Q-wave Myocardial Infarction Research Articles

A new stenting technique for bifurcation lesions a nine‐patient case series

This study describes and reports preliminary outcomes using kissing T-stenting and small protrusion (K-TAP), a novel modification of traditional T-stenting and small protrusion (TAP). Nine patients who were treated with K-TAP between May 2008 and February 2012 at two hospitals were retrospectively included in this study. The primary endpoints were angiographic success, procedural success, and the composite 30-day and long-term occurrences of major adverse cardiac events (MACEs), which consisted of death, coronary artery bypass graft surgery, repeated percutaneous coronary intervention of the target vessel, and non-Q-wave and Q-wave myocardial infarctions. Data were obtained from the review of institutional databases, folder auditing, a telephone survey of the patients, and the review of angiograms. Angiographic success and procedural success were achieved in all patients. The mean fluoroscopy time for the total procedure was 24.1 min (range 20-28). No complications occurred during the procedures. The MACE rate during the mean follow-up period of 102 weeks (range 22-196 weeks) was 0%. K-TAP, a new coronary bifurcation stenting method, has favorable angiographic and procedural success rates and a low early post-procedure MACE rate. Further studies are needed to evaluate the clinical efficacy of the K-TAP method.

Pathological Q Waves in Myocardial Infarction in Patients Treated by Primary PCI

In the present study, we investigated the association of pathological Q waves with infarct size. Furthermore, we investigated whether Q-wave regression was associated with improvement of left ventricular ejection fraction (LVEF), infarct size, and left ventricular dimensions in ST-segment elevation myocardial infarction (STEMI) patients with early Q-wave formation compared with patients without or persistent pathological Q waves. The criteria for pathological Q waves after acute myocardial infarction (MI) have changed over the years. Also, there are limited data regarding correlation of Q-wave regression and preservation of LVEF in patients with an initial Q-wave MI. Standard 12-lead electrocardiograms (ECGs) were recorded in 184 STEMI patients treated with primary percutaneous coronary intervention (PCI). ECGs were recorded before and following PCI, as well as at 1, 4, 12, and 24 months of follow-up. An ECG was scored as Q-wave MI when it showed Q waves in 2 or more contiguous leads according to the 4 readily available clinical definitions used over the years: "classic" criteria, Thrombolysis In Myocardial Infarction criteria, and 2000 and 2007 consensus criteria. Cardiac magnetic resonance (CMR) examination was performed at 4 ± 2 days after reperfusion and repeated after 4 and 24 months. Contrast-enhanced CMR was performed at baseline and 4 months. The classic ECG criteria showed strongest correlation with infarct size as measured by CMR. The incidence of Q-wave MI according to the classic criteria was 23% 1 h after PCI. At 24 months of follow-up, 40% of patients with initial Q-wave MI displayed Q-wave regression. Patients with a Q-wave MI had larger infarct size and lower LVEF on baseline CMR (24 ± 10% LV mass and 37 ± 8%, respectively) compared with patients with non-Q-wave MI (17 ± 9% LV mass, p < 0.01, and 45 ± 8%, p < 0.001, respectively). Patients with Q-wave regression displayed significantly larger LVEF improvement in 24 months (9 ± 11%) as compared with both persistent Q-wave MI (2 ± 8%) as well as non-Q-wave MI (3 ± 8%, p = 0.04 for both comparisons). Association of Q waves with infarct size is strongest when using the classic Q-wave criteria. Q-wave regression is associated with the largest improvement of LVEF as assessed with CMR.

