Is intravascular ultrasound beneficial for percutaneous coronary intervention of bifurcation lesions? Evidence from a 4,314-patient registry

Background

Coronary bifurcations remain a challenging lesion subset for percutaneous coronary intervention (PCI). It is unclear whether intravascular ultrasound (IVUS) guidance can improve PCI results in bifurcations. We aimed to compare IVUS-guided PCI versus standard PCI in a large registry of patients undergoing PCI for bifurcations in the drug-eluting stent era.

Methods

A multicenter, retrospective study was conducted enrolling consecutive patients undergoing bifurcation PCI between January 2002 and December 2006 at 22 centers. The primary end-point was the long term rate of major adverse cardiac events [MACE, i.e. death, myocardial infarction or target lesion revascularization (TLR)].

Results

A total of 4,314 patients were included, 226 (5.2%) undergoing IVUS-guided PCI, and 4,088 (94.8%) standard PCI. Early (30-day) outcomes were similar in the two groups, with MACE in 1.3 versus 2.1%, respectively, death in 0.9 versus 1.0%, and stent thrombosis in 0 versus 0.6% (all p?>?0.05). After 24?±?15?months, unadjusted rates of MACE were 17.7 versus 16.4%, with death in 2.7 versus 4.9%, myocardial infarction in 4.4 versus 3.7%, TLR in 15.0 versus 12.3%, and stent thrombosis in 3.1 versus 2.7% (all p?>?0.05). Even at multivariable Cox proportional hazard analysis with propensity score adjustment, IVUS was not associated with any statistically significant impact on the risk of MACE, death, myocardial infarction, TLR (neither on the main branch nor on the side branch), or stent thrombosis (all p?>?0.05).

Conclusions

Despite a sound rationale to choose stent size, optimize stent expansion and guide kissing inflation, IVUS usage during PCI for coronary bifurcation lesions was not associated with significant clinical benefits in this large retrospective study.     

国产雷帕霉素支架和进口紫杉醇支架治疗急性心肌梗死的对比研究

目的 比较国产雷帕霉素洗脱支架和进口紫杉醇洗脱支架治疗急性ST段抬高心肌梗死(STEMI)患者的安全性和临床疗效.方法 选择1年内接受国产雷帕霉素洗脱支架(51例)和进口紫杉醇洗脱支架(46例)治疗的STEMI患者共97例,观察术后9个月死亡、再次心肌梗死、支架内血栓形成、靶病变血运重建及主要不良心脏事件(MACE)发生率.结果 国产雷帕霉素支架和进口紫杉醇支架置入成功率均为100%.术后随访9个月,再发心绞痛(9.8%与8.7%)、死亡(0%与0%)、再次心肌梗死(2.0%与2.2%)、支架内血栓形成(0%与0%)、靶病变血运重建(0%与0%)及主要不良心脏事件发生率(11.8%与10.9%)比较,差异均无统计学意义(P均>0.05).结论 在STEMI患者直接PCI术中应用国产雷帕霉素洗脱支架与进口紫杉醇洗脱支架相比,具有相似的安全性和临床疗效,而性价比优于进口紫杉醇支架.     

Intravascular ultrasound-guided drug-eluting stent implantation is associated with improved clinical outcomes in patients with unstable angina and complex coronary artery true bifurcation lesions

