Setting Of Primary Percutaneous Coronary Intervention Research Articles

TIMI RISK INDEX, A SIMPLE TOOL IN EMERGENCY PERCUTANEOUS REVASCULARIZATION FOR THE PREDICTION OF CONTRAST INDUCED NEPHROPATHY

Objectives: Contrast induced nephropathy (CIN) is a common complication seen after primary percutaneous coronary intervention (PCI) which can contribute to increased morbidity and mortality in patients of acute ST elevation myocardial infarction (STEMI). Aim of this study was to validate the TIMI Risk Index (TRI) for the risk stratification of CIN in patients undergone primary PCI.
 Methodology: A total of 507 consecutive patients of STEMI undergone primary PCI at a tertiary care cardiac center were included for this study. Patients in Killip class IV at presentation, patients with history of any PCI and chronic kidney diseases were excluded from this study. TRI was calculated using the formula “heart rate systolic blood pressure” and post-procedure serum creatinine level increase of either 25% or 0.5 mg/dL was taken as CIN.
 Results: A total of 507 patients were included in this study out of which 82.2% were males and 17.8% were females. In total 8.7% (44) patients developed CIN. In the receiver operating characteristic (ROC) curve analysis, area under the curve (AUC) for TRI was found to be 0.717, [0.649 to 0.758] for the prediction of CIN. Sensitive, specificity, positive predictive value and negative predictive value of TRI>22.8 to predict the development of CIN were 59.09%, 76.69%, 19.55% and 95.19% respectively.
 Conclusion: In conclusion, our study has consolidated the findings of previous studies using TIMI risk index in STEMI patients undergoing primary PCI and has established that this easy to calculate and readily accessible score has good accuracy to evaluate the risk of CIN in primary PCI setting and could be of great help to take any pre-emptive strategies in those identified at high risk of post-procedure CIN.

SHOCK INDEX-C: A NEWFOUND SPECTRUM OF SHOCK INDEX WITH GREAT ACCURACY TO PREDICT CONTRAST INDUCED NEPHROPATHY IN PRIMARY PERCUTANEOUS CORONARY INTERVENTION COHORT

Objectives: This study was conducted to assess the predictive value of Shock Index-Creatinine Clearance (SI-C) for the risk stratification of contrast induced nephropathy (CIN) in patients after primary percutaneous coronary intervention (PPCI). Methodology: 1150 consecutive patients of STEMI and candidates of PPCI presenting at our tertiary care cardiac center were included in this study. Patients with significant hemodynamic instability, allergic reaction to contrast agent or having exposure to contrast agent within a week prior to PPCI and those requiring renal replacement therapy were excluded from this study. SI-C and Mehran risk scores were calculated and the rise in post procedure serum creatinine level by 0.5 mg/dL or up to 25% from baseline was characterized as CIN. The predictive power of both SIC and Mehran risk score was assessed with help of receiver operating characteristic (ROC) curve analysis. Results: Out of 1150 participants, 960 were male with a mean age of 55.64 ± 11.45 years. Out of which 113 (9.8%) patients developed CIN. Area under the cure (AUC) for the prediction of CIN was 0.702 [95% confidence interval (CI): 0.651 to 0.753] for SI-C as against 0.633 [95% CI: 0.574 to 0.692] for Mehran score. SIC also retained its statistical significance as independent predictor of CIN with adjusted odds ratio of 1.01 [95% CI: 1.01 to 1.02] on multivariable regression analysis. Conclusion: SI-C has demonstrated strong discriminative power to determine the risk of CIN in PPCI setting when compared with Mehran risk score.

Timi Risk Index, A Simple Tool In Emergency Percutaneous Revascularization For The Prediction Of Contrast Induced Nephropathy.

