Prospective evaluation of the development of contrast-induced nephropathy in patients with acute coronary syndrome undergoing rotational coronary angiography vs. conventional coronary angiography: CINERAMA study

INTRODUCTION AND OBJECTIVES

Rotational coronary angiography (RCA) requires less contrast to be administered and can prevent the onset of contrast-induced nephropathy (CIN) during invasive coronary procedures. The aim of the study is to evaluate the impact of RCA on CIN (increase in serum creatinine ≥0.5mg/dl or ≥25%) after an acute coronary syndrome.

METHODS

From April to September 2016, patients suffering acute coronary syndromes who underwent diagnostic coronary angiography, with the possibility of ad hoc coronary angioplasty, were prospectively enrolled. At the operator's discretion, patients underwent RCA or conventional coronary angiography (CCA). CIN (primary endpoint), as well as analytical, angiographic and clinical endpoints, were compared between groups.

RESULTS

Of the 235 patients enrolled, 116 patients received RCA and 119 patients received CCA. The RCA group was composed of older patients (64.0±11.8 years vs. 59.7±12.1 years; p=0.006), a higher proportion of women (44.8 vs. 17.6%; p<0.001), patients with a lower estimated glomerular filtration rate (76±25 vs. 86±27ml/min/1.73 m²; p=0.001), and patients who underwent fewer coronary angioplasties (p<0.001) compared with the CCA group. Furthermore, the RCA group, received less contrast (113±92 vs. 169±103ml; p<0.001), including in diagnostic procedures (54±24 vs. 85±56ml; p<0.001) and diagnostic-therapeutic procedures (174±64 vs. 205±98ml; p=0.049) compared with the CCA group. The RCA group presented less CIN (4.3 vs. 22.7%; p<0.001) compared to the CCA group, and this finding was maintained in the regression analysis (Adjusted relative risk: 0.868; 95% CI: 0.794-0.949; p=0.002). There were no differences in clinical endpoints between the groups.

CONCLUSIONS

RCA was associated with lower administration of contrast during invasive coronary procedures in acute coronary syndrome patients, resulting in lower incidence of CIN, in comparison with CCA.

False Positive STEMI Activations in a Regional Network: Comprehensive Analysis and Clinical Impact. Results From the Catalonian Codi Infart Network

INTRODUCTION AND OBJECTIVES

ST-segment elevation myocardial infarction (STEMI) network activation by a noncardiologist reduces delay times but may increase the rate of false-positive STEMI diagnoses. We aimed to determine the prevalence, predictors, and clinical impact of false-positive activations within the Catalonian STEMI network (Codi Infart).

METHODS

From January 2010 through December 2011, all consecutive patients treated within the Codi Infart network were included. Code activations were classified as appropriate if they satisfied both electrocardiogram and clinical STEMI criteria. Appropriate activations were classified as false positives using 2 nonexclusive definitions: a) "angiographic" if a culprit coronary artery was not identified, and b) "clinical" if the discharge diagnosis was other than STEMI.

RESULTS

In total, 5701 activations were included. Appropriate activation was performed in 87.8% of the episodes. The rate of angiographic false positives was 14.6%, while the rate of clinical false positives was 11.6%. Irrespective of the definition, female sex, left bundle branch block, and previous myocardial infarction were independent predictors of false-positive STEMI diagnoses. Using the clinical definition, hospitals without percutaneous coronary intervention and patients with complications during the first medical contact also had a false-positive STEMI diagnoses rate higher than the mean. In-hospital and 30-day mortality rates were similar for false-positive and true-positive STEMI patients after adjustment for possible confounders.

CONCLUSIONS

False-positive STEMI diagnoses were frequent. Outcomes were similar for patients with a true-positive or false-positive STEMI diagnosis treated within a STEMI network. The presence of any modifiable predictors of a false-positive STEMI diagnosis warrants careful assessment to optimize the use of STEMI networks.

QT interval prolongation and torsade de pointes: Synergistic effect of flecainide and H1 receptor antagonists

A high percentage of patients having atrial fibrillation (AF) presents with paroxysmal AF. Flecainide, the prototypic class Ic anti-arrhythmic drug is the most effective drug to maintain sinus rhythm in this subgroup of patients, though the drug has potential pro-arrhythmic effects. Furthermore, the H₁ receptor antagonists are the most commonly prescribed drugs for the symptomatic treatment of pruritus. Despite having low number of adverse effects, the H₁ receptor antagonists have cardiotoxic effects. Flecainide and H₁ receptor antagonists present arrhythmic complications including QT interval prolongation and torsade de pointes (TdP). The case presented here is a 65-year-old female who was diagnosed of atrial fibrillation and presented with rashes in lower extremities. The patient was treated using flecainide and H₁ receptor antagonists (loratadine and hydroxyzine) that prolonged QT interval and induced TdP. The concomitant administration of flecainide and H₁ receptor antagonists seems to have a synergistic effect in QT interval prolongation and subsequent TdP. The concurrent administration of H₁ receptor antagonists to patients receiving class Ic anti-arrhythmic drugs should be avoided in order to reduce arrhythmic risk in this population.

