Multivessel vs single-vessel revascularization in patients with non-ST-segment elevation acute coronary syndrome and multivessel disease in the drug-eluting stent era

Background:

We sought to compare long‐term outcomes for multivessel revascularization (MVR) vs single‐vessel revascularization (SVR) with drug‐eluting stents (DES) in patients with non–ST‐segment elevation acute coronary syndrome (NSTE‐ACS) and multivessel coronary artery disease (MVD).

Hypothesis:

In DES era, MVR would improve long‐term clinical outcomes in patients with NSTE‐ACS.

Methods:

We studied 179 patients undergoing MVR and 187 patients undergoing SVR for NSTE‐ACS and MVD. Major adverse cardiac events (MACE) were defined as death, myocardial infarction, or any revascularization.

Results:

During follow‐up (median 36 months), MACE occurred in 96 patients (26.2%); 35 (19.6%) in the MVR group and 61 (32.6%) in the SVR group (P = 0.003). In multivariate analysis, MVR was associated with a lower incidence of MACE (hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.30–0.85) and revascularization (HR: 0.43, 95% CI: 0.24–0.78), but not of death (HR: 0.69, 95% CI: 0.25–1.93) and myocardial infarction (HR: 0.39, 95% CI: 0.11–1.47). The incidence of periprocedural renal dysfunction was not significantly different between patients undergoing MVR vs SVR (3.4% vs 1.6%, P = 0.33). Definite or probable stent thrombosis occurred at a similar rate (2.2% in the MVR group and 2.7% in the SVR group, P = 0.99).

Conclusions:

In patients with NSTE‐ACS and MVD, MVR using drug‐eluting stents may reduce MACE. Our findings should be confirmed by a prospective, randomized trial. © 2011 Wiley Periodicals, Inc. This work was supported by Sungkyunkwan University Foundation for Corporate Collaboration (2008‐1366‐000) and the IN‐SUNG Foundation for Medical Research, Republic of Korea (CA88161). The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

The value of admission HbA(1c) level in diabetic patients with acute coronary syndrome

Background:

Elevated admission glucose level is a strong predictor of short‐term adverse outcome in patients with acute coronary syndrome (ACS). However, the prognostic value of diabetic control (ie, hemoglobin A_1c levels) in patients with ACS is still undefined.

Hypothesis:

Hemoglobin A_1c level may predict short‐term outcome in patients with ACS.

Methods:

We conducted a retrospective study with prospective follow‐up in 317 diabetic patients with ACS. Patients were stratified into 2 groups based on HbA_1c level, checked within 8 weeks of the index admission (optimal control group, HbA_1c ≤7%; suboptimal control group, HbA_1c >7%). All patients were followed up prospectively for major adverse cardiovascular events (MACE) and mortality for 6 months. Short‐term clinical outcomes were also compared between the 2 study groups.

Results:

In our cohort, 27.4%, 46.4%, and 26.2% patients had unstable angina, non–ST‐segment elevation myocardial infarction, and ST‐segment elevation myocardial infarction, respectively. In‐hospital mortality was similar in both HbA_1c groups (3.37% vs 2.88%, P = 0.803). Six‐month MACE was also similar (26.40% vs 26.47%, P = 0.919). All‐cause mortality, cardiovascular mortality, symptom‐driven revascularization, rehospitalization for angina, and hospitalization for heart failure were also similar in both groups. The hazard ratios for 6‐month MACE and individual endpoints were also similar in both groups.

Conclusions:

This study suggests that HbA_1c levels before admission are not associated with short‐term cardiovascular outcome in diabetic patients subsequently admitted with ACS. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

First‐in‐Man Study of Dedicated Bifurcation Sirolimus‐eluting Stent: 12‐month Results of BiOSS LIM® Registry

Objectives

The aim was to assess the effectiveness and safety profile of a new dedicated bifurcation stent ‐ sirolimus‐eluting BiOSS LIM® (Balton, Poland) in 12‐month Registry.

Background

The optimal approach to coronary bifurcations treatment by percutaneous coronary intervention (PCI) has been still a subject of debate. Dedicated bifurcation stents are one of the proposed solutions.

Methods

This was the international, 3‐center registry, which enrolled patients with non‐ST‐elevation acute coronary syndrome (NSTE‐ACS) and stable angina. Provisional T‐stenting was the obligatory strategy of the treatment. Angiographic control was planned at 12 months. The primary endpoint was cumulative rate of death, myocardial infarction (MI) and target lesion revascularization (TLR) at 12 months.

