Incidence, predictors, and clinical outcomes of early stent thrombosis in acute myocardial infarction patients treated with primary percutaneous coronary angioplasty (insights from the University of Ottawa Heart Institute STEMI registry)

Early in-hospital discontinuation of aspirin on the first post-procedural day after percutaneous coronary stent implantation in patients on direct oral anticoagulation

Background

Previous trials investigating antithrombotic therapy with a direct oral anticoagulant (DOAC) and a P2Y12 inhibitor after percutaneous coronary intervention (PCI), termed dual therapy, allowed a short period of triple therapy including a DOAC, a P2Y12 inhibitor, and aspirin.

Aims

This study aimed to determine whether discontinuation of aspirin on the first post-procedural day is safe or causes ischemic events.

Methods

Ischemic and bleeding events during hospitalization were investigated retrospectively in all patients treated with dual therapy (DOAC + P2Y12 inhibitor, designated as group 1) or triple therapy (DOAC + P2Y12 inhibitor+aspirin, designated as group 2) from day 1 after PCI at our center.

Results

Of 4,564 consecutive PCI procedures, 1,059 (23.2%) had an indication for OAC. Of these, 322 met the inclusion criteria for group 1 and 62 for group 2. Baseline characteristics, CHA2DS2-VASc and HAS-BLED scores showed no relevant differences between the two groups, and the main indication for DOAC therapy was atrial fibrillation in both groups. Approximately ¼ of patients were treated for acute coronary syndrome. The mean length of post-procedural hospitalization was 2.1 ± 2.5 and 2.2 ± 3.0 days in group 1 and 2, respectively (p = 0.305). One patient per group suffered a TIA (p = 0.297). There were no other ischemic events and no statistically significant differences in bleeding events. A subgroup analysis of cases hospitalized for ≥2 post-procedural days (group 1: 100 cases, mean 4.4 ± 3.4 days vs. group 2: 25 cases, mean 4.0 ± 4.1 days) confirmed these results.

Conclusion

The initiation of dual therapy and thus discontinuation of aspirin on the first postprocedural day appears to be safe with respect to short-term ischemic events in a real-world population. Almost ¼ of patients undergoing PCI have an indication for OAC, highlighting the relevance of this issue.

Comparison of intracoronary versus intravenous tirofiban in acute ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

OBJECTIVE

This study aimed to investigate the effect of intracoronary (IC) tirofiban compared to intravenously administered tirofiban in STEMI patients treated with PPCI.

METHODS

This study included 180 STEMI patients who were underwent PPCI. Patients were randomized into an IC group (n = 90) and intravenous (IV) group (n = 90). During the procedure, the both groups were administered IC or IV injections of tirofiban, respectively, followed by an IV infusion of tirofiban for 24 hours. Changes in TIMI flow grading, TMP grade 3, Sum-STR two hours after the operation, the number of thrombus aspirations during the operation, myocardial enzyme, inflammatory factors,cardiac functional parameters, MACE and bleeding were investigated.

RESULTS

Following treatment, TIMI flow grading and TMP grade 3 were improved in the IC tirofiban compared to the IV group (P = 0.022 and P = 0.014, respectively). Additionally, the Sum-STR two hours after operation, the incidence of MACEs, levels of AST, CRP, ESR, and TNI in the IC group was improved, compared with the IV group (all P < 0.05). Furthermore. Cardiac function including CO and LVEF were significantly improved in the IC group 6 months after discharge.

CONCLUSION

This study found that IC administration of tirofiban in patients with STEMI who underwent PPCI improved TIMI, TMP flow and cardiac function 6 months after discharge, and reduced CRP, ESR, and TNI. However, the incidence of bleeding between the two groups was comparable. These findings suggest that IC administration should be applied in certain acute STEMI patients.

Safety and effectiveness of introducing a robotic-assisted percutaneous coronary intervention program in a tertiary center: a prospective study

BACKGROUND

Robotic-assisted percutaneous coronary intervention (PCI) is a novel technology that permits remote operation of interventional devices. However, little is known about the safety and effectiveness of introducing a robotic PCI program in a hospital already experienced in traditional coronary angioplasty.