Contrast induced nephropathy (CIN) is a common complication seen after primary percutaneous coronary intervention (PCI) which can contribute to increased morbidity and mortality in patients of acute ST elevation myocardial infarction (STEMI). Aim of this study was to validate the TIMI Risk Index (TRI) for the risk stratification of CIN in patients undergone primary PCI. Consecutive patients of STEMI undergone primary PCI at a tertiary care cardiac center were included for this study. Patients in Killip class IV at presentation, patients with history of any PCI and chronic kidney diseases were excluded from this study. TRI was calculated using the formula " " and post-procedure serum creatinine level increase of either 25% or 0.5 mg/dL was taken as CIN. A total of 507 patients were included in this study out of which 82.2% were males and 17.8% were females. In total 8.7% (44) patients developed CIN. In the receiver operating characteristic (ROC) curve analysis, area under the curve (AUC) for TRI was found to be 0.717, [0.649-0.758] for the prediction of CIN. Sensitive, specificity, positive predictive value and negative predictive value of TRI >22.8 to predict the development of CIN were 59.09%, 76.69%, 19.55% and 95.19% respectively. TIMI risk index is and easy to calculate and readily accessible score which has good predictive value to evaluate the risk of CIN in primary PCI setting.

Thrombus aspiration during primary percutaneous coronary intervention: Which patients? An observational prospective study

Since the 2000s, thrombus aspiration (TA) has been widely used in the percutaneous coronary intervention (PCI) of ST elevated myocardial infarction (STEMI). Otherwise, recent trials have questioned its safety. Therefore, guidelines are against the routine use of manual TA during primary PCI. Our study aimed to evaluate the immediate angiographic results of the TA to assess the predictive factors of its failure. An observational prospective study was performed from 2016 to 2018. We included all patients who underwent TA using the ExportTM catheter during a primary PCI for less than 12 h of STEMI. The primary endpoint was the failure of TA assessed by TIMI classification for the final coronary flow. Insufficient reperfusion due to failed TA was defined as a TIMI flow < 3 in the culprit artery at the end of the PCI. The secondary composite endpoint was the occurrence of in-hospital Major Adverse CerebroCardiovascular Events (MACCE). We have included 60 consecutive patients. Mean age was 59.7 ± 13.6 years. 81.7% were males. Anterior location of STEMI was noted in 60%. The median delay between symptoms and wire crossing was 5 [3.8-8.7] hours. Initially, 68.3% of the patients presented a TIMI 0 flow and final TIMI 3 flow was established in 66.7% of cases. We identified 4 patients with in-hospital MACCE. Our results suggest a high rate of angiographic failure(33.3%) following a primary PCI despite the use of TA. The associate factors of a failure TA were: the delay between symptoms onset and wire crossing ≥ 5h( P = 0.025) and a cardiogenic shock( P = 0.04). The multivariate study showed that tardive presentation (> 5 h) was the only predictive factor of a failed TA HR = 4 [1.1-14], P = 0.037. Despite the limitation of our observational study, we noted an important rate of slow and no flow in the setting of primary PCI despite using TA. Identifying such risk factors will improve the effectiveness of the primary PCI with a selective TA.

TCT-50 Impact of a bifurcation culprit lesion in ST elevation myocardial infarction: procedural success, clinical outcome and 5-year follow-up.

Coronary artery bifurcation is a challenging scenario for percutaneous coronary intervention (PCI). We aimed to assess the impact of a bifurcation culprit lesion in the setting of primary PCI for ST elevation myocardial infarction (STEMI). From 2747 STEMI patients (January 2004 to January 2015)

Abstract 19724: Renoprotective Effect of Remote Ischemic Peri-conditioning During Air Medical Transport of Patients With ST-segment Elevation Myocardial Infarction