Stenting coronary artery bifurcation lesion is associated with suboptimal clinical results. Clinical improvement by intravascular ultrasound (IVUS) guided bifurcation stenting is controversial because small-side-branch (SB), low-risk patients and false bifurcations were included in previous studies that had no exact IVUS criteria for optimal stent expansion. We sought determine whether IVUS guidance is superior to angiography guidance for patients with true and complex bifurcation lesions. Between July 2006 and July 2012, 1465 patients with unstable angina and Medina 1,1,1 or 0,1,1 coronary bifurcation lesions were prospectively studied. 310 patients in the IVUS guidance (defined as stent symmetry index?>?0.7, stent expansion index?>?0.9, well apposition, and no Type B/C dissection) group were paired with 620 patients in the angiography group by propensity score-matching. The primary endpoint was the rate of composite major adverse cardiac events (MACE) (cardiac death, myocardial infarction (MI), or clinically-driven target vessel revascularization) at 1-year and at the end of study after indexed procedure. Use of IVUS guidance was mainly driven by stenting technique selection and identification of lesions’ specificities. IVUS criteria for optimal stent expansion were achieved in 82.9% of patients which contribute to IVUS group data assessment and the rest did not meet optimal criteria. MACE occurred in 10.0% of patients at 1-year follow-up and 15.2% at the 7-year follow-up in the IVUS group, significantly different from 15.0% (p?=?0.036) and 22.4% (p?=?0.01) in the angiography group, respectively. Compared to angiography guidance, IVUS guidance also resulted in a lower 7-year cardiac death rate (6.5 versus 1.3%, p?=?0.002) and MI (8.4 versus 2.3%, P?<?0.001). Any revascularization was also statistically lower in the IVUS group through whole study period, compared to the angiography group. Lower MACE rates were observed in IVUS guidance group in a 7-year follow-up compared with angiography guidance alone.     

Study comparing the double kissing (DK) crush with classical crush for the treatment of coronary bifurcation lesions: the DKCRUSH-1 Bifurcation Study with drug-eluting stents

Background  Classical crush has a lower rate of final kissing balloon inflation (FKBI) immediately after percutaneous coronary intervention (PCI). The double kissing (DK) crush technique has the potential to increase the FKBI rate, and no prospective studies on the comparison of classical with DK crush techniques have been reported.
Materials and methods  Three hundred and eleven patients with true bifurcation lesions were randomly divided into classical ( n  = 156) and DK crush ( n  = 155) groups. Clinical and angiographic details at follow-up at 8 months were indexed. The primary end point was major adverse cardiac events (MACE) including myocardial infarction, cardiac death and target lesion revascularization (TLR) at 8 months.
Results  FKBI was 76% in the classical crush group and 100% in the DK group ( P <  0·001). The incidence of stent thrombosis was 3·2% in the classical crush group (5·1% in without- and 1·7% in with-FKBI) and 1·3% in the DK crush group. Cumulative 8 month MACE was 24·4% in the classical crush group and 11·4% in the DK crush group ( P  = 0·02). The TLR-free survival rate was 75·4% in the classical crush group and 89·5% in the DK crush group ( P  = 0·002).
Conclusions  DK crush technique has the potential of increasing FKBI rate and reducing stent thrombosis, with a further reduction of TLR and cumulative MACE rate at 8 months.     

TAXUS支架治疗急性冠状动脉综合症的疗效评价

目的评价紫杉醇洗脱冠状动脉支架(TAXUStmBoston公司产品)应用于急性冠状动脉综合症病人的临床疗效及安全性。方法自2003年5月至2004年12月接受TAXUS支架治疗的94例急性冠状动脉综合症患者,观察术后即刻效果、术后6个月心脏性死亡、心肌梗塞、再次血管重建及冠状动脉造影复查情况。病例中包括ST段抬高的急性心肌梗塞27例,非ST段抬高的急性心肌梗死8例,不稳定心绞痛59例。结果支架植入成功率为99%,术中和随访期间无死亡,术后1例出现亚急性血栓,1例晚期血栓致心肌梗塞,另有5例随访中进行了血管重建术,6个月主要心脏不良事件(MACE)发生率7.4%。术后6～7个月23例的冠状动脉造影复查再狭窄率为13.0%(支架内为8.6%),靶病变重建率为2.7%。结论应用TAXUS支架治疗急性冠状动脉综合症是安全和有效的,支架内再狭窄率明显低于普通金属支架。     

Plaque characteristics and inflammatory markers for the prediction of major cardiovascular events in patients with ST-segment elevation myocardial infarction

