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The use of drug-eluting stents in acute myocardial infarction - is the battle coming to an end? From despair to acceptance. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2014; 9:50-4. [PMID: 24570691 PMCID: PMC3915954 DOI: 10.5114/pwki.2013.34028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 12/28/2012] [Accepted: 01/21/2013] [Indexed: 11/17/2022] Open
Abstract
The large-scale use of drug-eluting stents (DES) in elective percutaneous coronary interventions resulted in a significant reduction of restenosis and the need for repeat revascularization, compared to bare-metal stents (BMS) and balloon angioplasty. The position of DES used during primary percutaneous coronary intervention was not so well established. Based on the trials including the general population of patients, an increased risk of stent thrombosis was indicated, particularly late after implantation, which may be associated with increased mortality. A number of randomized clinical trials have compared first generation DES with BMS in acute ST-segment elevation myocardial infarction (STEMI). In most of them increased mortality after DES implantation was not confirmed, with demonstrated reduction of repeat revascularizations. However, long-term follow-up of these studies and the results from non-randomized “real world” registries are equivocal. A new generation of DES has been present on the market for several years. They have modern designs, are covered with more neutral polymers and release new drugs. The new generation DES have a better safety and efficacy profile, including a population of patients with acute STEMI, than the first generation stents. This paper is a review of randomized controlled trials, meta-analyses and registries, comparing DES with BMS in patients with acute STEMI. Attention was drawn to the current position and the role of new generation DES, which may prove to be a safe and effective choice in this population of patients.
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Kikkert WJ, Hoebers LP, Damman P, Lieve KVV, Claessen BEPM, Vis MM, Baan J, Koch KT, de Winter RJ, Piek JJ, Tijssen JGP, Henriques JPS. Recurrent myocardial infarction after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am J Cardiol 2014; 113:229-35. [PMID: 24188893 DOI: 10.1016/j.amjcard.2013.08.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 08/28/2013] [Accepted: 08/28/2013] [Indexed: 11/19/2022]
Abstract
The determinants and prognostic value of recurrent myocardial infarction (MI) in a contemporary cohort of ST-segment elevation MI patients treated with primary percutaneous coronary intervention (PPCI) and stenting are currently unknown. We investigated the predictors and prognostic impact of recurrent MI on subsequent clinical outcome in 1,700 ST-segment elevation MI patients treated with PPCI and stenting between January 1, 2003, and July 31, 2008. Two hundred forty patients had a recurrent MI during a median follow-up of 4 years and 7 months (Kaplan Meier estimate 21.2%). By multivariable analysis, recurrent MI was associated with a higher risk of subsequent cardiac mortality (hazard ratio [HR] 6.86, 95% confidence interval [CI] 4.24 to 8.72), noncardiac mortality (HR 2.02, 95% CI 1.10 to 3.69), stroke (HR 3.68, 95% CI 2.02 to 6.72), and Global Use of Strategies to Open Occluded Coronary Arteries criteria severe or moderate bleeding (HR 3.17, 95% CI 1.79 to 5.60). Early recurrent MI (within 1 day of the initial PPCI) was associated with higher unadjusted cardiac mortality rates (64.4%) compared with recurrent MIs occurring ≥1 day after PPCI. However, after multivariable adjustment, late recurrent MI (occurring >1 year after PPCI) was associated with the highest risk of subsequent cardiac mortality (HR 7.98, 95% CI 5.05 to 12.6). The risk of cardiac death was irrespective of the presence of persistent ST-segment elevation during the recurrent MI. In conclusion, recurrent MI after PPCI remains a relatively common complication in contemporary practice and confers a significantly increased risk of death, stroke, and bleeding.
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Affiliation(s)
- Wouter J Kikkert
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Loes P Hoebers
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter Damman
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Krystien V V Lieve
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Bimmer E P M Claessen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Marije M Vis
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Baan
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Karel T Koch
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Robbert J de Winter
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan J Piek
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan G P Tijssen
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jose P S Henriques
- Department of Cardiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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De Luca G, Schaffer A, Wirianta J, Suryapranata H. Comprehensive meta-analysis of radial vs femoral approach in primary angioplasty for STEMI. Int J Cardiol 2013; 168:2070-81. [PMID: 23490083 DOI: 10.1016/j.ijcard.2013.01.161] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Revised: 11/04/2012] [Accepted: 01/13/2013] [Indexed: 11/25/2022]
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54
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De Luca G, Dirksen MT, Spaulding C, Kelbæk H, Schalij M, Thuesen L, van der Hoeven B, Vink MA, Kaiser C, Musto C, Chechi T, Spaziani G, Diaz de la Llera LS, Pasceri V, Di Lorenzo E, Violini R, Suryapranata H, Stone GW. Impact of age on long-term outcome after primary angioplasty with bare-metal or drug-eluting stent (from the DESERT cooperation). Am J Cardiol 2013; 112:181-6. [PMID: 23664294 DOI: 10.1016/j.amjcard.2013.03.012] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 03/08/2013] [Accepted: 03/08/2013] [Indexed: 11/19/2022]
Abstract
Despite mechanical reperfusion, elderly patients with ST-segment elevation myocardial infarction (STEMI) still experience unsatisfactory outcomes. Drug-eluting stents (DES) have significantly reduced target-vessel revascularization (TVR), but concerns have emerged about the higher risk of late stent thrombosis, which may be more pronounced in elderly patients. Therefore, the aim of this study was to evaluate the impact of age on outcome in patients with STEMI who underwent primary angioplasty with bare-metal stents (BMS) or DES. Our population comprised 6,298 patients who underwent primary angioplasty and stent implantation included in the Drug-Eluting Stent in Primary Angioplasty (DESERT) Cooperation database. Age was significantly associated with female gender (p <0.001), diabetes (p <0.001), hypertension (p <0.001), previous myocardial infarction (MI; p <0.001), ischemia time (p <0.001), and anterior MI (p <0.001) but inversely related to smoking (p <0.001). Elderly patients most often had infarct-related artery located in the descending artery (p = 0.014) and impaired postprocedural thrombolysis in myocardial infarction flow (p <0.001). Elderly patients were less often on clopidogrel at follow-up. At long-term follow-up, age was associated with a higher rate of death (hazard ratio [95% confidence interval] = 2.17 [1.97 to 2.39], p <0.0001), whereas no impact was observed on reinfarction (p = 0.36), stent thrombosis (p = 0.84), and TVR (p = 0.54). These results were confirmed in patients receiving both BMS and DES. The impact of age on mortality was confirmed after correction for baseline confounding factors (gender, diabetes hypertension, hypercholesterolemia, smoking, ischemia time, anterior MI, infarct-related artery location, and postprocedural thrombolysis in myocardial infarction 3 flow; adjusted hazard ratio [95% confidence interval] = 2.13 [1.78 to 2.56], p <0.001). In conclusion, this study shows that in patients with STEMI who underwent primary angioplasty, age is independently associated with higher mortality, observed with both BMS and DES, whereas no impact was observed on the rate of reinfarction, stent thrombosis, and TVR.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Ospedale Maggiore della Carità, Eastern Piedmont University, Novara, Italy.