Background: Acute kidney injury (AKI) manifesting as acute increase in serum creatinine is a recognized complication to cardiac catheterization. Patients with ST-segment elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PCI) have a markedly increased risk of developing AKI. At present, there is no universally accepted strategy for prevention of AKI in the setting of primary PCI. We assessed whether remote ischemic peri-conditioning (RIPC) stimulus during ambulance transport of STEMI patient would reduce the rate of creatinine rise post primary PCI. Method: We evaluated STEMI patients transferred to two hospitals participating in the National Cardiovascular Data Registry (NCDR) Acute Coronary Treatment Intervention Outcomes Network Registry-Get With the Guidelines (ACTION Registry-GWTG) between March, 2013 and March, 2015. Patients were transferred by an air medical critical care service utilizing RIPC as part of a standard protocol and compared to controls matched by referring location/facility. Patient demographics, clinical characteristics, treatments, cardiac biomarkers, left ventricular function, serum creatinine and rate of any increase in creatinine post PCI were compared by the presence or absence of RIPC during transport. Results: Out of the 221 STEMI patients (Age, 63±12.7 yrs; 32.6% female) in this analysis, 107 received RIPC and 114 did not. Baseline characteristics were similar between the two groups. RIPC group had significantly lower rate of creatinine rise post PCI (38.6% vs 55.2%; OR, 1.40; CI, 1.03-1.90; p=0.03) despite having similar baseline serum creatinine (median (IQR), 1.0(0.36) mg/dl vs. median (IQR), 1.0(0.4) mg/dl; p=0.46). In multivariable logistic regression analysis adjusting for demographic factors and clinical characteristics, RIPC (OR, 1.62; CI, 1.12-2.35; p=0.01) was independently associated with lower rate of creatinine rise post PCI. Conclusion: Among patients with STEMI undergoing primary PCI, RIPC before hospital arrival compared with no RIPC was associated with significantly lower rate of creatinine rise post PCI. The use of RIPC as a potential renoprotective strategy for STEMI patients warrants further investigation.

Mechanisms by which transradial approach may reduce mortality in ST-segment-elevation myocardial infarction.

Radial access for central arterial catheterization was first described in 1948, but it was not until 1989 that Lucien Campeau published his experience of 100 successful coronary angiograms via the radial route.1 In 1993, the transradial approach for coronary angiography took a significant step forward when Kiemeneij and Laarman described the use of radial access for successful percutaneous coronary intervention (PCI).1 Since that time the use of the transradial approach for PCI has become increasingly popular, mainly because of improved patient comfort and observed reductions in periprocedural bleeding and vascular complications.2 Current use of transradial intervention (TRI) in the United States is 16%.3 Although still underused, TRI is becoming increasingly popular in the United States with a 13-fold increase during the past 6 years.3 Currently, TRI is considered not only an effective alternative to transfemoral intervention (TFI) but also in some instances the preferred approach. This may be particularly true in the setting of primary PCI because some studies have shown an association between TRI and reduced mortality when compared with the transfemoral approach. Although this association remains controversial, the purpose of this review is to propose and discuss the mechanisms for a potential reduction in mortality. The most important outcome measured in any cardiovascular study is the effect the intervention of interest has on mortality. Major adverse cardiac events (MACE), which is most commonly a composite of death, myocardial infarction (MI), or revascularization, is also an outcome of interest. Current data suggest that TRI when compared with TFI may be associated with a reduction in MACE and mortality in patients with ST-segment–elevation MI (STEMI). In a post hoc analysis of Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI), 30-day MACE was significantly lower in patients who underwent TRI when compared with …

Effect of Radial-to-Femoral Access Crossover on Adverse Outcomes in Primary Percutaneous Coronary Intervention

