Primary stenting of occluded native coronary arteries: final results of the Primary Stenting of Occluded Native Coronary Arteries (PRISON) study

Panax notoginseng Saponins Improve Angiogenesis in Coronary Heart Disease Based on the microRNA 200a Methylation Pathway

Background

Improving angiogenesis in the ischemic myocardium is a therapeutic strategy for preventing, reducing, and repairing myocardial injury of coronary artery disease (CAD). Panax notoginseng saponins (PNS) have been widely used in the clinical treatment of cardiovascular diseases, demonstrating excellent efficacy, and can potentially improve angiogenesis in the ischemic myocardium. However, the effects of PNS on angiogenesis and its underlying mechanism of action remain unclear.

Purpose

In this study, we aimed to evaluate the role of PNS in improving angiogenesis after myocardial infarction (MI) and explain the mechanism of PNS in improving angiogenesis in CAD from an epigenetic perspective.

Study Design

The MI rat model was established by ligating the left anterior descending coronary artery permanently. The in vitro model comprised hypoxic human coronary artery endothelial cells (HCEACs). The mice and cells were then treated with PNS.

Methods

Blood tests, histomorphology, polymerase chain reaction, enzyme-linked immunosorbent assay, Western blotting, and MassARRAY targeted methylation detection analyses were conducted in vivo and in vitro to investigate the potential mechanisms of PNS.

Results

Oral PNS significantly improved myocardial injury and activated angiogenesis in MI rats. DNA methylation analysis in vitro revealed that PNS decreased the hypermethylation of microRNA 200a (miR200a). PNS improved angiogenesis in hypoxic human coronary artery endothelial cells (HCEACs) by regulating the vascular endothelial growth factor (VEGF) pathway.

Conclusion

Our research shows that PNS can improve angiogenesis in rats with MI and hypoxic HCEACs and affect the level of miR200a promoter methylation and miR200a and VEGF molecular pathways.

Randomized Multicenter Trial Investigating Angiographic Outcomes of Hybrid Sirolimus-Eluting Stents With Biodegradable Polymer Compared With Everolimus-Eluting Stents With Durable Polymer in Chronic Total Occlusions: The PRISON IV Trial

OBJECTIVES

The aim of this study was to investigate the efficacy and safety of the hybrid ultrathin-strut sirolimus-eluting stent (SES) with biodegradable polymer compared with the thin-strut everolimus-eluting stent (EES) with durable polymer in successfully recanalized chronic total occlusions (CTOs).

BACKGROUND

The introduction of drug-eluting stents revolutionized the treatment of CTOs. However, limited data are available on new-generation drug-eluting stents with biodegradable polymer in CTOs.

METHODS

In this multicenter trial, patients were randomized, after successful CTO recanalization, to either SES or EES. The primary noninferiority endpoint was in-segment late lumen loss (noninferiority margin 0.2 mm). Secondary endpoints included in-stent late lumen loss and clinical endpoints.

RESULTS

Overall, 330 patients were included. At 9 months, angiography was available in 281 patients (85%). Duration of occlusion ≥3 months was 92.5%, with mean stent length of 52.4 ± 28.1 mm versus 52.3 ± 26.5 mm in the SES and EES groups. The primary noninferiority endpoint, in-segment late lumen loss, was not met for SES versus EES (0.13 ± 0.63 mm vs. 0.02 ± 0.47 mm; p = 0.08, 2-sided; difference 0.11 mm; 95% confidence interval: -0.01 to 0.25 mm; p_{noninferiority} = 0.11, 1-sided). In-stent late lumen loss was comparable between SES and EES (0.12 ± 0.59 mm vs. 0.07 ± 0.46 mm; p = 0.52). The incidence of in-stent and in-segment binary restenosis was significantly higher with SES compared with EES (8.0% vs. 2.1%; p = 0.028), with comparable rates of reocclusions (2.2% vs. 1.4%; p = 0.68). Clinically indicated target lesion and target vessel revascularization (9.2% vs. 4.0% [p = 0.08] and 9.2% vs. 6.0% [p = 0.33]), target vessel failure (9.9% vs. 6.6%; p = 0.35), and definite or probable stent thrombosis (0.7% vs. 0.7%; p = 1.00) were comparable between the SES and EES groups.