In-hospital versus postdischarge adverse events following carotid endarterectomy

Most studies based on state and nationwide registries evaluating perioperative outcome after carotid endarterectomy (CEA) rely on hospital discharge data only. Therefore, the true 30-day complication risk after carotid revascularization may be underestimated. We used the National Surgical Quality Improvement Program database 2005-2010 to assess the in-hospital and postdischarge rate of any stroke, death, cardiac event (new Q-wave myocardial infarction or cardiac arrest), and combinedstroke/death and combined adverse outcome (S/D/CE) at 30 days following CEA. Multivariable analyses were used to identify predictors for in-hospital and postdischarge events separately, and in particular, those that predict postdischarge events distinctly. A total of 35,916 patients who underwent CEA during 2005-2010 were identified in the National Surgical Quality Improvement Program database; 59% were male, median age was 72 years, and 44% had a previous neurologic event. Thirty-day stroke rate was 1.6% (n= 591), death rate was 0.8% (n= 272), cardiac event rate was 1.0% (n= 350), stroke or death rate was 2.2% (n= 794), and combined S/D/CE rate was 2.9% (n= 1043); 33% of strokes, 53% of deaths, 32% of cardiac events, 40% of combined stroke/death, and 38% of combined S/D/CE took place after hospital discharge. Patients with a prior stroke or transient ischemic attack had similar proportions of postdischarge events compared with patients without prior symptoms. Independent predictors for postdischarge events, but not for in-hospitalevents were female sex (stroke [odds ratio (OR), 1.6; 95% confidence interval (CI), 1.2-2.1] and stroke/death [OR, 1.4; 95% CI, 1.1-1.7]), renal failure (stroke [OR, 3.0; 95% CI, 1.4-6.2]) and chronic obstructive pulmonary disease (death [OR, 2.5; 95% CI, 1.6-3.7], stroke/death [OR, 1.8; 95% CI, 1.4-2.4], and S/D/CE [OR 1.8, 95% CI 1.4-2.3]). With 38% of perioperative adverse events after CEA happening posthospitalization, regardless of symptoms status, we need to be alert to the ongoing risks after discharge particularly in women, patients with renal failure, or chronic obstructive pulmonary disease. This emphasizes the need for reporting and comparing 30-day adverse event rates when evaluating outcomes for CEA, or comparing carotid stenting to CEA.

Circulating miR-133a and miR-423-5p fail as biomarkers for left ventricular remodeling after myocardial infarction

Recent studies have suggested that the microRNAs miR-133a and miR-423-5p may serve as useful biomarkers in patients with left ventricular (LV) heart failure or with LV remodeling after myocardial infarction (MI). These results were however obtained in small series of patients and control subjects were used as reference groups. Whether these microRNAs may be indicators of the degree of LV remodeling after MI is unknown. 246 patients with a first anterior Q-wave MI were included. Serial echocardiographic studies were performed at hospital discharge, 3 months, and 1 year after MI and analyzed at a core laboratory. We investigated the temporal profile (baseline, 1, 3 and 12 months) of circulating miR-133a and miR-423-5p and their relations with cardiac biomarkers (B-type natriuretic peptide, C-reactive protein, and cardiac troponin I) and LV remodeling during the 1 year follow-up. There were time-dependent changes in the levels of circulating miR-133a and miR-423-5p with significant increase of miR-133a at 12 months compared to 3 months and significant increase of miR-423-5p at 1, 3, and 12 months compared to baseline. However, miR-133a and miR-423-5p were not associated with indices of LV function and LV remodeling serially assessed during a 1 year period after an acute anterior MI, nor with B-type natriuretic peptide. Circulating levels of miR-133a and miR-423-5p are not useful biomarkers of LV remodeling after MI.

CLINICAL AND FUNCTIONAL CHARACTERISTICS OF PATIENTS AFTER Q-WAVE MYOCARDIAL INFARCTION DEPENDING ON THE METABOLIC SYNDROME PRESENCE OR ABSENCE

Aim. To study the clinical and functional parameters of patients after acute Q-wave myocardial infarction (Q-MI) depending on the concomitant metabolic syndrome (MS). Material and methods. Men after Q-MI (n=79; aged 51.7±8.9 years) were included into the study. Patients were divided into two groups depending on the MS presence or absence. Doppler echocardiography and determination of the serum C-reactive protein (CRP) level were performed in all patients on the 10-14 days after Q-MI, and treadmill test was performed in 25 patients. Results. Left ventricular ejection fraction was 12% lower and the CRP level was 2 times higher in MS patients versus these in non-MS patients (p<0.01). The silent segment ST depression ≥1.0 mm were more often observed in MS patients compared with this in non-MS patients (40% vs 5%; respectively, p<0.05). Conclusion. The MS presence complicates the post-infarction period by early heart failure progression, characterized by elevated CRP levels and more frequent occurrence of silent myocardial ischemia.

