Frequency and predictors of urgent coronary angiography in patients with acute pericarditis

OBJECTIVES

To determine the frequency of urgent coronary angiography in patients with acute pericarditis and to examine clinical characteristics associated with coronary angiography.

PATIENTS AND METHODS

This is a retrospective analysis of all incident cases of acute viral or idiopathic pericarditis evaluated at Mayo Clinic's site in Rochester, MN, between January 1, 2000, and December 31, 2006. The main outcome measures were use of urgent coronary angiography and rate of concomitant coronary artery disease in patients with pericarditis.

RESULTS

There were 238 patients with a final diagnosis of acute pericarditis (mean age, 47.7+/-17.9 years; 157 [66.0%] were male). On the initial electrocardiogram, 146 patients (61.3%) had ST-segment elevation, and 92 (38.7%) had no ST-segment elevation. Coronary angiography was performed in 40 patients (16.8% of all patients); the frequency was 5-fold higher among those with ST-segment elevation (24.7% vs 4.3%; P<.001). Additionally, 7 patients (4.8%) with ST-segment elevation received thrombolytics before transfer to our institution; no patients without ST-segment elevation received thrombolysis (P=.05). Characteristics associated with a higher likelihood of coronary angiography included typical anginal chest pain, ST-segment elevation, previous percutaneous coronary intervention, elevated troponin T values, diaphoresis, and male sex. Coronary angiography revealed concomitant mild to moderate coronary artery disease in 14 (35.0%) of the 40 patients who underwent this procedure.

CONCLUSION

Urgent coronary angiography is commonly performed in patients with acute pericarditis, particularly those with ST-segment elevation, typical myocardial infarction symptoms, and elevated troponin T values. Coronary artery disease was present angiographically in one-third of patients undergoing the procedure. Although patients with ST-segment elevation myocardial infarction must receive prompt reperfusion, clinicians must also consider the diagnosis of pericarditis to avoid unneeded coronary angiography.

Frequency and predictors of urgent coronary angiography in patients with acute pericarditis

OBJECTIVES

To determine the frequency of urgent coronary angiography in patients with acute pericarditis and to examine clinical characteristics associated with coronary angiography.

PATIENTS AND METHODS

This is a retrospective analysis of all incident cases of acute viral or idiopathic pericarditis evaluated at Mayo Clinic's site in Rochester, MN, between January 1, 2000, and December 31, 2006. The main outcome measures were use of urgent coronary angiography and rate of concomitant coronary artery disease in patients with pericarditis.

RESULTS

There were 238 patients with a final diagnosis of acute pericarditis (mean age, 47.7+/-17.9 years; 157 [66.0%] were male). On the initial electrocardiogram, 146 patients (61.3%) had ST-segment elevation, and 92 (38.7%) had no ST-segment elevation. Coronary angiography was performed in 40 patients (16.8% of all patients); the frequency was 5-fold higher among those with ST-segment elevation (24.7% vs 4.3%; P<.001). Additionally, 7 patients (4.8%) with ST-segment elevation received thrombolytics before transfer to our institution; no patients without ST-segment elevation received thrombolysis (P=.05). Characteristics associated with a higher likelihood of coronary angiography included typical anginal chest pain, ST-segment elevation, previous percutaneous coronary intervention, elevated troponin T values, diaphoresis, and male sex. Coronary angiography revealed concomitant mild to moderate coronary artery disease in 14 (35.0%) of the 40 patients who underwent this procedure.

CONCLUSION

Urgent coronary angiography is commonly performed in patients with acute pericarditis, particularly those with ST-segment elevation, typical myocardial infarction symptoms, and elevated troponin T values. Coronary artery disease was present angiographically in one-third of patients undergoing the procedure. Although patients with ST-segment elevation myocardial infarction must receive prompt reperfusion, clinicians must also consider the diagnosis of pericarditis to avoid unneeded coronary angiography.

Feasibility of prediction of myocardial viability with Doppler tissue imaging following percutaneous coronary intervention for ST elevation anterior myocardial infarction

BACKGROUND

In patients with acute ST elevation myocardial infarction (STEMI), it is clinically important to determine the viability of akinetic segments soon after acute reperfusion therapy. The purpose of this study was to determine whether Doppler tissue imaging can predict myocardial viability in this clinical setting.

METHODS

Twenty-four consecutive patients with the first acute anterior STEMI with akinetic apical segments were enrolled. Color-coded Doppler tissue imaging was performed. Myocardial velocity and strain values were determined from the septal and lateral walls at the normal basal and akinetic apical levels of the left ventricle on day 1 after percutaneous coronary intervention. The presence of isovolumic contraction of tissue velocity (TVivc) and strain rate (SRivc) were also determined.

RESULTS

Twenty patients (mean age 62 +/- 15 years; 11 men) returned for follow-up echocardiography to assess wall motion recovery and viability. Ten patients who had recovery of akinetic segments showed lower baseline E/e' ratios than those without recovery (13.4 +/- 5.9 vs 19.1 +/- 5.7; P = .04). There was no difference between 19 recovered and 21 nonrecovered apical segments in all TV, SR, and strain values except early diastolic SR (SRe; 0.64 +/- 0.35 vs 0.43 +/- 0.25 s(-1); P = .04) at day 1. With a cutoff value of 0.32 s(-1) for SRe, the receiver operating characteristic curve for the prediction of recovery showed the highest sensitivity of 84%. The presence of TVivc had sensitivity and specificity of 79% and 33%, respectively, and for SRivc, sensitivity and specificity were 84% and 63%, respectively. With the combination of SRe and SRivc, specificity was increased to 78%.

CONCLUSION

Patients with functional recovery from anterior STEMI showed better diastolic function, better SRe, and more isovolumic contraction. These parameters appear to be promising predictors for myocardial viability, and SR imaging was found to be a better method than TV imaging for the identification of viable myocardium in patients with STEMIs who underwent percutaneous coronary intervention.

Risk factors for Nipah virus encephalitis in Bangladesh

Patients in Goalando were likely infected by direct contact with fruit bats or their secretions, rather than through contact with an intermediate host.

Nipah virus (NiV) is a paramyxovirus that causes severe encephalitis in humans. During January 2004, twelve patients with NiV encephalitis (NiVE) were identified in west-central Bangladesh. A case–control study was conducted to identify factors associated with NiV infection. NiVE patients from the outbreak were enrolled in a matched case-control study. Exact odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by using a matched analysis. Climbing trees (83% of cases vs. 51% of controls, OR 8.2, 95% CI 1.25–∞) and contact with another NiVE patient (67% of cases vs. 9% of controls, OR 21.4, 95% CI 2.78–966.1) were associated with infection. We did not identify an increased risk for NiV infection among persons who had contact with a potential intermediate host. Although we cannot rule out person-to-person transmission, case-patients were likely infected from contact with fruit bats or their secretions.

Mortality differences between men and women after percutaneous coronary interventions. A 25-year, single-center experience

OBJECTIVES

Our aim was to examine whether gender-based differences in mortality after percutaneous coronary interventions (PCIs) have changed in the past 25 years.

BACKGROUND

Women with coronary artery disease have a higher risk of adverse outcomes after PCIs than do men. Recent temporal trends in short-term and long-term mortality in women after PCIs are unknown.

METHODS

We performed a retrospective cohort study of 18,885 consecutive, unique patients who underwent PCIs between 1979 and 1995 (early group, n = 7,904, 28% women) and between 1996 and 2004 (recent group, n = 10,981, 31% women). Thirty-day and long-term mortality were compared by gender.