CONCLUSIONS

This randomized trial failed to show noninferiority of hybrid SES relative to EES in terms of in-segment late lumen loss in successfully recanalized CTOs. Furthermore, a statistically significantly higher rate of binary restenosis was found with SES.

Relationship between early administration of abciximab and TIMI flow in STEMI patients undergoing primary angioplasty: findings from a large regional STEMI network

AIMS

The aim of this study is to assess whether in S-T Elevation Myocardial Infarction (STEMI) a relationship between early administration of abciximab and Thrombolysis In Myocardial Infarction (TIMI) flow before and after primary percutaneous coronary intervention (PCI) in 960 consecutive patients exists.

METHODS

From 1 February 2001 onward, in the Province of Mantua it has been operating a 'Cardiology Network for the Acute Infarction Care' having its Hub in the Central Coronary ICU/Cath Lab of Mantua Hospital and being its Spokes centers represented by the emergency rooms and Central Coronary ICUs of the four territorial hospitals.

RESULTS

T1 (time from symptoms onset to first medical contact) and T2 (time from first medical contact to angioplasty) are shorter for patients rescued by first aid units rather than for those presented in emergency rooms as well as Ta (time from symptoms onset to abciximab administration). Furthermore, the patients that received abciximab before hospital arrival had less frequently a coronary occlusion [odds ratio = 0.74, 95% confidence interval (0.57-0.96), P = 0.013]. The patients with T1 less than 4 h are 753/960 (78.4%). For this type of patients, there was a significant Ta difference between the pre-PCI TIMI-flow classes (F = 4.467, df = 3, P = 0.04). Planned contrasts revealed that mean time of TIMI flow 0 (M = 104.2) is statistically different from mean time of TIMI flow 3 (M = 85.7), P = 0.013.

CONCLUSION

Our results suggest that the use of abciximab, free from pharmacokinetic limits of oral P2Y12 inhibitors, should be considered in STEMI patients with early presentation before primary PCI.

Primary Stenting of Totally Occluded Native Coronary Arteries III (PRISON III): a randomised comparison of sirolimus-eluting stent implantation with zotarolimus-eluting stent implantation for the treatment of total coronary occlusions

AIMS

We investigated whether sirolimus-eluting stents (SES) are superior to next-generation zotarolimus-eluting stents (ZES) in treating patients with total coronary occlusions (TCO).

METHODS AND RESULTS

In a prospective, randomised trial we compared the SES with the zotarolimus-eluting stent (ZES; Endeavor or Resolute) after successful recanalisation of TCO. During the first phase of the trial, 51 patients were assigned to receive the SES and 46 patients to receive the Endeavor ZES. In the second phase we randomised 103 patients to the SES group and 104 patients to the Resolute ZES group. The primary endpoint was in-segment late lumen loss at eight-month follow-up. At eight months, patients in the SES group had less in-segment and in-stent late loss as compared to the Endeavor group: -0.13±0.3 mm vs. 0.27±0.6 mm (p=0.0002) and -0.13±0.5 mm vs. 0.54±0.5 mm (p<0.0001), respectively. In contrast, the SES and the Resolute ZES showed comparable amounts of in-segment (-0.03±0.7 mm vs. -0.10±0.7 mm, p=0.6) and in-stent (0.03±0.8 mm vs. 0.05±0.8 mm, p=0.9) late loss.

CONCLUSIONS

In the treatment of TCOs, the SES was associated with superior angiographic outcomes compared to the Endeavor ZES. On the other hand, the SES and the Resolute ZES showed comparable angiographic outcomes.

Management and outcomes of patients presenting with STEMI by use of chronic oral anticoagulation: results from the GRACE registry

AIMS

To describe the characteristics, treatment, and mortality in patients with ST-elevation myocardial infarction (STEMI) by use of chronic oral anticoagulant (OAC) therapy.

METHODS

Using data from the Global Registry of Acute Coronary Syndromes (GRACE), patient characteristics, treatment, and reperfusion strategies of STEMI patients on chronic OAC are described, and relevant variables compared with patients not on chronic OAC. Six-month post-discharge mortality rates were evaluated by Cox proportional hazard models.