Major clinical and angiographic outcome of drug eluting stents in native ostial coronary artery disease

Objectives: The study was designed to evaluate the efficacy and safety of drug eluting stents (DESs) in aorto-ostial (A-O) coronary artery lesions, in terms of early and late restenosis rate; including clinical assessment, non-invasive stress testing and angiographic follow-up. Also, the study was aimed to compare the results of implantation of drug eluting stents (DES) to that of bare metal stents (BMS) in aortoostial lesions done over a previous 5 years in Royal Brompton Hospital. Background: The safety and effectiveness of DESs for the treatment of aortoostial lesions. Methods: We included 161 consecutive patients with symptoms subjective of angina pectoris or objective evidence of myocardial ischemia; who underwent percutaneous coronary interventions (PCI) in coronary ostial lesions using DES. The patients were divided into two groups based on the site of ostial lesion. The control group consisted of 125 consecutive patients who underwent percutaneous coronary intervention for ostial lesions using bare metal stents (BMS) implantation in the period immediately before the introduction of DES. The incidence of major adverse cardiac events (MACE), including death or Q-wave myocardial infarction (MI), need for repeated revascularization procedure CABG or angioplasty, were recorded in-hospital and at twelve months ± 3 months. Follow-up angiography was only performed in case of recurrent symptoms subjective of myocardial ischemia or if there was objective evidence of myocardial ischemia by stress testing. Results: The initial procedure was successful in 149 patients (92.5%) in the DES arm. There were no statistically significant major in-hospital complications in the DES group, compared to BMS group which showed 4 cases of in-hospital deaths (p = 0.017). At Twelve months ± 3 months follow-up, MACE were significantly less frequent in the DES group compared to the BMS group, including death (0.8% vs. 6.4%, p = 0.004) and need for CABG (1.7% vs. 10%, p = 0.012). Conclusions: The main finding of our study is that, compared to the BMS, implantation of the DES in coronary ostial lesions appears safe and effective. It is associated with high procedural success rate, low immediate and in-hospital complication rate, infrequent late adverse events and favourable long-term clinical and angiographic outcomes compared with bare metal stents implantation at 12-month follow-up. Advanced age, previous myocardial infarction and acute coronary syndromes at presentation were all found to be independent positive predictors for clinical events after drug eluting stent implantation in ostial lesions.

225: Impact of platelet function monitoring and optimization of dual antiplatelet therapy in patients with unprotected left main disease treated by percutaneous coronary intervention: The ALMA Registry

Cardiac surgery is the recommended treatment for patients with left main (LM) disease, although percutaneous coronary intervention (PCI) is emerging as an alternative technique. Stent thrombosis (ST) even if rare is a serious complication after PCI with high rate of mortality. Aggregation tests can identify patients with high platelet reactivity under clopidogrel and aspirin. The objective of this registry was to evaluate the 2-years rate of ST and outcomes in patients with PCI for unprotected LM disease and adapted dual antiplatelet therapy (DAPT) according to aggregation tests. Fifty one patients with LM disease were prospectively included in a single center registry. Acute myocardial infarction (MI) and cardiogenic shock were exclusion criteria. DAPT response was evaluated by VASP index and light transmission aggregometry (LTA) with acid arachidonic acid (AA 0.5 mg/ml) and with adenosine diphosphate (ADP 20 µmol/L). Patients were 67±12 years old, 52% were diabetic, 33% admitted for acute coronary syndrome and 61% had multivessel disease. For distal LM lesions (73%), the provisional T-stenting approach was used in all cases with 84% of final kissing balloon inflation and 20% of T stenting. 27% patients were aspirin non responders (LTA-AA 0.5 mg/ml≥20%) and 47% clopidogrel non responders according to VASP index (≥50%). After optimization of DAPT, aspirin was given twice a day in 27% of patients, prasugrel in 45%, clopidogrel high dose (≥150 mg) in 35% and clopidogrel standard dose (75 mg) in only 20%. At 2 years, no ST occurred. Outcomes were 24% with 3 non Q-wave MI (6%), 2 cerebrovascular accidents (4%), and 7 repeat revascularizations (14%) with 4 target lesion revascularization (8%). Mortality rate was 4% (n=2) with one cardiovascular death (2%). Unprotected LM stenting and systematic platelet function assessment with DAPT optimization provides excellent clinical outcomes without any stent thrombosis at 2 years.