To investigate the clinical utility of culprit plaque characteristics and inflammatory markers for the prediction of future cardiovascular events in patients with ST-segment elevation myocardial infarction (STEMI) with successful drug-eluting stent (DES) implantation. We evaluated 172 STEMI patients with successful primary percutaneous coronary intervention (PCI) with DES using pre-PCI high-sensitivity C-reactive protein (hs-CRP), neutrophil-to-lymphocyte ratio (NLR) and pre-PCI intravascular ultrasound virtual histology (IVUS-VH) of culprit lesions. The incidence of major adverse cardiovascular events (MACE) including all-cause mortality, non-fatal MI, stroke and late revascularization were recorded during hospitalization and follow-up. During follow-up (median 41 months), the incidence of MACE did not significantly differ among patients with or without all 3 high-risk plaque features on IVUS-VH (15.1 vs. 16.2%; p?=?0.39). In contrast, patients with elevated hs-CRP and NLR levels were at significant risk for MACE [32.7 vs. 5.8%; hazard ratio (HR) 7.85; p?<?0.001 and 43.9 vs. 6.9%; HR 8.44; p?<?0.001, respectively]. High-risk plaque features had no incremental usefulness to predict future MACE. However, the incorporation of hs-CRP and NLR into a model with conventional clinical and procedural risk factors significantly improved the C-statistic for the prediction of MACE (0.76–0.89; p?=?0.04). High-risk plaque features identified by IVUS-VH in culprit lesions were not associated with future MACE in patients with STEMI receiving DES. However, elevated hs-CRP and NLR levels were significantly associated with poorer outcomes and had incremental predictive values over conventional risk factors.     

Optical coherence tomography-guided percutaneous coronary intervention compared with other imaging guidance: a meta-analysis

The use of optical coherence tomography (OCT) in PCI guidance is limited perhaps by the lack of adequately powered studies which compare its efficacy and outcomes to the other more popular imaging modalities. We therefore performed a meta-analysis to compare clinical outcomes following OCT-guided PCI with the other imaging modalities in two separate comparisons. We abstracted data from randomized control trials and observational comparative studies focusing on OCT versus either angiography- or IVUS-guided PCI outcomes identified following a systematic search (April 2006 and May 2017). This meta-analysis included a total of 2781 patients; OCT-guidance versus Angiography guidance (n?=?1753) and OCT-guidance versus IVUS-guidance (n?=?1028). Pooled estimates of outcomes, presented as odds ratios (OR) [95% confidence intervals], were generated with random-effect models. OCT guidance showed lower rates of MACE (OR 0.70 [0.49, 1.00] p?=?0.05) and cardiac deaths (OR 0.40 [0.18, 0.90] p?=?0.03) compared to Angiography-guidance alone but no statistical significant results for myocardial infarction (OR 0.70 [0.42, 1.16] p?=?0.17), stent thrombosis (OR 1.17 [0.40, 3.43] p?=?0.77) and target lesion revascularizations (OR 1.07 [0.48, 2.38] p?=?0.86).No statistical significance was observed in the OCT versus IVUS comparison; MACE (OR 0.89 [0.46, 1.73] p?=?0.73), cardiac deaths (OR 0.56 [0.12, 2.70] p?=?0.47), MI (OR 0.56 [0.12, 2.70] p?=?0.47), ST (OR 0.43 [0.06, 2.95] p?=?0.39), and TLR(OR 0.99 [0.45, 2.18] p?=?0.99). OCT-guided PCI in comparison with angiography-guided was associated with reduction in adverse events for the composite of cardiac deaths, myocardial infarction and repeat revascularizations. There was no statistically significant difference in clinical outcomes observed in the comparison between OCT- and IVUS-guidance.     