We aimed to describe the impact of the vascular access used when patients are treated with primary percutaneous coronary intervention (PPCI) and to assess whether this translates into differences in angiographic outcomes. Patients with ST-elevation myocardial infarction who underwent PPCI were divided into 3 groups: successful radial access (RA), successful femoral access (FA), and Crossover (failed RA with need for bailout FA) groups. Vascular access-related time (VART) was defined as the delay in PPCI that can be attributed to vascular access-related issues. Study end point was the final corrected Thrombolysis In Myocardial Infarction frame count. Multivariable analysis was used to identify predictors of RA failure (RAF: FA + Crossover). We included 241 patients (RA, n = 172; FA, n = 49; Crossover, n = 20). Mean VART was longer in Crossover (10.3 [8.8 to 12.4] minutes), relative to RA (4.1 [3.2 to 5.5] minutes) and FA (4.6 [3.4 to 8.4] minutes, p <0.001). A similar situation was found for time-to-first device (Crossover 22.5 [20.3 to 32.0], RA 15.0 [12.0 to 19.8]; FA 17.9 [13.5 to 22.3] minutes, p <0.001) and total procedure time (Crossover 60.3 [51.6 to 71.5], RA 46.8 [38.1 to 59.7], FA 52.3 [41.9 to 74.7] minutes, p <0.001). No differences in corrected Thrombolysis In Myocardial Infarction frame count were observed (Crossover 26 [18 to 32] frames, RA 24 [18 to 32] frames, FA 25 [16 to 34] frames, p = 0.625). Killip class IV (odds ratio [OR] 3.628, 95% confidence interval [CI] 1.098 to 11.981, p = 0.035), cardiopulmonary resuscitation before arrival (OR 3.572, 95% CI 1.028 to 12.407, p = 0.045), and glomerular filtration rate (OR 0.861, 95% CI 0.758 to 0.978, p = 0.021) were independent predictors of RA failure. In conclusion, in the setting of PPCI, radial-to-FA crossover can lead to VART delays that do not affect angiographic outcomes, in comparison with successful RA.

Unfractionated heparin versus bivalirudin in primary percutaneous coronary intervention (HEAT-PPCI): an open-label, single centre, randomised controlled trial

Bivalirudin, with selective use of glycoprotein (GP) IIb/IIIa inhibitor agents, is an accepted standard of care in primary percutaneous coronary intervention (PPCI). We aimed to compare antithrombotic therapy with bivalirudin or unfractionated heparin during this procedure. In our open-label, randomised controlled trial, we enrolled consecutive adults scheduled for angiography in the context of a PPCI presentation at Liverpool Heart and Chest Hospital (Liverpool, UK) with a strategy of delayed consent. Before angiography, we randomly allocated patients (1:1; stratified by age [<75 years vs ≥75 years] and presence of cardiogenic shock [yes vs no]) to heparin (70 U/kg) or bivalirudin (bolus 0·75 mg/kg; infusion 1·75 mg/kg per h). Patients were followed up for 28 days. The primary efficacy outcome was a composite of all-cause mortality, cerebrovascular accident, reinfarction, or unplanned target lesion revascularisation. The primary safety outcome was incidence of major bleeding (type 3-5 as per Bleeding Academic Research Consortium definitions). This study is registered with ClinicalTrials.gov, number NCT01519518. Between Feb 7, 2012, and Nov 20, 2013, 1829 of 1917 patients undergoing emergency angiography at our centre (representing 97% of trial-naive presentations) were randomly allocated treatment, with 1812 included in the final analyses. 751 (83%) of 905 patients in the bivalirudin group and 740 (82%) of 907 patients in the heparin group had a percutaneous coronary intervention. The rate of GP IIb/IIIa inhibitor use was much the same between groups (122 patients [13%] in the bivalirudin group and 140 patients [15%] in the heparin group). The primary efficacy outcome occurred in 79 (8·7%) of 905 patients in the bivalirudin group and 52 (5·7%) of 907 patients in the heparin group (absolute risk difference 3·0%; relative risk [RR] 1·52, 95% CI 1·09-2·13, p=0·01). The primary safety outcome occurred in 32 (3·5%) of 905 patients in the bivalirudin group and 28 (3·1%) of 907 patients in the heparin group (0·4%; 1·15, 0·70-1·89, p=0·59). Compared with bivalirudin, heparin reduces the incidence of major adverse ischaemic events in the setting of PPCI, with no increase in bleeding complications. Systematic use of heparin rather than bivalirudin would reduce drug costs substantially. Liverpool Heart and Chest Hospital, UK National Institute of Health Research, The Medicines Company, AstraZeneca, The Bentley Drivers Club (UK).