RESULTS

Compared with men, women undergoing PCIs were older and more likely to have diabetes mellitus, hypertension, or hypercholesterolemia. Overall, PCI was successful in 89% of women and 90% of men. In the recent group, 30-day mortality was significantly reduced compared with that in the early group in women (2.9% vs. 4.4%, p = 0.002) and men (2.2% vs. 2.8%, p = 0.04). However, long-term survival was similar between the early and recent groups among both men and women. After adjustment for risk factors, there was no difference between men and women from 1994 onward for either 30-day or long-term outcomes.

CONCLUSIONS

The 30-day mortality after PCI in men and women has decreased in the past 25 years. After accounting for baseline risks, no differences in short-term or long-term mortality were observed between men and women.

Cardiac function and brain-type natriuretic peptide in first-time flash pulmonary edema

OBJECTIVE

To assess left ventricular (LV) function and brain-type natriuretic peptide (BNP) in patients with first-time flash pulmonary edema (FPE).

PATIENTS AND METHODS

We retrospectively studied all patients presenting to Mayo Clinic's site in Rochester, MN, from January 5, 2000, to December 30, 2004, with FPE. Only patients with first-time FPE who had undergone BNP assessment and echocardiography within 24 hours of presentation were included. Patients were divided into 2 groups: those with reduced LV ejection fraction (LVEF) (less than 50%) and those with preserved LVEF (equals 50%).

RESULTS

Thirty-seven patients met the inclusion criteria (22 female, 15 male). Mean plus or minus SD LVEF was 41% plus or minus 13%. The LVEF was reduced in 73% (group 1, n equals 27; mean plus or minus SD age, 75 plus or minus 8 years) and preserved in 27% (group 2, n equals 10; mean plus or minus SD age, 75 plus or minus 13 years). Most frequent underlying causes for first-time FPE were coronary artery disease and hypertension. Patients with preserved LVEF had significantly lower BNP levels at presentation (535 pg/mL [interquartile range, 352-1210 pg/mL]) vs 1320 pg/mL (interquartile range, 768-2000 pg/mL; P equals .01), despite similar elevated LV filling pressures as measured by echocardiography. The mean plus or minus SD ratio of early diastolic mitral valve inflow velocity to early diastolic mitral annulus velocity was 23 plus or minus 8 vs 22 plus or minus 10; P equals .78. Early diastolic mitral annulus velocity, a surrogate measurement for myocardial relaxation, was reduced in all patients with preserved LVEF and in 95% of patients with reduced LVEF.

CONCLUSION

Coronary artery disease and hypertension are the most common precipitating factors for first-time FPE. Reduced myocardial relaxation in almost all patients regardless of LVEF supports the notion that diastolic dysfunction is a prerequisite for FPE. Levels of BNP were elevated in every patient regardless of LVEF but were significantly lower in patients with preserved LVEF despite similarly elevated LV filling pressures.

Regional Systems of Care to Optimize Timeliness of Reperfusion Therapy for ST-Elevation Myocardial Infarction

Background— Quality improvement efforts have focused on strategies to improve the timeliness of reperfusion therapy in ST-elevation myocardial infarction patients who present to hospitals with and without percutaneous coronary intervention (PCI) capability. We implemented and evaluated a protocol to optimize the timeliness of reperfusion therapy and to coordinate systems of care for a PCI center and 28 regional hospitals located up to 150 miles away across 3 states.

Methods and Results— The present study focused on a prospective, observational cohort of 597 patients who presented with ST-segment elevation and within 12 hours of symptom onset to Saint Marys Hospital and 28 regional hospitals up to 150 miles away between May 2004 and December 2006. The Mayo Clinic ST-elevation myocardial infarction protocol implemented strategies to improve timeliness of reperfusion therapy and to coordinate systems of care for transfer between hospitals. The study sample consisted of 258 patients who presented to Saint Marys Hospital and were treated with primary PCI (group A), 105 patients who presented to a regional hospital with symptom onset >3 hours and then were transferred for primary PCI (group B), and 131 patients who presented to a regional hospital with symptom onset <3 hours and were treated with full-dose fibrinolytic therapy (group C). For groups A and B, median door-to-balloon times were 71 and 116 minutes, respectively. Door-to-balloon time <90 minutes was achieved in 75% of group A and 12% of group B. Median door-to-needle time was 25 minutes for group C, and 70% had door-to-needle time <30 minutes.

Conclusions— The Mayo Clinic ST-elevation myocardial infarction protocol demonstrates the feasibility of implementing strategies to optimize the timeliness of reperfusion therapy and the times that can be achieved through coordinated systems of care for ST-elevation myocardial infarction patients presenting to a PCI center (Saint Marys Hospital) and 28 regional hospitals without PCI capability located up to 150 miles away across 3 states.

Eptifibatide vs abciximab as adjunctive therapy during primary percutaneous coronary intervention for acute myocardial infarction

OBJECTIVE

To compare outcomes among patients receiving eptifibatide or abciximab during primary percutaneous coronary intervention (PCI) for acute myocardial infarction (MI) with ST elevation or new left bundle branch block.

PATIENTS AND METHODS

From January 1999 through January 2004, 576 patients underwent primary PCI and received adjunctive glycoprotein IIb/IIIa receptor antagonists. Propensity scores were used to adjust for baseline differences between groups. Logistic regression and Cox proportional hazards were used to model the association between choice of glycoprotein IIlb/IIIa receptor antagonist and adverse events.

RESULTS

Abciximab was given to 327 patients (57%) and eptifibatide to 249 (43%). Observed rates of in-hospital death or MI did not differ between groups (eptifibatide, 6%; abciximab, 5%; P = .95). This result persisted with adjustment for various patient characteristics (adjusted odds ratio, 1.03; 95% confidence interval, 0.40-2.65; P = .95). Kaplan-Meier estimated rates of death, MI, or target vessel revascularization at 1-year follow-up were 20.9% with eptifibatide and 22.3% with abciximab. The adjusted hazard ratio for the composite end point during a median follow-up of 12 months was 1.36 (95% confidence interval, 0.89-2.07; P = -.16).

CONCLUSION

In this observational analysis, outcomes were similar with use of either abciximab or eptifibatide among patients undergoing primary PCI for acute MI. Additional comparative research is warranted to confirm these results.

Prognostic significance of echocardiographically defined mitral regurgitation early after acute myocardial infarction

BACKGROUND

There are limited data regarding the clinical correlates and prognostic significance of echocardiographically defined mitral regurgitation (MR) early after acute myocardial infarction (MI). The current study addressed these issues.

METHODS

Seven hundred thirty-seven patients with acute MI who underwent transthoracic echocardiography with assessment of MR during their index admission were identified. Patients were followed up a median of 19 months later. The study end point was all-cause mortality.

RESULTS

The prevalence of MR increased with age. It was more common in women, in patients with non-ST-elevation MI, and in those with a history of diabetes, hypertension, prior MI, or previous revascularization. Patients with MR had worse left ventricular (LV) systolic function, more LV dilatation, and more clinical evidence of LV failure. Patients with moderate or severe MR had worse survival than those with no or mild MR (hazard ratio 2.3, 95% CI 1.6-3.2, P < .0001). Even mild MR predicted a higher mortality when compared with no MR (hazard ratio 1.7, 95% CI 1.2-2.4, P = .004). Mild or moderate MR was not independently predictive of outcome, although, in multivariable analyses, a trend toward worse survival was maintained in patients with severe MR.