Results

A total of 60 patients with coronary bifurcations were enrolled (mean age 66.4 ± 11 years, 28.3% of female). There were 21.7% of patients with NSTE‐ACS, 78.3% with hypertension, 38.3% with diabetes, 28.3% had previous MI, and 46.7% and 10% underwent prior revascularization, respectively, PCI and coronary artery bypass graft. The device success rate was 100%. Side branch was treated with an additional classical drug‐eluting stent implantation in 23.3% of cases. At 12 months, the cumulative major adverse cardiovascular events rate was 11.7%. During follow‐up (11 ± 1 months) there was 1 non‐cardiac death (1.7%), 1 non‐ST‐elevated myocardial infarction (1.7%) due to restenosis and no case of stroke or in‐stent thrombosis. Overall TLR was 8.3% (clinically driven TLR – 1.7%, angiographically driven – 6.6%). Mean late lumen loss was as follows: In main vessel – 0.35 ± 0.33 mm, in main branch – 0.34 ± 0.27 mm and in side branch – 0.18 ± 0.38 mm.

Conclusion

Dedicated bifurcation stent BiOSS® LIM proved to be feasible device, with promising safety and long‐term clinical effectiveness in the treatment of coronary bifurcation lesions, including distal left main stem stenosis. (J Interven Cardiol 2015;28:51–60)

     

Effect of sex difference in clinical presentation (stable coronary artery disease vs unstable angina pectoris or non‐ST‐elevation myocardial infarction vs ST‐elevation myocardial infarction) on 2‐year outcomes in patients undergoing percutaneous coronary intervention

Objective

To determine whether there is a difference in 2‐year prognosis among patients across the spectrum of coronary artery disease undergoing percutaneous coronary intervention (PCI).

Methods

We analyzed all consecutive patients undergoing PCI at a single center from 1/1‐12/31/2013. Clinical presentations were compared between sexes according to baseline clinical, angiographic, and procedural characteristics and 2‐year (mean 730 ± 30‐day) outcomes.

Results

We grouped 10 724 consecutive patients based on sex and clinical presentation. Among patients with ST‐elevation myocardial infarction (STEMI), rates of all‐cause death (6.7% vs 1.4%) and cardiac death (3.8% vs 1.1%) were significantly higher in women than in men (P < 0.05), but these rates did not differ between men and women with stable coronary artery disease (SCAD) and non‐ST‐elevation acute coronary syndrome ((NSTE‐ACS). Incidence of major bleeding was greater than in men only in those women presenting with ACS. After multivariable adjustment, female sex was not an independent predictor of outcomes in STEMI (hazard ratio [HR] for all‐cause death: 1.33, 95% confidence interval [CI]:0.52‐3.38; P = 0.55; HR for cardiac death: 0.69, 95%CI: 0.23‐2.09, P = 0.51], but was still an independent predictor of bleeding in STEMI (HR: 3.53, 95%CI: 1.26‐9.91, P = 0.017).

Conclusion

Among STEMI patients, women had worse 2‐year mortality after PCI therapy, but female sex was not an independent predictor of mortality after adjustment for baseline characteristics. In STEMI patients, women were at higher bleeding risk than men after PCI, even after multivariable adjustment.     

Heart-type fatty acid binding protein--a reliable marker of myocardial necrosis in a heterogeneous group of patients with acute coronary syndrome without persistent ST elevation

BACKGROUND: Myocardial infarction (MI) is one of the most serious challenges of contemporary cardiology. Among biochemical markers, heart-type specific fatty acid binding protein (h-FABP) has a high potential as a marker for the early diagnosis of acute MI. The h-FABP is released early to the bloodstream and may be useful for both rapid confirmation and exclusion of infarction. As opposed to patients with ST segment elevation MI (STEMI), patients with unstable angina (UA)/non-ST segment elevation MI (NSTEMI) present a heterogeneous group in which the confirmation of MI often meets diagnostic difficulties. A rapid, qualitative immunoenzymatic 'point of care' type test, revealing h-FABP in blood, has recently been made available (CardioDetect med). AIM: To evaluate diagnostic value of early measurements of h-FABP and other markers of necrosis (cTnT, CK-MB, CK-MB mass) in a group of 100 patients with an acute coronary syndrome (ACS) without persistent ST segment elevation (NSTE ACS). METHODS: We studied 100 consecutive patients (34 women, 66 men; mean age 61.6 years) with strong suspicion of NSTE ACS and chest pain lasting <24 h before admission. During admission and after 3 and 6 hours patients had measured a panel of conventional biomarkers as well as quantitative measurements of h-FABP (on admission and 3 hours later) using CardioDetect med. The ultimate diagnosis of infarction (NSTEMI) was confirmed in case of a second (6 h after admission) positive quantitative result of cardiac troponin. Non-ST segment elevation MI was finally diagnosed in 56 patients. RESULTS: The comparison of diagnostic utility of all analysed biomarkers of necrosis revealed that h-FABP was superior to other parameters, when measured on admission, and was characterised by 94.7% sensitivity, 100% specificity, 100% positive predictive value, 93.4% negative predictive value and 97% accuracy. Other biomarkers had on admission lower sensitivity - 70.1% for CK-MB mass, 66.7% for CK-MB, 64.9% for cTnT, whereas their specificity was 97.6% for CK-MB mass, 93% for CK-MB and 100% for cTnT. CONCLUSIONS: Qualitative h-FABP test (CardioDetect med) showed excellent sensitivity, higher than measurements of CK-MB mass, CK-MB, and cTnT on hospital admission, and high specificity in the patient group with NSTE ACS. The h-FABP seems to be an excellent biochemical cardiac marker for diagnosing NSTEMI, especially in its early phase, allowing exclusion of myocardial necrosis.     