Coronary Chronic Total Occlusions in the Setting of Acute Myocardial Infarction

Approximately 10-15% of ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) are found to have a chronic total occlusion (CTO) in a non-infarct related artery (IRA). The presence of a coronary CTO in a non-IRA in STEMI patients is associated with increased mortality and above average deterioration of left ventricular function. A number of mechanisms may be responsible for this worsened prognosis, including impaired healing at the infarct border zone, decreased protection against future cardiovascular events, and potentially increased risk of arrhythmias. This review article aims to provide an overview of published data on the prognostic effect of CTOs in a non-IRA in the setting of primary PCI for acute STEMI. Additionally, observational data on staged PCI of CTOs after primary PCI, and future studies on additional CTO PCI after primary PCI, will be reviewed.

Predictors and prognosis of early ischemic mitral regurgitation in the era of primary percutaneous coronary revascularisation

BackgroundStudies assessing ischemic mitral regurgitation (IMR) comprised of heterogeneous population and evaluated IMR in the subacute setting. The incidence of early IMR in the setting of primary PCI, its progression and clinical impact over time is still undetermined. We sought to determine the predictors and prognosis of early IMR after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).MethodsUsing our primary PCI database, we screened for patients who underwent ≥2 transthoracic echocardiograms early (1–3 days) and late (1 year) following primary PCI. The primary outcomes were: (1) major adverse events (MACE) including death, ischemic events, repeat hospitalization, re-vascularization and mitral repair or replacement (2) changes in quantitative echocardiographic assessments.ResultsFrom January 2006 to July 2012, we included 174 patients. Post-primary PCI IMR was absent in 95 patients (55%), mild in 60 (34%), and moderate to severe in 19 (11%). Early after primary PCI, IMR was independently predicted by an ischemic time > 540 min (OR: 2.92 [95% CI, 1.28 – 7.05]; p = 0.01), and female gender (OR: 3.06 [95% CI, 1.42 – 6.89]; p = 0.004). At a median follow-up of 366 days [34–582 days], IMR was documented in 44% of the entire cohort, with moderate to severe IMR accounting for 15%. During follow-up, MR regression (change ≥ 1 grade) was seen in 18% of patients. Moderate to severe IMR remained an independent predictor of MACE (HR: 2.58 [95% CI, 1.08 – 5.53]; p = 0.04).ConclusionsAfter primary PCI, IMR is a frequent finding. Regression of early IMR during long-term follow-up is uncommon. Since moderate to severe IMR post-primary PCI appears to be correlated with worse outcomes, close follow-up is required.

Bivalirudin use during percutaneous coronary intervention in patients on chronic warfarin therapy

About 5 to 8 % of patients referred for percutaneous coronary intervention (PCI) have an indication for long-term oral anticoagulation (OAC), mainly due to atrial fibrillation (AF) [1]. Intravenous direct thrombin inhibitor, bivalirudin (Angiox, The Medicines company LTD, UK), is increasingly used in the setting of primary PCI for ST elevation myocardial infarction, and acute coronary syndromes, since it has provided a similar reduction in major adverse cardiac events but lower bleeding events, when compared to heparin and heparin plus glycoprotein inhibitors (GPIs) [2,3].

The Relationship Between Platelet Collagen Receptor Glycoprotein VI and No-Reflow Phenomenon in Patients With Acute ST-Segment Elevation Myocardial Infarction

ObjectivesThe purpose of this study was to determine whether admission soluble glycoprotein VI (sGP-VI) level is associated with no-reflow phenomenon (NRP) after primary percutaneous coronary intervention (P-PCI) in patients with...