CONCLUSIONS

Mitral regurgitation, identified by echocardiography, early after acute MI predicts poorer survival after acute MI. However, if mild or moderate, it is not an independent prognostic indicator.

Anticipated impact of drug-eluting stents on referral patterns for coronary artery bypass graft surgery: a population-based angiographic analysis

OBJECTIVES

To determine the clinical and angiographic characteristics of patients who underwent coronary artery bypass graft (CABG) surgery before the availability of drug-eluting stents (DES) and to project the potential impact of percutaneous coronary intervention using DES.

PATIENTS AND METHODS

We reviewed the coronary angiograms obtained between March 1999 and December 2001 of 192 consecutive patients from Olmsted County, Minnesota, who had undergone isolated CABG surgery for the first time. Three interventional cardiologists categorized the patients into 1 of 4 groups on the basis of technical feasibility of complete revascularization by percutaneous coronary intervention with DES.

RESULTS

The study population consisted primarily of men (78%), with a mean age of 67 years. Of the 192 patients, 58 (30%) had diabetes mellitus, and 124 (65%) had 3-vessel disease. Twelve patients (6%) had lesions suitable for stents that matched the inclusion criteria for DES in recently published trials; 77 (40%) had lesions suitable for stents but had lesion characteristics not included in the initial DES trials. Thirty-two patients (17%) had target lesions considered technically difficult, but feasible, for stent placement. Seventy-one patients (37%) had lesions unsuitable for percutaneous coronary intervention (75% of these due to chronic occlusions) with the current stent delivery technology.

CONCLUSION

This population-based analysis suggests that only a small proportion of patients undergoing CABG surgery meets the strict angiographic eligibility criteria for DES on the basis of recent trials. However, up to 46% of current CABG patients may ultimately undergo conversion to DES. The remaining 54% of this patient population may still not be ideal candidates for DES with the current stent delivery technology.

Incidence, correlates, management, and clinical outcome of coronary perforation: analysis of 16,298 procedures

BACKGROUND

Coronary perforation is a serious but uncommon complication of percutaneous coronary intervention (PCI) and is associated with significant morbidity and mortality.

METHODS

We performed an analysis of the Mayo Clinic PCI database. Clinical records, procedural reports, and angiographic studies were reviewed. Multiple logistic regression analysis was performed to identify clinical, procedural, anatomic, and angiographic correlates of coronary perforation.

RESULTS

A total of 16,298 PCI procedures were performed between January 1990 and December 2001. We identified 95 coronary perforations (0.58%; 95% CI, 0.47-0.71). The incidence of coronary perforation varied with time. Correlates of coronary perforation included the use of an atheroablative device and female sex. Twelve patients (12.6%) sustained an acute myocardial infarction, and cardiac tamponade developed in 11 patients (11.6%). Management strategies included reversal of heparin, pericardiocentesis, placement of a covered stent, and surgical repair. Seven patients died (7.4%).

CONCLUSIONS

Coronary perforation during PCI is rare, but is associated with significant morbidity and mortality. The variable frequency of perforation may be explained by temporal variations in the use of atheroablative devices.

Safety of abciximab in patients with chronic renal insufficiency who are undergoing percutaneous coronary interventions

BACKGROUND

Patients with chronic renal insufficiency (CRI) have worse outcomes during and after percutaneous coronary interventions (PCI). Abciximab reduces complications, but may cause excessive bleeding in patients with CRI. Therefore, we sought to determine the safety of abciximab in patients with CRI.

METHODS

Patients (n = 4158) undergoing PCI at the Mayo Clinic since abciximab became available were analyzed according to their estimated creatinine clearance (> or =70, 50-69, or <50 mL/min) or need for dialysis. Major bleeding was defined as a cerebrovascular bleed or a decrease in the hematocrit level >15%. Minor bleeding was defined as a decrease in the hematocrit level of 10% to 15% with an identifiable site of bleeding.

RESULTS

CRI was associated with increased bleeding in patients who received abciximab and patients who did not. However, there was only a trend toward an interaction between creatinine clearance and major bleeding with abciximab (odds ratio [OR], 1.18; P =.06) and no interaction with minor bleeding (OR, 1.01; P =.94) or any bleeding (OR, 1.10; P =.15).

CONCLUSION

CRI is associated with an increased risk of bleeding complications after PCI. Although abciximab increases the risk of bleeding in all patients, the increase in relative risk is not significantly greater in patients with CRI. Thus, abciximab may be given safely in patients with CRI who are undergoing PCI.

A randomized, double-blinded, placebo-controlled, dose-ranging study measuring the effect of an adenosine agonist on infarct size reduction in patients undergoing primary percutaneous transluminal coronary angioplasty: the ADMIRE (AmP579 Delivery for Myocardial Infarction REduction) study

BACKGROUND

Evidence suggests that myocardial ischemic preconditioning and reperfusion injury may be mediated by adenosine A1 and A2 receptors. AMP579 is a mixed adenosine agonist with both A1 and A2 effects. In animal models of acute myocardial infarction (MI), AMP579 reduced infarct size at serum levels of 15 to 24 ng/mL.

METHODS

The AMP579 Delivery for Myocardial Infarction REduction study evaluated AMP579 in a double-blind, multicenter, placebo-controlled trial of 311 patients undergoing primary percutaneous transluminal coronary angioplasty (PTCA) after acute ST-segment elevation MI. Patients were randomly assigned to placebo or to 3 different doses of AMP579 continuously infused over 6 hours. The primary end point was final MI size measured by technetium Tc-99m sestamibi scanning at 120 to 216 hours after PTCA. Secondary end points included myocardial salvage and salvage index at the same time interval (in a subset of patients who underwent baseline technetium Tc-99m sestamibi scan), left ventricular ejection fraction and heart failure at 4 to 6 weeks, duration of hospitalization, and cardiac events at 4 weeks and 6 months.

RESULTS

Final infarct size did not differ among the placebo group and the active treatment groups for either anterior MI or nonanterior MI. In patients with anterior MI, median myocardial salvage was increasingly higher in the groups receiving ascending dosages of AMP579 plus PTCA. Serum levels approaching levels shown to reduce infarct size in animal models were achieved only in the 60-mcg/kg treatment group.

CONCLUSION

AMP579 was safe at the doses tested, but it did not reduce infarct size. There was a trend toward greater myocardial salvage in treated patients with anterior MI.

Immediate ambulation following diagnostic coronary angiography procedures utilizing a vascular closure device (The Closer)

OBJECTIVE

We investigated the safety and efficacy of The Closer, a suture-mediated vascular closure device, to facilitate immediate ambulation after diagnostic coronary angiography.

METHODS AND RESULTS

We identified 487 non-consecutive patients who were eligible for an immediate ambulation protocol following vascular closure after diagnostic coronary angiography. A total of 434 patients (89%) were allowed immediate ambulation (mean time, 6.3 +/- 2.4 minutes) and 34 patients (7%) were treated with intermediate duration bed rest (mean time, 105.2 +/- 55.3 minutes). Of the 34 patients treated with intermediate duration bed rest, ten had minor bleeding from the arterial access tract requiring 2 5 minutes of light compression and 24 were delayed secondary to physician preference. Nineteen patients (4%) failed to achieve hemostasis with The Closer. Outpatients were followed up at 24 hours, and inpatients were followed up the next morning. Four patients (0.8%) suffered recurrent femoral artery bleeds after initially successful vascular closure. Three recurrent bleeds occurred during the observation period in-hospital and one occurred 6 days after device deployment. At follow-up, no patients developed the following: hematoma > 4 cm, ipsilateral retroperitoneal bleed, arterio-venous fistula, pseudoaneurysm, access site infection or loss of distal pulses. No patients had lower extremity ischemia or required blood transfusion.