血管内超声与冠状动脉造影指导的经皮冠状动脉介入治疗左主干病变有效性和安全性的Meta分析

目的系统评价血管内超声(IVUS)与冠状动脉造影指导的经皮冠状动脉介入(PCI)治疗左主干病变的有效性和安全性。方法计算机检索PubMed、EMbase、The Cochrane Library、CBM、CNKI、VIP和WanFang Data数据库,搜集IVUS与冠状动脉造影指导的PCI治疗左主干病变安全性和有效性的随机对照试验(RCT)和队列研究,检索时限均为建库至2019年3月。由2名研究者独立筛选文献、提取资料并评价纳入研究的偏倚风险后,采用RevMan 5.3软件进行Meta分析。结果共纳入7个研究,包括7 777例患者。Meta分析结果显示:与冠状动脉造影指导的PCI相比,IVUS指导的PCI心源性死亡[OR=0.45,95%CI(0.34,0.61),P<0.000 01]、心肌梗死[OR=0.67,95%CI(0.53,0.84),P=0.004]、主要心血管不良事件[OR=0.46,95%CI(0.34,0.61),P<0.000 01]、总死亡[OR=0.54,95%CI(0.44,0.67),P<0.000 01]、支架内血栓[OR=0.28,95%CI(0.18,0.45),P<0.000 01]的发生率均更低。两组靶血管再血管化[OR=0.80,95%CI(0.40,1.61),P=0.54]、靶病变血运重建[OR=0.68,95%CI(0.36,1.27),P=0.23]发生率的差异无统计学意义。结论当前证据显示,与冠状动脉造影相比,IVUS指导的PCI治疗左主干病变可降低心源性死亡、心肌梗死、主要不良心血管事件、支架内血栓形成、总死亡的发生率,但对靶病变血运重建和靶血管再血管化发生率无影响。受纳入研究数量和质量限制,上述结论尚需开展更多高质量研究予以验证。     

Paclitaxel-coated balloon treatment for functionally nonsignificant residual coronary lesions after balloon angioplasty

There is limited data on the efficacy of paclitaxel-coated balloon (PCB) compared to stents for de novo coronary lesions. The purpose of this study was to compare the efficacy of PCB treatment with stent implantation for de novo coronary lesions after successful plain old balloon angioplasty (POBA) guided by fractional flow reserve (FFR). In 200 patients scheduled for elective percutaneous coronary intervention (PCI) for de novo lesions, FFR was measured after POBA (POBA–FFR). If POBA–FFR was ≥?0.75, patients were treated with PCB (PCB group, n?=?78) or stent (Stent group, n?=?73). If POBA–FFR was <?0.75, stent was implanted as planned (Reference group, n?=?42). The primary endpoint was late lumen loss at 9 months and the secondary endpoint was adverse cardiac events (cardiac death, myocardial infarction, target lesion thrombosis, or repeat revascularization) at 12 months follow-up. There was no between-group differences in the POBA–FFR (0.87?±?0.05 in PCB, 0.89?±?0.06 in stent, p?=?0.101). At 9 months, late lumen loss was significantly lower in the PCB group compared to the Stent group (0.05?±?0.33 vs. 0.59?±?0.76 mm, p?<?0.001). Adverse cardiac events were not different between the PCB, Stent and Reference groups (2.6, 5.5, and 9.5% respectively; p?=?0.430 for PCB vs. Stent group; p?=?0.229 for the reference vs. both other groups). PCB treatment guided by POBA–FFR showed excellent 9 months angiographic and functional results, as well as comparable 12 months clinical outcomes, compared with stent implantation for de novo coronary lesions.     

Cobalt–chrome MULTI-LINK VISION™-stent implantation in diabetics and complex lesions: results from the DaVinci-Registry

Aims

Restenosis in bare-metal stents is in part related to stent design and material. Optimized strut design of cobalt–chrome (CoCr) stents may yield nearly comparable results to drug-eluting stents (DES) in selected lesions. The prospective multicenter DaVinci registry investigates the clinical outcome of a CoCr coronary stent (MULTI-LINK VISION?), particularly in terms of patients with diabetes and complex lesions (B1, B2, C).