[OPTIMIZATION OF GLUCOSE METABOLISM IN PATIENTS UNDERGOING THERAPEUTIC HYPOTHERMIA AFTER SUDDEN CARDIAC ARREST]

OBJECTIVE

Therapeutic hypothermia (TH) is recommended to improve survival and neurologic prognosis in sudden cardiac arrest (SCA) survivors. There are few data aboutglycemic levels in these patients. The aim of this study is to evaluate the glycemic control using a specific protocol in this group ofpeople.

METHOD

A retrospective analysis of the patients receiving TH in our institution, between January 2010 and March 2013,. was performed. Baseline characteristics, in-hospital prognosis and glycemic levels during different stages of the TH were analyzed.

RESULTS

From a total of 55 patients suffering a SCA, 49 patients underwent TH and received a specific insulin protocol. The mean age was 57.5 ± 12.8 years, the main cause of SCA was ischemic (76%) and ventricular fibrillation was the most frequent first rhythm detected (55%). Regarding glycemic alterations as each stage of TH, a high rate of glycemic alteration was observed in the induction stage, decreasing after starting the insulin protocol (induction stage: 95.9%; maintenance stage: 89.8%; rewarming stage: 69.4%; p = 0.001). With respectto clinicresults, there were low rates of severe hypoglycemia (12%), in-hospital mortality (20%) and anoxic encephalopathy (27%), with a high rate of infections (75%).

CONCLUSIONS

The implementation of a specific insulin protocol in patients receiving TH contributes to improve the blood glucose levels. Further studies are needed to evaluate the clinical impact of these protocols in this group ofpatients.

[Benefit of the implementation of a ST-segment elevation myocardial infarction network on women]

OBJECTIVE

The ST-segment elevation myocardial infarction network "Codi Infart" was implemented in Catalonia (Spain) in June 2009. The objective of this study was to evaluate the impact of the implementation of the Codi Infart on women.

METHOD

Women referred for primary percutaneous coronary intervention, were divided into two groups according to Codi Infart: Non-Codi Infart group (January 2003 to May 2009) and Codi Infart group (June 2009 to December 2012). Place of first medical contact, time intervals in diagnosis and treatment, treatments received and rate of major cardiovascular adverse events defined as all-cause death, reinfarction or stroke in-hospital, at 30 and 180 days were compared.

RESULTS

From a total population of 2,426 patients, 501 (20.7%) were women. One-hundred eighty-six women (2.09 cases/month) belonged to Non-Codi Infart group and 315 women (10.16 cases/month) to Codi Infart group. The percentage of women attended increased since the introduction of CI (22.2% vs. 18.5%, P=.028). In addition, the Codi Infart group had a higher percentage of women initially attended outside our institution (84.1% vs. 16.7%, P<.001), and lower total ischemia time (220 [155-380] vs. 272 [196-456], P=.003). However, no differences in 180-day major cardiovascular adverse events were detected (14.2% vs. 15.6%, P=.692).

CONCLUSIONS

The implementation of the major cardiovascular adverse events allowed to increase the rate and the percentage of women with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention and reducing total ischemic time.

Sex-related Impact on Clinical Outcome of Everolimus-eluting Versus Bare-metal Stents in ST-segment Myocardial Infarction. Insights From the EXAMINATION Trial

INTRODUCTION AND OBJECTIVES

The use of second-generation drug-eluting stents compared with bare-metal stents in patients with ST-segment elevation myocardial infarction reduces the rate of major adverse cardiac events. We aimed to evaluate the impact of sex on the performance of everolimus-eluting stents vs bare-metal stents in ST-segment elevation myocardial infarction at 2-year follow-up.

METHODS

This is a sub-study of the EXAMINATION trial that randomized 1498 patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention to everolimus-eluting or bare-metal stents. Primary end point was combined all-cause death, any recurrent myocardial infarction, and any revascularization. All end points were analyzed according to sex at 2-year follow-up.

RESULTS

Of 1498 patients included in the trial, 254 (17.0%) were women. Women were older and had higher prevalence of hypertension and lower prevalence of smoking compared with men. In contrast with men, stent diameter was smaller in women. After multivariate analysis, the primary end point was similar between women and men (hazard ratio=0.95; 95% confidence interval, 0.66-1.37), and among women, between those treated with bare-metal vs everolimus-eluting stents (hazard ratio=2.48; 95% confidence interval, 0.95-6.46). Women showed a lower rate of repeat revascularization than men (hazard ratio=0.55; 95% confidence interval, 0.32-0.95) despite worse baseline characteristics. This difference was driven by better performance of the everolimus-eluting stent in women.

CONCLUSIONS

Despite poorer baseline clinical characteristics, women with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention showed outcomes similar to men. The use of everolimus-eluting stents may represent an added value in women as it showed a reduced rate of repeated revascularization compared to men.