Perspectives: How to evaluate healthcare systems in primary angioplasty

Primary percutaneous coronary intervention (P-PCI) is the gold-standard treatment for ST-elevation myocardial infarction (STEMI). The main goals of a healthcare system in the setting of STEMI are two: first of all to reduce the time delays between diagnosis and P-PCI; secondly to increase the per cent of STEMI patients treated with P-PCI. The aim of this article was to propose a quality evaluation of healthcare system, identifying and defining measurable elements in the setting of P-PCI.

Does high-dose intracoronary adenosine improve regional systolic left ventricular function in patients with acute myocardial infarction?

Background Reperfusion injury limits the beneficial effects of primary percutaneous coronary intervention (PCI) in the setting of acute myocardial infarction (AMI). Adenosine limits reperfusion injury in animal models. Objective Is to study the effects of high-dose intracoronary adenosine administration in the setting of primary PCI on coronary blood flow and regional left ventricular function. Methods Sixty patients with a definite diagnosis of ST elevation AMI within 6 h from the onset of chest pain were randomly allocated to receive adenosine (6 mg) or saline placebo (on a 1:2 ratio) as an adjunct to primary PCI with assessment of TIMI flow, TIMI myocardial blush grade (MBG), and occurrence of no-reflow. Systolic (S) wave velocity was recorded at the mitral annulus in the territory of the infarct related artery using pulsed-wave tissue Doppler within 24 h from admission and one week after PCI. Results Both groups showed no significant difference in terms of age, sex, risk factors, infarct location, and distribution of coronary artery disease. The adenosine group showed a higher incidence of TIMI III flow (95% vs. 65%, p < 0.03), a higher incidence of MBG 2-3 (95% vs. 67.5%, p < 0.007), and a lower incidence of no-reflow (10% vs. 45%, p < 0.006). Only in the adenosine group, there was a significant improvement in the annular pulsed tissue Doppler S wave velocity at the infarct-related territory at day-7 (p < 0.01). Conclusion High-dose adenosine administration in the setting of primary PCI improves myocardial perfusion and regional left ventricular systolic function.

Deferred stenting in primary percutaneous coronary intervention: the Minimal Intervention for Myocardial Infarction (MIMI) study

Purpose: In the setting of primary percutaneous coronary intervention (PPCI), we hypothesized that a 24-48 hour delayed strategy of after successful thrombus aspiration and establishment of Thrombolysis In Myocardial Infarction (TIMI) 3 flow with optimal antithrombotic therapy may decrease the risk of microvascular obstruction as assessed by cardiac magnetic resonance imaging (CMRI). Methods: MIMI is a randomized, multicentre, prospective, open-label study with blindly assessed primary endpoints. Patients were included if the pre-procedural flow of the culprit artery was TIMI 0 or 1, thrombus aspiration restored a TIMI 3 flow, and the patients were eligible for stent implantation. Patients were randomized to either or 24-48 hours intentional stenting. Patients were treated with heparin, clopidogrel/prasugrel and glycoprotein IIb/IIIa inhibitors. The primary endpoint is the extent of microvascular obstruction, as assessed by CMRI, and expressed as the ratio of microvascular obstruction to left ventricular mass (Clinicaltrial.gov registration [NCT01360242][1]). Results: Of 160 patients included between June 2011 and December 2012 in 19 coronary interventional centres, 83 were randomized to the group and 77 to the intentional group. A total of 144 patients had a CMRI. None of the patients in the deferred intentional stenting group presented an infarct related artery reocclusion between thrombus aspiration and second procedure. Most (98%) of the patients in the immediate stenting group and 87% of those in the deferred intentional stenting group underwent a stent implantation (no definitive data). Results will be presented at the ESC congress 2013. Conclusions: In the setting of PPCI, the MIMI study is the first randomized study comparing the effects of versus delayed after TIMI 3 flow restoration on microvascular obstruction by CMRI. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01360242&atom=%2Fehj%2F34%2Fsuppl_1%2F1773.atom