Bivalirudin versus Unfractionated Heparin during Percutaneous Coronary Intervention in Patients with Non‐ST‐Segment Elevation Acute Coronary Syndrome Initially Treated with Fondaparinux: Results from an International, Multicenter, Randomized Pilot Study (SWITCH III)

We aimed to determine the optimal adjunctive anticoagulation regimen for percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS) initially treated with fondaparinux. The optimal adjunctive anticoagulation regimen for PCI in these patients is unclear. In this open-label, prospective, randomized, multicenter pilot study, we compared treatment with unfractionated heparin (UFH) versus bivalirudin in patients with non-ST-segment elevation ACS initially treated with fondaparinux and undergoing early invasive strategy. The randomized population consisted of 100 patients (62.7 ± 12.7 years, 68% men), all of whom were on clopidogrel. During the angioplasty, patients were randomized to either bivalirudin or UFH therapy in a 1:1 fashion. Baseline clinical and angiographic characteristics were similar except for a higher body mass index in the UFH group (29.4 ± 4.7 vs. 27.3 ± 4.2, P = 0.02). Major bleeding was the primary outcome; a major bleeding event was documented in only 1 patient from the bivalirudin group (2%) and in none from the UFH group (P = 0.49). There was no death, Q-wave MI, or acute revascularization in either group. There was no documentation of stent thrombosis, reinfarction, and catheter thrombus. Data from this prospective, multicenter pilot study suggest that bivalirudin, compared to standard-dose UFH, has a similar safety profile in terms of peri-PCI bleeding and thrombotic events and can be used safely in ACS patients initially treated with upstream fondaparinux who undergo PCI.

A prospective, randomized trial of intravascular-ultrasound guided compared to angiography guided stent implantation in complex coronary lesions: The AVIO trial

No randomized studies have thus far evaluated intravascular ultrasound (IVUS) guidance in the drug-eluting stent (DES) era. The aim was to evaluate if IVUS optimized DES implantation was superior to angiographic guidance alone in complex lesions. Randomized, multicentre, international, open label, investigator-driven study evaluating IVUS vs angiographically guided DES implantation in patients with complex lesions (defined as bifurcations, long lesions, chronic total occlusions or small vessels). Primary study endpoint was post-procedure in lesion minimal lumen diameter. Secondary end points were combined major adverse cardiac events (MACE), target lesion revascularization, target vessel revascularization, myocardial infarction (MI), and stent thrombosis at 1, 6, 9, 12, and 24 months. The study included 284 patients. No significant differences were observed in baseline characteristics. The primary study end point showed a statistically significant difference in favor of the IVUS group (2.70 mm ± 0.46 mm vs. 2.51 ± 0.46 mm; P = .0002). During hospitalization, no patient died, had repeated revascularization, or a Q-wave MI. No difference was observed in the occurrence of non-Q wave MI (6.3% in IVUS vs. 7.0% in angio-guided group). At 24-months clinical follow-up, no differences were still observed in cumulative MACE (16.9%vs. 23.2 %), cardiac death (0%vs. 1.4%), MI (7.0%vs. 8.5%), target lesion revascularization (9.2% vs. 11.9%) or target vessel revascularization (9.8% vs. 15.5%), respectively in the IVUS vs. angio-guided groups. In total, only one definite subacute stent thrombosis occurred in the IVUS group. A benefit of IVUS optimized DES implantation was observed in complex lesions in the post-procedure minimal lumen diameter. No statistically significant difference was found in MACE up to 24 months.

