Era Of Percutaneous Coronary Intervention Research Articles

A gender perspective on short- and long term mortality in ST-elevation myocardial infarction — A report from the SWEDEHEART register

Previous studies of patients admitted for ST-elevation myocardial infarction [STEMI] have indicated that women have a higher risk of early mortality than do men. These studies have presented limited information on gender related differences in the short term and almost no information on the long term. We analysed a prospective, consecutively included STEMI population consisting of 54,146 patients (35% women). This population consists of almost all patients hospitalised in Sweden between January 1, 1995 and December 31, 2006 as recorded in the SWEDEHEART register (formerly RIKS-HIA). Follow-up time ranged from one to 13 years (mean 4.6). Women had a lower probability of being given reperfusion therapy, odds ratio [OR] 0.83 (95% confidence interval [CI] 0.79-0.88). During the time these STEMI patients were in the hospital, 13% of the women and 7% of men died, multivariable adjusted OR 1.21 (95% CI 1.11-1.32). During the follow up period, 46% of the women died as compared with 32% of the men. There was, however, no gender difference in age-adjusted risk of long term mortality (hazard ratio [HR] 0.98, 95% CI 0.95-1.01) whereas the multivariable adjusted risk was lower in women (HR 0.92, 95% CI 0.89-0.96). The long term risk of re-infarction was the same in men and women (HR 0.98, 95% CI 0.93-1.03) whereas men in the youngest group had a higher risk than women in that age group (HR 0.82, 95% CI 0.72-0.94). In STEMI, women had a higher risk of in-hospital mortality but the long-term risk of death was higher in men. More studies are needed in the primary percutaneous coronary intervention (pPCI) era that are designed to determine why women fare worse than men after STEMI during the first phase when they are in hospital.

Left ventricular thrombus formation after acute myocardial infarction as assessed by cardiovascular magnetic resonance imaging

IntroductionLeft ventricular (LV) thrombus formation is a feared complication of myocardial infarction (MI). We assessed the prevalence of LV thrombus in ST-segment elevated MI patients treated with percutaneous coronary intervention (PCI) and compared the diagnostic accuracy of transthoracic echocardiography (TTE) to cardiovascular magnetic resonance imaging (CMR). Also, we evaluated the course of LV thrombi in the modern era of primary PCI. Methods200 patients with primary PCI underwent TTE and CMR, at baseline and at 4 months follow-up. Studies were analyzed by two blinded examiners. Patients were seen at 1, 4, 12, and 24 months for assessment of clinical status and adverse events. ResultsOn CMR at baseline, a thrombus was found in 17 of 194 (8.8%) patients. LV thrombus resolution occurred in 15 patients. Two patients had persistence of LV thrombus on follow-up CMR. On CMR at four months, a thrombus was found in an additional 12 patients. In multivariate analysis, thrombus formation on baseline CMR was independently associated with, baseline infarct size (g) (B=0.02, SE=0.02, p<0.001). Routine TTE had a sensitivity of 21–24% and a specificity of 95–98% compared to CMR for the detection of LV thrombi. Intra- and interobserver variation for detection of LV thrombus were lower for CMR (κ=0.91 and κ=0.96) compared to TTE (κ=0.74 and κ=0.53). ConclusionLV thrombus still occurs in a substantial amount of patients after PCI-treated MI, especially in larger infarct sizes. Routine TTE had a low sensitivity for the detection of LV thrombi and the interobserver variation of TTE was large.