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Meta-analysis comparing efficacy and safety of first generation drug-eluting stents to bare-metal stents in patients with diabetes mellitus undergoing primary percutaneous coronary intervention. Am J Cardiol 2013; 111:1295-304. [PMID: 23490029 DOI: 10.1016/j.amjcard.2013.01.281] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Revised: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 11/21/2022]
Abstract
Several concerns have emerged regarding the higher risk for stent thrombosis (ST) after drug-eluting stent (DES) implantation, especially in the setting of ST-segment elevation myocardial infarction (STEMI). Few data have been reported so far in patients with diabetes mellitus, which is associated with high rates of target vessel revascularization after bare-metal stent (BMS) implantation but also higher rates of ST after DES implantation. Therefore, the aim of this study was to perform a meta-analysis of individual patients' data to evaluate the long-term safety and effectiveness of DES compared with BMS in patients with diabetes who undergo primary percutaneous coronary intervention for STEMI. Published reports were scanned by formal searches of electronic databases (MEDLINE and CENTRAL). All completed randomized trials of DES for STEMI were examined. No language restrictions were enforced. Individual patients' data were obtained from 11 of 13 trials, including a total of 972 patients with diabetes (616 [63.4%] randomized to DES and 356 [36.6%] to BMS). At long-term follow-up (median 1,095 days, interquartile range 1,087 to 1,460), DES significantly reduced the occurrence of target vessel revascularization (hazard ratio 0.42, 95% confidence interval 0.29 to 0.59, p <0.0001), without any significant difference in terms of mortality, late reinfarction, and ST (>1 year) with DES. In conclusion, this meta-analysis, based on individual patients' data from 11 randomized trials, showed that among patients with diabetes with STEMIs who undergo primary percutaneous coronary intervention, sirolimus-eluting stents and paclitaxel-eluting stents, compared with BMS, are associated with a significant reduction in target vessel revascularization at long-term follow-up, without any apparent concern in terms of mortality, despite the trend toward higher rates of reinfarction and ST.
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56
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De Luca G, Dirksen MT, Spaulding C, Kelbæk H, Schalij M, Thuesen L, van der Hoeven B, Vink MA, Kaiser C, Musto C, Chechi T, Spaziani G, Diaz de la Llera LS, Pasceri V, Di Lorenzo E, Violini R, Suryapranata H, Stone GW. Impact of diabetes on long-term outcome after primary angioplasty: insights from the DESERT cooperation. Diabetes Care 2013; 36:1020-5. [PMID: 23275351 PMCID: PMC3609523 DOI: 10.2337/dc12-1507] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Diabetes has been shown to be associated with worse survival and repeat target vessel revascularization (TVR) after primary angioplasty. The aim of the current study was to evaluate the impact of diabetes on long-term outcome in patients undergoing primary angioplasty treated with bare metal stents (BMS) and drug-eluting stents (DES). RESEARCH DESIGN AND METHODS Our population is represented by 6,298 ST-segment elevation myocardial infarction (STEMI) patients undergoing primary angioplasty included in the DESERT database from 11 randomized trials comparing DES with BMS. RESULTS Diabetes was observed in 972 patients (15.4%) who were older (P < 0.001), more likely to be female (P < 0.001), with higher prevalence of hypertension (P < 0.001), hypercholesterolemia (P < 0.001), and longer ischemia time (P < 0.001), and without any difference in angiographic and procedural characteristics. At long-term follow-up (1,201 ± 441 days), diabetes was associated with higher rates of death (19.1% vs. 7.4%; P < 0.0001), reinfarction (10.4% vs. 7.5%; P < 0.001), stent thrombosis (7.6% vs. 4.8%; P = 0.002) with similar temporal distribution--acute, subacute, late, and very late--between diabetic and control patients, and TVR (18.6% vs. 15.1%; P = 0.006). These results were confirmed in patients receiving BMS or DES, except for TVR, there being no difference observed between diabetic and nondiabetic patients treated with DES. The impact of diabetes on outcome was confirmed after correction for baseline confounding factors (mortality, P < 0.001; repeat myocardial infarction, P = 0.006; stent thrombosis, P = 0.007; TVR, P = 0.027). CONCLUSIONS This study shows that among STEMI patients undergoing primary angioplasty, diabetes is associated with worse long-term mortality, reinfarction, and stent thrombosis in patients receiving DES and BMS. DES implantation, however, does mitigate the known deleterious effect of diabetes on TVR after BMS.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Ospedale Maggiore della Carità, Eastern Piedmont University, Novara, Italy.
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57
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Abe D, Sato A, Hoshi T, Takeyasu N, Misaki M, Hayashi M, Aonuma K. Initial culprit-only versus initial multivessel percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: results from the Ibaraki Cardiovascular Assessment Study registry. Heart Vessels 2013; 29:171-7. [DOI: 10.1007/s00380-013-0342-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2012] [Accepted: 03/08/2013] [Indexed: 11/30/2022]
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58
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De Luca G, Gibson M, Cutlip D, Huber K, Dudek D, Bellandi F, Noc M, Maioli M, Zorman S, Zeymer U, Secco GG, Mesquita Gabriel H, Emre A, Arntz HR, Rakowski T, Gyongyosi M, Hof AWV. Impact of multivessel disease on myocardial perfusion and survival among patients undergoing primary percutaneous coronary intervention with glycoprotein IIb/IIIa inhibitors. Arch Cardiovasc Dis 2013; 106:155-61. [DOI: 10.1016/j.acvd.2012.12.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2012] [Revised: 12/11/2012] [Accepted: 12/18/2012] [Indexed: 10/27/2022]
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59
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Kala P, Miklik R. Pharmaco-mechanic antithrombotic strategies to reperfusion of the infarct-related artery in patients with ST-elevation acute myocardial infarctions. J Cardiovasc Transl Res 2013; 6:378-87. [PMID: 23408112 PMCID: PMC3650237 DOI: 10.1007/s12265-013-9448-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 01/25/2013] [Indexed: 10/27/2022]
Abstract
Primary percutaneous coronary intervention is the best treatment of patients with ST elevation myocardial infarction (STEMI). When managing a STEMI patient, our approach must be rapid and aggresive in order to interrupt the pathological process of thrombus formation and stabilization. The therapy must be initiated prior to angiography (pretreatment), continued during the procedure (periprocedural), recovery phase (in-hospital), and follow-up. The treatment strategies resulting in thrombus dissolution/extraction have focused on optimization of both pharmacological and interventional therapies. At present, there is no optimal evidence-based approach to all patients with STEMI, and the treatment of these patients needs to be modified with respect to the risk profile, availability of medical resources, and our experience. In this review, we summarize current pharmacological and interventional strategies used in the setting of STEMI and discuss potential benefits of novel dosing regimens and combinations of drugs and techniques.
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Affiliation(s)
- Petr Kala
- Masaryk University and University Hospital Brno, Jihlavska 20, 625 00 Brno, Czech Republic.
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60
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Abstract
A prompt reperfusion with primary percutaneous coronary intervention represents the current gold standard treatment for patients with acute myocardial infarction. In this setting, coronary stents have been shown to improve outcomes compared to plain angioplasty and are routinely used. However, the stent selection among patients with acute myocardial infarction is still a matter of some debate. An increased risk of very late (>1-year) stent thrombosis has been associated with the use of early-generation drug-eluting stents (DES), leading to concerns regarding the long-term safety of these devices. Newer-generation DES were developed with the aim of addressing this safety issue, and were recently investigated in a few randomized studies in patients with acute myocardial infarction. The objective of the present review is to summarize the accumulated evidence, to guide the stent selection in patients with acute myocardial infarction.