CONCLUSION

Use of The Closer after diagnostic angiography with subsequent immediate ambulation is safe and effective for most patients. Overall, hemostasis was achieved in 96% of patients, with 89% of our patients able to ambulate immediately and 7% able to ambulate after intermediate duration bed rest.

Frequency and correlates of coronary stent thrombosis in the modern era: analysis of a single center registry

OBJECTIVES

The study examined the frequency, correlates, and outcome of patients with stent thrombosis within 30 days of stent placement.

BACKGROUND

Patients in trials evaluating stents or dual antiplatelet therapy to prevent coronary stent thrombosis have generally had narrow inclusion criteria; the extent to which stent thrombosis rates in such trials represent current practice, particularly with the availability of newer stents, is unclear.

METHODS

We performed a retrospective analysis of the Mayo Clinic Percutaneous Coronary Intervention database and identified all patients who received at least one coronary stent and dual antiplatelet therapy (aspirin and ticlopidine or clopidogrel for two to four weeks).

RESULTS

Four thousand five hundred nine patients underwent successful coronary stent implantation and were treated with dual antiplatelet therapy between July 1, 1994, and April 30, 2000. Stent thrombosis occurred in 23 patients (0.51%; 95% confidence interval 0.32%, 0.76%) within 30 days of stent placement. Multivariate analysis using bootstrap model selection to avoid over-fitting the model indicated that only the number of stents placed was an independent correlate of stent thrombosis (odds ratio 1.80, p < 0.001). The frequency of death and frequency of nonfatal myocardial infarction (MI) among the 23 patients with stent thrombosis were 48% and 39%, respectively.

CONCLUSIONS

Stent thrombosis is even more rare in the current era than in earlier trials. Number of stents placed was an independent correlate of stent thrombosis. Most patients who suffer stent thrombosis either die or suffer MI.

Correlates of procedural complications and a simple integer risk score for percutaneous coronary intervention

OBJECTIVES

Our goals were to identify clinical and angiographic risk factors associated with major cardiovascular complications of percutaneous coronary intervention (PCI) (in-hospital death, Q-wave myocardial infarction, urgent or emergent coronary artery bypass surgery and stroke) and to construct a simple score for risk stratification.

BACKGROUND

Both clinical and angiographic features influence risk of PCIs.

METHODS

Percutaneous coronary interventions performed between January 1, 1996, and December 31, 1999, were analyzed. Logistic regression and bootstrap methods were used to create an integer risk score for estimating the risk of procedural complications using baseline, angiographic and procedural characteristics. The risk score was tested in a validation-set consisting of all procedures performed in the year 2000.

RESULTS

Among 5,463 procedures, 5 clinical and 3 angiographic variables were significantly correlated with procedural complications: cardiogenic shock, left main coronary artery disease, severe renal disease, urgent or emergent procedure, congestive heart failure class III or higher, thrombus, multivessel disease and older age. In the validation-set, the model fitted the data adequately; the average receiver operating characteristic curve area was 0.782 (standard deviation, 0.018).

CONCLUSIONS

Eight variables were combined into a convenient bedside risk scoring system that estimates the risk of complications after PCIs.

Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention

BACKGROUND

In patients undergoing percutaneous coronary intervention (PCI) in the modern era, the incidence and prognostic implications of acute renal failure (ARF) are unknown.

METHODS AND RESULTS

With a retrospective analysis of the Mayo Clinic PCI registry, we determined the incidence of, risk factors for, and prognostic implications of ARF (defined as an increase in serum creatinine [Cr] >0.5 mg/dL from baseline) after PCI. Of 7586 patients, 254 (3.3%) experienced ARF. Among patients with baseline Cr <2.0, the risk of ARF was higher among diabetic than nondiabetic patients, whereas among those with a baseline Cr >2.0, all had a significant risk of ARF. In multivariate analysis, ARF was associated with baseline serum Cr, acute myocardial infarction, shock, and volume of contrast medium administered. Twenty-two percent of patients with ARF died during the index hospitalization compared with only 1.4% of patients without ARF (P<0.0001). After adjustment, ARF remained strongly associated with death. Among hospital survivors with ARF, 1- and 5-year estimated mortality rates were 12.1% and 44.6%, respectively, much greater than the 3.7% and 14.5% mortality rates in patients without ARF (P<0.0001).

CONCLUSIONS

The overall incidence of ARF after PCI is low. Diabetic patients with baseline Cr values <2.0 mg/dL are at higher risk than nondiabetic patients, whereas all patients with a serum Cr >2.0 are at high risk for ARF. ARF was highly correlated with death during the index hospitalization and after dismissal.

The impact of renal insufficiency on clinical outcomes in patients undergoing percutaneous coronary interventions

OBJECTIVES

We sought to determine the effect of varying degrees of renal insufficiency on death and cardiac events during and after a percutaneous coronary intervention (PCI).

BACKGROUND

Patients with end-stage renal disease have a high mortality from coronary artery disease. Little is known about the impact of mild and moderate renal insufficiency on clinical outcomes after PCI.

METHODS

Cardiac mortality and all-cause mortality were determined for 5,327 patients undergoing PCI from January 1, 1994, to August 31, 1999, at the Mayo Clinic, based on the estimated creatinine clearance or whether the patient was on dialysis.

RESULTS

In-hospital mortality was significantly associated with renal insufficiency (p = 0.001). Even after successful PCI, one-year mortality was 1.5% when the creatinine clearance was > or =70 ml/min (n = 2,558), 3.6% when it was 50 to 69 ml/min (n = 1,458), 7.8% when it was 30 to 49 ml/min (n = 828) and 18.3% when it was < 30 ml/min (n = 141). The 18.3% mortality rate for the group with < 30 ml/min creatinine clearance was similar to the 19.9% mortality rate in patients on dialysis (n = 46). The mortality risk was largely independent of all other factors.

CONCLUSIONS

Renal insufficiency is a strong predictor of death and subsequent cardiac events in a dose-dependent fashion during and after PCI. Patients with renal insufficiency have more baseline cardiovascular risk factors, but renal insufficiency is associated with an increased risk of death and other adverse cardiovascular events, independent of all other measured variables.

Unrestricted availability of intracoronary stents is associated with decreased abrupt vascular closure rates and improved early clinical outcomes

The purpose of this study was to determine whether the unrestricted availability of intracoronary stents is affecting abrupt vascular closure rates and early clinical outcomes. Intracoronary stents have improved procedural outcome despite their application in more complex lesions, but the impact of unrestricted availability of stents on abrupt closure and early clinical outcomes is unknown. Two cohorts were identified retrospectively from a coronary intervention registry: patients treated between 1988 and 1992 (n = 3,617) when stents were not generally available, and patients treated between 1994 and 1997 (n = 4,518) when stents were freely available. The late cohort patients consisted of more females; it also had greater comorbidity and more complex presentation. However, there was a significant reduction in the abrupt closure rates between the two time periods (7% vs. 4%, P < 0.0001). After adjusting for female gender, thrombus, and lesion angulation, the late cohort remained significantly associated with decreased odds of abrupt closure (odds ratio [OR] = 0.62, 95% upper and lower confidence intervals [CI] = 0.52-0.75, P = 0.0001). The late cohort also had decreased in-hospital mortality (OR = 0.91, CI = 0.86-0.95, P = 0.0002) and major adverse clinical event (OR = 0.93, CI = 0.91-0.96, P = 0.0001). Unrestricted availability of intracoronary stents is associated with reduced abrupt closure rates and improved early clinical outcomes among patients undergoing coronary intervention despite treatment of high-risk patients.

