Use of drug-eluting stents in acute myocardial infarction with persistent ST-segment elevation: results of the ALKK PCI-registry

Efficacy of Drug-Eluting Stents in Diabetic Patients Admitted with ST-Elevation Myocardial Infarctions Treated with Primary Percutaneous Coronary Intervention

Background: Diabetic patients show higher adverse ischemic event rates and mortality when undergoing percutaneous coronary intervention (PCI) in acute myocardial infarctions. Therefore, diabetic patients might benefit even more from modern-generation drug-eluting stents (DES). The aim of the present study was to compare adverse ischemic events and mortality rates between bare-metal stents (BMS) and DES in diabetic patients admitted with ST-elevation-myocardial infarction (STEMI) with non-diabetic patients as the control group. Methods: All STEMI patients undergoing emergency PCI and stent implantation documented between 2006 and 2019 in the Bremen STEMI registry entered the analysis. Efficacy was defined as a combination of in-stent thrombosis, myocardial re-infarction or additional target lesion revascularization at one year. Results: Of 8356 patients which entered analysis, 1554 (19%) were diabetics, while 6802 (81%) were not. 879 (57%) of the diabetics received a DES. In a multivariate model, DES implantation in diabetics compared to BMS was associated with lower rates of in-stent thrombosis (OR 0.16, 95% CI 0.05–0.6), myocardial re-infarctions (OR 0.35, 95%CI, 0.2–0.7, p < 0.01) and of the combined endpoint at 1 year ((ST + MI + TLR): OR 0.31, 95% CI 0.2–0.6, p < 0.01), with a trend towards lower 5-year mortality (OR 0.56, 95% CI 0.3–1.0, p = 0.058). When comparing diabetic to non-diabetic patients, an elevation in event rates for diabetics was only detectable in BMS (OR 1.78, 95% CI 0.5–0.7, p < 0.01); however, this did not persist when treated with a DES (OR 1.03 95% CI 0.7–1.6, p = 0.9). Conclusions: In STEMI patients with diabetes, the use of DES significantly reduced ischemic event rates and, unlike with BMS, adverse ischemic event rates became similar to non-diabetic patients.

Quantitative myocardial blush score (QuBE) allows the prediction of heart failure development in long-term follow-up in patients with ST-segment elevation myocardial infarction: Proof of concept study

BACKGROUND

Acute myocardial infarction (AMI) might lead to left ventricular remodeling. Adequate myocardial perfusion is critical to prevent this adverse remodeling. Quantitative myocardial blush evaluator (QuBE) software, available on-line, is a simple analysis tool which enables the precise quan-tification of myocardial perfusion in the infarct area immediately after interventional treatment. The aim of this study was to assess whether the results of QuBE analysis might predict the development of heart failure (HF) in AMI patients in 3 year-long follow-up.

METHODS

Ninety five patients with first AMI, single vessel coronary artery disease, Killip class I at presentation were enrolled in the study. Angiograms were reanalyzed using the on-line QuBE software. Data on heart failure development (ICD 10 codes I50) provided by the National Health Fund were considered as primary outcome.

RESULTS

QuBE values ranged from 0.0 to 25.3 arbitrary units, mean value was 9.9 ± 5.2 arbitrary units. QuBE correlated positively with myocardial blush grade (MBG; Spearman R = 0.342 at p < 0.05). Multivariate Cox proportional hazard modeling, adjusted for initial Thrombolysis in Myocardial In-farction (TIMI flow, and TIMI thrombus grade indicated QuBE score (1 unit increase - HR 0.919, 95% CI 0.846-0.999, p = 0.049) and left ventricular ejection fraction at discharge (1% increase - HR 0.936, 95% CI 0.902-0.971, p = 0.000) as independent predictors of HF development.

CONCLUSIONS

The QuBE assessment of myocardial perfusion allows the prediction of HF development in the post-infarction period in this highly selective group of patients.

Real-world use of fractional flow reserve in Germany: results of the prospective ALKK coronary angiography and PCI registry

BACKGROUND

There is growing evidence for beneficial prognostic and economic effects of FFR-guided treatment of stable coronary artery disease. We sought to evaluate the real-world use of FFR measurements in patients undergoing elective coronary angiography.

METHODS AND RESULTS

We analyzed the data of the prospective ALKK coronary angiography and PCI registry including data of 38 hospitals from January 2010 to December 2013. A total of 100,977 patients undergoing coronary angiography were included. In 3240 patients (3.2 %) intracoronary pressure measurement was performed. There was a wide range of use of FFR measurement in the different analyzed ALKK hospitals from 0.1 to 8.8 % in elective patients with suspected or known coronary artery disease (median 2.7 %, quartiles 0.9 and 5.3 %), with a successive increase of use over time during the study period. Overall, it was performed in 3.2 % of coronary angiographies. Use in patients with three-vessel disease (2.5 %) and recommendation for bypass surgery (1.6 %) was less frequent. In procedures without PCI, dose area product was higher in the FFR group (2641 cGy × cm² vs. 2368 cGy × cm², p < 0.001), while it was lower in procedures with ad hoc PCI (4676 cGy × cm² vs. 5143 cGy × cm², p < 0.001). The performing center turned out to be the strongest predictor.

CONCLUSIONS

The use of FFR measurement was very heterogeneous between different hospitals and in general relatively low, in particular in patients with multivessel disease or recommendation for bypass surgery, but there was a positive trend during the study period. Technically, FFR measurement was not associated with an increased periprocedural complication rate.

External validity of the "all-comers" design: insights from the BIOSCIENCE trial

OBJECTIVES

We sought to systematically evaluate the external validity of a contemporary randomized controlled stent trial (BIOSCIENCE).