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61
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Hong MK. Recent Advances in the Treatment of ST-Segment Elevation Myocardial Infarction. SCIENTIFICA 2012; 2012:683683. [PMID: 24278728 PMCID: PMC3820598 DOI: 10.6064/2012/683683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 09/12/2012] [Indexed: 06/02/2023]
Abstract
ST-segment elevation myocardial infarction (STEMI) represents the most urgent condition for patients with coronary artery disease. Prompt diagnosis and therapy, mainly with primary angioplasty using stents, are important in improving not only acute survival but also long-term prognosis. Recent advances in angioplasty devices, including manual aspiration catheters and drug-eluting stents, and pharmacologic therapy, such as potent antiplatelet and anticoagulant agents, have significantly enhanced the acute outcome for these patients. Continuing efforts to educate the public and to decrease the door-to-balloon time are essential to further improve the outcome for these high-risk patients. Future research to normalize the left ventricular function by autologous stem cell therapy may also contribute to the quality of life and longevity of the patients surviving STEMI.
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Affiliation(s)
- Mun K. Hong
- Cardiac Catheterization Laboratory and Interventional Cardiology, St. Luke's-Roosevelt Hospital Center, 1111 Amsterdam Avenue, New York, NY 10025, USA
- Columbia University College of Physicians and Surgeons, 630 W. 168th St., New York, NY 10032, USA
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Meta-analysis of long-term outcomes for drug-eluting stents versus bare-metal stents in primary percutaneous coronary interventions for ST-segment elevation myocardial infarction. Am J Cardiol 2012; 109:932-40. [PMID: 22221949 DOI: 10.1016/j.amjcard.2011.11.021] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Revised: 11/23/2011] [Accepted: 11/23/2011] [Indexed: 11/23/2022]
Abstract
The use of drug-eluting stents (DESs) in primary percutaneous coronary intervention (PPCI) has shown early benefit over bare-metal stents (BMSs) in decreasing adverse cardiac events. However, there are concerns regarding the increased risk of late and very late stent thrombosis (ST) after DES use. With the paucity of ST events individual trials may have been underpowered to detect significant differences. We sought to perform a meta-analysis to evaluate the available literature examining the outcomes of DESs and BMSs in PPCI after ≥3 years of follow-up. We analyzed 8 randomized clinical trials (RCTs) and 5 observational studies comparing DESs to BMSs in PPCI. Clinical end-point data were analyzed for RCTs and observational studies separately using random-effect models. RCTs included 5,797 patients in whom first-generation DESs (sirolimus- or paclitaxel-eluting stents) were compared to BMS control arms. Patients receiving DESs had a significantly lower risk of target lesion revascularization (odds ratio [OR] 0.48, confidence interval [CI] 0.37 to 0.61), target vessel revascularization (OR 0.53, CI 0.42 to 0.66), and accordingly major adverse cardiac events (OR 0.69; CI 0.56 to 0.84). Incidence of ST was not different between groups (OR 1.02, CI 0.76 to 1.37). There was no significant difference in mortality (OR 0.88, CI 0.68 to 1.12) or recurrent myocardial infarction (OR 0.97; CI 0.61 to 1.54). Among observational studies (n = 4,650) fewer studies reported on target lesion revascularization and target vessel revascularization, but the trend remained in favor of DESs. A small but statistically significant increase in ST was noted with DES use (OR 1.62, CI 1.18 to 2.21) at ≥3 years of follow up, without evidence of recurrent myocardial infarction. Those receiving DESs had a significantly lower mortality compared to those receiving BMSs (OR, 0.65, 95% CI 0.53 to 0.80, p <0.001). In conclusion, this meta-analysis of RCTs examining the long-term outcomes of first-generation DESs versus BMSs in PPCI, DES use resulted in decreased repeat revascularization with no increase in ST, mortality, or recurrent myocardial infarction.
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63
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Möckel M, Vollert J, Lansky AJ, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Kornowski R, Dudek D, Farkouh ME, Parise H, Mehran R, Stone GW. Comparison of direct stenting with conventional stent implantation in acute myocardial infarction. Am J Cardiol 2011; 108:1697-703. [PMID: 21906709 DOI: 10.1016/j.amjcard.2011.07.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Revised: 07/15/2011] [Accepted: 07/15/2011] [Indexed: 11/19/2022]
Abstract
Small studies have suggested that direct stenting without balloon predilatation in ST-segment elevation myocardial infarction may reduce microcirculatory dysfunction. To examine the clinical benefits of direct stenting in a large cohort of patients who underwent primary percutaneous coronary intervention treated with contemporary pharmacotherapy, the 1-year outcomes from the multicenter, randomized Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial were analyzed. A total of 3,602 patients with ST-segment elevation myocardial infarction who underwent primary percutaneous coronary intervention were enrolled. The present study cohort consisted of 2,528 patients in whom single lesions (excluding bypass grafts) were treated with stent implantation. At operator discretion, direct stenting was attempted in 698 patients (27.6%), and stenting was performed after predilatation in 1,830 patients (72.4%). Propensity-score matching was performed to reduce bias. Direct stenting was successful in 677 patients (97.0%). ST-segment resolution at 60 minutes after the procedure was improved in patients who underwent direct compared to conventional stenting (median 74.8% vs 68.9%, respectively, p = 0.01). At 1-year follow-up, direct compared to conventional stenting was associated with a significantly lower rate of all-cause death (1.6% vs 3.8%, p = 0.01) and stroke (0.3% vs 1.1%, p = 0.049), with nonsignificant differences in target lesion revascularization, myocardial infarction, stent thrombosis, and major bleeding. Death at 1 year remained significantly lower in the direct stenting group after multivariate adjustment (hazard ratio 0.42, 95% confidence interval 0.21 to 0.86, p = 0.02) and in a propensity score-based analysis (hazard ratio 0.92, 95% confidence interval 0.88 to 0.95, p = 0.02). In conclusion, compared to stent implantation after predilatation, direct stenting is safe and effective in appropriately selected lesions in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention and may result in improved survival.
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64
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Abstract
Platelets play a pivotal role in the pathogenesis of coronary artery disease and myocardial infarction. Therefore, great interests have been focused in the last decades on improvement in antiplatelet therapies, that currently are regarded as main pillars in the prevention and treatment of coronary artery disease, with special attention to glycoprotein IIb-IIIa (GP IIb-IIIa) receptors, that mediates the final stage of platelet activation. GP IIb-IIIa inhibitors, especially abciximab, have been shown to improve clinical outcome in patients undergoing primary angioplasty for STEMI. Upstream administration cannot routinely recommended, but may potentially be considered among high-risk patients within the first 4 h from symptoms onset. In case of periprocedural administration of antithrombotic therapy, Bivalirudin should be considered, especially in patients at high risk for bleeding complications. Among high-risk patients with acute coronary syndromes, an early invasive strategy with selective downstream administration of GP IIb-IIIa inhibitors is the strategy of choice, whereas bivalirudin should be considered in patients at high risk for bleeding complications. Among patients with unstable angina GP IIb-IIIa inhibitors should be considered only in case of evidence of intracoronary thrombus or in case of thrombotic complications (as provisional use). Further, randomized trials are certainly needed in the era of new oral antiplatelet therapies, and with strategies to prevent bleeding complications such as larger use of radial approach, mechanical closure devices, bivalirudin, or postprocedural protamine administration to promote early sheat removal.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Maggiore della Carità Hospital, Università del Piemonte Orientale A. Avogadro, Novara, Italy.