The role of PCI and CABG in the management of coronary artery disease in patients with diabetes

The role of percutaneous coronary intervention (PCI) and coronary artery bypass surgery (CABG) in patients with diabetes mellitus (DM) is evolving. Data from clinical trials and observational studies are reviewed as well as current clinical practice guidelines. The importance of aggressive medical therapy to achieve recommended glycemic control targets, and management of usual risk factors in patients with coronary artery disease (CAD) cannot be overemphasized regardless of the revascularization therapy selected. Patients with type 2 diabetes are at increased risk for CAD, which is the cause of death in the majority of patients. Outcomes following PCI and CABG are worse in patients with DM compared to those without DM. This calls for randomized trials and other studies focused on patients with DM.

Hemorrhagic and vascular complications after percutaneous coronary intervention with adjunctive abciximab

OBJECTIVES

To examine the frequency and nature of hemorrhagic and peripheral vascular complications associated with use of abciximab during percutaneous coronary intervention and to characterize high-risk patients.

PATIENTS AND METHODS

We report the frequency and severity of bleeding and vascular complications recorded prospectively in 2,559 consecutive nonselected patients who underwent percutaneous coronary intervention at Mayo Clinic, Rochester, Minn, between July 1, 1996, and April 30, 1998, 831 of whom received abciximab and 1,728 did not. Abciximab and heparin were administered according to guidelines of the Evaluation of PTCA [percutaneous transluminal coronary angioplasty] to Improve Long-Term Outcome With Abciximab GP IIb/IIIa Blockade (EPILOG).

RESULTS

Patients who received abciximab were more likely to be men, were more often treated within 12 hours of an acute myocardial infarction, and were more likely to have received heparin after the procedure (8.7 % vs 4.5%, P<.001). Major bleeding occurred in 18 patients (2.4%) who received abciximab and in 10 patients (0.6%) who did not receive abciximab (P<.001). Minor bleeding occurred in 108 patients (14.3%) and in 92 patients (5.9%), respectively (P<.001). Both major bleeding and minor bleeding were more frequent among patients within 12 hours of an acute myocardial infarction and were more frequent if abciximab had been used. Multivariate analysis revealed that use of abciximab was independently associated with major and minor bleeding.

CONCLUSION

In this clinical setting, use of adjunctive abciximab during percutaneous coronary intervention was associated with a significantly increased risk of both major and minor bleeding.

Effect of abciximab on the outcome of emergency coronary artery bypass grafting after failed percutaneous coronary intervention

OBJECTIVE

To evaluate the outcome of coronary artery bypass grafting (CABG) for failed percutaneous coronary intervention (PCI) in patients who had received abciximab.

PATIENTS AND METHODS

In this retrospective study, we analyzed the records of patients who had PCI at our institution between January 1994 and December 1998 and identified those who had urgent or emergency CABG within 48 hours after PCI. CABG was performed for failed PCI in patients who had ongoing ischemia, hemodynamic compromise, or both. These patients were categorized into 2 groups depending on whether they had been given abciximab during PCI. We compared blood product transfusion requirements, bleeding complications, and frequency of in-hospital adverse events of the 2 groups.

RESULTS

Of 5636 patients who had PCI, 77 (1.4%) had urgent or emergency CABG within 48 hours, including 11 who were given abciximab (abciximab group) during PCI and 66 who were not given abciximab (no abciximab group). The 2 groups had similar baseline characteristics. The mean +/- SD time to surgery was 8.4 +/-8.0 hours (median, 6 hours) for the abciximab group vs 12.1 +/- 12.5 hours (median, 4 hours) for the no abciximab group. Major bleeding (Thrombolysis in Myocardial Infarction criteria) occurred in 9 (90%) of 10 patients in the abciximab group vs 48 (77%) of 62 patients in the no abciximab group. The total volumes of intraoperative autotransfusion and transfusion of red blood cells and fresh frozen plasma tended to be higher for the abciximab group. Also, this group received a mean of 13.9 U of platelets vs 3.2 U for the no abciximab group (P<.001). However, no in-hospital deaths occurred among patients in the abciximab group, and adverse events were infrequent and comparable between the 2 groups. No difference was noted between the 2 groups in the frequency of surgical reexploration for bleeding.

CONCLUSION

Transfusion requirements are higher for patients who undergo emergency or urgent CABG after having received abciximab during PCI. However, in-hospital adverse events are infrequent and comparable to those for patients who do not receive abciximab.

Alveolar hemorrhage as a complication of treatment with abciximab

STUDY OBJECTIVE

The use of abciximab, a chimeric monoclonal antibody Fab fragment specific for platelet glycoprotein IIb/IIIa receptors, is associated with improved outcome after angioplasty and stent placement. Major complications include bleeding, but pulmonary hemorrhage has been reported rarely. This study was done to identify patients with pulmonary hemorrhage following abciximab infusion and to define, if possible, any specific risk factors.

DESIGN

Retrospective review of institutional coronary angiography and bronchoscopy databases to identify patients who received abciximab and developed pulmonary hemorrhage.

SETTING

Tertiary-care teaching hospital.

PATIENTS

All patients who underwent coronary angiography and received abciximab between June 1995 and March 2000.

INTERVENTION

None.

MEASUREMENTS AND RESULTS

Seven of 2,553 patients (0.27%) had documented severe pulmonary hemorrhage associated with chest radiographic abnormalities, impaired oxygenation, and the need for blood product transfusions. The initial symptom was hemoptysis in four of the seven patients. There were two early deaths and one late death. No cases of pulmonary hemorrhage were identified in 5,412 patients who underwent coronary procedures without abciximab infusion. No other risk factors predicting hemorrhage were identified.

CONCLUSIONS

Severe pulmonary hemorrhage is a complication of abciximab use. Although hemoptysis is an important alerting symptom, it may not be present initially and the diagnosis may be missed or considered late, with the potential for inappropriate treatment until the diagnosis is established. Lesser degrees of bleeding are potentially easily missed, and this report should alert physicians to this complication so that it can be considered early in the evaluation of patients presenting with pulmonary events after abciximab use.

Infarct artery reocclusion after primary angioplasty, stent placement, and thrombolytic therapy for acute myocardial infarction

BACKGROUND

The benefits of thrombolytic therapy for acute myocardial infarction (AMI) are limited by reocclusion of the infarct-related artery, which occurs in 25% to 30% of patients after successful reperfusion. The frequency of reocclusion after balloon angioplasty and stenting in this setting is less well documented. The aim of this study was to analyze the frequency and timing of reocclusion after percutaneous transluminal coronary angioplasty (PTCA) and stent placement during AMI from all available studies compared with previously published reocclusion rates after thrombolysis.

METHODS AND RESULTS

The previously published thrombolysis data included 4231 patients in 19 studies with > or = 75 patients. Only PTCA studies with > or = 50 patients and stent studies with > or = 30 patients, in which routine angiographic follow-up was obtained in > or = 60% of patients, were included. Ten PTCA studies with a total of 1943 patients were analyzed, with follow-up angiography in 1391 (72%). Reocclusion rates ranged from 5% to 16.7%. The stent studies included 698 patients from 7 studies, with follow-up angiography in 92%. Reocclusion rates ranged from 0% to 6%. With the use of logistic regression analysis with allowance for overdispersion, there was a significantly lower rate of reocclusion after PTCA (odds ratio, 0.38; confidence interval, 0.24 to 0.57; P <.0001) and stent placement (odds ratio, 0.11; confidence interval, 0.05 to 0.22; P <.0001) compared with thrombolysis. Reocclusion after stent placement was lower than after PTCA (odds ratio, 0.28; confidence interval, 0.13 to 0.6; P <.0001).