Cells and Iron Oxide Nanoparticles on the Move

The treatment of myocardial infarction (MI) has focused heavily on early reperfusion of the infarct-related artery. However, the inflammatory processes in the infarct that occur shortly after MI and govern wound healing in the heart have not been targeted therapeutically. Perhaps this has resulted from our inability to visualize these processes. In contrast to coronary angiography, which has clearly depicted stenotic arteries for decades and initiated the era of percutaneous coronary interventions, imaging inflammation in the heart of patients with MI has been difficult. In this issue of Circulation: Cardiovascular Imaging , Alam et al1 describe important progress to overcome this hurdle. Their article reports the first human study in which an iron oxide nanoparticle (ferumoxytol, AMAG Pharmaceuticals, Lexington, MA) was used to image leukocytes in the infarcted tissue by T2* weighted magnetic resonance imaging (MRI). Building on previous preclinical data in mice with MI,2 and the use of ferumoxtran in patients with inflammatory disease,3–5 the authors imaged 16 patients within the first week after MI, 10 of whom received intravenous ferumoxytol. R2* values tripled in the infarct and doubled in the remote zone 24 to 48 hours after ferumoxytol administration. Because all patients in this small pilot study survived the subacute infarct period, corroborating histologic data on the tissue uptake of ferumoxytol were not available. Article see p 559 The uptake of ferumoxtran and ferumoxytol by leukocytes in vivo occurs without active targeting and is caused by the size, blood half-life, and surface properties of these agents. In a recent issue of the journal, Richards et al6 report another clinical first with the agent ferumoxides, an iron oxide nanoparticle designed and used clinically for liver imaging. Here, they use ferumoxides to label human monocytes ex vivo and then reinject the labeled cells to …

Ventricular septal rupture complicating acute myocardial infarction following percutaneous coronary intervention

Abstract Ventricular septal rupture (VSR) is a rather rare, but at the same time very dreadful complication of acute myocardial infarction in the percutaneous coronary intervention (PCI) era and only limited evidence exist on the optimal treatment of this critical medical condition. VSR is less common following successful early thrombolysis and PCI occurring in myocardium supplied by infarct-related artery (IRA). We report two well-documented cases of successful VSR treatment which will provide valuable information for clinical practice especially due to the long-tem follow-up. Both cases underwent delayed elective surgical closure of VSR. This report clearly describes the incidence, potential risks and timing of occurrence, clinical features, and outcomes of ventricular septal rupture complicating acute myocardial infarction (AMI) after PCI. Hence the topic of this report is of great importance. Although the prognosis of patients who develop VSR is generally grave without immediate surgical repair, both our patients remained hemodynamically stable at discharge and during follow-up of more than 4 years.

Bilateral internal mammary arteries: a new trick for coronary artery bypass grafting

I read with interest the article in the April 2012 edition by Grau et al. I congratulate Grau et al. [1] for an excellent study. It will be interesting to know how both internal mammary arteries were used—either in situ or as y graft. In spite of the established superiority of left internal mammary artery graft, the use of the bilateral internal mammary artery has not gained popularity. In recent trials, stroke after coronary artery bypass grafting (CABG) was reported as one of the major complications that reduces the superiority of CABG over percutaneous coronary intervention. It is also evident that avoiding cardiopulmonary bypass is probably not enough to prevent stroke as aortic clamping can lead to stroke after off-pump CABG (OPCAB). OPCAB with aorticno-touch can reduce the incidence of stroke to the lowest [2]. CABG with aortic-no-touch has become synonymous with left internal mammary artery-right internal mammary artery or left internal mammary artery—radial artery y graft with single inflow. The use of both internal mammary arteries has become synonymous with y graft which has only single left internal mammary artery inflow. We presented an alternative technique of using both internal mammary arteries during OPCAB [3], in which one internal mammary artery is used to graft the left anterior descending artery and the other internal mammary artery is used for composite graft. We suggest that this technique of using both internal mammary artery in situ can be easily adopted by younger surgeons in newer centres. There is no fear of damaging one in situ internal mammary artery while creating a composite graft. I congratulate Dr Taggart for a timely editorial comment highlighting the importance of using both internal mammary arteries in the era of percutaneous coronary intervention.

High-degree atrioventricular block complicating ST-segment elevation myocardial infarction in the era of primary percutaneous coronary intervention