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65
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Di Lorenzo E, Carbone G, Sauro L, Casafina A, Capasso M, Sauro R. Bare-Metal Stents Versus Drug-Eluting Stents for Primary Angioplasty: Long-Term Outcome. Curr Cardiol Rep 2011; 13:459-64. [DOI: 10.1007/s11886-011-0207-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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66
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Long-term safety and efficacy of drug-eluting stents in patients with acute myocardial infarction: A meta-analysis of randomized trials. Atherosclerosis 2011; 217:149-57. [DOI: 10.1016/j.atherosclerosis.2011.03.007] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2011] [Revised: 03/04/2011] [Accepted: 03/06/2011] [Indexed: 11/15/2022]
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67
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Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock – Diagnose, Monitoring und Therapie“. ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s00390-011-0284-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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68
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Andrade PBD, Tebet MA, Silva FSMD, Andrade MVAD, Labrunie A, Piva e Mattos LA. Drug-eluting stents during ST-segment elevation acute myocardial infarction: a critical analysis. J Interv Cardiol 2011; 24:416-23. [PMID: 21539610 DOI: 10.1111/j.1540-8183.2011.00650.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Primary percutaneous coronary intervention is the preferred reperfusion therapy for ST-segment elevation acute myocardial infarction patients within 12 hours of symptom-onset. Routine stent implantation during the procedure significantly reduces the rate of target vessel revascularization, although restenosis still represents a current limitation of the technique. Drug-eluting stents were developed to treat and prevent coronary restenosis. Randomized trials, meta-analysis, and registries proved their efficacy and safety in different clinical situations, including acute myocardial infarction. However, the increased risk of late stent thrombosis associated with drug-eluting stents during primary percutaneous coronary interventions encourages a careful analysis to identify which patients most benefit from them, as well as those where a prolonged dual antiplatelet therapy does not represent a limiting factor.
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Affiliation(s)
- Pedro Beraldo de Andrade
- Irmandade da Santa Casa de Misericórdia de Marília, Av. Vicente Ferreira 828, Marília, São Paulo, Brazil.
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Spaulding C, Teiger E, Commeau P, Varenne O, Bramucci E, Slama M, Beatt K, Tirouvanziam A, Polonski L, Stella PR, Clugston R, Fajadet J, de Boisgelin X, Bode C, Carrié D, Erglis A, Merkely B, Hosten S, Cebrian A, Wang P, Stoll HP, Henry P. Four-year follow-up of TYPHOON (trial to assess the use of the CYPHer sirolimus-eluting coronary stent in acute myocardial infarction treated with BallOON angioplasty). JACC Cardiovasc Interv 2011; 4:14-23. [PMID: 21251624 DOI: 10.1016/j.jcin.2010.10.007] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 10/04/2010] [Accepted: 10/15/2010] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The aim of this study was to assess the long-term safety and efficacy of the CYPHER (Cordis, Johnson and Johnson, Bridgewater, New Jersey) sirolimus-eluting coronary stent (SES) in percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI). BACKGROUND Concern over the safety of drug-eluting stents implanted during PCI for STEMI remains, and long-term follow-up from randomized trials are necessary. TYPHOON (Trial to assess the use of the cYPHer sirolimus-eluting stent in acute myocardial infarction treated with ballOON angioplasty) randomized 712 patients with STEMI treated by primary PCI to receive either SES (n = 355) or bare-metal stents (BMS) (n = 357). The primary end point, target vessel failure at 1 year, was significantly lower in the SES group than in the BMS group (7.3% vs. 14.3%, p = 0.004) with no increase in adverse events. METHODS A 4-year follow-up was performed. Complete data were available in 501 patients (70%), and the survival status is known in 580 patients (81%). RESULTS Freedom from target lesion revascularization (TLR) at 4 years was significantly better in the SES group (92.4% vs. 85.1%; p = 0.002); there were no significant differences in freedom from cardiac death (97.6% and 95.9%; p = 0.37) or freedom from repeat myocardial infarction (94.8% and 95.6%; p = 0.85) between the SES and BMS groups. No difference in definite/probable stent thrombosis was noted at 4 years (SES: 4.4%, BMS: 4.8%, p = 0.83). In the 580 patients with known survival status at 4 years, the all-cause death rate was 5.8% in the SES and 7.0% in the BMS group (p = 0.61). CONCLUSIONS In the 70% of patients with complete follow-up at 4 years, SES demonstrated sustained efficacy to reduce TLR with no difference in death, repeat myocardial infarction or stent thrombosis. (The Study to Assess AMI Treated With Balloon Angioplasty [TYPHOON]; NCT00232830).
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Affiliation(s)
- Christian Spaulding
- Cochin Hospital, Assistance-Publique Hôpitaux de Paris, Paris Descartes University and INSERM U 970, Paris, France.
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Swanson N, Gershlick A. Primary and Rescue PCI in Acute Myocardial Infarction. Interv Cardiol 2011. [DOI: 10.1002/9781444319446.ch16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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71
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Vink MA, Dirksen MT, Suttorp MJ, Tijssen JG, van Etten J, Patterson MS, Slagboom T, Kiemeneij F, Laarman GJ. 5-Year Follow-Up After Primary Percutaneous Coronary Intervention With a Paclitaxel-Eluting Stent Versus a Bare-Metal Stent in Acute ST-Segment Elevation Myocardial Infarction. JACC Cardiovasc Interv 2011; 4:24-9. [PMID: 21251625 DOI: 10.1016/j.jcin.2010.11.003] [Citation(s) in RCA: 101] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 11/08/2010] [Accepted: 11/16/2010] [Indexed: 11/26/2022]
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Navarese EP, De Servi S, Buffon A, Suryapranata H, De Luca G. Clinical impact of simultaneous complete revascularization vs. culprit only primary angioplasty in patients with st-elevation myocardial infarction and multivessel disease: a meta-analysis. J Thromb Thrombolysis 2010; 31:217-25. [DOI: 10.1007/s11239-010-0510-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Piscione F, Piccolo R, Cassese S, Galasso G, De Rosa R, D'Andrea C, Chiariello M. Effect of drug-eluting stents in patients with acute ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention: a meta-analysis of randomised trials and an adjusted indirect comparison. EUROINTERVENTION 2010; 5:853-60. [PMID: 20142203 DOI: 10.4244/eijv5i7a143] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
AIMS The role of drug-eluting stent (DES) remains an unsettled issue in patients with ST-segment elevation myocardial infarction (STEMI). Therefore, we performed a meta-analysis of randomised trials to evaluate the clinical outcome of DES as compared with bare-metal stent (BMS) after percutaneous coronary intervention (PCI). METHODS AND RESULTS We undertook a literature search until July 2009. Thirteen clinical trials met inclusion criteria, with 7,244 patients enrolled. Up to 1-year, patients treated with DES as compared with BMS experienced less target-vessel revascularisation (TVR) (5.11% versus 11.19% respectively, p<0.00001) and recurrent myocardial infarction rates (3.03% versus 3.70% respectively, p=0.02). In addition, no significant differences were found in terms of cardiac death (2.80% versus 3.52%, p=0.21) and stent thrombosis (2.65% versus 2.76%, p=0.37). Using the adjusted indirect comparison, a significant difference between sirolimus- and paclitaxel-eluting stent was found when TVR was evaluated (OR [95% CI] =0.59 [0.40-0.89], p=0.01), without differences in other clinical outcomes. CONCLUSIONS In patients undergoing PCI for STEMI, treatment with DES is associated with decreased TVR and myocardial infarction rates, without increasing cardiac death or stent thrombosis occurrence. Sirolimus-eluting stent is associated with a greater TVR reduction as compared to paclitaxel-eluting stent.