METHODS

Prospective single-arm survey to assess the safety and effectiveness of robotic-assisted PCI in comparison to pre-defined performance goals. The study cohort comprised all consecutive cases treated with robotic PCI since its introduction. The safety primary endpoint was a composite of (I) overall death or (II) non-fatal adverse events related to target vessel complications (stent thrombosis, myocardial infarction, vessel perforation or cardiac tamponade, or repeat invasive treatment) during the index hospitalization. The efficacy primary endpoint was robotic-assisted procedural success, a composite of (I) successful dilatation of the target lesion and (II) successful robotic assistance, defined as absent non-planned manual conversion.

RESULTS

A total of 83 patients and 112 lesions were prospectively enrolled. The rate of angiographic success was 99.1%. From these, 97 lesions (86.6%) were treated with only robotic PCI or with hybrid according to the pre-interventional plan. The rates of efficacy and safety primary endpoints were 85.7% and 2.4% respectively (P<0.01 for non-inferior to the pre-defined performance threshold).

CONCLUSIONS

Introduction of robotic-assisted PCI in a tertiary center was associated with safe and effective results, comparable to pre-defined goals of optimal performance.

Frequency, Etiology, and Impact of Unplanned Repeat Coronary Angiography After ST-Elevation Myocardial Infarction

Unplanned repeat coronary angiography (CAG) after balloon angioplasty for ST-elevation myocardial infarction (STEMI) was common before the advent of coronary stenting. Limited data are available regarding the role of unplanned repeat CAG in contemporary percutaneous coronary intervention (PCI) for STEMI. Therefore, we analyzed a large, 2-center prospective STEMI registry (January 2011 to June 2020) stratified by the presence or absence of unplanned repeat CAG during index hospitalization. Patients with planned CAG for staged PCI or experimental drug administration were excluded. Among 3,637 patients with STEMI, 130 underwent unplanned repeat CAG (3.6%) during index hospitalization. These patients were more likely to have cardiogenic shock (16% vs 9.8%, p = 0.021), left anterior descending culprit (44% vs 31%, p <0.001), lower left ventricular ejection fraction (45% vs 52%, p <0.001), and higher peak troponin levels (22 vs 8 ng/ml, p <0.001) than those without repeat CAG. At repeat CAG, 80 patients had a patent stent (62%) including 65 requiring no further intervention (50%) and 15 who underwent intervention on a nonculprit lesion (12%). Only 32 patients had stent thrombosis (25%). Repeat CAG was associated with a higher incidence of recurrent MI (19% vs 0%, p <0.001) and major bleeding (12% vs 4.5%, p <0.001), yet similar in-hospital mortality (7% vs 6.4%, p = 0.93) than those without repeat CAG. In conclusion, in the era of contemporary PCI for STEMI, unplanned repeat CAG during index hospitalization was infrequent and more commonly observed in patients with left anterior descending culprit in the presence of significant left ventricular dysfunction or shock and was associated with higher in-hospital recurrent myocardial infarction and major bleeding complications.

The outcome of primary percutaneous coronary intervention in patients with stent thrombosis

BACKGROUND

Primary percutaneous coronary intervention (PCI) is a recommended management strategy for patients with de novo ST-segment elevation myocardial infarction (STEMI). Still, the efficacy of primary PCI in-stent thrombosis (ST) induced STEMI is unclear. The aim was to assess the clinical characteristics and the in-hospital outcomes of patients undergoing primary PCI for STEMI caused by acute, sub-acute, or late ST.

METHODS

A sample of hundred consecutive patients who presented with STEMI due to ST were included in this study. The angiographic evidence of a flow-limiting thrombus or total vessel occlusion (thrombolysis in myocardial infarction (TIMI) flow grade 0 to II) at the site of the previous stent implant was taken as ST. Primary PCI was performed, and all enrolled patients and in-hospital mortality were observed.