Distal embolic protection during percutaneous coronary intervention in patients with acute coronary syndromes: The RUBY study

Objective: To assess the safety and feasibility of the GuardWire^TM system as an embolic protection device during percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS). Background: Distal embolization occurs in approximately 15% of patients after primary angioplasty and is associated with reduced myocardial reperfusion, more extensive myocardial damage and a poor prognosis. Distal embolic protection could reduce the rate of embolic complications and improve outcome. Methods: 329 patients (mean age 60±12 years) were included: 278 (84.5%) with ST‐elevation myocardial infarction (STEMI), 50 (15.2%) with unstable angina/non‐STEMI and 1 (0.3%) with post‐infarction angina. Primary endpoint was the incidence of major adverse cardiac events (MACE) at 30 days. Secondary endpoints were the magnitude of ST‐segment resolution at 90 and 180?min post‐procedure, myocardial blush grade, and angiographically visible distal emboli. Results: The GuardWire^TM system was successfully positioned in 99% of patients. Complete ST‐elevation resolution (>70%) was observed in 28.5% immediately post‐procedure, and in 35.4% and 41.6% at 90 and 180?min post‐procedure. TIMI‐3 flow grade was achieved by 89.8% of patients after intervention and mean corrected TIMI frame count was 20.2±13.2. Grade‐3 myocardial blush was seen in 47.7% of patients and distal emboli were angiographically visible in 7.4%. Incidence of MACE at 30 days was 3.3% (death 1.2%; Q‐wave MI 0.3%; non‐Q‐wave MI 0.3%; coronary artery bypass graft 0.6%; repeat PCI 0.9%). Conclusion: The GuardWire^TM system was successfully positioned in nearly all patients without complications. The use of this embolic protection device in ACS patients undergoing PCI was associated with low rates of distal embolization and 30‐day MACE.     

Crush Stenting With Drug‐Eluting Stents: Relevance of Coronary Bifurcation Lesion Location on Angiographic and Clinical Outcomes

Background

Data on the relevance of the location of coronary bifurcation lesions treated by crush stenting with outcomes were limited.

Hypothesis

We hypothesized that the location of the bifurcation lesion correlated with clinical outcome.

Method

A total of 212 patients with 230 true bifurcation lesions treated by crush stenting with drug‐eluting stents (DES) were assessed prospectively. Surveillance quantitative angiographies were indexed at 8 months after procedure. Primary endpoint was major adverse cardiac events (MACE), defined as cardiac death, myocardial infarction, and target lesion revascularization (TLR).

Results

Patients in the distal right coronary artery (RCAd) group were characterized by higher proportions of prior myocardial infarction and very tortuous lesions. However, lesions in the RCAd group, compared to those of other groups, had the lowest late lumen loss, with resultant lowest incidence of MACE at a mean follow‐up of 268±35 days. Independent predictors of MACE included unsatisfied kissing (KUS; hazard ratio [HR]: 12.14, 95% confidence interval [CI]: 4.01–12.10, P = .001) and non‐RCA lesion (HR: 20.69, 95% CI: 5.05–22.38, P = .001), while those of TLR were KUS (HR: 10.21, 95% CI: 0.01–0.34, P = .002), bifurcation angle (HR: 4.728, 95% CI: 2.541–4.109, P = .001), and non‐RCA lesion (HR: 16.05, 95%CI: 1.01–4.83, P = .001).