CONCLUSIONS

Reocclusion after PTCA and stent placement during AMI is less frequent than after thrombolysis. This may contribute to the superior outcome of patients treated with PTCA and stent placement in this setting.

Evaluation of the coronary venous system using electron beam computed tomography

New therapeutic strategies in interventional cardiology and electrophysiology involve the coronary veins. This study examines the potential usefulness of electron beam computed tomography to obtain detailed noninvasive definition of the coronary venous anatomy and of arteriovenous relationships. Electron beam computed tomography allows acquisition and three-dimensional reconstruction of tomographic images of the beating heart with high spatial and temporal resolution. Contrast-enhanced, thin-section electron beam computed tomographic coronary arteriographic images of 34 patients (21 men and 13 women, age 60+/-10 years) were analyzed. The visibility of the coronary veins and their spatial relationship to the coronary arteries were assessed qualitatively on two- and three-dimensional displays. The coronary sinus was visible in 91%, the great cardiac vein in 100%, the middle cardiac vein in 88%, at least one vein overlying the lateral surface of the left ventricle in 97%, the anterior interventricular vein in 97%, and the small cardiac vein in 68%. A left marginal and a left posterior vein were seen in 44%, one of the two in 38%, and neither in 3%. The course of the anterior interventricular vein was parallel to the left anterior coronary artery in 79% and a crossover between the two vessels at an obtuse angle occurred in 12%. Contrast-enhanced electron beam computed tomography imaging of the heart noninvasively provides information on the coronary venous system and arteriovenous relationships that may help guide new interventional procedures.

Immediate and one-year outcome of intracoronary stent implantation in small coronary arteries with 2.5-mm stents

BACKGROUND

The role of coronary stenting in the treatment of stenoses in small coronary arteries with use of 2.5-mm stents is not well defined.

METHODS AND RESULTS

Between January 1995 and August 1999, 651 patients with stenoses in small coronary arteries were treated with 2.5-mm stents (n = 108) or 2.5-mm conventional balloon angioplasty (BA) (n = 543). Patients who received treatment with both 2.5-mm and > or =3.0-mm stent placement or balloons were excluded. Procedural success and complication rates as well as 1-year follow-up outcomes were examined. Baseline clinical characteristics were similar between the two groups, except patients in the stent group were more likely to have hypertension and a family history of coronary artery disease and less likely to have prior myocardial infarction. Angiographic success rates were higher in the stent group (97.2% vs 90.2%, P =.02). In-hospital complication rates were comparable between the two groups. Among successfully treated patients, 1-year follow-up revealed no significant differences in the survival (96.2% vs 95.2%, P =.89) or the frequency of Q-wave myocardial infarction (0% vs 0.4%, P =.60) or coronary artery bypass grafting (8.4% vs 6.8%, P =.89) between the stent and BA groups, respectively. However, patients in the stent group were more likely to have adverse cardiac events (35.4% vs 22.1%, P =.05). Stent use after excluding GR II stent use, however, was not independently associated with reduced cardiac events at follow-up (relative risk 1. 3 [95% confidence interval 0.8-2.3], P =.30).

CONCLUSIONS

Intracoronary stent implantation of stenoses in small coronary arteries with 2.5-mm stents can be carried out with high success and acceptable complication rates. However, compared with BA alone, stent use was not associated with improved outcome through 1 year of follow-up.

The PARAGON stent study: a randomized trial of a new martensitic nitinol stent versus the Palmaz-Schatz stent for treatment of complex native coronary arterial lesions

A new martensitic nitinol stent with improved flexibility and radiopacity was tested to evaluate whether these differences improve initial or long-term outcome. Patients who underwent percutaneous revascularization of a discrete native coronary lesion were randomly assigned to the new stent (PARAGON, n = 349) or to the first-generation Palmaz-Schatz (PS) stent (n = 339). The primary end point was target vessel failure at 6 months (a composite of cardiac or noncardiac death, any infarction in the distribution of the treated vessel, or clinically indicated target vessel revascularization). Secondary end points were, among others, device and procedural success and angiographic restenosis. Mean age was 62 years; diabetes was present in 21% of patients, prior bypass surgery in 6%, and recent infarction in 22% (p = NS for comparison between the 2 randomized arms). The PARAGON stent group had smaller reference vessels (2.97 vs 3.05 mm, p = 0.05), more prior restenosis (8.0% vs 4.5%, p = 0.07), and a longer average stent length (21.3 vs 19.4 mm, p < 0.05). Device success was significantly higher in the PARAGON arm (99.1% vs 94.3%, p < 0.05). Death and infarction at 6-month follow-up were infrequent in both groups. There was no significant difference in death (2.0% vs 1.2%, p = 0.546), but a higher rate of infarction for the PARAGON cohort (9.2% vs 4.7%, p = 0.025). Although target vessel failure (20.3% vs 12.4%, p = 0.005) and target lesion revascularization (12.0% vs 5.9%, p = 0.005) were higher in the PARAGON group, there was no significant difference in 6-month follow-up in in-stent minimal lumen diameter or in the rate of binary angiographic restenosis. Both PARAGON and PS stents are safe and associated with infrequent adverse events. The PARAGON stent can be delivered more frequently than the first-generation PS stent. Although there was no significant difference in in-stent minimal lumen diameter or the frequency of angiographic restenosis, clinical restenosis was more frequent in the PARAGON group.

Decreasing mortality with primary percutaneous coronary intervention in patients with acute myocardial infarction: the Mayo Clinic experience from 1991 through 1997

OBJECTIVE

To characterize and determine the overall impact of changes in primary percutaneous coronary intervention (PCI) on the clinical outcome of patients presenting within 24 hours of acute myocardial infarction (AMI).

PATIENTS AND METHODS

We retrospectively analyzed a prospective PCI registry for 1073 consecutive patients undergoing primary PCI for AMI at the Mayo Clinic in Rochester, Minn, from 1991 through 1997. The primary outcome measure was mortality from any cause within 30 days and 1 year.

RESULTS

The number of patients treated for AMI by primary PCI per year increased from 119 in 1991 to 193 in 1997. Intracoronary stent use increased from 1.7% in 1991 to 64.8% in 1997 (P < .001). This coincided with an increase in ticlopidine use from 3.6% in 1994 to 62.1% in 1997 (P < .001) and in abciximab use from 2.7% in 1995 to 63.2% in 1997 (P < .001). An increase in beta-blocker (58.3% to 75.3%; P < .001), angiotensin-converting enzyme inhibitor (0.9% to 40.0%; P < .001), and 3-hydroxy-3-methylglutaryl coenzyme A reductase use (1.9% to 40.5%; P < .001) as well as a decrease in calcium channel antagonist (34.3% to 8.4%; P < .001) use occurred on discharge. From 1991 through 1997, there was a significant decrease in the 30-day mortality rate (10.1% to 5.2%; P = .05). The 1-year mortality rate also decreased (13.4% in 1991 to 10.4% in 1997) (P = .09). After adjustment for other confounding variables, treatment in more recent years was associated with a significant decrease in death at 30 days (odds ratio, 0.89; 95% confidence interval, 0.79-1.00; P = .05) and during long-term follow-up (odds ratio, 0.93; 95% confidence interval, 0.87-1.00; P = .04).

