OPCAB in acute coronary syndrome: predictors of intra-aortic balloon pump use

AIM

Acute coronary syndrome (ACS) patients undergoing offpump coronary artery bypass (OPCAB) often require intra-aortic balloon pump (IABP) support. Indications and timing of IABP insertion are controversial. A study was done to determine criteria for predicting the use of IABP in these patients.

METHOD

46 patients were operated for ACS within one week of event between January 2004 and July 2006 and categorized into, Unstable angina (UA) (n=25), with ongoing pain after late admission to emergency room (>6 hours) and acute myocardial infarction (AMI) (n=21) with AMI within 7 days of event.

RESULTS

There was no statistical difference in the demographic data of two groups. UA group had higher incidence of mitral regurgitation preoperatively (p = 0.004) which improved postoperatively (p = 0.1). IABP was usedpreoperatively more in AMI group (10 vs. 6, p = 0.03). Multivariate analysis revealed pressure ratio of mean pulmonary and systemic arteries as a predictor of IABP use (p = 0.01, odds ratio 19.4, 95% CI 1.9-190). There is a significant positive correlation (r = 0.519) between IABP use and ratio of mean pulmonary and systemic arterial pressures (p = 0.004) with cutoff value at 0.40.

CONCLUSION

Ratio of mean pulmonary and systemic artery of > 0.40 indicates preoperative use of IABP to complete the operation safely.

Incidence of stent thrombosis and adverse cardiac events 5 years after sirolimus stent implantation in clinical practice

BACKGROUND

The long-term incidence of stent thrombosis (ST) and complications after sirolimus-eluting stents (SES) implantation is still a matter of debate.

METHOD

We conducted a systematic follow-up on the day of their 5-year SES implantation anniversary, in a series of consecutive real-world patients treated with a SES. The use of SES implantation was not restricted to "on-label" indications, and target lesions included in-stent restenosis, vein graft, left main stem locations, bifurcations, and long lesions. The Academic Research Consortium criteria were used for ST classification.

RESULTS

Three hundred fifty consecutive patients were treated with SES between April and December 2002 in 3 Swiss hospitals. Mean age was 63 +/- 6 years, 78% were men, 20% presented with acute coronary syndrome, and 19% were patients with diabetes. Five-year follow-up was obtained in 98% of eligible patients. Stent thrombosis had occurred in 12 patients (3.6%) [definite 6 (1.8%), probable 1 (0.3%) and possible 5 (1.5%)]. Eighty-one percent of the population was free of complications. Major adverse cardiac events occurred in 74 (21%) patients and were as follows: cardiac death 3%, noncardiac death 4%, myocardial infarction 2%, target lesion revascularization 8%, non-target lesion revascularization target vessel revascularization 3%, coronary artery bypass graft 2%. Non-TVR was performed in 8%.

CONCLUSION

Our data confirm the good long-term outcome of patients treated with SES. The incidence of complications and sub acute thrombosis at 5 years in routine clinical practice reproduces the results of prospective randomized trials.

Bleeding risk with AZD6140, a reversible P2Y12 receptor antagonist, vs. clopidogrel in patients undergoing coronary artery bypass grafting in the DISPERSE2 trial

AZD6140, the first reversible oral P2Y(12) receptor antagonist, exhibits greater and more consistent inhibition of platelet aggregation than the irreversible thienopyridine clopidogrel. As a result of its reversible effect, AZD6140 may pose less risk for bleeding when antiplatelet treatment cannot be stopped at least 5 days before coronary artery bypass graft (CABG) surgery or other invasive procedures. The Dose conflrmation Study assessing anti-Platelet Effects of AZD6140 vs. clopidogRel in NSTEMI (DISPERSE2) trial showed overall comparable bleeding rates with antiplatelet treatment with AZD6140 90 mg twice daily or 180 mg twice daily vs. clopidogrel 75 mg once daily in 984 patients with non-ST-elevation acute coronary syndromes. A post hoc exploratory analysis of bleeding outcomes in the subset of 84 patients undergoing CABG in DISPERSE2 suggests reduced risk for total bleeding (41% and 58% vs. 62%), all major bleeding (38% and 50% vs. 62%), and life-threatening bleeding (22% and 38% vs. 54%) with AZD6140 90 mg (n = 32) and 180 mg (n = 26) vs. clopidogrel (n = 26) respectively. Trends suggested that major bleeding rates were reduced with AZD6140 (combined groups) vs. clopidogrel when treatment was stopped < or = 5 days prior to surgery (39% vs. 63%, p = 0.15) but not when treatment was stopped > 5 days before surgery (50% vs. 60%). This observation is consistent with the reversible binding of AZD6140 to the P2Y(12) receptor. Further prospective studies are planned to assess the relationship between this potential clinical benefit of AZD6140 and the reversibility of its antiplatelet effects.