Conclusions

Classical crush stenting with drug‐eluting stents is associated with significantly better outcomes in RCAd. Quality of kissing inflation is mandatory to improve outcome. Copyright © 2009 Wiley Periodicals, Inc.     

In‐hospital outcomes in invasively managed acute myocardial infarction patients who receive morphine

Objective

We aimed to analyze the association between morphine and in‐hospital outcomes in invasively managed ST elevation myocardial infarction (STEMI) and non‐ST elevation acute coronary syndrome (NSTE‐ACS) patients.

Background

Morphine is commonly used for analgesia in the setting of acute coronary syndromes (ACS); however, recently its utility in ACS has come under closer scrutiny.

Methods

We identified all STEMI and NSTE‐ACS patients undergoing coronary angiogram +/? percutaneous intervention between January 2009 and July 2016 in our center and recorded patient characteristics and inpatient outcomes.

Results

Overall, 3027 patients were examined. Overall, STEMI patients who received morphine had no difference in in‐hospital mortality [4.18% vs. 7.54%, odds ratio (OR): 0.36, P = 0.19], infarct size (mean troponin level 0.75 ng/mL vs. 1.29 ng/mL, P = 0.32) or length of hospital stay (P = 0.61). The NSTE‐ACS patients who received morphine had a longer hospital stay (mean 6.58 days vs. 4.78 days, P < 0.0001) and larger infarct size (mean troponin 1.16 ng/mL vs. 0.90 ng/mL, P = 0.02). Comparing matched patients, the use of morphine was associated with larger infarct size (mean troponin 1.14 ± 1.92 ng/mL vs. 0.83 ± 1.49 ng/mL, P = 0.01), longer hospital stay (6.5 ± 6.82 days vs. 4.89 ± 5.36 days, P = 0.004) and a trend towards increased mortality (5% vs. 2%, OR: 2.55, P = 0.06) in NSTE‐ACS patients but morphine did not affect outcomes in the propensity matched STEMI patients.

Conclusion

In a large retrospective study, morphine was associated with larger infarct size, a longer hospital stay and a trend towards increased mortality in invasively managed NSTE‐ACS patients even after adjustment for clinical characteristics.

     

Six‐ and Twelve‐Month Clinical Outcomes after Implantation of Prokinetic BMS in Patients with Acute Coronary Syndrome

Aims: To evaluate the Prokinetic bare metal stent implanted in patients presenting with acute coronary syndrome (ACS). Methods: We retrospectively studied ACS patients who underwent percutaneous coronary intervention (PCI) with a Prokinetic stent implantation. Excluded were patients presenting with cardiogenic shock, undergoing PCI to left main coronary artery (LM), or having implantation of additional stents other than Prokinetic. Six and 12 months clinical follow‐up was obtained by phone. Results: A total of 140 Prokinetic stents were implanted in 117 patients (age 64±13.0 years, 78% men). Thirty two percent of the patients had unstable angina, 36% had non ST‐elevation myocardial infarction (NSTEMI) and 33% had ST‐elevation myocardial infarction (STEMI). Forty two percent of lesions were categorized as B2 and 21% as C type. Procedural success was achieved in 99.1% of lesions. Clinical success was achieved in 97.4% of patients. Major adverse cardiac events (MACE) rate was 8.5% and 11.1% at 6 and 12 months follow‐up, respectively. The incidence of cardiac death, MI and TLR was 2.6%, 3.4% and 2.6%, respectively at 6 months, and 4.3%, 4.3%, 2.6% respectively at 12 months. Conclusions: Clinical outcomes at 6 and 12 months after Prokinetic stent implantation are excellent and may be attributable to its unique combination of composition, design and coating. (J Interven Cardiol 2010;23:377–381)     

Different patients,different outcomes: A case‐control study of spontaneous coronary artery dissection versus acute coronary syndrome

Introduction

There is progressive interest worldwide in spontaneous coronary artery dissection (SCAD). To identify a SCAD cohort and compare risk factors, presentation, and management outcomes compared to acute coronary syndrome (ACS) matched controls.

Methods

Retrospective analysis was performed from 2000 to 2015. Clinical data included a neuropsychiatric history, with management and clinical outcomes assessed at 12 months. Patients were matched on a 1:3 case‐control basis according to type of ACS. Twenty‐two SCAD patients were matched to 66 controls by ACS type (ST‐elevation myocardial infarction 45%, Non‐ST‐elevation myocardial infarction 41%, unstable angina 14%).

