Complete Revascularization with Multivessel PCI for Myocardial Infarction

Should fractional flow reserve follow angiographic visual inspection to guide preventive percutaneous coronary intervention in ST-elevation myocardial infarction?

Aims

We aimed to quantify the effect of preventive percutaneous coronary intervention (PCI to non-infarct arteries) on cardiac death and non-fatal myocardial infarction (MI) in patients with ST-elevation myocardial infarction (STEMI) according to whether the decision to carry out preventive PCI was based on angiographic visual inspection (AVI alone) or AVI plus fractional flow reserve (FFR) if AVI showed significant stenosis (AVI plus FFR).

Methods and results

Randomized trials comparing preventive PCI with no preventive PCI in STEMI without shock were identified by a systematic literature search and categorized according to whether they used AVI alone or AVI plus FFR to select patients for preventive PCI. Random effects meta-analyses and tests of heterogeneity were used to compare the two categories in respect of cardiac death and MI as a combined outcome and individually. Eleven eligible trials were identified. For cardiac death and MI, the relative risk estimates for AVI alone vs. AVI plus FFR were 0.39 (0.25–0.61) and 0.85 (0.57–1.28), respectively (P = 0.01 for difference), for cardiac death, alone the estimates were 0.36 (0.19–0.71) and 0.79 (0.36–1.77), respectively (P = 0.15 for difference), and for MI alone, 0.41 (0.23–0.73) and 0.98 (0.62–1.56), respectively (P = 0.04 for difference).

Conclusion

In preventive PCI among STEMI patients, AVI alone achieves a ∼60% reduction in cardiac death and MI but selecting patients using FFR in AVI positive patients loses much of the benefit. Angiographic visual inspection is best used without FFR in this group of patients.

A risk score based on simple angiographic characteristics to aid in choosing the optimal revascularization strategy for patients with multivessel disease presenting with ST-elevation myocardial infarction

BACKGROUND

The optimal revascularization strategy is not clearly defined for patients with ST-elevation myocardial infarction with multivessel disease (MV-STEMI). We aimed to develop a simple angiographic risk score for identifying patients with MV-STEMI that might benefit from a multivessel percutaneous coronary intervention (MV-PCI), compared to a PCI for only the infarct-related artery (IRA-PCI).

METHODS AND RESULTS

This retrospective study acquired data from a single-center STEMI registry on 841 consecutive patients with MV-STEMI (645 IRA-PCI and 196 MV-PCI). Patients were stratified according to high- and low-risk scores. We devised a score based on three characteristics of non-culprit lesions previously reported to predict overall mortality (proximal left anterior descending artery involvement, maximal % stenosis, and number of involved vessels). The primary endpoint was major adverse cardiac events (MACEs: a composite of death/MI/urgent repeat revascularization). After a median follow-up of 1909 days, MACE occurred in 205/841 (24.4%) patients. MACE risk was higher in the high-risk than in the low-risk group (HR 1.43, P < 0.001). In comparing the IRA-PCI and MV-PCI approaches within each risk group, we found that these revascularization strategies had differential effects on outcome. Compared to the MV-PCI, IRA-PCI was associated with less MACE in the low-risk group (HR 0.597, P = 0.033), and more MACE in the high-risk group (HR 3.14, P < 0.001).

CONCLUSION

For patients with MV-STEMI that undergo primary PCI, a simple risk score based on three angiographic characteristics could identify patients at high risk of future adverse events. This score might facilitate choosing the optimal revascularization strategy.

Complete Revascularization in Patients With STEMI and Multi-Vessel Disease: A Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Percutaneous coronary intervention (PCI) is the treatment of choice for ST-elevation myocardial infarction (STEMI). However, efficacy of complete vs culprit only revascularization in patients with STEMI and multivessel disease remains unclear.