ACCF/SCAI/STS/AATS/AHA/ASNC 2009 Appropriateness Criteria for Coronary Revascularization: a report by the American College of Cardiology Foundation Appropriateness Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, and the American Society of Nuclear Cardiology Endorsed by the American Society of Echocardiography, the Heart Failure Society of America, and the Society of Cardiovascular Computed Tomography

The American College of Cardiology Foundation (ACCF), Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, and the American Association for Thoracic Surgery, along with key specialty and subspecialty societies, conducted an appropriateness review of common clinical scenarios in which coronary revascularization is frequently considered. The clinical scenarios were developed to mimic common situations encountered in everyday practice and included information on symptom status, extent of medical therapy, risk level as assessed by noninvasive testing, and coronary anatomy. Approximately 180 clinical scenarios were developed by a writing committee and scored by a separate technical panel on a scale of 1 to 9. Scores of 7 to 9 indicate that revascularization was considered appropriate and likely to improve health outcomes or survival. Scores of 1 to 3 indicate revascularization was considered inappropriate and unlikely to improve health outcomes or survival. The mid range (4 to 6) indicates a clinical scenario for which the likelihood that coronary revascularization would improve health outcomes or survival was considered uncertain. For the majority of the clinical scenarios, the panel only considered the appropriateness of revascularization irrespective of whether this was accomplished by percutaneous coronary intervention (PCI) or coronary artery bypass graft surgery (CABG). In a select subgroup of clinical scenarios in which revascularization is generally considered appropriate, the appropriateness of PCI and CABG individually as the primary mode of revascularization was considered. In general, the use of coronary revascularization for patients with acute coronary syndromes and combinations of significant symptoms and/or ischemia was viewed favorably. In contrast, revascularization of asymptomatic patients or patients with low-risk findings on noninvasive testing and minimal medical therapy were viewed less favorably. It is anticipated that these results will have an impact on physician decision making and patient education regarding expected benefits from revascularization and will help guide future research.

Indications for coronary artery bypass grafting in 2009: what is left to surgery

Coronary artery bypass grafting (CABG) remains the most common procedure performed by cardiac surgeons, yet it is clear that the landscape of coronary intervention is constantly changing as new technology is introduced and data from countless studies continues to be published. However, no single study will be able to clearly define the indications for surgical versus percutaneous revascularization in every clinical scenario given the complexity of this disease as well as that of the patients it afflicts. Moreover, the significant improvements in percutaneous therapy, medical therapy management, perioperative care and secondary prevention after revascularization have decreased the morbidity and mortality of coronary artery disease making comparison between therapies far more difficult. Based on the available literature to date, surgical revascularization (CABG) provides significant benefit in certain patient populations; particularly those with comorbid conditions (for example diabetes, left ventricular [LV] dysfunction) and with more severe disease (for example left main, three-vessel). The goal of this article is to outline the current for surgical revascularization (CABG) understanding that coronary artery disease will continue be an important cause of morbidity and mortality and further study and re-evaluation of these recommendations will likely be necessary as time goes on.

Potential unrecognised costs of clopidogrel pretreatment in acute coronary syndrome

OBJECTIVE

To examine adherence in clinical practice to the American College of Cardiology/American Heart Association (ACC/AHA) guideline recommendations of observing a 5-day waiting period after clopidogrel administration before undergoing coronary artery bypass graft (CABG) surgery and to examine the costs of waiting.