Primary percutaneous coronary intervention (pPCI) has replaced thrombolysis as treatment-of-choice for ST-segment elevation myocardial infarction (STEMI). However, the incidence and prognostic significance of high-degree atrioventricular block (HAVB) in STEMI patients in the pPCI era has been only sparsely investigated. The objective of this study was to assess the incidence, predictors and prognostic significance of HAVB in STEMI patients treated with pPCI. This study included 2073 STEMI patients treated with pPCI. The patients were identified through a hospital register and the Danish National Patient Register. Both registers were also used to establish the diagnosis of HAVB. All-cause mortality was the primary endpoint. During a median follow-up of 2.9 years [interquartile range (IQR) 1.8-4.0] 266 patients died. High-degree atrioventricular block was documented in 67 (3.2%) patients of whom 25 died. Significant independent predictors of HAVB included right coronary artery occlusion, age >65 years, female gender, hypertension, and diabetes. The adjusted mortality rate was significantly increased in patients with HAVB compared to patients without HAVB [hazard ratio = 3.14 (95% confidence interval 2.04-4.84), P< 0.001]. A landmark-analysis 30 days post-STEMI showed equal mortality rates in the two groups. The incidence of HAVB in STEMI patients treated with pPCI has been reduced compared with reports from the thrombolytic era. However, despite this improvement high-degree AV block remains a severe prognostic marker in the pPCI era. The mortality rate was only increased within the first 30 days. High-degree atrioventricular block patients who survived beyond this time-point thus had a prognosis equal to patients without HAVB.

033 Out-of-hours mortality in the current primary percutaneous coronary intervention era

BackgroundThere is conflicting evidence to whether the outcomes of primary percutaneous coronary Intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) are as favourable out of hours as during routine working...

AS-275: Predictive Value of Plasma Apolipoprotein A1 Levels for Mortality in Acute Myocardial Infarction in the Percutaneous Coronary Intervention Era

AS-275: Predictive Value of Plasma Apolipoprotein A1 Levels for Mortality in Acute Myocardial Infarction in the Percutaneous Coronary Intervention Era

Acute Coronary Stent Thrombosis in Cancer Patients: A Case Series Report

There have been a growing numbers of patients diagnosed with malignancy and coronary artery disease simultaneously or serially. In the era of percutaneous coronary intervention (PCI), stent thrombosis has been a rare but challenging problem. Recently, we experienced two unique cases of acute stent thrombosis in patients with malignancy. The first case showed acute and subacute stent thrombosis after PCI. The second case revealed simultaneous thromboses in stent and non-treated native coronary artery. We believe that we need rigorous precautions in the treatment of patients with coronary artery disease and malignancy, especially with regards to deciding how and whether to revascularize, as well as which anti-platelet agents to select.

The Tyranny of Distance: Emergency Regional Transfers for STEMI

Aim: We aimed to characterise regional center emergency catheterisation referrals for ST elevationmyocardial infarction (STEMI) or cardiac arrest (CA). Methods: A single institution prospective database of STEMI/CA patients was interrogated to identify these patients and descriptive statistics derived. Findings: Sixty-five (65) patients were identified (2008 to February 2012). The following baseline characteristics were present: age 60± 13 years (mean± standard deviation), 82% male, 66% post-fibrinolysis, 7% CA, and 15% shocked. Percutaneous intervention (PCI) was performed in 89% (success 98%). Balloonpumpswereused in 9%.Two patients received urgent bypass surgery. One patient had the final diagnosis not STEMI. The hospital mortality was: 7.7%. The median distance from the institution of referring site was 138 (72,240) km with range 6–597 km. A map is shown below (point size scaled to referral number). The average time from onset of symptoms to cath lab arrival (CLA) was 5.8 h. This time was correlated with distance (p< 0.05). It explained only 19% of the variation. The day of week and time of day of CLA are shown in the second viously been assessed in the era of primary percutaneous coronary intervention (PCI). We sought to determine the validity of the TRS in both male and female ST Elevation Myocardial Infarction (STEMI) patients who have undergone early field triage. Methods: This was a single centre retrospective cohort study identifying consecutive STEMI patients presenting for primary-PCI via field triage between May 2004 and December 2010. Unpaired t-tests were used to determine significant demographic differences in males and females. Linear regression analysis was used to determine the correlation of the TRS with the endpoints of 30 day majoradverse cardiacevents (MACE)andmedianhospital length of stay (LOS). Results: 329 patients presented with STEMI via field triage, of which 248 (75.4%)weremale and 81 (24.6%)were female. Women were more likely to be older (73.2 vs 68.2, p< 0.0001), hypertensive (60.5% vs 44.9%, p< 0.05), show signsofpulmonaryoedemaatpresentation (17.5%vs7.6%, p< 0.05) andhaveahigherTRS (4.90 vs 3.14,p< 0.0001). The TRS was predictive of MACE (R2 = 0.57, p< 0.02) and hospital LOS (R2 = 0.79, p< 0.001) in the entire cohort. The TRS was found to be predictive of MACE and hospital LOS in males (R2 = 0.57, p< 0.02; R2 = 0.87, p< 0.0001 respectively) as well as females (R2 = 0.58, p< 0.02; R2 = 0.66, p< 0.02 respectively). Conclusion: The TRS is a useful prognostic tool in