METHODS

We searched PubMed/MEDLINE, and Cochrane library. The primary endpoint was major adverse cardiovascular events (MACE). Secondary outcomes were all-cause mortality, cardiovascular mortality, myocardial infarction (MI), repeat revascularization, stroke, major bleeding, and contrast induced nephropathy. Estimates were calculated as random effects hazard ratios (HRs) with 95% confidence intervals (CI).

RESULTS

Twelve trials with 7592 patients were included. There was a significantly lower risk of MACE [HR 0.61; 95% CI (0.43-0.60); p = 0.0009; I² = 72%], cardiovascular mortality [HR 0.74; 95% CI (0.56-0.99); p = 0.04; I² = 2%], and repeat revascularization [HR 0.43; 95% CI (0.31-0.59); p < 0.00001; I² = 67%] in patients treated with complete compared with culprit-only revascularization. There was no statistically significant difference in MI [HR 0.77; 95% CI (0.52-1.12); p = 0.17; I² = 49%], all-cause mortality [HR 0.86; 95% CI (0.65-1.13); p = 0.28; I² = 14%], heart failure [HR 0.82 95% CI (0.51-1.32); p = 0.42; I² = 26%], major bleeding [HR 1.07; 95% CI (0.66-1.75); p = 0.78; I² = 25%], stroke [HR 0.67; 95% CI (0.24-1.89); p = 0.45; I² = 54%], or contrast induced nephropathy, although higher contrast volumes were used in the complete revascularization group [HR 1.22; 95% CI (0.78-1.92); p = 0.39; I² = 0%].

CONCLUSION

Complete revascularization was associated with a significantly lower risk of MACE, cardiovascular mortality, and repeat revascularization compared with culprit-only revascularization. These results suggest complete revascularization with PCI following STEMI and multivessel disease should be considered.

Rationale and design of the Flow Evaluation to Guide Revascularization in Multivessel ST-Elevation Myocardial Infarction (FLOWER-MI) trial

BACKGROUND

In ST-elevation myocardial infarction (STEMI) patients presenting with multivessel disease (MVD), recent studies have demonstrated the superiority of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) for non-culprit lesions compared to culprit lesion treatment-only therapy. FFR- and angio-guided PCI have however never been compared in STEMI patients.

TRIAL DESIGN

FLOWER-MI is an open-label multicenter national randomized clinical trial. The aim is to investigate FFR-guided complete revascularization in comparison to angio-guided complete revascularization in STEMI patients with successful PCI of the culprit lesion and ≥50% stenosis in at least one additional non-culprit lesion requiring PCI. Eligible patients will be randomized after successful primary PCI in a 1:1 fashion to either FFR-guided or angio-guided complete revascularization during the index procedure or a staged procedure before discharge (≤5 days). Patients assigned to FFR guidance first have FFR measured in each non-culprit vessel and only undergo PCI if FFR is ≤0.80. The primary end point of the study is a composite of major adverse cardiac events, including all-cause death, non-fatal MI, and unplanned hospitalization leading to urgent revascularization at 1 year. Secondary end points will include the individual adverse events, cost-effectiveness, quality of life, and 30-day, 6-month, and 3-year outcomes. Based on estimated event rates, a sample size of 1170 patients is needed to show superiority of the FFR-guided revascularization with 80% power.

CONCLUSION

The aim of FLOWER-MI trial is to assess whether FFR-guided complete revascularization in the acute setting is superior angio-guided complete revascularization.

Effect of thrombus aspiration on microcirculatory resistance and ventricular function in patients with high thrombus burden

Background

Studies have not demonstrated consistent outcomes following thrombus aspiration in Primary Percutaneous Coronary Intervention (PPCI). We investigated the relationship between thrombus aspiration and microvascular obstruction as measured using Index of Microcirculatory Resistance (IMR) immediately following PPCI and Left Ventricle Function Improvement measured using Global Longitudinal Strain (GLS) six months following PPCI. Our aim is to determine microvascular obstruction and left ventricle function improvement six months following thrombus aspiration during PPCI.