METHODS

This retrospective study used a nationwide inpatient database (Solucient ACTracker) to identify patients who were admitted for acute coronary syndrome (ACS), and who had same-stay CABG. Cost of additional days of stay was estimated using regression analysis.

RESULTS

The recommended 5-day waiting was adhered to in 16.9% (n=3,809) of patients. The percentage of patients with ACS undergoing CABG surgery on day 0 was 14.6%. Adherence to the waiting was higher for teaching and rural hospitals; and in female and elderly patients and urgent admissions.

CONCLUSIONS

The recommended 5-day waiting for CABG surgery after clopidogrel treatment is poorly adhered to in clinical practice. This study was unable to determine specific reasons for the low adherence; however, there may be a compromise between the clinically urgent need for revascularisation and increased risk of bleeding, as well as economic costs associated with waiting. The cost of an additional hospital day in this group of patients was approximately £1,400 per day or £7,000 for 5 days. Thus, a full 5-day wait would have a significant economic impact on hospital costs.

[Anticoagulant and thrombolytic agents in acute coronary syndromes]

The term acute coronary syndrome (ACS) pertains to the instable and life-threatening forms of a clinically manifest coronary artery disease with biochemical and/or electro-cardiographic evidence of myocyte cell death. In detail, it includes the unstable angina pectoris, the non-ST segment elevation myocardial infarction (NSTEMI) the ST segment elevation myocardial infarction (STEMI) and as well the sudden cardiac death. As early reperfusion of ischaemic myocardium is the most effective way for limiting infarct size by restoring the balance between myocardial oxygen supply and demand, it is the most important therapeutic goal to achieve early and complete antegrade flow in the occluded or restricted vessel, related with a reduction of short and longtime complications as heart failure and severe arrhythmias. It is generally accepted, that the primary percutaneous coronary intervention (PCI) is the method of choice in acute myocardial infarction (STEMI) to restore TIMI-3 blood flow in occluded coronary arteries, if this can be performed within two hours of symptom onset and by a highly specialized team. Since these requirements are only met in 20% of hospitals caring for patients with STEMI in Germany, the therapy with thrombolytic and anticoagulant agents plays still an important role. Apart from a rapid and effective prehospital primary care, it depends furthermore on a differentiated anticoagulatory and antithrombotic therapy during coronary intervention to get optimal results.

Cardiogenic shock in acute coronary syndrome in the Spanish population

BACKGROUND

To evaluate the frequency and factors associated with cardiogenic shock (CS) in acute myocardial infarction (AMI) and unstable angina (UA) and percutaneous coronary intervention (PCI).

MATERIAL/METHODS

Spanish registry. The study period was June 1996 to December 2005. Follow-up was length of stay in an intensive care or coronary care unit (ICU/CCU). Multivariate studies evaluated factors associated with CS, mortality in CS, and PCI performance.

RESULTS

The study included 45.688 AMI patients and 17.277 UA patients. Cardiogenic shock occurred in 9.3% of patients with AMI and 1.79% of those with UA, frequencies that decreased over time. Variables associated with cardiogenic shock in AMI patients were female sex, age, type of infarction, diabetes, previous stroke, arrhythmia, previous angiography, complicated angina, and reinfarction. Hypertension and oral beta-blocking, ACE inhibitor, and hypolipidemic agents protected against CS. In UA, these variables were age, previous angina or AMI, right ventricular heart failure, arrhythmia. Beta-blocking agents were associated with a reduction in CS. Deaths from CS and AMI, respectively, were 62.8% and 38.7% in persons with UA. Doing PCIs has increased significantly; it is more prevalent in ex-smokers and those with right ventricular heart failure and mechanical ventilation; lower performance is associated with need for cardiopulmonary resuscitation; patients who die are older or have a history of AMI.

CONCLUSIONS

There has been a slight drop in the frequency of CS and its mortality. Factors associated with CS are similar to those associated with acute coronary syndromes. The frequency of PCI was low.

Patterns of use and effectiveness of early invasive strategy in non-ST-segment elevation acute coronary syndromes: an assessment by propensity score

BACKGROUND

The patterns of use and the benefit of an early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome in a real-life population are not well established.