Abstract 286: Inverse Relationship Between Body Mass Index And Glomerular Filtration Rate Following Contrast Media Administration In Patients With Primary Percutaneous Coronary Intervention

Background: Renal dysfunction following contrast (CM) media administration carries poor prognosis and less predictable in patients undergoing Primary percutaneous Coronary Intervention (PPCI). Although obesity is a known risk factor for renal failure, its prognostic significance in renal dysfunction following CM administration in the setting of PPCI is less explored. Therefore we sought to investigate the relationship between obesity as measured by body mass index (BMI) and renal function after CM administration during PPCI. Methods: Cohort consisted 113 patients at our institution who underwent PPCI from 01/2009 to 11/2012 as per evidence based guidelines. Obesity was defined as BMI ≥30 kg/m2. Patients with hemodynamic instability (intra aortic balloon pump use) and end stage renal failure (GFR&lt;15 mL/min/m2 or on chronic dialysis) were excluded. Glomerular filtration rates (GFR) at baseline, at 24 hours post PPCI and before hospital discharge were calculated with modified diet in renal disease (MDRD) equation. The relationship between BMI and GFR was assessed in stepwise multiple linear regression analysis (MLRA) Results: Cohort dominated by PPCI performed for ST segment elevation myocardial infarction (STEMI) (104; 92%), African American race (70; 61%) and male gender (77; 68%). When compared to non obese [median BMI (IQR) = 25 (23.2-28.1) kg/m2], obese [median BMI (IQR) = 33.5 (31.9-35.7) kg/m2] had greater proportion of patients with dyslipidemia [30% (16) vs. 51% (25); P=0.026]. Other covariates were similarly distributed between both groups. BMI was negatively correlated with GFR 24 hours post PPCI (r= -0.206; P=0.043) and GFR prior to hospital discharge (r= -0.209; P=0.038) (Graph 1). MLRA adjusted for factors known to influence renal function showed that BMI was negatively associated with GFR prior to hospital discharge: r square =0.427;β=- 2.98; t= - 2.98 P=0.005. (Table 1) Conclusions: BMI increase is independently associated with GFR decline following CM administration in patients with PPCI. Clinical guidelines at present do not account for BMI during CM administration. These data suggest the need for CM dose adjustment according to individual’s BMI. Further studies are needed.

Bivalirudin in patients undergoing primary percutaneous coronary intervention for acute ST-elevation myocardial infarction: outcomes in a large real-world population

Within a clinical trial population, direct thrombin inhibition using bivalirudin in patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is associated with a reduction in mortality and major bleeding compared to heparin/glycoprotein IIb/IIIa receptor inhibition (GPI), but a higher incidence of acute stent thrombosis (ST), particularly in the absence of pre-procedural heparin. The safety and efficacy of bivalirudin in an all-comer, real-world primary PCI setting is unknown. 968 consecutive STEMI patients (mean age 63 years, 72% male, 42% anterior STEMI, 3.7% cardiogenic shock) undergoing primary PCI with bivalirudin as the recommended anticoagulation, and with heparin/GPI (abciximab) as an alternative, were prospectively followed. Bivalirudin was administered as a bolus, high-dose procedural infusion and, unlike the HORIZONS-AMI trial, as a low-dose infusion for four hours post-PCI. Additional heparin was not routinely given. Mortality, major adverse cardiovascular events (MACE), major bleeding and ST were assessed at 30 days. Initial antithrombotic therapy was bivalirudin in 885 patients (91%), of whom 123 (13.9%) received additional antithrombin therapy, and 114 (11.8%) "bail-out" GPI. Outcomes for bivalirudin-treated patients were; mortality 5.2%, MACE 7.5%, major bleeding 3.8%. The incidence of acute ST was 1.0%, including in the absence of additional heparin (1.2%). Most cases of acute ST (7/9) occurred in the first four hours post-PCI. There was no significant difference in outcomes between patients treated with bivalirudin versus heparin/GPI. Routine use of bivalirudin in a real-world primary PCI population was associated with good 30-day outcomes. Acute stent thrombosis was infrequent, even without additional heparin. A continued low-dose infusion of bivalirudin did not appear to offer protection against very early stent thrombosis.