RESULTS

Male patients were 69, and the mean age was 58.9 ± 7.78 years. ST was categorized as acute in 40 patients, sub-acute in 53, and late in the remaining seven patients. Killip class III/IV was observed in 45 patients. Dissection was observed in 25, under deployment in 74, and/or malposition in 24 patients. Thrombus aspiration was performed in 97, plain old balloon angioplasty in 76, and stenting in 22 patients. Final TIMI III flow was achieved in 32 patients. During a mean hospital stay of 4.93 ± 2.46 days, the mortality rate was 27%.

CONCLUSION

In-hospital mortality after primary PCI was observed in more than 1/4th of the patients with STEMI due to ST undergoing primary PCI.

Effects of Intracoronary Pro-urokinase or Tirofiban on Coronary Flow During Primary Percutaneous Coronary Intervention for Acute Myocardial Infarction: A Multi-Center, Placebo-Controlled, Single-Blind, Randomized Clinical Trial

Background: To determine whether intracoronary pro-urokinase or tirofiban improves myocardial reperfusion during primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI).

Methods: The study included patients with acute STEMI presenting within 12 h of symptoms at 11 hospitals in China between November 2015 and July 2017. Patients were randomized to receive selective intracoronary infusion of recombinant pro-urokinase (20 mg), tirofiban (10 μg/kg), or saline (20 mL) proximal to the infarct-related lesion over a 3-min period before stent implantation during primary PCI. The primary outcome was final corrected thrombolysis in myocardial infarction (TIMI) frame count (CTFC) after PCI.

Results: This study included 345 patients. Initial angiography identified a high-grade thrombus (TIMI 4–5) in 80% of patients. Final CTFC after PCI was significantly lower in the pro-urokinase (P < 0.001) and tirofiban (P < 0.001) groups than in the saline group and similar between the pro-urokinase and tirofiban groups (P > 0.05). The pro-urokinase (P = 0.008) and tirofiban groups (P = 0.022) had more complete ST-segment resolution at 2 h and lower peak creatine kinase-MB levels after PCI than the saline group (P = 0.006 and P = 0.023). The 30-day incidence of major adverse cardiac events was 4.5% in the pro-urokinase group, 3.4% in the tirofiban group, and 2.6% in the saline group. The incidence of in-hospital TIMI major bleeding events was low and comparable between groups.

Conclusions: Adjunctive intracoronary pro-urokinase or tirofiban given before stent implantation during primary PCI improves myocardial reperfusion without increasing the incidence of major bleeding events.

Clinical outcomes following ST-elevation myocardial infarction secondary to stent thrombosis treated by percutaneous coronary intervention

OBJECTIVES

To assess the clinical outcomes of patients presenting with ST-elevation myocardial infarction (STEMI) secondary to stent thrombosis (ST) compared to those presenting with STEMI secondary to a de novo culprit lesion and treated by percutaneous coronary intervention (PCI).

BACKGROUND

ST is an infrequent but serious complication of PCI with substantial associated morbidity and mortality, however with limited data.

METHODS

We studied consecutive patients who underwent PCI for STEMI from 2005 to 2013 enrolled prospectively in the Melbourne Interventional Group registry. Patients were divided into two groups: the ST group comprised patients where the STEMI was due to ST and the de novo group formed the remainder of the STEMI cohort and all patients were treated by PCI. The primary endpoint was 30-day all-cause mortality.

RESULTS

Compared to the de novo group (n = 3,835), the ST group (n = 128; 3.2% of STEMI) had higher rates of diabetes, hypertension and dyslipidemia, established cardiovascular diseases, myocardial infarction, and peripheral vascular disease, all p < .01. Within the ST group, very-late ST was the most common form of ST, followed by late and early ST (64, 19, and 17%, respectively). There was no significant difference in the primary outcome between the ST group and the de novo group (4.7 vs. 7.1%, p = .29). On multivariate analysis, ST was not an independent predictor of 30-day mortality (odds ratio: 0.62, 95% confidence interval: 0.07-1.09, p = .068).

CONCLUSION

The short-term prognosis of patients with STEMI secondary to ST who were treated by PCI was comparable to that of patients with STEMI due to de novo lesions.