RESULTS

Of 19,094 patients with STEMI, 574 (3.0%) were on chronic OAC at admission. Compared with OAC non-users, OAC users were older (mean age 73 vs. 65 years), more likely to be female (37 vs. 29%), were more likely to have a history of atrial fibrillation, prosthetic heart valve, venous thromboembolism, or stroke/transient ischaemic attack, had a higher mean GRACE risk score (166 vs. 145), were less likely to be Killip class I (68 vs. 82%), and were less likely to undergo catheterization/percutaneous coronary intervention (52 vs. 66%, respectively). Of the patients who underwent catheterization, fewer OAC users had the procedure done within 24 h of admission (56.5 vs. 64.5% of OAC non-users). In propensity-matched analyses (n=606), rates of in-hospital major bleeding and in-hospital and 6-month post-discharge mortality were similar for OAC users and OAC non-users (2.7 and 3.7%, p=0.64; 15 and 13%, p=0.56; 15 and 12%, p=0.47, respectively), rates of in-hospital recurrent myocardial infarction (8.6 and 2.0%, p<0.001) and atrial fibrillation (32 and 22%, p=0.004) were higher in OAC patients, and rates of 6-month stroke were lower (0.6 and 4.3%, p=0.038). Patients in both groups who underwent catheterization had lower mortality than those who did not undergo catheterization.

CONCLUSIONS

This is the largest study to describe the characteristics and treatment of STEMI patients on chronic OAC. The findings suggest that patients on chronic OAC are less likely to receive guideline-indicated management, but have similar adjusted rates of in-hospital and 6-month mortality.

Contemporary overview and clinical perspectives of chronic total occlusions

Chronic total occlusions (CTOs) are often detected on diagnostic coronary angiograms, but percutaneous coronary intervention (PCI) for CTO is currently infrequently performed owing to high technical difficulty, perceived risk of complications, and a lack of randomized data. However, successful CTO-PCI can significantly increase a patient's quality of life, improve left ventricular function, reduce the need for subsequent CABG surgery, and possibly improve long-term survival. A number of factors must be taken into account for the selection of patients for CTO-PCI, including the extent of ischaemia surrounding the occlusion, the level of myocardial viability, coronary location of the CTO, and probability of procedural success. Moreover, in patients with ST-segment elevation myocardial infarction, a CTO in a noninfarct-related artery might lead to an increase in infarct area, increased end-diastolic left ventricular pressure, and decreased left ventricular function, which are all associated with poor clinical outcomes. In this Review, we provide an overview of the anatomy and histopathology of CTOs, perceived benefits of CTO-PCI, considerations for patient selection for this procedure, and a summary of emerging techniques for CTO-PCI.

Late catch-up in lumen diameter at five-year angiography in MACE-free patients treated with sirolimus-eluting stents in the Primary Stenting of Totally Occluded Native Coronary Arteries: a randomised comparison of bare metal stent implantation with sirolimus-eluting stent implantation for the treatment of total coronary occlusions (PRISON II)

AIMS

The present study was designed to examine the five-year angiographic follow-up of MACE-free patients enrolled in the PRISON II study.

METHODS AND RESULTS

In the PRISON II study a total of 200 patients were randomised to either bare metal stents (BMS) or sirolimus-eluting stents (SES) after successful recanalisation of total coronary occlusions (TCO). Patients free of MACE with available angiography at six months were approached for repeated angiography at five years. The primary endpoint was in-stent very late luminal loss (VLLL) at five years. The secondary endpoint was additional late luminal loss (ALLL) between six months and five years. At five years, repeated angiography was performed in 72 patients, 50/82 (61%) in the SES group and 22/58 (38%) in the BMS group. In-stent VLLL was lower in the SES group (0.19 mm ± 0.72 vs. 0.51 mm ± 0.71, p=0.09) compared to the BMS group and in-segment VLLL was comparable in both groups (0.01 mm±0.58 vs. 0.03 mm ± 0.73, p=0.89). Late catch-up in lumen diameter was observed in the SES group with a trend towards increased ALLL compared to the BMS group (in-stent, 0.35 mm ± 0.88 vs. 0.04 mm ± 0.81, p=0.16; in-segment, 0.20 mm ± 0.74 vs. -0.05 mm ± 0.73, p=0.19).