Results

The SCAD group were more likely female (77.3% vs 19.7%, P < 0.0001), of younger age (48.7 ± 10.7 years vs 61.3 ± 10.6 years, P < 0.0001) with no cases of diabetes (0% vs 33.3%, P = 0.002), compared to controls. SCAD patients had a high prevalence of anxiety, depression or previous neuropsychiatric history (52.4% SCAD vs 1.5% ACS, P < 0.0001). A conservative revascularization strategy with stenting was performed in a minority of SCAD patients (13.6% SCAD vs 83.3% ACS, P < 0.0001), with no significant difference in cumulative major adverse cardiac or cerebrovascular events (MACCE) of death, stroke, re‐admission, or repeat angiography rates between both groups (13.6% SCAD vs 27.3% ACS P = NS).

Conclusion

SCAD affects young females with a paucity of cardiovascular risk factors. The major risk factor for SCAD was a history of anxiety, depression, or neuropsychiatric illness. A conservative approach to SCAD revascularization led to similar MACCE when compared to ACS controls undergoing guideline revascularization at 12 months.     

Association Between Tp-e/QT Ratio and Prognosis in Patients Undergoing Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction

Background:

Both the Tpeak‐Tend interval (Tp‐e) and the Tp‐e/QT ratio have been linked to increased risk for arrhythmia. Patient Tp‐e/QT ratios were investigated prior to primary percutaneous coronary intervention (pPCI) in patients with ST‐segment elevation myocardial infarction (STEMI).

Hypothesis:

Tp‐e/QT ratio maybe asscioated with the prognosis in patients with ST‐segment elevation.

Methods:

A total of 338 patients (N = 338) with STEMI treated by pPCI were included. The Tp‐e and Tp‐e/QT ratio were determined using electrocardiograms in the subjects exhibiting ST‐segment elevation.

Results:

The Tp‐e/QT ratio was correlated with both short‐ and long‐term outcomes. Analysis of the receiver operating characteristic curve demonstrated that the optimal cutoff value for outcome prediction was a Tp‐e/QT ratio of 0.29. Of the 388 patients enrolled, 115 (34.0%) exhibited a Tp‐e/QT ratio ≥0.29. Patients with a Tp‐e/QT ratio ≥0.29 showed elevated rates of both in‐hospital death (21.9% vs 2.3%; P < 0.001) and main adverse cardiac events (MACE) (48.1% vs 15.3%; P < 0.005). After discharge, Tp‐e/QT ratios ≥0.29 remained an independent predictor of all‐cause death (35.5% vs 5.2%, P < 0.001) and cardiac death (32.3% vs 2.6%, P < 0.001).

Conclusions:

The Tp‐e/QT ratio may serve as a prognostic predictor of adverse outcomes after successful pPCI treatment in STEMI patients. Clin. Cardiol. 2012 doi: 10.1002/clc.22022 This work was supported by grants from the Henan Provincial People's Hospital. The authors have no other funding, financial relationships, or conflicts of interest to disclose.     

Morphological Findings in Typical Variant Angina Presenting as Acute Coronary Syndrome Using Optical Coherence Tomography

Background

Coronary vasospasm causes variant angina, as well as acute myocardial infarction, ventricular tachycardia, and sudden cardiac death. We evaluated morphological changes due to vasospastic lesions, which may cause acute coronary syndrome (ACS), using a novel technique called optical coherence tomography (OCT).

Methods

Twenty patients (40–83 years old, 19 males) with vasospasm‐induced ACS who visited the emergency room because of continuous chest pain and displayed transient ST segment elevation in their electrocardiogram were enrolled in the study. None of these patients had significant coronary artery disease and all had positive results in the provocation test. OCT examinations were performed for evaluation of vasospastic lesions.

Results

Intraluminal thrombi and intimal erosion were found in 6 (33.3%) and 2 patients (10%), respectively. High‐sensitivity C‐reactive protein levels were significantly higher in patients with microthrombi (2.66 ± 3.33 mg/L) compared with those in patients without microthrombi (0.49 ± 0.30 mg/L; P = 0.022). Serum cardiac troponin‐I levels were not significantly different between patients with or without microthrombi (2.37 ± 5.31 ng/mL vs. 1.45 ± 4.68 ng/mL; P = 0.704). Other parameters, including creatinine kinase–myocardial band isoenzyme, total cholesterol, pain duration, residual stenosis, lesion length, and coronary risk factors, were not significantly different between the 2 groups.