METHODS

All consecutive patients hospitalized because of non-ST-segment elevation acute coronary syndrome between November 2004 and June 2005 in 32 randomly selected hospitals were prospectively included. Patients were stratified by their baseline risk profile using the Global Registry of Acute Coronary Events (GRACE) risk score in 2 groups. Inhospital mortality and 1- and 6-month mortality or rehospitalization for acute coronary syndromes were analyzed. To ensure optimal adjustment propensity score, conventional logistic regression and Cox regression were used.

RESULTS

Of 2,856 patients analyzed, 1,616 (56%) had low/intermediate risk (GRACE<or=140) and 1,240 had high risk (GRACE>140). Patients who underwent EIS had lower risk than those who did not (GRACE score 128.2+/-41 vs 138.5+/-43, P<.001). Coronary angiography facility emerged as the strongest predictor of EIS (odds ratio [OR] 13.7 [95% CI 7.1-25]). Patients who underwent EIS had lower rate of the 6-month outcome in both the whole population (9% [95% CI 6.6-11.9] vs 14% [95% CI 12.5-15.6], P=.003) and in high-risk patients (16.5% [95% CI 11-23] vs 23.6% [95% CI 20.8-26.5], P=.04). However, this benefit of EIS was not apparent after statistical adjustment in the whole population (OR 0.8, CI 0.55-1.1, P=.17) or in high-risk patients (OR 0.7, CI 0.46-1.1, P=.16).

CONCLUSIONS

In a real-life population, EIS was mainly performed in patients of low/intermediate risk. An obvious benefit of this strategy could not be found.

Late outcomes after drug-eluting stent implantation in "real-world" clinical practice

BACKGROUND

We report the late outcomes in 411 consecutive patients undergoing drug-eluting stent (DES) implantation by a single operator between 2003-2006.

METHODS

Prospective registry with continuous follow up. Patients with stable angina (SA) or acute coronary syndrome (ACS) received DES for long lesions, small vessels, chronic total occlusion, bifurcation, aorto-ostial, left main, post atherectomy or saphenous vein graft lesions, multivessel/multilesion single-vessel (V) disease, in-stent restenosis (ISR) or diabetes.

RESULTS

Age range: 34-86 years. One hundred sixty-six (40.3%) had ACS, 98.3% hypercholesterolemia and 14.6% diabetes. Two hundred sixty-one (63.5%) had percutaneous coronary intervention (PCI) to 1V and 150 (36.5%) to >1V. Six hundred seven V were treated. Two hundred fifty-nine patients (63%) had multilesion PCI, and 109 (26.5%) 1V multilesion PCI. Two hundred ninety-three (71.3%) patients had long lesions and 224 had Vs < 2.75 mm diameter. 75.5% of lesions were Type B2/C. 1-8 stents were implanted/patient. Eight hundred twenty-two of 883 stents were DES. One hundred eight patients received > or = 1 stent of < or = 2.5 mm diameter and 246 patients received stents greater than or equal to 20 mm long. Twenty-five patients developed late complications. ISR occurred in 23, 3.5-38 months after DES implantation. Three had sudden late DES thrombosis (LST). One-third also had ISR. Twenty of twenty-five required PCI, 1 CABG and 4 medical treatment. Subsequently, 3 of the 20 required further PCI for recurrent ISR and 1 CABG. 9 patients died during 1-5-year follow up.

CONCLUSIONS

In "real-world" patients at increased risk of ISR after bare-metal stenting (BMS), "off-label" DES implantation has a low incidence of late complications. The most common is ISR which presents later than after BMS. Acute LST is serious but unusual and may be accompanied by ISR.

Use of Impella Recover 2.5 left ventricular assist device in patients with cardiogenic shock or undergoing high-risk percutaneous coronary intervention procedures: experience of a high-volume center

AIM

Percutaneous coronary interventions are increasingly applied to high-risk patients. The availability of hemodynamic support devices offers a promising option to prevent and treat low-output syndrome in these patients. The aim of this study was to evaluate the feasibility, safety and efficacy of the Impella Recover'' LP 2.5 left ventricular assist device in patients with cardiogenic shock or undergoing high-risk percutaneous coronary interventions.