Intracoronary adenosine as an adjunct to primary coronary intervention in acute myocardial infarction

The beneficial effects of primary percutaneous coronary intervention (PCI) in the setting of acute myocardial infarction (AMI) are limited by reperfusion injury. Adenosine limits reperfusion injury in animal models. The aim is to study the effects of intracoronary adenosine administration in the setting of primary PCI on the coronary blood flow and left ventricular function. Sixty patients with a definite diagnosis of ST elevation AMI within 6 h of onset of chest pain were randomly allocated to receive adenosine or saline (on a 1:2 ratio) as an adjunct to primary PCI with assessment of postintervention TIMI flow and TIMI myocardial perfusion grading (TMP). S wave velocity was recorded at the mitral annulus in the territory of the infarct related artery using pulsed-wave tissue Doppler within 24 h from admission and one week after PCI. Both groups showed no significant difference in terms of age, sex, risk factors, infarct location, and distribution of coronary artery disease. The adenosine group showed higher incidence of TIMI III flow (95% vs. 65%; p < 0.03), higher incidence of TMP grade 3 (85% vs. 40%; p < 0.007), and lower incidence of no-reflow (10% vs. 45%; p < 0.006). Only in the adenosine group, there was a significant improvement in S wave velocity at the infarct-related territory at day- 7 ( P < 0.01). Adenosine administration in the setting of primary PCI improves myocardial perfusion and early post-infarction regional LV systolic function.

Safety and Efficacy of Adjuvant Glycoprotein IIb/IIIa Inhibitors During Primary Percutaneous Coronary Intervention Performed From the Radial Approach for Acute ST Segment Elevation Myocardial Infarction

The use of glycoprotein IIb/IIIa receptor inhibitors (GPIs) in high-risk patients with acute coronary syndromes has been associated with reductions in ischemic events but increases in bleeding complications. The role of GPIs in patients who undergo primary percutaneous coronary intervention (PCI) by the transradial approach (TRA) is not well studied. The aim of this post hoc analysis from the randomized prospective Acute Myocardial Infarction Treated With Primary Angioplasty and Intravenous Enoxaparin or Unfractionated Heparin to Lower Ischemic and Bleeding Events at Short- and Long-Term Follow-Up (ATOLL) trial was to assess the safety and efficacy of GPIs in primary PCI performed using the TRA. A total of 910 patients were enrolled in ATOLL; 522 patients (67%) underwent PCI using the TRA. Two comparative analyses were performed. First, patients who underwent PCI using the TRA who received GPIs were compared with those who did not receive GPIs. Second, patients who underwent PCI using the TRA who received GPIs were compared with those who underwent PCI using a nonradial route and received GPIs. Composite end points of net clinical benefit, ischemic outcomes, and safety consisting of bleeding and transfusion at 1 month were analyzed. A propensity score was constructed, and weight adjustment were made for variables, including but not limited to age, weight, gender, renal function, concomitant use of other medications, Killip class, and medical history, when analyzing the end points. There was no significant difference in net clinical benefit or ischemic outcomes between either TRA patients with versus without GPIs or TRA patients with GPIs versus non-TRA patients with GPIs. Additionally, there were significantly fewer major bleeding events and blood transfusions in TRA patients with GPIs compared with non-TRA patients with GPIs. In conclusion, the addition of GPIs in the setting of primary PCI using the TRA was not associated with bleeding liability. The use of GPIs with TRA was associated with safer outcomes than using GPIs with a nontransradial approach. This study was limited in that it was a nonrandomized retrospective analysis.