Impact of Periprocedural Atrial Fibrillation on Short-Term Clinical Outcomes Following Percutaneous Coronary Intervention

There are few data on the incidence and clinical outcomes of patients with atrial fibrillation (AF) treated in the era of percutaneous coronary intervention (PCI). We analyzed 30-day clinical outcomes in 3,307 consecutive patients with and without AF (sinus rhythm) undergoing PCI from January 2007 through December 2008 enrolled in a multicenter Australian registry. Periprocedural AF was present in 162 patients (4.9%). AF was associated with older age (74.1 ± 8.9 vs 63.9 ± 11.9 years, p <0.001), higher baseline serum creatinine (0.13 ± 0.14 vs 0.10 ± 0.13 mmol/L, p = 0.01), and lower left ventricular ejection fraction (49.5 ± 13.2% vs 53.4% ± 11.6%, p <0.001). Significantly more patients with AF had a history of heart failure and cerebrovascular and peripheral arterial diseases (p ≤0.01 for all comparisons). Periprocedural glycoprotein IIb/IIIa inhibitor (31.5% vs 31.4%, p = 0.98) and antithrombin use were not different between groups, but in-hospital bleeding complications were higher in patients with AF (5.0% vs 2.1%, p = 0.015). Fewer patients with AF received drug-eluting stents (p = 0.004). AF was associated with a greater than fourfold increase in 30-day mortality (9.9% vs 2.2%, p <0.0001) and readmission rates at 30 days (p = 0.01). Fewer patients with AF were on dual antiplatelet therapy at 30 days (86.3% vs 94.3%, p <0.0001), although 28.1% of patients with AF were on triple therapy (dual antiplatelet therapy plus oral anticoagulation). In conclusion, patients with periprocedural AF represent a very high-risk group. Excess 30-day morbidity and mortality after PCI may be due to the higher incidence of co-morbidities, bleeding complications, and suboptimal antiplatelet therapy.

Acute myocardial infarction in women: is there a sex disparity between door-to-balloon time and clinical outcomes?

Coronary artery disease (CAD) has traditionally been thought of as a disease that predominantly affects men. Women, however, are more likely than men to die from a myocardial infarction (MI). Despite increased awareness of heart disease in women and improved outcomes after percutaneous coronary intervention (PCI), women with MI have more mortality and delays to treatment than men. Although all of the reasons behind these differences are not clear, women presenting with MI are a more morbid patient population than their male counterparts. Women consistently demonstrate higher baseline risk, including older age, higher rates of diabetes mellitus (DM), hypertension (HTN) and congestive heart failure (CHF) [1–5]. This was initially demonstrated in trials conducted in the thrombolytic era, but has persisted in the current era of PCI [3,5]. Another source of sex disparity in ST-elevation MI (STEMI) management is delay to treatment. It is well established that the benefit of PCI over fibrinolytic therapy is lost with delay in administering treatment. A meta-regression analysis of 23 randomized controlled trials in 2003 showed that for every 10-minute delay in PCI (defined as the difference between door to balloon and door to needle), the favorable reduction in mortality is reduced by 0.94% (P=.016). When the delay in PCI is 62 min, there is no longer a reduction in mortality with PCI over fibrinolytics [6]. Unfortunately, studies have shown that women make up

Antiplatelet therapy in the era of percutaneous coronary intervention with drug-eluting balloons

The high rate of restenosis associated with percutaneous coronary intervention (PCI) procedures can be reduced with the implantation of metallic stents into the stenotic vessels. The knowledge that neointimal formation can result in restenosis after stent implantation led to the development of drug-eluting stents (DES) which require long lasting antiplatelet therapy to avoid thrombotic complications. In the last years, the drug-eluting balloon (DEB) technology has emerged as an alternative option for the treatment of coronary and peripheral arteries. Clinical studies demonstrated the safety and effectiveness of DEB in various clinical scenarios and support the use of paclitaxel-eluting balloons for the treatment of in-stent restenosis, of small coronary arteries and bifurcations lesions. The protocols of DEB studies suggest that the dual antiplatelet therapy with aspirin and clopidogrel of four weeks after DEB is safe and effective.