Comparison between magnitude reconstruction and phase-sensitive mR imaging in the detection of myocardial infarction

ObjectiveTo determine the deference between phase sensitive magnetic resonance (MR) imaging and magnitude reconstruction to detect infracted myocardium. MethodsTwenty patients (16 men; 4 women; mean age, 56 years). experienced Q-wave myocardial infarction 2 weeks earlier were examined with a 3.0-T MR system 10 minutes after administration of 0.1 mmol/kg body weight gadobenate dimeglumine. To determine the optimal TI, a TI scout sequence was used. A segmented 2D IR true fast imaging with steady-state precession (trueFISP) sequence that produces both phase-sensitive and magnitude-reconstructed images were used at TI values of 200-600 msec (TI values were varied in 100-msec steps) and at optimal TI (mean value, 330 msec). Contrast-noise ratios (CNRs) of normal and infarcted myocardium and the area of infarcted myocardium were determined. Two-tailed unpaired sample Student t test was used to compare CNRs, and area of infarction. ResultsMMean CNR phase-sensitive and magnitude-reconstructed images at optimal TI (mean value, 330 msec) were 6.2, and 6.1, respectively. For a TI of 200 msec, CNR values were 5.5, and 4.2, respectively; for TI of 600 msec, CNR values were 5.8 and 4.3, respectively. Area of infarcted myocardium was underestimated on magnitude-reconstruction images (P = 0.002-0.03) for short TI values (ie., 200 msec) but not on phase sensitive reconstructed when compared with IR tureFISP images obtained at optimal TI. ConclusionsLPhase-sensitive image reconstruction results in reduced need for precise choice of TI and more consistent image quality.

THE INFLUENCE OF ADMISSION HEART RATE ON THE CLINICAL COURSE AND SHORT-TERM OUTCOME OF THE DISEASE IN PATIENTS WITH Q-MYOCARDIAL INFARCTION LEFT VENTRICULAR AND EARLY SYSTOLIC DYSFUNCTION

ObjectivesThe purpose of the study was to assess the influence of admission heart rate (HR) on the clinical course and immediate outcomes in patients with Q-myocardial infarction (MI) with left...

Electrocardiographic Q-Wave “Remodeling” in Reperfused ST-Segment Elevation Myocardial Infarction: Validation Study With CMR

The aim of this study was to evaluate the evolution in Q-wave expression during the first 5 years after a primary, successfully reperfused ST-segment elevation myocardial infarction (MI), using cardiac magnetic resonance (CMR) for infarct location, and to depict changes in infarct size and left ventricular remodeling over time. In the absence of QRS confounders, abnormal Q waves are usually diagnostic of myocardial necrosis. It is hypothesized that Q-wave regression after MI could be related to smaller infarct sizes. Late gadolinium enhancement accurately depicts MI of any age. Forty-six MI patients underwent electrocardiography and CMR at 1 week (baseline), 4 months, 1 year, and 5 years post-infarction. Conventional CMR parameters were analyzed, and infarct presence, location, and size were assessed using late gadolinium enhancement CMR. Infarct locations were anterior or nonanterior (inferior and/or lateral), using late gadolinium enhancement CMR as a reference. For each time point, patients were classified as having a diagnostic/nondiagnostic electrocardiogram (ECG) using the European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation consensus criteria for previous Q-wave infarct. At baseline, 11 patients (23%) did not meet the criteria for Q-wave MI. Non–Q-wave infarcts were significantly smaller than Q-wave infarcts (p < 0.0001). All anterior Q-wave infarcts (n = 17) were correctly localized, whereas in 7 of 19 nonanterior Q-wave infarcts, the location or extent of the infarct was misjudged by electrocardiography. At 4-month/1-year follow-up, in 10 patients (3 anterior/7 nonanterior), the ECG became nondiagnostic. The ECG remained nondiagnostic at 5-year follow-up. A cutoff infarct size of 6.2% at 1 year yielded a sensitivity of 89% and a specificity of 74% to predict the presence or absence of Q waves. The incidence of nondiagnostic ECGs for previous MI using the current European Society of Cardiology/American College of Cardiology Foundation/American Heart Association/World Heart Federation criteria is substantial and increases with time post-infarction from 23% immediately post-infarction to 44% at 5-year follow-up.

