2 and adenosine diphosphate, and platelet-surface receptors (e.g., glycoprotein IIb/IIIa receptors). The rationale for upstream versus deferred administration of antiplatelet therapy in patients scheduled for percutaneous intervention and the current ACC/AHA guidelines for the management of patients with unstable angina/non-ST-segment myocardial infarction are discussed. The next-generation antiplatelet drugs are in various stages of clinical development, with unique differentiating mechanistic and pharmacokinetic properties. The newer P2Y12 thienopyridine receptor antagonists and protease receptor inhibitor are also examined, in addition to the rationale of various outcome studies evaluating the efficacy and safety of the different agents.

Quality of Life with PCI versus Medical Therapy in Stable Coronary Disease

Quality of Life with PCI versus Medical Therapy in Stable Coronary Disease

Abstract 913: Persistent High Risk of Death and Myocardial Infarction in Patients with Peripheral Arterial Disease Undergoing PCI: Results from the NHLBI Dynamic Registry

Patients with peripheral arterial disease (PAD) undergoing PCI are at high risk for adverse cardiovascular events in follow up. Trends over time in outcomes with advances in PCI and medical therapy are unknown. We evaluated 866 patients with PAD in the NHLBI Dynamic Registry undergoing PCI according to treatment eras: the early bare metal stent (BMS) era (Wave 1: ‘97–’98, n=180), the BMS era (Waves 2 and 3; ’99 and ’01–’02; n=339), and the drug-eluting stent (DES) era (Waves 4 and 5:’04 and ‘06; n=347). We compared in-hospital and 1-year outcomes by recruitment era. In-hospital CABG rates were significantly lower in the later eras (3.9%, 0.9%, 0.6%, early BMS, BMS, and DES eras respectively, p=0.005), and an increasing percentage of patients were discharged on asprin, beta blockers, statins, and ticlopidine or clopidogrel (all p&lt;0.001). The cumulative 1-year adverse event rates are seen in the table . Comparison cumulative 1-year event rates in patients without PAD in the early BMS era (n=2323), BMS era (n=3803) and DES era (n=3915) of death were 4.2%, 4.4%, and 4.0% (p=0.76); of MI were 5.3%, 5.0%, and 4.4% (p=0.19), and repeat revasculatization were 21.5%, 15.9%, and 11.4% (p&lt;0.001). The 1-year adjusted hazard ratios (HR) of adverse events in patients with PAD using the early BMS era as the reference are as follows: Death: BMS era HR=0.84 (95% CI 0.46–1.55, p=0.58) and DES era HR=1.35 (95% CI 0.71–2.56, p=0.36); MI: BMS era HR=0.89 (95% CI 0.48–1.66, p=0.72) and DES era HR=1.02 (95% CI 0.55–1.87, p=0.95); and Repeat Revascularization: BMS era HR=0.63 (95% CI 0.41– 0.97, p=0.04) and DES era HR=0.46 (95% CI 0.29–0.73, p=001).

In STEMI, Swift Postlytic Transfer for PCI Therapy Is Ideal

In STEMI, Swift Postlytic Transfer for PCI Therapy Is Ideal

PCI plus Optimal Medical Therapy Offers Benefit in Moderate-to-Severe Ischemia

PCI plus Optimal Medical Therapy Offers Benefit in Moderate-to-Severe Ischemia

Integrated Management of Patients with Diabetes Mellitus and Ischemic Heart Disease: PCI, CABG, and Medical Therapy

Modern coronary revascularization strategies are based on studies performed in the 1970s and 1980s that compared coronary artery bypass surgery with standard medical therapy available at the time. Studies comparing surgical and percutaneous revascularization followed, demonstrating similar long-term outcome among thousands of randomized patients. The largest of these trials, the Bypass Angioplasty Revascularization Investigation (BARI), cast doubt on the generalizability of these findings to all subgroups, finding that patients with diabetes mellitus and multivessel disease had worse long-term outcome with an initial strategy of percutaneous transluminal coronary angioplasty (PTCA). Indeed, patients with diabetes mellitus are at increased risk for cardiovascular morbidity and mortality, while the benefit of standard therapies in these patients is attenuated by the underlying metabolic abnormalities and significant comorbidities associated with the diabetic state. However, surgical and percutaneous revascularization techniques continue to evolve. Similarly, modern medical therapy is markedly superior to that available during these early studies, with demonstrable benefit in primary and secondary prevention of vascular events in both diabetic and nondiabetic patients. Ongoing trials will define the impact of current treatment modalities in this important and growing population.

Future of interventional cardiology in the treatment of coronary artery disease

The development of interventional cardiology (PCI) started already with the introduction of catheterization but was pushed forward by A. Grüntzig with the percutaneous transluminal coronary angioplasty (PTCA) 1977. In the beginning very slow progress could be observed. This changed when Grüntzig changes to Emory university, Atlanta. Already after 10 years alternative techniques were introduced like stent implantation and rotablation, coronary atherectomy, laser angioplasty, ultrasound therapy. During the following years, it became obvious that only for stent implantation (see W. Rutsch et al, Berlin, p.481) and rotablation (see T. Dill et al, Bad Nauheim, p.502) standard indications could be seen in addition to PTCA. Brachytherapy for treatment of in stent restenosis and laserwire recanalisation of occluded vessels were added. New protection systems - aspiration or filters - were introduced for increase of PCI safety in venous bypass stenosis (see C. Hamm et al, Bad Nauheim, p.527). The main step forward seems to be the introduction of drug eluting covered stent either with polymer (see E. Grube et al, Siegburg, p.508) or ceramic coating (see H. Wieneke et al, Essen, p.518). Restenosis rates, which were already reduced by bare stent for 20-30%, could be lowered below 10%. In patients with diabetes and main stem stenosis or multi vessel disease, coronary artery bypass surgery is indicated, but in other patients PCI seems to be as good as surgery in relation to mortality and myocardial infarction rates. With drug eluting stents the role of PCI may become even more pronounced, because the revascularization rate could be further reduced (see W. Rutsch, Berlin, p.481). The future will demonstrate even further main steps for interventions like the percutaneous bypass attempts and the introduction of gen-therapy (A. B. Buchwald, Göttingen, p.533). Meanwhile we can observe a drop of 1-2% mortality in coronary artery disease related to 60% influence of prevention and 40% to advanced PCI therapy. This is still a remarkable successful story in medicine provided by cardiology.