Incidence of left ventricular thrombus formation in the modern era of primary percutaneous coronary intervention

Incidence of left ventricular thrombus formation in the modern era of primary percutaneous coronary intervention

Female gender is an independent predictor of in-hospital mortality after STEMI in the era of primary PCI: insights from the greater Paris area PCI Registry

To determine if female gender is an independent predictor of in-hospital mortality after percutaneous coronary intervention (PCI) for ST segment elevation myocardial infarction (STEMI). A higher early mortality rate after STEMI has been reported in women before the widespread use of PCI in STEMI. PCI improves the prognosis of STEMI, however, the effect of PCI in women in this setting is controversial. In a large regional prospective registry, we examined the in-hospital mortality after PCI for STEMI. The greater Paris area comprises 11 million inhabitants. Data from all PCIs performed in 41 centres is entered in a mandatory registry. In-hospital mortality is recorded in another hospital-based database. From 2003 to 2007, 16,760 patients were treated by PCI for STEMI <24 hours; 21.9% were women. Female patients were significantly older than men, 69.7 ± 14.3 years versus 59.3 ± 13.0 years (p<0.0001). The rate of diabetes mellitus and cardiogenic shock were significantly higher in women versus men, respectively 19.0% versus 15.6%, p<0.0001 and 6.7% versus 4.0%, p<0.0001. The success rate of PCI was significantly lower in women: 94.7% versus 95.9%, p=0.002. In-hospital mortality was significantly higher in women 9.8 % versus 4.3%, p<0.0001 and the impact of gender on mortality was significant only after the age of 75. By multivariate analysis, female gender is associated with higher in-hospital mortality. After PCI for STEMI, female gender is still an independent predictor of in-hospital mortality.

Efficacy and Safety of Glycoprotein IIb/IIIa Inhibitors During Elective Coronary Revascularization: A Meta-Analysis of Randomized Trials Performed in the Era of Stents and Thienopyridines

The purpose of this study was to investigate the efficacy and safety of glycoprotein IIb/IIIa inhibitors (GPIs) during elective percutaneous coronary intervention (PCI). Studies have documented that GPIs are useful during PCI; however, much of this research was conducted before the routine use of coronary stents and thienopyridines. We searched the MEDLINE, Cochrane clinical trials, and ClinicalTrials.gov databases from inception for studies that randomly assigned patients undergoing elective PCI to a GPI versus control. Trials were included if stents and thienopyridines were used routinely and clinical outcomes were reported. Outcomes were assessed within 30 days. A DerSimonian-Laird model was used to construct random effects summary risk ratios (RRs) and 95% confidence intervals (CIs). Our search yielded 22 studies with 10,123 patients. The incidence of nonfatal myocardial infarction was 5.1% with GPI versus 8.3% with control (RR: 0.66, 95% CI: 0.55 to 0.79, p < 0.0001). Major bleeding was 1.2% versus 0.9% (RR: 1.37, 95% CI: 0.83 to 2.25, p = 0.22), minor bleeding was 3.0% versus 1.7% (RR: 1.70, 95% CI: 1.28 to 2.26, p < 0.0001), and mortality was 0.3% versus 0.5% (RR: 0.70, 95% CI: 0.36 to 1.33, p = 0.27), respectively. In the current era of elective PCI performed with stents and thienopyridines, GPIs provide clinical benefit. These agents reduce nonfatal myocardial infarction without a notable increase in major bleeding; however, they increase the risk of minor bleeding. All-cause mortality is not reduced.