Methods

This was a single-center, observational, prospective non-randomized study involving 45 patients with thrombus score 4–5 (defined as high thrombus burden) and Thrombolysis in Myocardial Infarction (TIMI) flow of 0–2 who subsequently underwent PPCI. Thrombus aspiration was conducted based on physician discretion. The IMR was measured immediately following the procedure. All patients underwent echocardiography to measure GLS at 24 h, 3 months and 6 months following PPCI.

Results

Thirty-three (73%) patients underwent thrombus aspiration during PPCI and twelve (27%) patients underwent the conventional PPCI. No significant difference in IMR was found between the group that underwent thrombus aspiration and the group that underwent conventional PCI (51.9 ± 41.5 vs 47.1 ± 35.6 p = 0.723). TIMI flow after PPCI was worse in thrombus aspiration group (OR 5.2 [1.2–23.2], p = 0.041). There was no difference in GLS between two groups at 6-month follow-up (− 13.0 ± 3.4 vs − 12.8 ± 4.6, p = 0.912).

Conclusion

This study indicates no benefit of thrombus aspiration during PPCI in reducing either microvascular obstruction or left ventricular function at 6-month follow-up for patients with high thrombus burden. Nevertheless, further studies are required before definite conclusions can be made.

Noninvasive detection of coronary artery stents by transthoracic echocardiography postprocessing subtraction technique

AIM

To explore the feasibility and value of transthoracic echocardiography (TTE) postprocessing subtraction technique in the detection of a stent in the coronary artery.

METHOD

Transthoracic echocardiography was used to examine 46 coronary artery stents in 30 patients by two-dimensional ultrasound postprocessing subtraction technique. The shape of each stent and its flow patency were observed. The patency was assessed according to blood flow and mosaic flow in the stent. Then, the results were compared with those of percutaneous coronary intervention (PCI) records and coronary angiography (CAG).

RESULTS

Transthoracic echocardiography detected 36 stents among 46 stents (two in the LMCA, 23 in the LAD, seven in the RCA, and two in the LCX); the detection rate was 78.3%. The average length of the stents was 21.8 ± 4.1 mm, and the average diameter was 2.4 ± 0.5 mm; both are shorter than those from PCI records (P < .001). Of the 36 stents, blood flow could be observed in 27. Compared with the results of CAG, TTE had 75% feasibility and 92.6% accuracy in detecting flow patency in the stents.

CONCLUSION

Transthoracic echocardiography postprocessing subtraction technique could be a noninvasive method for detecting a coronary artery stent and, although the measurements of stent length and diameter were shorter than those of PCI records, an accurate detection of flow patency in the stents was achieved.

Residual SYNTAX Score and One-Year Outcome in Elderly Patients With Acute Coronary Syndrome

Background

The residual burden of coronary artery disease after percutaneous coronary intervention (PCI) has been associated with worse ischemic outcome. However, data are conflicting in elderly patients. The aim of our study was to verify the incremental value of the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (rSS) over clinical variables and baseline SYNTAX score (bSS) in predicting 1-year mortality or cardiovascular events.

Methods

A post hoc analysis of data collected in the Elderly-ACS 2 multicenter randomized trial was performed. We included 630 patients aged > 75 years with multivessel coronary disease undergoing PCI for acute coronary syndrome (ACS). The primary outcome was a composite of death, recurrent myocardial infarction, and stroke at 1-year follow up. Change in c-statistic and standardized net benefit were used to evaluate the incremental value of the rSS.

Results

Event rates were significantly higher in patients with incomplete revascularization (rSS > 8). When the rSS was included in a core Cox regression model containing age, previous myocardial infarction, and ACS type, the hazard ratio for patients with score values > 8 was 2.47 (95% confidence interval, 1.51-4.06). However, the core model with rSS did not increase the c-statistic compared with the core model with the bSS (from 0.69 to 0.70) and gave little incremental value in the standardized net benefit.