METHODS

Baseline characteristics and clinical outcomes of patients enrolled into the BIOSCIENCE trial at Bern University Hospital (n = 1216) were compared to those of patients included in the CARDIOBASE Bern PCI Registry at the same institution (n = 1045). The primary study endpoint was the rate of target lesion failure (TLF), defined as a composite of cardiac death, target vessel-myocardial infarction (MI) or target lesion revascularization (TLR), at 1 year.

RESULTS

Women were underrepresented in the RCT compared to the registry (25 vs. 29.4 %, p = 0.020). Non-participants were older compared to study participants (69.2 ± 12.4 vs. 67.0 ± 11.6, p < 0.001), and had a higher prevalence of previous cerebrovascular events (10.8 vs. 5.2 %, p < 0.001), and chronic renal failure (35.5 vs. 15.6 %, p < 0.001). ST-segment elevation myocardial infarction (STEMI) and Killip class IV at presentation were more common among non-participants than participants (30.7 vs. 21.1 %, p < 0.001 and 7.8 vs. 0.4 %, p < 0.001, respectively). At 1 year, non-participants experienced a significantly higher rate of TLF, (15.0 vs. 6.5 %, p < 0.001), and patient-oriented composite endpoint (POCE), including death, MI or any repeat revascularization (21.6 vs. 11.2 %, p < 0.001). There was a significant interaction between POCE and presence or absence of an acute coronary syndrome in participants versus non-participants, respectively (p = 0.009).

CONCLUSIONS

Non-participants of this all-comers trial had a higher risk profile and adverse prognosis compared to study participants. Further efforts are needed to improve the external validity of contemporary RCTs.

Safety of percutaneous coronary intervention in patients with acute ischemic stroke/transient ischemic attack and acute coronary syndrome

BACKGROUND

Cardiac events in patients with acute stroke are frequent. Urgent PCI in myocardial infarction is crucial to improve outcome. However, the situation is complex as intracranial hemorrhage is a frequent complication of stroke but antithrombotic medication is indispensable during and after PCI. Therefore in this study, we aimed to investigate the safety of percutaneous coronary intervention (PCI) in patients hospitalized with acute ischemic stroke and concomitant acute coronary syndrome (ACS).

METHODS AND RESULTS

In a single-center, case-series study we investigated 80 patients hospitalized with acute stroke/transient ischemic attack (TIA) and concomitant ACS undergoing coronary angiography. Patients with subsequent PCI were compared to patients with medical treatment alone. The primary end point was the composite of death, recurrent MI, coronary re-intervention, recurrent stroke or bleeding during 1-year follow-up. The secondary end point consisted of the components of the primary end point. Age, gender and cardiovascular risk factors did not differ between groups. However, severity of initial stroke and coronary artery disease was higher in the PCI group. Accordingly, antiplatelet medication with aspirin and clopidogrel was prescribed more frequently in the PCI group. Nevertheless, during 1-year follow-up, the primary end point did not differ between groups [38 vs. 50 %, odds ratio (OR) 1.7, CI 0.69-4.07, P = 0.23]. Intracranial hemorrhage was even numerically lower in patients undergoing PCI (5 vs. 3 %, OR 0.4, CI 0.04-5.6, P = 0.46).

CONCLUSIONS

The primary and secondary end points were not enhanced in patients undergoing PCI. Therefore PCI is safe in patients with stroke/TIA and concomitant ACS.

Use and impact of thrombectomy in primary percutaneous coronary intervention for acute myocardial infarction with persistent ST-segment elevation: results of the prospective ALKK PCI-registry

BACKGROUND

Data about the impact of thrombectomy in primary percutaneous coronary intervention (PCI) are inconsistent. The aim of our study was an evaluation of both the real-world use of thrombectomy and the impact of thrombectomy on outcome in unselected patients treated with primary PCI for ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

We used the data of the prospective ALKK PCI-registry of 35 hospitals from January 2010 to December 2013. A total of 10,755 patients receiving single-vessel primary PCI for acute STEMI were included. In 2176 patients (20.2 %) thrombectomy was performed. There was a wide range of use of thrombectomy in the different ALKK hospitals from 1.1 to 61.7 % (median 18.6 %, quartiles 6.0 and 40.3 %) with a general increase of use over the first years of the study period. In patients with and without thrombectomy there was TIMI 0 flow present before PCI in 6010 patients, TIMI 1 in 1338, TIMI 2 in 2002, and TIMI 3 in 1405. Patients with acute heart failure or cardiogenic shock received significantly more often thrombectomy. Fluoroscopy time (8.1 vs. 7.3 min, p < 0.0001) and dose area product (5373 cGy × cm(2) vs. 4802 cGy × cm(2), p < 0.0001) were significantly higher in patients treated with thrombectomy. The subgroup of patients with TIMI 0 flow before PCI had significantly higher rates of TIMI 3 flow after PCI when treated with thrombectomy (87.1 vs. 84.1 %, p < 0.01), while there was no difference in post-PCI TIMI 3 flow in patients with TIMI 1, 2 or 3 flow before PCI. Rates of major adverse cardiac and cerebrovascular events were similar in both groups in general and in all subgroups of TIMI flow.

CONCLUSIONS

The use of thrombectomy in patients with STEMI is heterogenous between hospitals. Overall, there was no impact of thrombectomy on TIMI 3 patency or mortality after PCI. In the subgroup of STEMI patients with TIMI 0 flow before PCI individualized thrombectomy had a positive impact on restoration of normal blood flow.