STEMI Patients—The More You Bleed, the More You Die: A Comparison Between Classifications

In patients with acute coronary syndromes, an increase in hemorrhagic complications has been observed, and bleeding is now the most frequent noncardiac complication in these patients. Clinical trials and registries have used different scales to classify the severity of bleeding; so far, none of them has been developed for ST-segment elevation myocardial infarction (STEMI) patients in the era of primary percutaneous coronary intervention. We analyzed data from our Intensive Cardiac Care Florence STEMI Registry, comprising 991 STEMI patients consecutively admitted to our intensive cardiac care unit after mechanical revascularization, to assess the clinical impact of both Thrombolysis In Myocardial Infarction (TIMI) and Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) classifications in identifying patients with major bleeding at higher risk for in-hospital mortality. Major bleeding events occurred in 8.9% of patients (88/991) in the TIMI classification and in 17.2% of patients (170/991) in the ACUITY classification. Among patients with major bleeding classified according to ACUITY, 82 patients did not meet the TIMI criteria for major bleeding. These patients represent the so-called gray zone, where no transfusion was performed and only 1 patient died. In STEMI patients who undergo primary percutaneous coronary intervention and receive dual antiplatelet therapy, TIMI is more capable than ACUITY in identifying patients with major bleeding at higher risk for early mortality. The presence of renal failure represents an independent predictor for major bleeding.

The role of fibrinolysis in the era of primary percutaneous coronary intervention

Most cases of acute myocardial infarction are caused by disruption of an atherosclerotic plaque followed by coronary thrombosis (1). In ST-elevation myocardial infarction (STEMI), the thrombus occludes a major epicardial coronary artery. Such an occlusion is an emergency situation, and flow in the occluded vessel should be restored as fast as possible. Various strategies for reperfusion are available, namely pharmacological reperfusion by fibrinolytic therapy or mechanical reperfusion by primary percutaneous coronary intervention (PCI). Primary PCI has been established as the preferred reperfusion strategy today (2). The percentage of STEMI-patients treated with primary PCI is steadily increasing, and in most European countries, primary PCI is the leading reperfusion strategy (3). In this era of primary PCI, one might wonder whether fibrinolytic therapy should remain a part of the therapeutic armamentarium of acute STEMI. In this overview, we will briefly present the evidence for the benefit of fibrinolytic therapy in STEMI and discuss the role of fibrinolysis in this era of primary PCI. Benefit of fibrinolytic therapy

Chest pain and ST elevation: not always ST-segment-elevation myocardial infarction

A 59-year-old male patient affected by pleural mesothelioma presented with chest pain and localized ST elevation in the electrocardiogram. Urgent coronary angiography excluded an acute coronary occlusion, whereas high-resolution computed tomography of the chest revealed tumor infiltration and associated acute inflammation of the pericardial sac. This case illustrates how initial clinical evaluation during emergency conditions could be misled by the time-effectiveness imperative in the primary percutaneous coronary intervention era. In conclusion, early valorization of clinical signs and noninvasive diagnostic elements may add accuracy in directing the postadmission patient course.

Is There an Obesity Paradox After Percutaneous Coronary Intervention in the Contemporary Era?: An Analysis From a Multicenter Australian Registry

We sought to determine whether an obesity paradox exists in the contemporary era of percutaneous coronary intervention (PCI) and to explore potential clinical factors that might contribute. Previous studies have suggested that overweight and obese patients might have better outcomes after PCI than patients with a normal or low body mass index (BMI); however this "obesity paradox" remains poorly understood. We evaluated 4,762 patients undergoing PCI between April 1, 2004 and September 30, 2007, enrolled in the MIG (Melbourne Intervention Group) registry. Patients were classified as underweight, normal, overweight, class I obese, and class II to III obese, BMI <20, 20 to 25, 25.1 to 30, 30.1 to 35, and >35 kg/m(2), respectively. We compared in-hospital, 30-day, and 12-month outcomes. As BMI increased from <20 to >35 kg/m(2), there was a statistically significant, linear reduction in 12-month major adverse cardiac events (MACE) (21.4% to 11.9%, p = 0.008) and mortality (7.6% to 2.0%, p < 0.001). Obesity was, with multivariate analysis, an independent predictor of reduced 12-month MACE and showed a trend for reduced 12-month mortality. At 12 months, obese patients had higher use of aspirin, clopidogrel, beta-blockers, renin-angiotensin system blockers and statins. Compared with normal-weight individuals, overweight and obese patients had lower in-hospital and 12-month MACE and mortality rates after PCI. Moreover, obese patients had a higher rate of guideline-based medication use at 12 months, which might in part explain the obesity paradox seen after PCI.