CONCLUSIONS

Percutaneous coronary intervention methods of reperfusion for AMI, along with adjuvant pharmacotherapy, have changed over recent years and have been associated with improved short- and long-term survival.

Improving outcome over time of percutaneous coronary interventions in unstable angina

OBJECTIVE

This study was performed to evaluate the recent changes in the outcome of coronary interventions in patients with unstable angina (UA).

BACKGROUND

An early invasive strategy has not been shown to be superior to conservative treatment in patients with UA. Earlier studies had utilized older technology. Interventional approaches have changed in the recent past, but to our knowledge, no large studies have addressed the impact of these changes on the outcome of coronary interventions.

METHODS

We analyzed the in-hospital and intermediate-term outcome in 7,632 patients with UA who underwent coronary interventions in the last two decades. The study population was divided into three groups: group 1, n = 2,209 who had coronary intervention from 1979 to 1989; group 2, n = 2,212 with interventions from 1990 to 1993; and group 3, n = 3,211 treated from 1994 to 1998.

RESULTS

Group 2 and 3 patients were older and sicker compared with group 1 patients. The clinical success improved significantly in group 3 (94.1%) compared with group 2 (87%) and group 1 (76.5%) (p < 0.001). There was a significant reduction in in-hospital mortality, Q-wave myocardial infarction and need for emergency bypass surgery in group 3 compared with the earlier groups. One-year event-free survival was also significantly higher in the recent group compared with the earlier groups: 77% in group 3, 70% in group 2 and 74% in group 1 (p < 0.001). With the use of multivariate models to adjust for clinical and angiographic variables, treatment during the most recent era was found to be independently associated with improved in-hospital and intermediate-term outcomes.

CONCLUSIONS

There has been significant improvement in the in-hospital and intermediate-term outcome of coronary interventions in patients with UA in recent years; newer trials comparing conservative and invasive strategies are therefore needed.

Application of the New York State PTCA mortality model in patients undergoing stent implantation

BACKGROUND

This study applied the New York State conventional coronary angioplasty (PTCA) model of clinical outcomes to evaluate whether it has relevance in the current era of stent implantation. The model was developed in 62 670 patients treated with conventional PTCA from 1991 to 1994 to risk adjust mortality and bypass surgery after PTCA. Since then, stents have become the dominant form of intervention. Whether that model remains relevant is uncertain.

METHODS AND RESULTS

All patients undergoing stenting at the Mayo Clinic from 1995 to 1998 were analyzed for in-hospital mortality, bypass surgery performed after attempted stenting, and longer-term mortality. No patients were excluded. The New York model was used to risk adjust and predict in-hospital and follow-up mortality. There were 3761 patients with 4063 procedural admissions for stenting; 6,472 target vessel segments were attempted, and 96.1% of procedures were successful. With the New York multivariable risk factor equation, 79 in-hospital deaths were expected (1.95%); 66 deaths (1.62%) were observed. The New York model risk score in a logistic regression model was the most significant factor associated with in-hospital mortality (OR, 1.86; P<0.001). During a mean follow-up of 1.2+/-1.0 years, there were 154 deaths. Multivariable analysis documented 6 factors associated with subsequent mortality; New York risk score was the most significant (chi(2)=16.64, P=0.0001).

CONCLUSIONS

Although the New York mortality model was developed in an era of conventional angioplasty, it remains relevant in patients undergoing stenting. The risk score derived from that model is the variable most significantly associated with not only in-hospital but also longer-term outcome.

Prediction of death after percutaneous coronary interventional procedures

BACKGROUND

The prediction and comparison of procedural death after percutaneous coronary interventional procedures is inherently difficult because of variations in case mix and practice patterns. The impact of modern, expanded patient selection criteria, and newer technologic approaches is unknown. Our objective was to determine whether a risk equation based on patient-related variables and derived from an independent data set can accurately predict procedural death after percutaneous coronary intervention in the current era.

METHODS AND RESULTS

An analysis was made of the Mayo Clinic Coronary Interventional Database January 1, 1995, to October 31, 1997. Expected mortality rate was calculated with the use of the New York State multivariate risk score. In 3387 patients, 3830 procedures (55.1% stents) were performed, with an expected mortality rate of 2.32% and observed mortality rate of 2.38% (P = not significant). The risk score derived from the New York multivariate model was highly predictive of death (chi-square = 213.8; P <.0001). The presence of a high-risk lesion characteristic such as calcium, thrombus, or type C lesion was modestly associated with death.

CONCLUSIONS

The New York State multivariate model accurately predicted procedural death in our database.

Capacity of the low-photon-rate direct-detection optical pulse-position-modulation channel in the presence of noise photons

We derive expressions for the capacity of the pulse-position-modulated (PPM) direct-detection photon-counting channel in the presence of noise photons in addition to the signal-dependent shot noise that is normally considered in studying photon counting at low photon rates. We note that even a small mean number of noise photons per PPM count bin significantly decreases the capacity of the channel. These results are useful for comparisons of performance that are obtained by use of real coding and synchronization algorithms with photon-counting PPM schemes that are currently being considered for deep-space optical communications.

Immediate and long-term outcome of intracoronary stent implantation for true bifurcation lesions

OBJECTIVES

The aim of this study was to evaluate the immediate and long-term outcome of intracoronary stent implantation for the treatment of coronary artery bifurcation lesions.

BACKGROUND

Balloon angioplasty of true coronary bifurcation lesions is associated with a lower success and higher complication rate than most other lesion types.

METHODS

We treated 131 patients with bifurcation lesions with > or =1 stent. Patients were divided into two groups; Group (Gp) 1 included 77 patients treated with a stent in one branch and percutaneous transluminal coronary angioplasty (PTCA) (with or without atherectomy) in the side branch, and Gp 2 included 54 patients who underwent stent deployment in both branches. The Gp 2 patients were subsequently divided into two subgroups depending on the technique of stent deployment. The Gp 2a included 19 patients who underwent Y-stenting, and Gp 2b included 33 patients who underwent T-stenting.

RESULTS

There were no significant differences between the groups in terms of age, gender, frequency of prior myocardial infarction (MI) or coronary artery bypass grafting (CABG), or vessels treated. Procedural success rates were excellent (89.5 to 97.4%). After one-year follow-up, no significant differences were seen in the frequency of major adverse events (death, MI, or repeat revascularization) between Gp 1 and Gp 2. Adverse cardiac events were higher with Y-stenting compared with T-stenting (86.3% vs. 30.4%, p = 0.004).

CONCLUSIONS

Stenting of bifurcation lesions can be achieved with a high success rate. However, stenting of both branches offers no advantage over stenting one branch and performing balloon angioplasty of the other branch.

Immediate and late outcomes after direct stent implantation without balloon predilation

OBJECTIVES

The aim of our study was to compare the in-hospital and long-term clinical outcomes of direct coronary stenting with balloon predilation followed by stent placement.

BACKGROUND

With improvement in stent designs, the practice of direct stenting without balloon predilation has become more widespread.

METHODS

We analyzed the Mayo Clinic Coronary Intervention data base between January 1, 1995 and March 5, 1999 and identified 777 patients who were treated with direct stenting (DS) and 3,176 patients treated with balloon angioplasty plus stenting (BA+S).