Methods and results

The prospective internet-based registry included 1,344 patients (76% males, aged 66 ± 10 years) undergoing stent implantation (n = 1,642) in 32 centres from July 2003 to June 2004. Follow-up data (median 9 ± 1 months) of this cohort were available for 1,289 patients (98.1%). Of these patients 327 (26.2%) were diabetics. In total, 1,429 de-novo lesions (A 11.9%, B1 47.7%, B2 31.6%, C 8.8%) were treated with the CoCr stent. The predefined primary endpoint was defined as a composite of death, Q-wave myocardial infarction (STEMI), non-STEMI (NSTEMI), target vessel revascularization (TVR) by coronary bypass graft (CABG) or PCI at 270 days (target vessel failure, TVF). Secondary endpoints include death, time to the first myocardial infarction, TVR and CABG. The cumulative incidence of major adverse cardiac events (MACE) was 12.4% with 0.8% deaths, 1.5% non-fatal MI, and 9.7% TVR. TVF in the overall cohort was documented in 137 (10.8%) patients. For diabetics and complex lesions TVF was 13.8% (95% CI 4.2–18) and 11.4% (95% CI 2.0–13.3), respectively.

Conclusion

This large registry confirms good acute and long-term success of CoCr stents making this strategy valuable, particularly in a special cohort (diabetics and complex lesions) as long as late stent thrombosis with DES plays a role and short-term antiplatelet therapy is favoured.     

Bivalirudin in ST-segment-elevation myocardial infarction: for better or worse?

Bivalirudin and heparin are the major available parenteral anticoagulants for percutaneous coronary intervention (PCI) in ST-segment-elevation myocardial infarction. Even though hard clinical outcomes are comparable with both drugs, bivalirudin appears to be safer (less bleeding events) at the expense of lower short-term efficacy (more acute stent thrombosis events). The selection of anticoagulation during PCI in ST-segment-elevation myocardial infarction should be individualized, taking into account the patient’s ischemic and bleeding risk. In patients with increased bleeding risk, bivalirudin might be preferable to heparin, whereas in complex PCI with increased risk for stent thrombosis, heparin is preferable. Further clinical studies are needed to elucidate the role of these drugs in PCI for ST-segment-elevation myocardial infarction in the era of radial approaches, new potent antiplatelet agents and the use of glycoprotein IIb/IIIa inhibitors.     

急性冠状动脉综合征介入治疗联合应用盐酸替罗非班对围手术期转归的影响

目的:探讨在急性冠脉综合征(ACS)患者病程中常规治疗联合应用盐酸替罗非班对心肌组织水平再灌注与围PCI术期严重心脏不良事件(MACE)的影响。方法:2005—2006年间15例在急诊或择期PCI术前具有形成血栓的高危因素或PCI术时发现慢血流现象或血栓的ACS患者,在术前、术中或术后应用盐酸替罗非班,按推荐剂量经外周静脉或冠脉内直接注入药物,观察15～20min后相关血管的血栓征象、血栓负荷、TIMI分级情况、术后MACE及出血并发症等。结果:15例ACS患者,男性13例,女性2例,年龄44～75岁,起病时间在数小时至数天。全部患者术中即刻造影均未见有明显的新发血栓形成,原有新鲜血栓消失,肇事血管前向血流由TIMI0～2级恢复至TIMI3级。术后14例患者术后一般情况稳定,症状明显改善或消失,住院期间未发生MACE与出血并发症,但有1例患者在住院期间因心源性休克、多器官功能衰竭死亡。结论:对ACS介入治疗围手术期存有靶血管高危因素存在(如慢血流、血栓等征象)的患者,经冠脉或外周静脉应用盐酸替罗非班有助于改善心肌组织再灌注水平,减少围手术期血栓并发症所致的MACE发生。     