Conclusion

In patients with vasospasm‐induced ACS, microthrombi with or without intimal erosion are major abnormal morphologic findings of OCT examinations. However, further large‐scale studies are required for validation. (J Interven Cardiol 2013;26:491‐500)

     

Multicenter international registry of unprotected left main coronary artery percutaneous coronary intervention with drug‐eluting stents in patients with myocardial infarction

Background: Patients who present with myocardial infarction (MI) and unprotected left main coronary artery (ULMCA) disease represent an extremely high‐risk subset of patients. ULMCA percutaneous coronary intervention (PCI) with drug‐eluting stents (DES) in MI patients has not been extensively studied. Methods: In this retrospective multicenter international registry, we evaluated the clinical outcomes of 62 consecutive patients with MI who underwent ULMCA PCI with DES (23 ST‐elevation MI [STEMI] and 39 non‐ST‐elevation MI [NSTEMI]) from 2002 to 2006. Results: The mean age was 70 ± 12 years. Cardiogenic shock was present in 24%. The mean EuroSCORE was 10 ± 8. Angiographic success was achieved in all patients. Overall in‐hospital major adverse cardiac event (MACE) rate was 10%, mortality was 8%, all due to cardiac deaths from cardiogenic shock, and one patient suffered a periprocedural MI. At 586 ± 431 days, 18 patients (29%) experienced MACE, 12 patients (19%) died (the mortality rate was 47% in patients with cardiogenic shock), and target vessel revascularization was performed in four patients, all of whom had distal bifurcation involvement (two patients underwent repeat PCI and two patients underwent bypass surgery). There was no additional MI. Two patients had probable stent thrombosis and one had possible stent thrombosis. Diabetes [hazard ratio (HR) 4.22, 95% confidence interval (CI) (1.07–17.36), P = 0.04), left ventricular ejection fraction [HR 0.94, 95% CI (0.90–0.98), P = 0.005), and intubation [HR 7.00, 95% CI (1.62–30.21), P = 0.009) were significantly associated with increased mortality. Conclusions: Patients with MI and ULMCA disease represent a very high‐risk subgroup of patients who are critically ill. PCI with DES appears to be technically feasible, associated with acceptable long‐term outcomes, and a reasonable alternative to surgical revascularization for MI patients with ULMCA disease. Randomized trials are needed to determine the ideal revascularization strategy for these patients. © 2008 Wiley‐Liss, Inc.     

Effects of high-dose statin administered prior to coronary angioplasty on the incidence of cardiac events in patients with acute coronary syndrome

INTRODUCTION: Statins given after acute coronary syndrome without ST elevation (NSTE-ACS) reduce the incidence of major adverse cardiac events (MACE) in long-term follow-up. AIM: To evaluate the effects of high-dose statin administered in patients with NSTE ACS and increased CRP level prior to percutaneous coronary intervention (PCI) on the incidence of MACE in long-term follow-up. METHODS: The study involved 140 consecutive patients with NSTE ACS and increased CRP level at baseline. Patients from group A (n=54) did not receive statin before PCI, whereas subjects in group B (n=86) were given 80 mg of atorvastatin. Patients in both groups received typical cardiological therapy including aspirin, thienopyridine and low molecular weight heparin. After PCI all patients received 40 mg of atorvastatin. Incidence of MACE (death, myocardial infarction (MI), re-PCI) during long-term followup was evaluated in both groups. RESULTS: Study groups did not differ with respect to demographic parameters and rate of ischaemic heart disease risk factors. Also, no differences occurred regarding CRP level (group A vs. B: hsCRP 10.8+/-1.8 mg/l vs. 8.2+/-2.8 mg/l; p=NS) and TIMI Risk Score (group A vs. B: 4.3+/-0.71 vs. 4.37+/-0.79; p=NS). During long-term follow-up the incidence of MI (9.25% vs. 1.2%, p=0.03), composite endpoint: death + MI (14.8% vs. 2.32%, p=0.013) and death + MI + re PCI (25.9% vs. 8.1%, p=0.006) was significantly higher in group A than group B. CONCLUSIONS: Administration of high-dose statin in NSTE ACS patients before PCI was associated with significant reduction of MACE in long-term follow-up. This effect was observed despite the same therapy given after PCI.     

Short‐term Effect of Upstream Administration in Comparison to Deferred Injection of Tirofiban on Patients with Acute ST‐Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background

High bolus dose tirofiban has been demonstrated to provide greater inhibition of platelet aggregation, but the most appropriate timing of its administration remains unknown.

Objectives

To evaluate the efficacy of upstream vs. deferred administration of tirofiban in patients with acute ST‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) on clinical outcomes.