METHODS

Eleven patients presenting cardiogenic shock (N=6) or scheduled for high-risk percutaneous revascularization (N=5) were evaluated. The Impella pump was successfully implanted in all patients, except one. When implanted, the device was correctly positioned in the left ventricle and remained in a stable position.

RESULTS

Bleedings occurred in 7 patients (5 of them presented cardiogenic shock), while renal failure and severe thrombocytopenia were observed in 4 and 1 patients respectively, all with cardiogenic shock. During high-risk procedures, the Impella pump succeeded in obtaining hemodynamic stability, while in only two patients with cardiogenic shock the device determined a significant improvement of hemodynamic variables. All elective patients and two patients with cardiogenic shock were discharged from the hospital and were still alive at 30-day follow-up.

CONCLUSION

These data, although preliminary due to the limited sample size, demonstrated the feasibility, safety and efficacy of the Impella Recover LP 2.5 during high-risk percutaneous procedures, even though the benefits of prophylactic deployment of such a system have to be further investigated. The use of Impella Recover LP 2.5 in patients with cardiogenic shock is feasible and safe, however it maybe insufficient in reversing an advanced cardiogenic shock which, probably, has to be treated with more powerful left ventricular assist devices.

Percutaneous coronary intervention versus coronary artery bypass grafting as primary revascularization in patients with acute coronary syndrome

New European Society of Cardiology/American College of Cardiology guidelines classify patients with acute coronary syndrome and increased cardiac troponins as non-ST-segment elevation myocardial infarction (NSTEMI) who would have been classified as unstable angina pectoris (UAP) using the older World Health Organization (WHO) definition. The optimal revascularization strategy in these patients is poorly defined. This prospective cohort study included 1,024 consecutive patients with acute coronary syndrome classified as UAP, NSTEMI according to the WHO definition (WHO NSTEMI), and NSTEMI additionally identified by the novel European Society of Cardiology/American College of Cardiology definition (additional NSTEMI). All patients underwent coronary angiography within 24 hours and were treated with immediate percutaneous coronary intervention (PCI) or early coronary artery bypass grafting (CABG). The primary end point was all-cause mortality during follow-up of 36 months. Patients with additional NSTEMI showed excessive cumulative 3-year mortality if undergoing CABG (hazard ratio 5.9, 95% confidence interval 2.7 to 13.1, p <0.001). In patients with UAP or WHO NSTEMI, mortality was similar in the CABG and PCI groups. In conclusion, in the absence of randomized trials specifically including patients with additional NSTEMI, the excessive mortality observed with CABG in this cohort study suggested that PCI may be the preferable revascularization strategy in this subgroup.

Acute coronary syndromes

The mortality rate for coronary artery disease has decreased steadily over the past 25 yeas, attributable to a great extent to advances in medical and mechanical interventions. Nevertheless, mortality rates for acute coronary syndromes remain between 4% and 7%. This article highlights treatment options and the challenge of implementing evidence-based recommendations.

A national study on lipid management

BACKGROUND

Hyperlipidemia remains a major cause of morbidity in Western countries. The objective of this study was to document the percentage of adults who underwent periodical LDL measurement, and the percentage of patients with diabetes and post-angioplasty who were treated to goal.

METHODS

Using a national database, data were obtained on the percentage of adults who had an LDL performed and the percentage of adults with an LDL at pre-specified levels. We also assessed the attainment of target LDL levels in diabetic and post-angioplasty patients. Data were also collected from patients with an acute coronary syndrome (ACS) admitted to seven hospitals within a 5 year period (2000-2004).

RESULTS

Primary prevention: In 2005, 64.6% of the total population of 754,910 aged 35-44 had at least one record of LDL cholesterol measurement documented. This figure was 79.6% in the 717,617 adults aged 45-54. Secondary prevention: Of 253,233 diabetics in 2005, 220,023 (86.9%) have undergone at least one annual LDL measurement. The percentage of patients on statin therapy 3 and 12 months after an ACS admission increased significantly during the years 2000-2004 and reached 87%. Of the 42,292 patients who underwent PTCA during 2005, 34,346 (81.2%) have purchased at least 3 prescriptions of statins during 2005, 35,261 (83.4%) have performed at least one LDL measurement and 57.8% attained an LDL level of <100 mg/dl.