Conclusions

In elderly patients with ACS with multivessel disease undergoing PCI, incomplete revascularization was associated with worse outcome at 1-year follow-up. However, there was no clear incremental value of the rSS in the prediction of 1-year adverse outcome compared with a model including clinical variables and bSS.

[The Role of Residual Stenosis of the Coronary Arteries in the Dynamics Systolicdiastolic Left Ventricular Function after Acute Coronary Syndrome]

OBJECTIVE

The aim of the research under consideration was to study the dynamics of a local systolic-diastolic function of patients with various ischemic heart disease (IHD) progressions after survival of an acute coronary syndrome (ACS) provided there are residual stenoses of coronary arteries.

MATERIALS AND METHODS

 There were 112 patients suffering from ACS who took part in the research. The diagnosis was verified (acute myocardial infarction or unstable angina) in accordance with the recommendations of European Society of Cardiology (ESC). All patients were divided into two groups depending on the occurrence of major acute cardiac events (MACE): 59 patients with aggravated IHD progression and 152 patients with non-aggravated course. Echo-cardiography was performed on a scanner Philips iE33 (the Netherlands) with a consideration to systolic and diastolic functions parameters of a left ventricle. Quantitative analysis of the left ventricle was executed in the mode of Tissue Doppler Imaging (TDI) and according to the method of tracing the patches of the ultra-sound image gray scale (ST).

RESULTS

In the course of the aggravated IHD a decrease in systolic-diastolic function of left ventricle has been discovered. It has been found out that the amount of the systolic peak of longitudinal strain of the left ventricle anteroseptal wall less than 12% is associated with a greater extent of coronary atherosclerosis and aggravated progression of IHD. TDI and ST methods have enabled to reveal that in the course of non-aggravated IHD the contractility and the diastolic function of the left ventricle anteroseptal wall improve in combination with the increase in the contractility of the left ventricle inferolateral wall. During an aggravated IHD progression the contractility and diastolic function of the left ventricle anteresoptal wall decreases without an increase in contractility and diastolic function of the inferior and inferolateral walls of the left ventricle. The reason for such results might be a progressing myocardial ischemia of the left ventricle anteroseptal wall despite the sufficient anterior interventricular artery stenting. The presence of the relevant residual stenoses of the circumflex and right coronary arteries increases the possibility of the aggravated IHD progressing especially by the end of the fourth year of observation.

CONCLUSION

The disbalance of the local contractility of anterior, inferior and inferolateral left ventricle walls in the course of aggravated IHD is connected with the CA residual stenoses presence and forwards the decrease in global systolic-diastolic function of the left ventricle. The final results can serve as a foundation for optimization of recommendations for performing PCI on the patients with multivessel disease of CA.

Determining the Significance of Coronary Plaque Lesions: Physiological Stenosis Severity and Plaque Characteristics

The evaluation of coronary lesions has evolved in recent years. Physiologic-guided revascularization (particularly with pressure-derived fractional flow reserve (FFR)) has led to superior outcomes compared to traditional angiographic assessment. A greater importance, therefore, has been placed on the functional significance of an epicardial lesion. Despite the improvements in the limitations of angiography, insights into the relationship between hemodynamic significance and plaque morphology at the lesion level has shown that determining the implications of epicardial lesions is rather complex. Investigators have sought greater understanding by correlating ischemia quantified by FFR with plaque characteristics determined on invasive and non-invasive modalities. We review the background of the use of these diagnostic tools in coronary artery disease and discuss the implications of analyzing physiological stenosis severity and plaque characteristics concurrently.

Predictors of In-Hospital Adverse Outcomes after Rotational Atherectomy: Impact of the Target Vessel SYNTAX Score

BACKGROUND

Rotational atherectomy (RA) is an established treatment of calcified lesions, but has some inherent procedural hazards. However, predictors of in-hospital adverse outcomes after RA are poorly investigated.

