Primary stenting in nonselected patients with acute myocardial infarction: the Multilink Duet in Acute Myocardial Infarction (MIAMI) trial

Domestic versus imported drug-eluting stents for the treatment of patients with acute coronary syndrome

BACKGROUND

The application of coronary stents, especially drug-eluting stents (DESs), has made percutaneous coronary intervention (PCI) one of important therapeutic methods for CHD. DES has reduced the in-stent restenosis to 5%-9% and significantly improved the long-term prognosis of patients with CHD. The study aimed to investigate the long-term efficacy and safety of domestic drug-eluting stents (DESs) in patients with acute coronary syndrome (ACS).

METHODS

All patients with ACS who had undergone successful percutaneous coronary intervention (PCI) in the First Affiliated Hospital of Zhengzhou University from July 2009 to December 2010 were included in this study. Patients were excluded from the study if they were implanted with bare metal stents or different stents (domestic and imported DESs) simultaneously. The included patients were divided into two groups according to different stents implanted: domestic DESs and imported DESs.

RESULTS

In the 1 683 patients of this study, 1 558 (92.6%) patients were followed up successfully for an average of (29.1±5.9) months. 130 (8.3%) patients had major adverse cardiovascular events (MACEs), including cardiac death in 32 (2.1%) patients, recurrent myocardial infarction in 16 (1%), and revascularization in 94 (6%). The rates of cardiac death, recurrent myocardial infarction, revascularization, in-stent restenosis, stent thrombosis and other MACEs were not significantly different between the two groups (all P>0.05). Multivarite logistic regression revealed that diabetes mellitus (OR=1.75, 95%CI: 1.09-2.82, P=0.021), vascular numbers of PCI (OR=2.16, 95%CI: 1.22-3.83, P=0.09) and PCI with left main lesion (OR=9.47, 95%CI: 2.96-30.26, P=0.01) were independent prognostic factors of MACEs. The Kaplan-Meier method revealed that there was no significant difference in cumulative survival rates and survival rates free from clinical events between the two groups (all P>0.05).

CONCLUSIONS

The incidences of clinical events and cumulative survival rates are not statistically different between domestic DESs and imported DESs. Domestic DES is effective and safe in the treatment of patients with ACS.

Comparison of coronary stenting versus conventional balloon angioplasty on five-year mortality in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention

Little is known about the influence of stenting versus balloon angioplasty on long-term outcomes (particularly mortality) after primary percutaneous coronary intervention (PCI). We evaluated 2,087 patients with ST-elevation myocardial infarction enrolled in various Primary Angioplasty in Myocardial Infarction (PAMI) trials in the United States, who underwent primary PCI. The main outcome was all-cause mortality at 5 years, obtained through the National Death Index. Of the 2,087 patients, stenting was performed in 692 (33%). The absolute difference in the hospital (2.2% vs 3.3%), 1-year (3.3% vs 5.2%), and 5-year (10% vs 13%) mortality rates favored patients receiving a stent versus conventional balloon therapy, with the difference increasing with time. A multivariate Cox model identified stent use (vs balloon alone) as an independent correlate of lower 5-year mortality (hazard ratio 0.60, 95% confidence interval 0.42 to 0.85). The absolute reduction in mortality was greatest in the highest risk group. In conclusion, compared with balloon angioplasty, stenting during primary PCI not only resulted in better angiographic and short-term outcomes, but also in a sustained beneficial effect on mortality at 5 years. These data support the routine use of coronary stenting in most patients undergoing primary PCI, when feasible.

Early Administration of Intracoronary Verapamil Improves Myocardial Perfusion During Percutaneous Coronary Interventions for Acute Myocardial Infarction

BACKGROUND

Intracoronary calcium-channel blockers administered in the event of no reflow during percutaneous coronary intervention (PCI) in acute myocardial infarction (AMI) have been shown to improve myocardial perfusion.

STUDY OBJECTIVE

To evaluate the effects of the administration of intracoronary verapamil before the occurrence of no reflow during direct PCI.

DESIGN AND SETTING

Single-center, nonrandomized, prospective study with a retrospective control group.