CONCLUSIONS

We have shown an improvement in primary and secondary preventions of CV disease as documented by LDL measured and attainment of treatment goals, but further efforts are needed.

A multicenter, randomized, open-label, therapeutic, and exploratory trial to evaluate the tolerability and efficacy of platelet glycoprotein IIb/IIIa receptor blocker (Clotinab) in high-risk patients with percutaneous coronary intervention

PURPOSE

This study was designed as a multicenter, randomized, open-label study to evaluate the efficacy and tolerability of Clotinab. We expected to obtain same results as with ReoPro in improving ischemic cardiac complications in high-risk patients who were about to undergo percutaneous coronary intervention (PCI).

PATIENTS AND METHODS

Patients of 19-80 years of age with acute coronary syndrome (ACS) who were about to undergo PCI were enrolled. After screening and confirmation of eligibility, patients were randomly assigned to different groups. Clotinab was given to 84 patients (58.7+/-10.6 years, M:F=68:16)and ReoPro(59.0+/-10.5 years, M:F=30:10) was given to 40 patients before PCI. The primary efficacy endpoint was the onset of major adverse cardiac event (MACE) within 30 days from day 1. The tolerability endpoints were assessed based on bleeding, thrombocytopenia, change in Hb/Hct, human antichimetric antibody development, and adverse events.

RESULTS

The number of Clotinab patients experiencing MACE was 0 out of 76 per protocol (PP) patients. The MACE rate was 0%, and its 95% exact CI was [0.00-4.74%]. A major bleeding event developed in 3 patients in the ReoPro group. The probability of MACE onset in Clotinab was estimated to be less than 5%. There was no clinically significant result in tolerability variables.

CONCLUSION

Clotinab is an effective and safe medicine in preventing ischemic cardiac complications for high-risk patients who will receive PCI.

[Successful RF ablation of permanent VT in a patient with acute coronary syndrome treated by complex angioplasty and stent implantation]

We describe a case of a 59-year-old male with permanent VT in the course of an acute coronary syndrome. Coronary angiography revealed acute occlusion of the right coronary artery. Although the underlying condition was treated by implantation of 4 stents with excellent haemodynamic effect (TIMI 3), the tachycardia continued, being refractory to drugs (amiodarone). The attempts to restore sinus rhythm by DC electrical cardioversion or transvenous pacing were unsuccessful. The patient was referred to the EP lab. A critical isthmus localised at the paraseptal region of the LV and parallel to the mitral annulus was identified. The isthmus was closed by linear RF application, resulting in VT termination. Due to impaired LV ejection fraction (<30%) the patient was scheduled for ICD implantation. During 6-week follow-up the patient remained free of arrhythmia.

Management of chronic coronary disease: is the pendulum returning to equipoise?

Over the last 3 decades, our ability to mechanically dilate obstructive coronary arterial stenoses has fundamentally altered our approach to managing patients with coronary artery disease (CAD). The result has been a swing from an initial pharmacologic approach to anatomically driven revascularization. An accumulation of clinical evidence provides strong support for such intervention in acute coronary syndromes (ACS). In stable CAD, dilative therapy was believed to be superior based on the assumption that high-risk coronary anatomy or myocardial ischemia increases the risk of future death and myocardial infarction. However, there have been major advances in our understanding of the pathophysiology of ACS and the recognition of the significance of predisposing non-flow-limiting coronary stenoses prone to rupture, as well as increasing insight into plaque and patient vulnerability. This improved understanding of the disease has led to the more aggressive use of appropriately targeted pharmacologic agents and an evolution in what constitutes optimal medical therapy (OMT). Data from recent studies, such as the Clinical Outcomes Utilizing Revascularization and Aggressive Drug Evaluation (COURAGE) trial, support the concept that in patients with stable CAD, OMT alone in this day and age compares favorably with a therapeutic strategy combining OMT with mechanical intervention. Thus, the treatment pendulum may be swinging back to the understanding that "best practice" today requires the judicious use of interventional and medical therapies in the appropriate patient population.