OBJECTIVE

To explore the predictors of in-hospital adverse outcomes after RA and to introduce the target vessel SYNTAX score (tvSS) as a potential causal variable.

METHODS

Patients who underwent RA at our center (n = 323) were divided into two groups according to the occurrence of in-hospital adverse outcomes (a composite of residual stenosis ≥30%, persistent slow flow, dissection requiring additional stenting beyond the primary lesion, perforation, burr entrapment, and in-hospital major adverse cardiac events [MACE]).

RESULTS

In-hospital adverse outcomes were more frequent in patients with severely-tortuous target vessels or lesions >20 mm, while aorto-ostial and bifurcation lesions, as well as chronic total occlusion rates, were equally distributed among patients with and without adverse outcomes. TvSS was 18 [13-24] vs. 12 [8-17] in patients with vs. without in-hospital adverse outcomes (p < 0.001). A tvSS cut-off value of 15 showed 73% sensitivity and 62% specificity for predicting in-hospital adverse outcomes. TvSS emerged as an independent predictor for in-hospital adverse outcomes along with bailout RA and reduced left ventricular ejection fraction (LVEF). However, after one year, the occurrence of in-hospital adverse outcomes was not associated with an increase in the MACE rate (log-rank p = 0.857).

CONCLUSION

In-hospital adverse outcomes are higher in patients with more complex target vessel anatomies as indicated by a higher tvSS. Bailout RA and reduced LVEF emerged as additional predictors of in-hospital adverse outcomes.

Effects of Percutaneous Coronary Intervention on Death and Myocardial Infarction Stratified by Stable and Unstable Coronary Artery Disease: A Meta-Analysis of Randomized Controlled Trials

Supplemental Digital Content is available in the text.

In patients presenting with ST-segment–elevation myocardial infarction, percutaneous coronary intervention (PCI) reduces mortality when compared with fibrinolysis. In other forms of coronary artery disease (CAD), however, it has been controversial whether PCI reduces mortality. In this meta-analysis, we examine the benefits of PCI in (1) patients post–myocardial infarction (MI) who did not receive immediate revascularization; (2) patients who have undergone primary PCI for ST-segment–elevation myocardial infarction but have residual coronary lesions; (3) patients who have suffered a non–ST-segment–elevation acute coronary syndrome; and (4) patients with truly stable CAD with no recent infarct. This analysis includes data from the recently presented International Study of Comparative Health Effectiveness with Medical and Invasive Approaches (ISCHEMIA) and Complete versus Culprit-Only Revascularization Strategies to Treat Multivessel Disease after Early PCI for STEMI (COMPLETE) trials.

Meta-Analysis Comparing Complete Versus Infarct-Related Artery Revascularization in Patients With ST-Elevation Myocardial Infarction and Multivessel Coronary Disease

A strategy of complete revascularization (CR) versus infarct-related artery revascularization (IRA) in patients with ST-elevation myocardial infarction (STEMI) continues to be a subject of debate. We performed an updated meta-analysis to compare the 2 strategies. Outcomes of interest included major adverse cardiovascular events (MACE), cardiovascular mortality, all-cause mortality, stroke, repeat revascularization, myocardial infarction, and contrast-induced nephropathy. Ten randomized trials including 7,423 patients (CR = 3,574 and IRA = 3,849), with a follow-up of 2.0 ± 0.8 years were included. There was a significant reduction in MACE with CR versus IRA (10.7% vs 18.6%, relative risk [RR] 0.64, 95% confidence interval [CI] 0.51 to 0.81, p = 0.002, I² = 66%), with higher risk reduction with immediate versus stages revascularization (RR 0.40, 95% CI 0.32 to 0.5 vs RR 0.69, 95% CI 0.54 to 0.89, P-interaction = 0.002). Complete revascularization was associated with lower rates of repeat revascularization (4.0% vs 11.7%, RR 0.44, 95% CI 0.28 to 0.70, p <0.0001, I² = 81%), and a nonsignificant trend toward lower cardiovascular mortality (2.8% vs 3.7%, RR 0.78, 95% CI 0.60 to 1.03, p = 0.08, I² = 0%). However, there was no difference between the 2 strategies in all-cause mortality (4.6% vs 4.8%, RR 0.90, 95% CI 0.73 to 1.12, p = 0.36, I² = 0%), myocardial infarction (5.2% vs 6.5%, RR 0.73, 95% CI, 0.58 to 1.08, p = 0.08, I² = 30%), stroke (1.5% vs 1.2%, RR 1.14, 95% CI 0.56 to 2.29, p = 0.33, I² = 14%), or contrast-induced nephropathy (1.6% vs 1.2%, RR 1.35, 95% CI 0.85 to 2.15, p = 0.78, I² = 0%). In conclusion, CR in patients with STEMI is associated with significant reduction in MACE compared with IRA. This reduction is derived mainly by the low rates of repeat revascularization in the CR group.