Long-Term Outcome of Stents Versus Bypass Surgery in Diabetic and Nondiabetic Patients With Multivessel or Left Main Coronary Artery Disease

Coronary artery bypass grafting and percutaneous coronary intervention (PCI) are alternative treatments for complex multivessel or left main disease. However, the relative treatment effects in diabetic and nondiabetic patients remain uncertain. We performed a pooled analysis of 5775 patients from 3 clinical studies comparing PCI and coronary artery bypass grafting for multivessel or left main disease and compared adverse outcomes (death; a composite outcome of death, Q-wave myocardial infarction, or stroke; and repeat revascularization) according to the diabetic status. Over a median follow-up of 5.5 years, risk-adjusted mortality after PCI relative to coronary artery bypass grafting was not different in diabetic (hazard ratio [HR], 1.15; 95% CI, 0.88-1.51) and nondiabetic (HR, 1.15; 95% CI, 0.88-1.50) patients. The adjusted risks of the composite outcome of death, Q-wave myocardial infarction, or stroke were also not different in diabetic (HR, 1.00; 95% CI, 0.79-1.26) and nondiabetic (HR, 0.99; 95% CI, 0.78-1.26) patients. However, PCI was significantly associated with higher risk of repeat revascularization both in diabetic (HR, 3.56; 95% CI, 2.62-4.83) and in nondiabetic (HR, 3.55; 95% CI, 2.61-4.83) patients. Significant interactions were absent between diabetic status and revascularization strategies for death (P=0.27), composite outcome of death, Q-wave myocardial infarction, or stroke (P=0.97), and repeat revascularization (P=0.08). For multivessel or left main disease, the long-term risks of mortality and composite serious outcomes were not different between PCI and coronary artery bypass grafting in diabetic and nondiabetic patients, but PCI was associated with higher risk of repeat revascularization. These relative treatment effects were not modified by diabetic status. These results are hypothesis generating and should be addressed in a randomized trial.

Circulation: Clinical Summaries

<i>Circulation:</i> Clinical Summaries

Sex-related differences in prognosis after myocardial infarction: changes from 1978 to 2007

Women with myocardial infarction (MI) have shown a 28-day survival disadvantage compared with men. However, results were less consistent when considering long-term mortality in 28-day survivors. The aim was to estimate the trends for sex-related differences in the three endpoints considered for this study: (1) 28-day mortality or severe ventricular dysfunction (acute pulmonary oedema or cardiogenic shock) during the hospital stay, (2) 28-day mortality and (3) two-year cardiovascular mortality or non-fatal MI in 28-day survivors after a first MI. A cohort of 3,982 consecutive patients with first Q-wave MI admitted to a university tertiary reference hospital between 1978 and 2007 was followed for 2 years. Short-term prognosis improved in women over the studied period; similar rates were observed in both sexes in the 2000s. After adjusting for age, co-morbidities and anterior location of MI, female sex had an odds ratio=1.71 (95% confidence interval [CI] 1.34-2.17) of short-term severe MI or death over the studied period. Overall, sex differences in long-term prognosis remained similar over the studied period (hazard ratio=1.40; 95% CI 1.02-1.91). In conclusion, short-term prognosis improved over the past 30 years for first Q-wave MI patients, becoming similar for both men and women in the most recent decade. Long-term prognosis did not improve in either men or women, indicating that secondary prevention should be reinforced to achieve consistent reductions in the number of cardiovascular events.