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Affiliation(s)
- Federico Piscione
- Department of Clinical Medicine, Cardiovascular Sciences and Immunology, Federico II University, Naples, Italy.
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74
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Brar SS, Stone GW. Decision-making: stenting in acute myocardial infarction. Future Cardiol 2010; 6:301-14. [PMID: 20462337 DOI: 10.2217/fca.10.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Percutaneous coronary intervention (PCI) plays a pivotal role in the management of patients with acute myocardial infarction (AMI). Rapid revascularization of the patient with evolving AMI results in reduced rates of mortality, reinfarction and greater myocardial salvage with smaller infarct size. Since the performance of the first balloon angioplasty in 1977, remarkable advances have improved the safety and efficacy of PCI. Advances in stent technology and adjunct pharmacology have improved the outcomes for patients with AMI undergoing primary PCI. Drug-eluting stents result in a significant reduction in the clinical and angiographic rates of restenosis. Early concerns of stent thrombosis in the AMI setting have been allayed by recent results from numerous randomized clinical trials and observational studies. Reduced ischemic and hemorrhagic complications from new antithrombin and antiplatelet agents have further reduced mortality and improved event-free survival after primary PCI.
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Affiliation(s)
- Somjot S Brar
- Regional Cardiac Catheterization Laboratory, 4867 Sunset Blvd, 3rd Floor, Room 3755, Kaiser Permanente Medical Center, Los Angeles, CA 90027, USA.
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Kirschner R, Toth L, Varga-Szemes A, Simor T, Suranyi P, Kiss P, Ruzsics B, Toth A, Baker R, Brott BC, Litovsky S, Elgavish A, Elgavish GA. Differentiation of acute and four-week old myocardial infarct with Gd(ABE-DTTA)-enhanced CMR. J Cardiovasc Magn Reson 2010; 12:22. [PMID: 20377842 PMCID: PMC2867985 DOI: 10.1186/1532-429x-12-22] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Accepted: 04/07/2010] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Standard extracellular cardiovascular magnetic resonance (CMR) contrast agents (CA) do not provide differentiation between acute and older myocardial infarcts (MI). The purpose of this study was to develop a method for differentiation between acute and older myocardial infarct using myocardial late-enhancement (LE) CMR by a new, low molecular weight contrast agent.Dogs (n = 6) were studied in a closed-chest, reperfused, double myocardial infarct model. Myocardial infarcts were generated by occluding the Left Anterior Descending (LAD) coronary artery with an angioplasty balloon for 180 min, and four weeks later occluding the Left Circumflex (LCx) coronary artery for 180 min. LE images were obtained on day 3 and day 4 after second myocardial infarct, using Gd(DTPA) (standard extracellular contrast agent) and Gd(ABE-DTTA) (new, low molecular weight contrast agent), respectively. Triphenyltetrazolium chloride (TTC) histomorphometry validated existence and location of infarcts. Hematoxylin-eosin and Masson's trichrome staining provided histologic evaluation of infarcts. RESULTS Gd(ABE-DTTA) or Gd(DTPA) highlighted the acute infarct, whereas the four-week old infarct was visualized by Gd(DTPA), but not by Gd(ABE-DTTA). With Gd(ABE-DTTA), the mean +/- SD signal intensity enhancement (SIE) was 366 +/- 166% and 24 +/- 59% in the acute infarct and the four-week old infarct, respectively (P < 0.05). The latter did not differ significantly from signal intensity in healthy myocardium (P = NS). Gd(DTPA) produced signal intensity enhancements which were similar in acute (431 +/- 124%) and four-week old infarcts (400 +/- 124%, P = NS), and not statistically different from the Gd(ABE-DTTA)-induced SIE in acute infarct. The existence and localization of both infarcts were confirmed by triphenyltetrazolium chloride (TTC). Histologic evaluation demonstrated coagulation necrosis, inflammation, and multiple foci of calcification in the four day old infarct, while the late subacute infarct showed granulation tissue and early collagen deposition. CONCLUSIONS Late enhancement CMR with separate administrations of standard extracellular contrast agent, Gd(DTPA), and the new low molecular weight contrast agent, Gd(ABE-DTTA), differentiates between acute and late subacute infarct in a reperfused, double infarct, canine model.
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Affiliation(s)
- Robert Kirschner
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Heart Institute, Faculty of Medicine, University of Pecs, Hungary
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Levente Toth
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Akos Varga-Szemes
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Heart Institute, Faculty of Medicine, University of Pecs, Hungary
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Tamas Simor
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Heart Institute, Faculty of Medicine, University of Pecs, Hungary
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Pal Suranyi
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Pal Kiss
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Balazs Ruzsics
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Attila Toth
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Robert Baker
- Animal Resources Program, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brigitta C Brott
- Division of Cardiovascular Disease, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Silvio Litovsky
- Department of Anatomical Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ada Elgavish
- Division of Clinical Immunology and Rheumatology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
| | - Gabriel A Elgavish
- Department of Biochemistry and Molecular Genetics, University of Alabama at Birmingham, MCLM 556, Birmingham, AL 35294-0005, USA
- Elgavish Paramagnetics Inc., Birmingham, Alabama, USA
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Drug-eluting stents in acute myocardial infarction: updated meta-analysis of randomized trials. Clin Res Cardiol 2010; 99:345-57. [DOI: 10.1007/s00392-010-0133-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2009] [Accepted: 02/15/2010] [Indexed: 10/19/2022]
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77
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Nakagawa Y. What Is the Effectiveness of Drug-Eluting Stents in the Treatment of ST-Elevation Myocardial Infarction? - Should Drug-Eluting Stents Be Indicated for Patients With Acute Coronary Syndrome? (Pro) -. Circ J 2010; 74:2225-31. [DOI: 10.1253/circj.cj-10-0729] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Safety and feasibility of returning patients early to their originating centers after transfer for primary percutaneous coronary intervention. Rev Esp Cardiol 2009; 62:1356-64. [PMID: 20038401 DOI: 10.1016/s1885-5857(09)73529-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES At present, little information is available on returning patients with ST-elevation myocardial infarction (STEMI) to their originating centers after transfer for primary percutaneous coronary intervention (PPCI). The objective of this study was to evaluate the safety and feasibility of the early return of these patients to their originating centers. METHODS The cohort study involved 200 consecutive STEMI patients (age 62+/-13 years, 83% male) who were returned to their originating centers after PPCI. They were compared with a group of 297 patients with similar characteristics from our healthcare catchment area. The length of stay in the intervention hospital and major adverse cardiovascular events occurring within 30 days were recorded. RESULTS The median length of stay in the intervention hospital was 8 hours. No adverse events occurred during transport in the group who returned to their originating centers. At 30-day follow-up, no significant difference was observed between patients who returned and the control group in either mortality (1.0% vs. 3.7%; P=.064), readmission (5.0% vs. 4.5%; P=.657), ischemic complications (2.5% vs. 2.0%; P=.721), re-catheterization (5.0% vs. 2.5%; P=.112), stroke (1% vs. 1%; P=.936) or the composite end-point (11% vs. 9.2%; P=.540). Multivariate analysis showed that returning patients after PPCI was not associated with a significantly greater number of major adverse cardiovascular events (odds ratio=1.32; 95% confidence interval, 0.62-2.80). CONCLUSIONS The early return of patients with low-risk STEMI to their originating centers after PPCI was safe and feasible.