Long-term outcome after thrombus aspiration in non-ST-elevation myocardial infarction: results from the TATORT-NSTEMI trial : Thrombus aspiration in acute myocardial infarction

AIMS

To investigate the long-term prognostic value of aspiration thrombectomy in conjunction with primary percutaneous coronary intervention (PCI) compared to conventional PCI in patients with non-ST-elevation myocardial infarction (NSTEMI).

METHODS

In the randomized TATORT-NSTEMI (Thrombus aspiration in thrombus containing culprit lesions in non-ST-elevation myocardial infarction) trial, NSTEMI patients with thrombus containing culprit lesions were randomized to either PCI with aspiration thrombectomy or conventional PCI. The endpoint was a combination of all-cause death, reinfarction and new congestive heart failure.

RESULTS

From 440 patients initially randomized, outcome data were available in 432 (98.2%) patients at a median follow-up of 4.9 (interquartile range [IQR] 4.4-5.0) years. Thrombectomy was associated with a significant reduction of the combined endpoint compared to conventional PCI (19.9% vs. 30.7%, p = 0.01). This finding was primarily driven by a reduced rate of reinfarction with thrombectomy (3.4% vs. 10.3%, p = 0.01). Thrombectomy was still independently associated with the combined endpoint after multivariable adjustment (hazard ratio [HR] 0.47, 95% confidence interval [CI] 0.30-0.76, p = 0.002). Findings were consistent across all analyzed subgroups (p values for interaction all > 0.05).

CONCLUSIONS

In NSTEMI, thrombus aspiration is associated with favorable clinical outcome during long-term follow-up.

CLINICAL TRIAL REGISTRATION

NCT01612312.

Complete Revascularization of Multivessel Coronary Artery Disease Does Not Improve Clinical Outcome in ST-Segment Elevation Myocardial Infarction Patients with Reduced Left Ventricular Ejection Fraction

The benefit of complete revascularization (CR) in ST-segment elevation myocardial infarction (STEMI) patients with left ventricular (LV) dysfunction is uncertain. A total of 1314 STEMI patients with multivessel coronary artery disease were analyzed. CR was defined angiographically and by a residual Synergy between PCI with Taxus and Cardiac Surgery trial (SYNTAX) score (SS) <8. Patients with a left ventricular ejection fraction (LVEF) <40% were classified as the reduced LVEF group. The major study endpoints were patient-oriented composite outcome (POCO) and cardiac death during three-year follow-up. Overall, patients that received angiographic CR (579 patients, 44.1%) had significantly lower three-year clinical events compared with incomplete revascularization (iCR). CR reduced three-year POCO and cardiac death rates in the preserved LVEF group (POCO: 13.2% vs. 21.9%, p < 0.001, cardiac death: 1.8% vs. 6.5%, p < 0.001, respectively) but not in the reduced LVEF group (POCO: 26.0% vs. 33.1%, p = 0.275, cardiac death: 15.1% vs. 19.0%, p = 0.498, respectively). Multivariate analysis showed that CR significantly reduced three-year POCO (hazard ration (HR) 0.59, 95% confidence interval (CI) 0.43–0.82) and cardiac death (HR 0.34, 95% CI 0.14–0.80), only in the preserved LVEF group. Additionally, the results were corroborated using the SS-based CR definition. In STEMI patients with multivessel disease, CR did not improve clinical outcomes in those with reduced LVEF.