90岁以上急性冠脉综合征支架治疗的长期观察

目的 探讨90岁以上急性冠脉综合征患者经皮冠状动脉支架治疗的疗效和预后.方法 回顾性分析17例90岁以上急性冠脉综合征患者(16.7%为ST段抬高心肌梗死,24.4%为非ST段抬高心肌梗死,47.8%为不稳定心绞痛)经皮冠状动脉支架治疗的临床和造影特点、住院期间和长期疗效.结果 在17例患者中,4例应用金属裸支架(bare metal stent,BMS),13例应用药物洗脱支架(drug eluting stent,DES).3支病变和2支病变各6例,单支病变5例.B2型和C型病变达88.2%.94.1%为不完全血运重建,82.3%植入1个支架,手术成功率为88.2%,术前与术后TIMI-3级血流比例分别为70.6%和88.2%.手术相关并发症为17.6%,均为冠脉夹层.住院期间主要心血管不良事件(major adverse cardiac event,MACE)为11.8%,其中1例心源性死亡(DES组)和1例心肌梗死(BMS组). DES组出现2例严重出血.生存的16例患者随访1年时无MACE、脑卒中和严重出血.生存的16例患者中12例随访18个月,总的MACE为8.3%,3例脑卒中,无严重出血.生存的16例患者中10例随访2年,总的MACE为20.0%,有3例脑卒中,无严重出血.结论 尽管采取不完全血运重建策略,90岁以上高危急性冠脉综合征患者可以从经皮冠状动脉支架治疗获益,住院期间和长期的MACE事件发生率较低.     

Marked reduction of early stent thrombosis with pre-hospital initiation of high-dose Tirofiban in ST-segment elevation myocardial infarction

Summary.  Background : No randomized comparisons are yet available evaluating the effect of pre-hospital high dose tirofiban on the incidence of early stent thrombosis after primary percutaneous coronary intervention (PCI). Objectives : The aim of this analysis was to evaluate whether routine pre-hospital administration of high-dose tirofiban in ST-segment elevation myocardial infarction (STEMI) decreases the incidence of early stent thrombosis after primary PCI. Patients/methods : The Ongoing Tirofiban in Myocardial Evaluation (On-TIME) 2 trial was a prospective multicenter study of consecutive STEMI patients referred for primary PCI in which patients were randomized to pre-hospital no high-dose tirofiban/placebo. We examined the incidence of Academic Research Consortium definite and probable early stent thrombosis and determined predictors and outcome of early stent thrombosis. Results : Primary PCI was performed in 1203 out of 1398 patients (86.1%). In 1073 patients (89.2%) a coronary stent was placed. Early stent thrombosis occurred in 39 patients (3.6%). Pre-hospital initiation of high-dose tirofiban significantly reduced early stent thrombosis (2.1% vs. 5.2%, P  = 0.006) and was associated with a lower incidence of urgent repeat PCI (1.9% vs. 5.2%, P  = 0.005). Early stent thrombosis, as well as pre-hospital initiation of high-dose tirofiban, was independently associated with 30-day mortality. Conclusions : Pre-hospital initiation of high-dose tirofiban reduces the 30-day incidence of stent thrombosis in STEMI patients treated with primary PCI and stenting. Early stent thrombosis and pre-hospital initiation of high-dose tirofiban were independent predictors of 30-day mortality.     

替罗非班联合雷帕霉素洗脱支架在急诊冠状动脉介入治疗中的应用

目的评价替罗非班联合雷帕霉素洗脱支架在急诊冠状动脉介入治疗中应用的疗效及安全性。方法入院诊断为急性心肌梗死并行急诊冠状动脉介入治疗的患者126例,分为试验组60例和对照组66例。试验组于术前给予替罗非班并维持36h,植入雷帕霉素洗脱支架;对照组单纯植入金属裸支架。观察两组手术成功率,手术前后TIMI血流分级,住院期间和6个月主要不良心脏事件（MACE）以及左室射血分数（LVEF）、心功能纽约心脏病协会（NYHA）分级,出血及血小板减少并发症,并作统计学分析。结果两组手术成功率、术前TIMI血流、住院期间MACE和LVEF相似（P〉0．05）。与对照组相比较,试验组术后TIMI3级血流比例较高,6个月MACE发生率较低（其中主要是靶血管再次血运重建减少）,同时LVEF较高和NYHAI级比例较大,差异均有统计学意义（P〈0．05）。试验组出血并发症较多见（P〈0．05）,但主要为不明显出血（P〈0．05）;两组均无重度出血和血小板减少。试验组无支架血栓形成发生。结论替罗非班联合雷帕霉素洗脱支架在急诊冠状动脉介入治疗中应用能改善冠状动脉血流和心功能,降低6个月不良心血管事件,并不增加严重出血和支架内血栓形成,具有良好疗效和安全性。     