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Seguridad y viabilidad del retorno precoz de pacientes transferidos para angioplastia primaria a sus centros de origen. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)73120-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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80
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De Luca G, Sauro R, Varricchio A, Capasso M, Lanzillo T, Manganelli F, Mariello C, Siano F, Carbone G, Pagliuca MR, Rosato G, Di Lorenzo E. Impact of diabetes on long-term outcome in STEMI patients undergoing primary angioplasty with glycoprotein IIb–IIIa inhibitors and BMS or DES. J Thromb Thrombolysis 2009; 30:133-41. [DOI: 10.1007/s11239-009-0420-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Piscione F, Piccolo R, Cassese S, Galasso G, Chiariello M. Clinical impact of sirolimus-eluting stent in ST-segment elevation myocardial infarction: a meta-analysis of randomized clinical trials. Catheter Cardiovasc Interv 2009; 74:323-32. [PMID: 19360858 DOI: 10.1002/ccd.22017] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To evaluate outcome of patients undergoing sirolimus-eluting stent (SES) as compared to bare-metal stent (BMS) implantation during primary angioplasty for ST-segment elevation myocardial infarction (STEMI). BACKGROUND The role of SES in primary percutaneous coronary intervention setting is still debated. METHODS We searched Medline, EMBASE, CENTRAL, scientific session abstracts, and relevant Websites for studies in any language, from the inception of each database until October 2008. Only randomized clinical trials with a mean follow-up period >6 months and sample size >100 patients were included. Primary endpoint for efficacy was target-vessel revascularization (TVR) and primary endpoint for safety was stent thrombosis. Secondary endpoints were cardiac death and recurrent myocardial infarction (MI). RESULTS Six trials were included in the meta-analysis, including 2,381 patients (1,192 randomized to SES and 1,189 to BMS). Up to 12-month follow-up, TVR was significantly lower in patients treated with SES as compared to patients treated with BMS (4.53% vs. 12.53%, respectively; odds ratio [OR] 0.33; 95% confidence interval [CI] 0.24-0.46; P < 0.00001). There were no significant differences in the incidence of stent thrombosis (3.02% vs. 3.70%, OR = 0.81 [95% CI, 0.52-1.27], P = 0.81), cardiac death (2.77% vs. 3.28%, OR = 0.84 [95% CI, 0.52-1.35], P = 0.47), and recurrent MI (2.94% vs. 4.04%, OR = 0.71 [95% CI, 0.45-1.11], P = 0.13) between the two groups. CONCLUSION SES significantly reduces TVR rates as compared to BMS in STEMI patients up to 1 year follow-up. Further studies with larger population and longer follow-up time are needed to confirm our findings.
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Affiliation(s)
- Federico Piscione
- Department of Clinical Medicine, Cardiovascular Sciences and Immunology, Federico II University, Naples, Italy.
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Di Lorenzo E, Sauro R, Varricchio A, Capasso M, Lanzillo T, Manganelli F, Mariello C, Siano F, Pagliuca MR, Stanco G, Rosato G, De Luca G. Benefits of drug-eluting stents as compared to bare metal stent in ST-segment elevation myocardial infarction: four year results of the PaclitAxel or Sirolimus-Eluting stent vs bare metal stent in primary angiOplasty (PASEO) randomized trial. Am Heart J 2009; 158:e43-50. [PMID: 19781402 DOI: 10.1016/j.ahj.2009.03.016] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2009] [Accepted: 03/05/2009] [Indexed: 01/21/2023]
Abstract
BACKGROUND Drug-eluting stent (DES) may offer benefits in terms of repeat revascularization, which may be counterbalanced by a potential higher risk of stent thrombosis, especially among patients with STEMI. No data have been reported so far on the long-term benefits and safety of DES in STEMI. The aim of the current study was to evaluate the short- and long-term benefits of sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES) as compared to bare-metal stent (BMS) in patients undergoing primary angioplasty. METHODS Consecutive patients with STEMI admitted within 12 hours of symptom onset and undergoing primary angioplasty and stent implantation at a tertiary center with 24-hour primary percutaneous coronary intervention capability were randomly assigned to BMS, PES, and SES. All patients received upstream glycoprotein IIb-IIIa inhibitors. Primary end point was target-lesion revascularization at 1-year follow-up. Secondary end points were (1) cumulative combined incidence of death and/or reinfarction; (2) cumulative incidence of in-stent thrombosis; and (3) major adverse cardiac events (MACE) (combined death and/or reinfarction and/or target lesion revascularization [TLR]) at long-term follow-up (up to 4 years). No patient was lost to follow-up. RESULTS From October 1, 2003, to December 2005, 270 patients with STEMI were randomized to BMS (n = 90), PES (n = 90), or SES (n = 90). Procedural success was obtained in 93% to 95% of patients. Follow-up data were available for all patients. As compared to BMS (14.4%), both PES (4.4%, hazard ratio [HR] 0.29, 95% CI 0.095-0.89, P = .023) and SES (3.3%, HR 0.21, 95% CI 0.06-0.75, P = .016) were associated with a significant reduction in TLR at 1-year follow-up (primary study end point). At long-term follow-up (1,233 +/- 215 days), no difference was observed in terms of death, reinfarction, and combined death and/or reinfarction, but as compared to BMS (21.1%), both PES (6.7%, HR 0.29, 95% CI 0.12-0.73, P = .008) and SES (5.6%, HR 0.24, 95% CI 0.09-0.63, P = .002), respectively, were associated with a significant reduction in TLR. CONCLUSIONS This study shows that among patients with STEMI undergoing primary angioplasty, both SES and PES are safe and associated with significant benefits in terms of TLR up to 4 years' follow-up, as compared to BMS. Thus, until the results of further large randomized trials with long-term follow-up become available, DES may be considered among patients with STEMI undergoing primary angioplasty.