PATIENTS AND METHODS

From September 2001 to December 2003, 50 consecutive patients with AMI were prospectively enrolled for intracoronary verapamil treatment. Intracoronary verapamil was administered immediately prior to balloon inflation and at short intervals during the procedure thereafter. Retrospectively, 50 consecutive AMI patients who had undergone direct PCI and had not received intracoronary calcium-channel blockers were enrolled as control subjects. Patients with cardiogenic shock or platelet glycoprotein IIb/IIIa inhibitor were excluded. Thrombolysis in Myocardial Infarction (TIMI) flow grade, corrected TIMI frame count (CTFC), and TIMI myocardial perfusion grade (TMPG) were assessed prior to and following PCI by two independent cardiologists blinded to the procedures.

RESULTS

The two groups had similar baseline and post-procedural angiographic characteristics, although the patients who been administered verapamil received more stent implantations than the control subjects (84% vs 60%, p = 0.008). Post-procedural TIMI flow < 3 (odds ratio [OR], 0.39; 95% confidence interval [CI], 0.12 to 1.30; p = 0.18) and TMPG (OR, 1.24; 95% CI, 0.46 to 3.34; p = 0.68) were not associated with the implantation of the stents. There were no significant difference in post-PCI TIMI flow (p = 0.68) and CTFC (p = 0.36) between patients treated with verapamil and the control subjects. Post-PCI TMPG was significantly better in patients treated with intracoronary verapamil (p = 0.003). Forty-two percent of the patients treated with verapamil were found to have TMPG-3, while only 14% of the control subjects were found to have the same degree of TMPG (p = 0.004). Treatment with intracoronary verapamil (OR, 0.26; 95% CI, 0.12 to 0.58; p = 0.001) and pre-PCI TIMI flow (OR, 0.54; 95% CI, 0.35 to 0.84; p = 0.006) were found by multiple logistic regression to be independent predictors of TMPG.

CONCLUSIONS

Early administration of intracoronary verapamil during direct PCI improves post-procedural myocardial perfusion, as evaluated by TMPG.

Early and Late Angiographic and Clinical Outcome Following Helistent Stent Implantation

There is still a lack of data on the influence of different stent designs on long-term restenosis rates and major adverse cardiac events (MACE) with the use of new antithrombotic regimens. We evaluated the midterm (6 months) clinical and angiographic and lateterm (2 years) clinical outcome of Helistent stent implantation. The study population consisted of 150 patients with high risk factor rates who had single or multivessel disease and had undergone coronary Helistent stent implantation with new antiplatelet regimens. The control coronary angiographies were done at 6 months and they were followed clinically to the end of 2 years. In 150 patients, 236 Helistent stents were implanted for 224 lesions. Helistent stent implantation was associated with a very high success rate (99%). The angiographic re-stenosis rate was 11.3% at 6 months. Only 16% of the patients experienced target lesion revascularization, 20% of the patients experienced MACE and of them, only 3.3% died at the end of two year follow-up period. The results demonstrate that the Helistent stent can be implanted with a high success rate with encouraging 6 month angiographic and late clinical outcomes.

Clinical and angiographic results after MULTI-LINK stent implantation and their relation to aggregation of risk factors: two-year follow-up

Results of trials using the ACS MULTI-LINK (ML) stent, one of the new generation stents, were similar to or slightly better than those of trials using the Palmaz-Shatz stent. The purpose of this study was to evaluate relatively long-term (2 years) clinical outcomes of patients with coronary artery disease treated with the ML stent and to determine independent factors correlated with target lesion revascularization and cardiac events. The present study consisted of 82 consecutive patients who had undergone successful coronary ML stent implantation from January 1997 to December 1999. During the follow-up period, cardiac events occurred in 16 (19.5%) patients. All patients underwent follow-up angiography and 12 (14.6%) of the 82 patients underwent target lesion revascularization. Multiple logistic regression analysis showed that aggregation of risk factors (> or = 3 risk factors) (p = 0.0274, odds ratio=5.14) and percent diameter stenosis >20% (p = 0.0395, OR = 4.586) were the significant explanatory factors of target lesion revascularization. In addition, aggregation of risk factors (> or = 3 risk factors) exhibited a tendency to correlate with cardiac events (p = 0.0528) on multiple logistic regression analysis. The results of the present study suggest that target lesion revascularization after coronary ML stent implantation was influenced by aggregation of major coronary risk factors and residual percent diameter stenosis and that long-term clinical outcome is influenced by the aggregation of risk factors.