Methods

The 660 patients with acute ST‐segment elevation myocardial infarction undergoing primary percutaneous coronary intervention were divided into upstream (n = 330, administration of tirofiban to all patients in emergency room) and deferred groups (n = 330, treatment of patients with large thrombus burden or no‐reflow phenomenon in cardiac catheterization laboratory during PCI). The primary end‐points were death, nonfatal myocardial infarction (MI), stent thrombosis (ST), revascularization of targeted vessels (TVR) or major adverse cardiac events (MACE) at 1 month and 6 months following PCI, with safety end‐point at 7 days.

Results

Compared with that of the deferred group, there was a significant increase of left ventricular ejection fraction (LVEF) in the upstream group within 7 days (55.5 ± 6.6% vs. 54.6 ± 7.9%, P = 0.011). The rates of 7‐day and 1‐month MACE in the upstream group were lower than those in the deferred group (1.5% vs. 4.2%, 3.3% vs. 7.0%, P = 0.037 and 0.034, respectively). However, there were higher tendencies for major and minor bleedings in the upstream group (1.8% vs. 0.9%, 2.7% vs. 1.5%, P = 0.315 and 0.280, respectively).

Conclusion

To the Chinese patients with acute myocardial infarction undergoing primary PCI, upstream administration of tirofiban was slightly superior to deferred injection for short‐term clinical outcomes.

     

Impact of Calcified Target Lesions on the Outcome of Percutaneous Coronary Intervention for Acute Coronary Syndrome: Insights From the BASE ACS Trial

Objectives

We performed a post hoc analysis of outcome in patients with, versus those without, calcified target lesions from the BASE ACS trial.

Background

The outcome of contemporary stent implantation in patients with calcified lesions presenting with acute coronary syndrome is unknown.

Methods

The BASE ACS trial randomized 827 patients (1:1) presenting with acute coronary syndrome to receive either titanium‐nitride‐oxide‐coated stents or everolimus‐eluting stents. Calcified lesions were defined as moderate or severe calcification in the vessel wall by coronary angiography. The primary endpoint was major adverse cardiac events (MACE): a composite of cardiac death, non‐fatal myocardial infarction or ischemia‐driven target lesion revascularization. Follow‐up was planned at 12 months, and yearly thereafter for up to 7 years.

Results

Of 827 patients enrolled in the trial, 352 (42.6%) had calcified target lesions. Median follow‐up was 5.0 years. The incidence of MACE was higher in patients with, versus those without, calcified target lesions (19.6% vs. 12.2%, respectively, P = 0.004). This was driven by more frequent cardiac death and non‐fatal myocardial infarction events (P < 0.05, both). The rates of ischemia‐driven target lesion revascularization were comparable (P > 0.05). MACE and the other endpoints were comparable between the 2 propensity‐score matched subgroups (P > 0.05 for all). Hypertension and smaller vessel size independently predicted MACE in patients treated for calcified lesions.

Conclusions

Patients presenting with acute coronary syndrome who were treated for calcified lesions had worse long‐term clinical outcome, compared with those treated for non‐calcified lesions, mainly due to more frequent safety events. In the propensity score‐matched analysis, the outcome was comparable.

     

Current management of acute coronary syndromes in Australia: observations from the acute coronary syndromes prospective audit

Background: Acute coronary syndromes (ACS) management is now well informed by guidelines extrapolated from clinical trials. However, most of these data have been acquired outside the local context. We sought to describe the current patterns of ACS care in Australia. Methods: The Acute Coronary Syndrome Prospective Audit study is a prospective multi‐centre registry of ST‐segment elevation myocardial infarction (STEMI), high‐risk non‐ST‐segment elevation ACS (NSTEACS‐HR) and intermediate‐risk non‐ST‐segment elevation ACS (NSTEACS‐IR) patients, involving 39 metropolitan, regional and rural sites. Data included hospital characteristics, geographic and demographic factors, risk stratification, in‐hospital management including invasive services, and clinical outcomes. Results: A cohort of 3402 patients was enrolled; the median age was 65.5 years. Female and non‐metropolitan patients comprised 35.5% and 23.9% of the population, respectively. At enrolment, 756 (22.2%) were STEMI patients, 1948 (57.3%) were high‐risk NSTEACS patients and 698 (20.5%) were intermediate‐risk NSTEACS patients. Evidence‐based therapies and invasive management use were highest among suspected STEMI patients compared with other strata (angiography: STEMI 89%, NSTEACS‐HR 54%, NSTEACS‐IR 34%, P < 0.001) (percutaneous coronary intervention: STEMI 68.1%, NSTEACS‐HR 22.2%, NSTEACS‐IR 8.1%, P < 0.001). In hospital mortality was low (STEMI 4.0%, NSTEACS‐HR 1.8%, NSTEACS‐IR 0.1%, P < 0.001), as was recurrent MI (STEMI 2.4%, NSTEACS‐HR: 2.8%, NSTEACS‐IR 1.2%, P = 0.052). Conclusion: There appears to be an ‘evidence‐practice gap’ in the management of ACS, but this is not matched by an increased risk of in‐hospital clinical events. Objective evaluation of local clinical care is a key initial step in developing quality improvement initiatives and this study provides a basis for the improvement in ACS management in Australia.     