Bleeding Is Rarely Good for You

In a careful statistical analysis of 651 775 patients undergoing elective noncardiac, non-neurological, noncarotid surgery in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database between 2005 and 2009, Kamel and colleagues1 have reaffirmed that bleeding is bad, and that more bleeding is worse, at least in the intraoperative period. Patients who received >4 units of packed red blood cells or whole blood had an ≈2.5-fold increased risk of a subsequent stroke or Q-wave myocardial infarction (MI), independent of a multitude of other risk factors. The relationship between blood loss and postoperative MI or stroke was related to the severity of bleeding: For each unit of intraoperative transfusion with packed red blood cells or whole blood, the risk was reported to increase by ≈1.1-fold (95% confidence interval, 1.10–1.13). In a sensitivity analysis reported in their Discussion section, these results were unchanged when “limited to large intraoperative transfusions in patients without baseline anemia.” Article see p 207 This study must be interpreted in the context of another study from the NSQIP dataset. Glance and colleagues2 reported that a 1- to 2-unit intraoperative blood transfusion was not significantly associated with cardiac or neurological complications in an analysis limited to 10 100 patients who underwent general, vascular, or orthopedic surgery. The adjusted risk of cardiac complications (odds ratio, 1.31; 95% confidence interval, 0.88–1.95) was not inconsistent with the findings of Kamel and colleagues. But, in this report, the risk of central nervous system complications was actually insignificantly lower (odds ratio, 0.68; 95% confidence interval, 0.34–1.38) in patients who received 1 to 2 units of intraoperative blood. These 2 studies, put together, indicate that a lot of bleeding is bad and a little bit is probably not good. The authors acknowledge some of the limitations of their study design. …

Percutaneous Coronary Intervention With Second-Generation Paclitaxel-Eluting Stents Versus Everolimus-Eluting Stents in United States Contemporary Practice (REWARDS TLX Trial)

Registry Experience at the Washington Hospital Center, DES - Taxus Liberte Versus Xience V (REWARDS TLX) is a physician-initiated, retrospective, real-world, multicenter, observational study for all patients >18 years of age subjected to percutaneous coronary intervention with everolimus-eluting stents (EESs) or paclitaxel-eluting stents (PESs). Outcomes of patients receiving a TAXUS Liberté or XIENCE V drug-eluting stent were compared. Baseline clinical, procedural, and follow-up data at 12 months were collected from 10 clinical centers by an electronic data capture system. The study's primary end point was major adverse cardiac events: a composite of all-cause death, Q-wave myocardial infarction, target vessel revascularization, and stent thrombosis. The trial is registered with http://www.clinicaltrials.gov (NCT01134159). Data were entered for 1,195 patients (PES, n = 595; EES, n = 600). Baseline clinical characteristics were similar except for higher dyslipidemia, systemic hypertension, and family history of coronary artery disease in the EES group. In-hospital outcome was similar between groups, with an overall in-hospital stent thrombosis rate of 0.2%. The primary end point at 12 months was similar (EES 7.8% vs 10.8%, p = 0.082). Overall stent thrombosis rate was lower in the EES group (0.3% vs 1.2%, respectively, p = 0.107); however, target lesion revascularization was similar (PES, hazard ratio 1.46, 95% confidence interval 0.98 to 2.19, p = 0.064). There was no difference in overall mortality between groups. In conclusion, second-generation EESs and PESs demonstrated similar efficacy and safety profiles for broadened patient and lesion subsets compared to a selected population from the pivotal trials. However, for composite efficacy and safety end points, EESs outperformed second-generation PESs.

Association Between Major Perioperative Hemorrhage and Stroke or Q-Wave Myocardial Infarction

Hemorrhage is associated with ischemic complications in cardiac patients. The nature of this relationship in surgical patients is unknown. We examined the association between major perioperative hemorrhage and stroke or myocardial infarction among adults who underwent surgery from 2005 through 2009 at centers participating in the National Surgical Quality Improvement Program. We excluded patients with emergent, trauma-related, transplantation, cardiac, or neurological operations. Major hemorrhage was defined as bleeding necessitating transfusion of >4 U of packed red blood cells or whole blood. Stroke was defined as focal brain dysfunction lasting ≥24 hours from a vascular cause. A diagnosis of myocardial infarction required new ECG Q waves. Outcomes were assessed from surgery until 30 days afterward. Among 651,775 patients who underwent surgery, 5233 (0.80%) experienced major hemorrhage, 1575 (0.24%) developed Q-wave myocardial infarction, and 1321 (0.20%) suffered a stroke. In Cox proportional hazards analyses controlling for vascular risk factors, illness severity, and type of surgery, hemorrhage was independently associated with subsequent stroke (hazard ratio, 2.5; 95% confidence interval, 1.9-3.3) and subsequent Q-wave myocardial infarction (hazard ratio, 2.7; 95% confidence interval, 2.1-3.4). Interaction terms revealed no significant variation in these associations by age, sex, or type of surgery. Our results were robust across multiple sensitivity analyses. Major perioperative hemorrhage is associated with subsequent stroke and myocardial infarction in patients undergoing noncardiac, nonneurological surgery. This suggests the need for randomized trials to guide perioperative use of antiplatelet drugs, which affect the risk of both bleeding and vascular events.