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Juwana YB, Suryapranata H, Ottervanger JP, De Luca G, van't Hof AWJ, Dambrink JHE, de Boer MJ, Gosselink ATM, Hoorntje JCA. Comparison of rapamycin- and paclitaxel-eluting stents in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction. Am J Cardiol 2009; 104:205-9. [PMID: 19576348 DOI: 10.1016/j.amjcard.2009.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 03/12/2009] [Accepted: 03/12/2009] [Indexed: 01/18/2023]
Abstract
Compared with bare metal stents, sirolimus- and paclitaxel-eluting stents (SESs and PESs, respectively) have been shown to improve angiographic and clinical outcomes after percutaneous coronary intervention (PCI) in elective patients and those with ST-elevation myocardial infarction (STEMI). The aim of the present study was to compare SESs with PESs in patients with STEMI undergoing primary PCI. Patients with STEMI were randomized 1:1 to receive SESs (n = 196) or PESs (n = 201). The primary end point was late lumen loss at 9-month follow-up by quantitative coronary angiography. Secondary end points were major adverse cardiac clinical events (death, reinfarction, target vessel revascularization) at 1 month and 9 and 12 months. Three hundred ninety-seven patients with STEMI were randomized. The 2 groups had comparable baseline clinical and angiographic characteristics. Mortality was low, 1.5% after 30 days, 2.3% after 9 months, and 3.1% after 1 year. There was no difference in any clinical outcome at any follow-up period between the 2 treatment groups. Follow-up angiography was completed in 272 of 397 patients (69%). Mean +/- SD in-stent late loss was 0.01 +/- 0.42 mm in the SES group versus 0.21 +/- 0.50 mm in the PES group (difference -0.20 mm, p = 0.001). In conclusion, in patients with STEMI, primary PCI with SESs results in less late loss compared with PESs. However, these benefits did not translate into a significant decrease in major adverse cardiac events at 1-year follow-up.
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Affiliation(s)
- Yahya B Juwana
- Cardiovascular Center, Hospital Cinere, Jakarta, Indonesia
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Carver A, Rafelt S, Gershlick AH, Fairbrother KL, Hughes S, Wilcox R. Longer-Term Follow-Up of Patients Recruited to the REACT (Rescue Angioplasty Versus Conservative Treatment or Repeat Thrombolysis) Trial. J Am Coll Cardiol 2009; 54:118-26. [DOI: 10.1016/j.jacc.2009.03.050] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2008] [Revised: 03/23/2009] [Accepted: 03/24/2009] [Indexed: 10/20/2022]
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Rolley JX, Davidson PM, Salamonson Y, Fernandez R, Dennison CR. Review of nursing care for patients undergoing percutaneous coronary intervention: a patient journey approach. J Clin Nurs 2009; 18:2394-405. [PMID: 19538559 DOI: 10.1111/j.1365-2702.2008.02768.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To evaluate the existing literature to inform nursing management of people undergoing percutaneous coronary intervention. BACKGROUND. Percutaneous coronary intervention is an increasingly important revascularisation strategy in coronary heart disease management and can be an emergent, planned or rescue procedure. Nurses play a critical role in delivering care in both the independent and collaborative contexts of percutaneous coronary intervention management. DESIGN Systematic review. METHOD The method of an integrative literature review, using the conceptual framework of the patient journey, was used to describe existing evidence and to determine important areas for future research. The electronic data bases CINAHL, Medline, Cochrane and the Joanna Briggs data bases were searched using terms including: (angioplasty, transulminal, percutaneous coronary), nursing care, postprocedure complications (haemorrhage, ecchymosis, haematoma), rehabilitation, emergency medical services (transportation of patients, triage). RESULTS Despite the frequency of the procedure, there are limited data to inform nursing care for people undergoing percutaneous coronary intervention. Currently, there are no widely accessible nursing practice guidelines focusing on the nursing management in percutaneous coronary intervention. Findings of the review were summarised under the headings: Symptom recognition; Treatment decision; Peri-percutaneous coronary intervention care, describing the acute management and Postpercutaneous coronary intervention management identifying the discharge planning and secondary prevention phase. CONCLUSIONS Cardiovascular nurses need to engage in developing evidence to support guideline development. Developing consensus on nurse sensitive patient outcome indicators may enable benchmarking strategies and inform clinical trial design. RELEVANCE TO CLINICAL PRACTICE To improve the care given to individuals undergoing percutaneous coronary intervention, it is important to base practice on high-level evidence. Where this is lacking, clinicians need to arrive at a consensus as to appropriate standards of practice while also engaging in developing evidence. This must be considered, however, from the central perspective of the patient and their family.
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Affiliation(s)
- John X Rolley
- School of Nursing & Midwifery, College of Health Science, Curtin University of Technology, Level 7, 39 Regent Street, Chippendale, Sydney, NSW, Australia.
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Di Lorenzo E, De Luca G, Sauro R, Varricchio A, Capasso M, Lanzillo T, Manganelli F, Mariello C, Siano F, Pagliuca MR, Stanco G, Rosato G. The PASEO (PaclitAxel or Sirolimus-Eluting Stent Versus Bare Metal Stent in Primary Angioplasty) Randomized Trial. JACC Cardiovasc Interv 2009; 2:515-23. [PMID: 19539255 DOI: 10.1016/j.jcin.2009.03.012] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 03/17/2009] [Indexed: 11/17/2022]
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87
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Stone GW, Lansky AJ, Pocock SJ, Gersh BJ, Dangas G, Wong SC, Witzenbichler B, Guagliumi G, Peruga JZ, Brodie BR, Dudek D, Möckel M, Ochala A, Kellock A, Parise H, Mehran R. Paclitaxel-eluting stents versus bare-metal stents in acute myocardial infarction. N Engl J Med 2009; 360:1946-59. [PMID: 19420364 DOI: 10.1056/nejmoa0810116] [Citation(s) in RCA: 358] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND There is no consensus regarding the safety and efficacy of drug-eluting stents, as compared with bare-metal stents, in patients with ST-segment elevation myocardial infarction who are undergoing primary percutaneous coronary intervention (PCI). METHODS We randomly assigned, in a 3:1 ratio, 3006 patients presenting with ST-segment elevation myocardial infarction to receive paclitaxel-eluting stents (2257 patients) or otherwise identical bare-metal stents (749 patients). The two primary end points of the study were the 12-month rates of target-lesion revascularization for ischemia (analysis powered for superiority) and a composite safety outcome measure of death, reinfarction, stroke, or stent thrombosis (powered for noninferiority with a 3.0% margin). The major secondary end point was angiographic evidence of restenosis at 13 months. RESULTS Patients who received paclitaxel-eluting stents, as compared with those who received bare-metal stents, had significantly lower 12-month rates of ischemia-driven target-lesion revascularization (4.5% vs. 7.5%; hazard ratio, 0.59; 95% confidence interval [CI], 0.43 to 0.83; P=0.002) and target-vessel revascularization (5.8% vs. 8.7%; hazard ratio, 0.65; 95% CI, 0.48 to 0.89; P=0.006), with noninferior rates of the composite safety end point (8.1% vs. 8.0%; hazard ratio, 1.02; 95% CI, 0.76 to 1.36; absolute difference, 0.1 percentage point; 95% CI, -2.1 to 2.4; P=0.01 for noninferiority; P=0.92 for superiority). Patients treated with paclitaxel-eluting stents and those treated with bare-metal stents had similar 12-month rates of death (3.5% and 3.5%, respectively; P=0.98) and stent thrombosis (3.2% and 3.4%, respectively; P=0.77). The 13-month rate of binary restenosis was significantly lower with paclitaxel-eluting stents than with bare-metal stents (10.0% vs. 22.9%; hazard ratio, 0.44; 95% CI, 0.33 to 0.57; P<0.001). CONCLUSIONS In patients with ST-segment elevation myocardial infarction who were undergoing primary PCI, implantation of paclitaxel-eluting stents, as compared with bare-metal stents, significantly reduced angiographic evidence of restenosis and recurrent ischemia necessitating repeat revascularization procedures. No safety concerns were apparent at 1 year. (ClinicalTrials.gov number, NCT00433966.)