Baseline Clinical Characteristics and Midterm Prognosis of STE‐ACS and NSTE‐ACS Patients with Normal Coronary Arteries

Objective: We sought to compare clinical profiles and midterm prognosis of patients with normal coronary arteries presenting with ST‐elevation ACS (STE‐ACS) versus non‐ST‐elevation ACS (nSTE‐ACS). Background: There are limited data regarding ACS in patients with normal coronary arteries, and especially clinical differences between ST‐ACS and nSTE‐ACS patients have not been evaluated sufficiently. Methods: The study group comprised 190 patients (mean age: 53.2 years, 63.1% males, 63.6% STE‐ACS) presenting with ACS and normal coronary angiograms. The participants were evaluated in terms of 42 clinical variables. MACE [cardiac death (CD) and hospitalization for angina (HA)] were the study end points. Results: STE‐ACS in comparison to nSTE‐ACS patients were younger (P < 0.01), were more frequently males (P < 0.01), had more often infection prior to ACS (P < 0.01), higher hsCRP on admission (P < 0.01), and greater infarct size, measured by maximal troponin I (P < 0.01). By multivariate analysis in this subgroup, predictors of outcome were hsCRP (P = 0.03) and raised troponin I (P = 0.02). nSTE‐ACS in comparison to STE‐ACS patients were more obese (BMI, P < 0.01), had higher LDL cholesterol (P < 0.01), fasting glucose (P = 0.03). LDL cholesterol (P = 0.02) and fasting glucose (P = 0.03) emerged as independent predictors of outcome in these patients. Mean follow‐up period was 25.4 months. STE‐ACS patients had twice fewer MACE rate than nSTE‐ACS patients [(1‐CD, 12‐HA; 11%) vs (1‐CD, 16‐HA; 25%), respectively, log rank P < 0.01]. Conclusions: STE‐ACS and nSTE‐ACS patients with normal coronary arteriography have different clinical profiles. In nSTE‐ACS patients more pronounced metabolic abnormalities were identified, while in STE‐ACS patients inflammatory background was more significant.     

Comparison of medical treatment and coronary revascularization in patients with moderate coronary lesions and borderline fractional flow reserve measurements

Objectives : (1) To evaluate the clinical outcomes of patients with moderate coronary lesions and borderline fractional flow reserve (FFR) measurements (between 0.75 and 0.80), comparing those who underwent coronary revascularization (CR) to those who had medical treatment (MT), and (2) to determine the predictive factors of major adverse cardiac events (MACE) at follow‐up. Methods : A total of 107 consecutive patients (mean age 62 ± 10 years) with at least one moderate coronary lesion (mean percent diameter stenosis 47 ± 12%) evaluated by coronary pressure wire with FFR measurement between 0.75 and 0.80 (mean 0.77 ± 0.02) were included in the study. MACE [CR, myocardial infarction (MI), cardiac death) and the presence of angina were evaluated at follow‐up. Results : Sixty‐three patients (59%) underwent CR and 44 patients (41%) had MT, with no clinical differences between groups. At a mean follow‐up of 13 ± 7 months, MACE related to the coronary lesion evaluated by FFR were higher in the MT group compared with CR group (23% vs. 5%, P = 0.005). Most MACE consisted of CRs, with no differences between groups in MI and cardiac death rate at follow‐up. Both MT and FFR measurements in an artery supplying a territory with previous MI were independent predictive factors of MACE at follow‐up, respectively (hazard ratio 5.2, 95% CI 1.4–18.9, P = 0.01; hazard ratio 4.1, 95% CI 1.1–15.3, P = 0.03). The presence of angina at follow‐up was more frequent in the MT group compared with the CR group (41% vs. 9%, P = 0.002). Conclusions : In patients with moderate coronary lesions and borderline FFR measurements deferral of revascularization was associated with a higher rate of MACE (CR) and a higher prevalence of angina at follow‐up, especially in those with previous MI in the territory evaluated by FFR. Further prospective randomized studies should confirm whether or not an FFR cut‐off point of 0.80 instead of 0.75 would be more appropriate for deferring CR in these cases. © 2008 Wiley‐Liss, Inc.