Utility of Intravascular Ultrasound Guidance in Patients Undergoing Percutaneous Coronary Intervention for Type C Lesions

Percutaneous coronary intervention (PCI) of complex lesions (i.e., American College of Cardiology/American Heart Association class type C) remains challenging and the outcome may be compromised. The use of intravascular ultrasound (IVUS) to guide PCI was suggested to improve outcome. A cohort of 1,984 patients who underwent PCI to type C lesions in our center from April 2000 to March 2010 was identified. Using propensity score matching with clinical and angiographic characteristics, we identified 637 patients who underwent IVUS guidance and 637 patients who had only angiographic guidance PCI. Major adverse cardiovascular events (MACE), a composite end-point of all-cause mortality, Q-wave myocardial infarction and target lesion revascularization, were compared between the 2 groups. After propensity score matching, baseline clinical and angiographic characteristics were well matched. Patients undergoing IVUS-guided PCI had less predilatation and more postdilatation, and were treated more often with cutting balloon. Final diameter stenosis was significantly smaller in the IVUS-guided group (3 ± 11% vs. 7 ± 19%, P < 0.001), resulting in higher angiographic success compared with the non-IVUS-guided group (97.9% vs. 94.8%, P < 0.001). The incidence of MACE was significantly lower in the IVUS-guided group compared to the angiography-guided group (11.0% vs. 15.6%, P = 0.017) as was cardiac death (1.9% vs. 4.4%, P = 0.010). IVUS-guided PCI for complex type C lesions is associated with better outcome and should be considered for these lesions.

Outcomes of PCI at Hospitals with or without On-Site Cardiac Surgery

BackgroundPerformance of percutaneous coronary intervention (PCI) is usually restricted to hospitals with cardiac surgery on site. We conducted a noninferiority trial to compare the outcomes of PCI performed at hospitals without and those with on-site cardiac surgery.MethodsWe randomly assigned participants to undergo PCI at a hospital with or without on-site cardiac surgery. Patients requiring primary PCI were excluded. The trial had two primary end points: 6-week mortality and 9-month incidence of major adverse cardiac events (the composite of death, Q-wave myocardial infarction, or target-vessel revascularization). Noninferiority margins for the risk difference were 0.4 percentage points for mortality at 6 weeks and 1.8 percentage points for major adverse cardiac events at 9 months.ResultsA total of 18,867 patients were randomly assigned in a 3:1 ratio to undergo PCI at a hospital without on-site cardiac surgery (14,149 patients) or with on-site cardiac surgery (4718 patients). The 6-week mortality rate was 0.9% at hospitals without on-site surgery versus 1.0% at those with on-site surgery (difference, −0.04 percentage points; 95% confidence interval [CI], −0.31 to 0.23; P=0.004 for noninferiority). The 9-month rates of major adverse cardiac events were 12.1% and 11.2% at hospitals without and those with on-site surgery, respectively (difference, 0.92 percentage points; 95% CI, 0.04 to 1.80; P=0.05 for noninferiority). The rate of target-vessel revascularization was higher in hospitals without on-site surgery (6.5% vs. 5.4%, P=0.01).ConclusionsWe found that PCI performed at hospitals without on-site cardiac surgery was noninferior to PCI performed at hospitals with on-site cardiac surgery with respect to mortality at 6 weeks and major adverse cardiac events at 9 months. (Funded by the Cardiovascular Patient Outcomes Research Team [C-PORT] participating sites; ClinicalTrials.gov number, NCT00549796.)