Additive prognostic value of the SYNTAX score over GRACE, TIMI, ZWOLLE, CADILLAC and PAMI risk scores in patients with acute ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention

This study evaluated additive prognostic value of the SYNTAX score over GRACE, TIMI, ZWOLLE, CADILLAC and PAMI risk scores in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI). All six scores were calculated in 209 consecutive STEMI patients undergoing pPCI. Primary end-point was the major adverse cardiovascular event (MACE—composite of cardiovascular mortality, non-fatal myocardial infarction and stroke); secondary end point was cardiovascular mortality. Patients were stratified according to the SYNTAX score tertiles (≤12; between 12 and 19.5; >19.5). The median follow-up was 20 months. Rates of MACE and cardiovascular mortality were highest in the upper tertile of the SYNTAX score (p < 0.001 and p = 0.003, respectively). SYNTAX score was independent multivariable predictor of MACE and cardiovascular mortality when added to GRACE, TIMI, ZWOLLE, and PAMI risk scores. However, the SYNTAX score did not improve the Cox regression models of MACE and cardiovascular mortality when added to the CADILLAC score. The SYNTAX score has predictive value for MACE and cardiovascular mortality in patients with STEMI undergoing primary PCI. Furthermore, SYNTAX score improves prognostic performance of well-established GRACE, TIMI, ZWOLLE and PAMI clinical scores, but not the CADILLAC risk score. Therefore, long-term survival in patients after STEMI depends less on detailed angiographical characterization of coronary lesions, but more on clinical characteristics, myocardial function and basic angiographic findings as provided by the CADILLAC score.     

静脉溶栓及急诊PCI术治疗75岁以上老年急性心肌梗死患者的临床对比分析

目的探讨静脉溶栓及急诊经皮冠状动脉介入治疗(PCI)术治疗75岁以上老年急性心肌梗死患者的临床疗效。方法将171例75岁以上确诊为急性心肌梗死的老年患者分为静脉溶栓组(溶栓组)85例、急诊PCI组(介入组)86例,分别接受静脉溶栓及急诊PCI术治疗,并进行随访,比较两组梗死相关血管(IRA)再通率及治疗后0、1、3个月左心室射血分数(LVEF)、左心室舒张末期内径(LVEDD)、主要心脏不良事件(MACE,包括再梗死、再发心绞痛、严重心力衰竭、死亡等)发生率的差异。结果随访结束溶栓组因重度肺炎死亡1例,介入组失访1例,共有169例患者完成随访。IRA再通率介入组显著高于溶栓组(90.70%vs.58.82%,P<0.05),两组相比差异有统计学意义。治疗前后,左心室功能指标,溶栓组及介入组LVEF为(53.1±8.7)%vs.(63.2±7.4)%,LVEDD为(54.2±9.4)mm vs.(46.6±9.5)mm;介入组优于溶栓组,差别有统计学意义(P<0.05)。两组MACE发生率(33.3%vs.17.6%),介入组显著低于溶栓组(P<0.05),差异有统计学意义。结论针对75岁以上老年急性心肌梗死患者,急诊PCI术较静脉溶栓治疗能更有效地开通梗死相关动脉,及时灌注缺血心肌,改善左心室功能,降低心血管事件再发率。     

Long-term outcome of early percutaneous coronary intervention in diabetic patients with acute coronary syndrome: insights from the BASE ACS trial

Background: The BASE ACS trial demonstrated an outcome of titanium-nitride-oxide-coated bioactive stents (BAS) that was non-inferior to everolimus-eluting stents (EES) in patients with acute coronary syndrome (ACS). We performed a post-hoc analysis of diabetic versus non-diabetic patients from the trial.

Methods: We randomised 827 patients (1:1) with ACS to receive either BAS or EES. The primary endpoint was major adverse cardiac events (MACE): a composite of cardiac death, non-fatal myocardial infarction (MI) or ischaemia-driven target lesion revascularisation (TLR). Follow-up was planned yearly through 7 years.