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Affiliation(s)
- Gregg W Stone
- Columbia University Medical Center and New York-Presbyterian Hospital and the Cardiovascular Research Foundation, New York, NY 10022, USA.
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88
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Celik T, Iyisoy A, Kardesoglu E, Isik E. Stenting versus plain old angioplasty in patients with ST segment elevation myocardial infarction: understanding of the randomized trials. Int J Cardiol 2009; 133:394-6; author reply 396. [PMID: 18077019 DOI: 10.1016/j.ijcard.2007.08.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Accepted: 08/10/2007] [Indexed: 11/27/2022]
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89
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Reply to “Stenting versus plain old angioplasty in patients with ST segment elevation myocardial infarction: Understanding of the randomized trials”. Int J Cardiol 2009. [DOI: 10.1016/j.ijcard.2007.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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90
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Short and long-term benefits of sirolimus-eluting stent in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. J Thromb Thrombolysis 2009; 28:200-10. [DOI: 10.1007/s11239-009-0305-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Accepted: 01/06/2009] [Indexed: 10/21/2022]
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91
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De Luca G, Suryapranata H, van't Hof AWJ, Ottervanger JP, Hoorntje JCA, Dambrink JH, Gosselink ATM, de Boer MJ. Routine stenting vs. balloon angioplasty in ST-segment elevation myocardial infarction due to proximal left anterior descending coronary artery occlusion. J Cardiovasc Med (Hagerstown) 2009; 10:22-6. [PMID: 19145115 DOI: 10.2459/jcm.0b013e32830a48d2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Primary angioplasty has been shown to improve the outcome in selected patients with ST-segment elevation myocardial infarction. However, no data have been reported of patients with proximal left anterior descending artery occlusion. In the Zwolle-6 randomized trial, a total of 1683 consecutive patients with ST-segment elevation myocardial infarction were randomized to stenting or balloon angioplasty without any exclusion criteria. The aim of this substudy was to investigate the benefits of coronary stenting as compared to balloon angioplasty in patients with proximal left anterior descending artery occlusion. METHODS From April 1997 to October 2001, among a total of 1683 consecutive patients with ST-segment elevation myocardial infarction randomized to stenting or balloon angioplasty before the initial angiography, a total of 218 patients underwent primary angioplasty of proximal left anterior descending artery occlusion. One-year follow-up data were available from all patients. RESULTS A total of 107 patients were randomized to stent and 111 patients to balloon angioplasty. The cross-over rates from balloon to stent and stent to balloon were 35.1 and 13.1%, respectively (P<0.0001). The groups were comparable in terms of postprocedural thrombolysis in myocardial infarction flow, myocardial blush grade, distal embolization, and ST-segment resolution. Stenting was associated with benefits in terms of restenosis (27.6 vs. 53.8%, P=0.03) and target vessel revascularization (15.0 vs. 24.3%, P=0.081), whereas no difference was observed in mortality (11.2 vs. 13.5%, P>0.1) and reinfarction (11.2 vs. 8.1%, P>0.1) as compared with balloon angioplasty. CONCLUSION As compared with balloon angioplasty, routine stenting does reduce angiographic restenosis, without significant benefits in terms of death and reinfarction among patients undergoing primary angioplasty for ST-segment elevation myocardial infarction due to proximal left anterior descending artery occlusion.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology and Centro di Biotecnologie per la Ricerca Medica Applicata (BRMA), Eastern Piedmont University, Novara, Italy.
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92
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De Luca G, Savonitto S, Greco C, Parodi G, Dajelli Ermolli NC, Silva C, Lucci D, Gonzini L, Maggioni AP, Cuccia C. Cardiogenic shock developing in the coronary care unit in patients with ST-elevation myocardial infarction. J Cardiovasc Med (Hagerstown) 2008; 9:1023-9. [DOI: 10.2459/jcm.0b013e328304ae7f] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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93
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De Luca G, Cassetti E, Marino P. Impact of duration of clopidogrel prescription on outcome of DES as compared to BMS in primary angioplasty: a meta-regression analysis of randomized trials. J Thromb Thrombolysis 2008; 27:365-78. [DOI: 10.1007/s11239-008-0223-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 04/10/2008] [Indexed: 12/01/2022]
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94
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Efficacy and safety of drug-eluting stents in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. Int J Cardiol 2008; 133:213-22. [PMID: 18394731 DOI: 10.1016/j.ijcard.2007.12.040] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Revised: 12/11/2007] [Accepted: 12/14/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent concerns have emerged on the potential higher risk of stent thrombosis after DES implantation, that might be even more pronounced among STEMI patients. Thus, the aim of the current study was to perform a meta-analysis to evaluate the benefits and safety of DES as compared to BMS in patients undergoing primary angioplasty for STEMI. METHODS The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of DES for STEMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, stenting, DES, sirolimus-eluting stent (SES), Cypher, paclitaxel-eluting stent (PES), Taxus. Information on study design, type of stent, inclusion and exclusion criteria, primary endpoint, number of patients, angiographic and clinical outcome, were extracted by two investigators. Disagreements were resolved by consensus. RESULTS A total of 11 trials were included in the meta-analysis, involving 3605 patients (1888 or 52.3% randomized to DES and 1719 or 47.7% randomized to BMS). At 12 months follow-up, no significant difference was observed in mortality (4.1% vs 4.4%, OR [95% CI]=0.91 [0.66-1.27], p=0.59, reinfarction (3.1% vs 3.4%, OR [95% CI]=0.85 [0.58, 1.23], p=0.38 or stent thrombosis (1.6% vs 2.2%, OR [95% CI]=0.76 [0.47, 1.23], p=0.22), whereas DES were associated with a significant reduction in TVR (5.0% vs 12.6%, OR [95% CI]=0.36 [0.28, 0.47], p<0.0001). Safety and efficacy of DES were confirmed at 18 to 24 months follow-up (data available from 4 trials including 1178 patients). CONCLUSIONS This meta-analysis shows that among selected STEMI patients undergoing primary angioplasty, SES and PES, as compared to BMS, are safe and associated with a significant reduction in TVR at 1 and 2 years follow-up.
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Abstract
The majority of proteasome substrates identified to date are marked for degradation by polyubiquitinylation. Exceptions to this principle, however, are well documented and can help us understand the process proteasomes use to recognize their substrates. Examples include ornithine decarboxylase, p21/Cip1, TCRalpha, IkappaBalpha, c-Jun, calmodulin and thymidylate synthase. Degradation of these proteins can be completely ubiquitin-independent or coexist with ubiquitin-dependent pathways. Uncoupling degradation from ubiquitin modification may reflect the evolutionary conservation of mechanisms optimized for highly specialized regulatory functions.
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Affiliation(s)
- M. A. Hoyt
- Department of Microbiology and Immunology, University of California, San Francisco, 94143-0414 San Francisco, California USA
| | - P. Coffino
- Department of Microbiology and Immunology, University of California, San Francisco, 94143-0414 San Francisco, California USA
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