Physiological Assessment of Coronary Lesions in 2020

PURPOSE OF REVIEW

Physiological assessment of coronary artery disease (CAD) is an essential component of the interventional cardiology toolbox. However, despite long-term data demonstrating improved outcomes, physiology-guided percutaneous coronary intervention (PCI) remains underutilized in current practice. This review outlines the indications and technical aspects involved in evaluating coronary stenosis physiology, focusing on the latest developments in the field.

RECENT FINDINGS

Beyond fractional flow reserve (FFR), non-hyperemic pressure ratios (NHPR) that assess coronary physiology at rest without hyperemia now abound. Additional advances in other alternative FFR approaches, including non-invasive coronary CT (FFR_CT), invasive angiography (FFR_angio), and optical coherence tomography (FFR_OCT), are being realized. Artificial intelligence algorithms and robust tools that enable detailed pre-procedure "virtual" intervention are also emerging. The benefits of coronary physiological assessment to determine lesion functional significance are well established. In addition to stable CAD, coronary physiology can be especially helpful in clinical scenarios such as left main and multivessel CAD, serial lesions, non-infarct-related arteries in acute coronary syndromes, and residual ischemia post-PCI. Today, coronary physiological assessment remains an indispensable tool in the catheterization laboratory, with an exciting technological future that will further refine clinical practice and improve patient care.

ST-elevation Myocardial Infarction and Multivessel Coronary Artery Disease – A Critical Review of Current Practice, Evidence and Meta-analyses

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The Impact of Kinase Insert Domain (KDR) Gene Polymorphism rs2305948 on Clopidogrel Resistance in Iraqi Patients Undergoing Elective Percutaneous Coronary Intervention (PCI)

Introduction:

Clopidogrel, the first-choice antiplatelet agent for patient undergoing Percutaneous Coronary Intervention (PCI) along with Aspirin. Clopidogrel resistance is one of the major obstacles that cause MACE and failure of PCI. Kinase Insert Domain (KDR) gene responsible for VEGFR2 coding, the major receptor that translates VEGF ligand. The rs2305948 SNP in VEGFR2 gene has been documented to be involved atherogenesis and in CAD pathogenesis.

Aim:

To study the impact of KDR gene polymorphism rs2305948 on clopidogrel resistance in patients undergoing elective PCI.

Methods:

A case control study with 324 patients documented for elective PCI whom divided according to platelet aggregation level measured into (CR) with 111patients and (NCR) that consists of 213 patients. Serum lipids and VEGFR2 levels, BMI and platelet count were measured. Genotype for rs2305948 was done by PCR-RFLP.

Results:

Allele frequency and genotype results indicate a significant association with the pathogenesis of CR in all models in CR group compared to NCR group, a significant correlation for T allele with LDL, cholesterol and serum VEGFR2 in dominant and co-dominant models. RFLP-PCR results were documented by gene sequencing and results were compatible with HWE.

Conclusion:

rs2305948 SNP is associated with occurrences of CR and have an influence in the development of other metabolic changes.

Revascularization strategies for patients with myocardial infarction and multi-vessel disease: A critical appraisal of the current evidence

Approximately half of patients presenting with myocardial infarction are found to have non-infarct related multi-vessel severe coronary artery disease. Various observational studies and randomized controlled trials have been conducted to assess if revascularization of non-infarct related artery is associated with better clinical outcomes. In this review, the authors discuss the various revascularization strategies in patients with multi-vessel disease who present with myocardial infarction.