Results: Of 827 patients, 140 (16.9%) were diabetic; of these, 36 (25.7%) were insulin-treated. Mean follow-up duration was 4.2?±?1.9 years. MACE was more frequent in diabetics versus non-diabetics (23.6% versus 13.7%, respectively, p?=?0.003), mainly driven by more frequent cardiac death (7.9% versus 2.2%, respectively, p?=?0.002). The rates of non-fatal MI, ischaemia-driven TLR were comparable (p?>?0.05 for all). In diabetic patients, MACE was comparable between the two stent arms (18.5% versus 28.0%, for BAS versus EES, respectively, p?=?0.18).

Conclusions: Diabetic patients treated with early percutaneous coronary intervention for ACS had worse long-term outcome, compared with non-diabetics, mainly driven by more frequent cardiac death. The long-term outcome of BAS was comparable to EES in diabetics.

• Key Messages

• Diabetic patients presenting with acute coronary syndrome who were treated with early percutaneous coronary intervention had worse long-term clinical outcome, compared with non-diabetics, mainly driven by a high incidence of cardiac death.

• Age independently predicted both major adverse cardiac events and cardiac death in diabetic patients.

• The long-term clinical outcome of titanium-nitride-oxide-coated bioactive stents was comparable to that of everolimus-eluting stents in the diabetic, as well as in the non-diabetic subgroup.

     

Rationale and design: Impact of intravascular ultrasound guidance on long-term clinical outcomes of everolimus-eluting stents in long coronary lesions

BackgroundAlthough the use of drug-eluting stents (DESs) in patients with coronary artery disease has contributed to a significant reduction in in-stent restenosis and repeat revascularization, treating diffuse long lesions using DESs remains challenging due to the high rates of in-stent restenosis and stent thrombosis. Intravascular ultrasound (IVUS) provides tomographic images of coronary vascular structure and is useful for evaluating lesion morphology and stent optimization during percutaneous coronary intervention. However, it remains controversial whether IVUS guidance in DES implantation for long coronary lesions could reduce adverse clinical outcomes.HypothesisWe hypothesize that the long-term clinical outcomes of IVUS-guided DES implantation would be superior to those of angiography-guided DES implantation in a subset of patients with long coronary lesions.Study designThis study is a randomized, prospective, multi-center trial comparing the long-term clinical outcomes of IVUS-guided and angiography-guided everolimus-eluting stent implantation in patients with long coronary lesions (implanted stent ≥ 28 mm in length). The primary end point is a composite of major adverse cardiac events, including cardiac death, target lesion-related myocardial infarction, or target lesion revascularization at 1 year following intervention. A total of 1,400 patients will be required to be enrolled according to sample size calculations.ConclusionThis study will test the hypothesis that IVUS guidance improves long-term clinical outcomes in patients treated with everolimus-eluting stents for long coronary lesions compared with angiographic guidance.     

新型可降解涂层药物支架治疗澳门华裔人群冠心病的临床应用和效果分析

目的探讨Nobori支架治疗澳门华裔人群冠心病的有效性和安全性。方法将50例冠心病患者随机分成Nobori组（n=20）和Xience V组（n=30）,分别植入上述支架,术后随访观察支架内血栓形成、心源性死亡、心肌梗死、需冠状动脉搭桥、靶病变血运重建（TLR）、靶血管血运重建（TVR）、靶病变失败（TLF）、主要不良心血管事件（MACE）等指标。结果在随访2年支架内血栓形成发生率方面,早期、晚期两组相同,超晚期血栓形成发生率Nobori组稍高（5.0%vs.3.3%,P〉0.05）,但差异无统计学意义。在随访1年的主要终点事件发生率方面,Xience V组的MACE稍高（3.3%vs.0.0%,P〉0.05）,但差异无统计学意义。在随访2年的主要终点事件发生率方面,Xience V组的MACE稍高（6.7%vs.5.0%,P〉0.05）,但差异也无统计学意义。结论 Nobori支架治疗华裔人群有一定的安全性和有效性,其疗效与Xience V支架疗效相当,值得临床推广。