RESULTS

The procedural success rates between the DS and BA+S groups were not significantly different (96.3% vs. 96.4%). The ability to deliver the stent in a subgroup of patients who had DS was 95%, with 5% requiring crossover to predilation. Multivariate analysis showed no significant differences with respect to in-hospital death (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.5 to 1.8), in-hospital myocardial infarction (OR 0.9, 95% CI 0.6 to 1.2) or revascularization (OR 0.7, 95% CI 0.4 to 1.5) in the DS compared with the BA+S group. Long-term outcomes were not significantly different between the DS and BA+S groups. The procedural duration was significantly shorter in the DS group, and there was a decreased utilization of contrast agent, balloons and wires.

CONCLUSIONS

The in-hospital and long-term clinical outcomes in patients undergoing a coronary intervention are equivalent when comparing stenting without balloon predilation with balloon angioplasty followed by stenting. Direct stenting is associated with decreased utilization of contrast agent and equipment and shorter procedure times. A randomized study should be performed to better determine the impact of this technique on short- and long-term procedural outcomes.

Effect of age on the outcome of angioplasty for acute myocardial infarction among patients treated at the Mayo Clinic

PURPOSE

Elderly patients, especially those 80 years of age and older, have been excluded from most studies of thrombolysis or primary coronary angioplasty in patients with acute myocardial infarction. We compared the outcomes of elderly patients who underwent coronary angioplasty with the outcomes of younger patients and determined whether there were any temporal trends in survival.

PATIENTS AND METHODS

We reviewed the outcomes of 1,597 consecutive patients who underwent primary coronary angioplasty between 1979 and 1997, including 127 patients who were 80 years of age or older (mean [+/-SD] age, 83 +/- 3 years, 47% male). Their in-hospital and long-term outcomes were compared with those of 524 patients who were 70 to 79 years old, 527 patients who were 60 to 69 years old, and 419 patients who were 50 to 59 years old. The oldest group of patients was divided into two groups, based on whether they had intervention through the end of 1993 (n = 56) or between 1994 and 1997 (n = 71). The survival rate of the patients who had no complications and left the hospital was compared with expected survival based on age- and sex-adjusted data.

RESULTS

Patients 80 years of age or older had more adverse baseline characteristics, including risk factors and comorbid conditions, than the younger patients. The clinical success rate of primary angioplasty in this group was lower than those in the other three groups (61% versus 74% in those aged 70 to 79 years, 73% in those aged 60 to 69 years, and 81% in those aged 50 to 59 years, P < 0.001). The in-hospital mortality rate among patients 80 years of age or older was significantly greater than among patients in the other three groups (21% in those aged 80 years or older, 13% in those aged 70 to 79 years, 9% in those aged 60 to 69 years, and 4% in those aged 50 to 59 years, P < 0.001 ). The clinical success rate of the angioplasty improved significantly in the more recent period (75% versus 45%, P = 0.0006) and in-hospital mortality declined (16% versus 29%, P = 0.07). During follow-up, mortality in the oldest age group in whom angioplasty was successful was significantly greater than in the three younger groups, but was similar to the expected survival in the general US population.

CONCLUSIONS

The mortality associated with primary angioplasty for acute myocardial infarction in octogenarians remains high, although there has been significant improvement in the clinical success rate. The long-term prognosis following a successful angioplasty is not different from that in an age- and sex-adjusted U.S. white population.

The iron (Fe) and atherosclerosis study (FeAST): a pilot study of reduction of body iron stores in atherosclerotic peripheral vascular disease

BACKGROUND

Levels of body iron stores, represented by the serum ferritin concentration, rise with age after adolescence in men and menopause in women. This rise has been implicated mechanistically and epidemiologically in the pathogenesis of atherosclerosis through iron-induced oxygen free radical-mediated lipid oxidation. However, the precise contribution of iron stores to atherosclerosis and its complications are unknown because prospective randomized trials designed to test effects of reduction of iron stores on clinical outcomes in this disease have not been performed.

METHODS AND RESULTS

In preparation for a prospective randomized trial, a randomized pilot study was conducted to evaluate the feasibility, safety, and methodologic accuracy of calibrated reduction in iron stores by phlebotomy in a cohort of patients with advanced peripheral vascular disease. Phlebotomy resulted in a significant reduction in serum ferritin concentration to near targeted levels. Thus the formula for calculating the volume of blood to be removed to achieve a predetermined decrement in serum ferritin concentration was accurate and phlebotomy was not associated with any adverse laboratory or clinical effects.

CONCLUSIONS

Reduction of body iron stores to a predetermined level is feasible and can be achieved in a timely manner with excellent patient compliance. Prospective randomized trials of calibrated reduction of body iron stores may be undertaken to define their pathophysiologic significance in atherosclerosis and other diseases in which excessive iron-induced oxidative stress has been implicated.

Clopidogrel versus ticlopidine after intracoronary stent placement

OBJECTIVES

The study compared the safety and efficacy of ticlopidine with clopidogrel in patients receiving coronary stents.

BACKGROUND

Stent thrombosis is reduced when ticlopidine is administered with aspirin. Clopidogrel is similar to ticlopidine in chemical structure and function but has fewer side effects; few data are available about its use in stent patients.

METHODS

We compared 30-day event rates in 500 consecutive coronary stent patients treated with aspirin and clopidogrel (300 mg loading dose immediately prior to stent placement, and 75 mg/day for 14 days) to 827 consecutive stent patients treated with aspirin and ticlopidine (500 mg loading dose and 250 mg twice daily for 14 days).

RESULTS

Patients treated with clopidogrel had more adverse clinical characteristics including older age, more severe angina, and more frequent infarction within the prior 24 h. Nonetheless, mortality was 0.4% in clopidogrel patients versus 1.1% in ticlopidine patients; nonfatal myocardial infarction occurred in 0% versus 0.5%, stent thrombosis in 0.2% versus 0.7%, bypass surgery or repeat angioplasty in 0.4% versus 0.5%, and any event occurred in 0.8% versus 1.6% of patients, respectively (p = NS). Based on the observed 30-day event rate of 1.6% with ticlopidine, the statistical power of the study was 43% to detect an even rate of 0.5% with clopidogrel, and 75% to detect an event rate with of 4% with clopidogrel, with a p value of 0.05.

CONCLUSIONS

These data indicate that clopidogrel can be safely substituted for ticlopidine in patients receiving coronary stents.

Clinical, angiographic, and procedural correlates of abrupt vascular closure during coronary intervention: a 10-year experience at Mayo Clinic

A large matched-cohort study was carried out to determine correlates of in-hospital abrupt vascular closure (AC). Univariate analysis identified current cigarette smoking (P = 0.021), myocardial infarction within 24 hr prior to procedure (P = 0.0035), emergency procedure (P = 0.02), lesion thrombus (P = 0.0001), and lesion angulation (P = 0.021) as significant clinical and angiographic variables. Relative to balloon angioplasty (PTCA), use of atherectomy (P = 0.015) and laser devices (P = 0.018) but not elective stent placement (P = 0.97) were associated with increased risk of AC. In the multivariate model, current cigarette smoking (P = 0.0474), lesion thrombus (P = 0.0001), lesion angulation (P = 0.0124), use of atherectomy devices (P = 0.001), and laser devices (P = 0.0037) remained as significant correlates of increased AC events. In conclusion, the risk of AC appears associated primarily with lesion characteristics and use of nonballoon devices other than stents. Elective stent placement did not appear to reduce AC risk over conventional PTCA; the small number of patients studied may have prevented any benefit from being observed.