CONCLUSIONS

At five-year angiographic follow-up, late catch-up was observed after successful recanalisation of TCOs treated with SES. Despite a late catch-up, the angiographic results of SES were superior in-stent and similar in-segment compared to BMS.

A randomized multicenter comparison of hybrid sirolimus-eluting stents with bioresorbable polymer versus everolimus-eluting stents with durable polymer in total coronary occlusion: rationale and design of the Primary Stenting of Occluded Native Coronary Arteries IV study

BACKGROUND

Percutaneous recanalization of total coronary occlusion (TCO) was historically hampered by high rates of restenosis and reocclusions. The PRISON II trial demonstrated a significant restenosis reduction in patients treated with sirolimus-eluting stents compared with bare metal stents for TCO. Similar reductions in restenosis were observed with the second-generation zotarolimus-eluting stent and everolimus-eluting stent. Despite favorable anti-restenotic efficacy, safety concerns evolved after identifying an increased rate of very late stent thrombosis (VLST) with drug-eluting stents (DES) for the treatment of TCO. Late malapposition caused by hypersensitivity reactions and chronic inflammation was suggested as a probable cause of these VLST. New DES with bioresorbable polymer coatings were developed to address these safety concerns. No randomized trials have evaluated the efficacy and safety of the new-generation DES with bioresorbable polymers in patients treated for TCO.

METHODS/DESIGN

The prospective, randomized, single-blinded, multicenter, non-inferiority PRISON IV trial was designed to evaluate the safety, efficacy, and angiographic outcome of hybrid sirolimus-eluting stents with bioresorbable polymers (Orsiro; Biotronik, Berlin, Germany) compared with everolimus-eluting stents with durable polymers (Xience Prime/Xpedition; Abbott Vascular, Santa Clara, CA, USA) in patients with successfully recanalized TCOs. In total, 330 patients have been randomly allocated to each treatment arm. Patients are eligible with estimated duration of TCO ≥4 weeks with evidence of ischemia in the supply area of the TCO. The primary endpoint is in-segment late luminal loss at 9-month follow-up angiography. Secondary angiographic endpoints include in-stent late luminal loss, minimal luminal diameter, percentage of diameter stenosis, in-stent and in-segment binary restenosis and reocclusions at 9-month follow-up. Additionally, optical coherence tomography is performed in the first 60 randomized patients at 9 months to assess neointima thickness, percentage of neointima coverage, and stent strut malapposition and coverage. Personnel blinded to the allocated treatment will review all angiographic and optical coherence assessments. Secondary clinical endpoints include major adverse cardiac events, clinically driven target vessel revascularization, target vessel failure and stent thrombosis to 5-year clinical follow-up. An independent clinical event committee blinded to the allocated treatment will review all clinical events.

TRIAL REGISTRATION

Clinical Trials.gov: NCT01516723. Patient recruitment started in February 2012.

Treatment of in-stent restenosis with beraprost sodium: an experimental study of short- and intermediate-term effects in dogs

1. The aim of the present study was to evaluate the inhibitory effects of the short-term administration of beraprost sodium, a stable prostaglandin I(2) analogue, on neointimal thickening after stenting. 2. To examine the immediate and short-term effects, Z-stents were placed in the iliac veins of 12 dogs, which were randomly assigned to either a beraprost-treated or control (saline) group. Beraprost (0.35 microg/kg per min) or saline (1.5 mL/min) was administered 30 min before stenting and was continued for 5 h thereafter. Platelet aggregation was measured before and after drug administration. At 3, 7 and 14 days after stenting, dogs were killed and immunohistochemical staining for proliferating cell nuclear antigen was used to quantify the proliferation of vascular smooth muscle cells (SMC). To evaluate intermediate-term effects, a Z-stent was placed in the right iliac vein in 10 dogs, followed by beraprost treatment. Three days later, a second Z-stent was placed contralaterally with saline infusion as a control. After 4 weeks, dogs were killed and neointimal thickness was measured under a light microscope to calculate the intima : media area ratio. 3. Platelet aggregation was more significantly suppressed in the beraprost-treated than in the control group (P = 0.01). In addition, SMC proliferation was significantly lower in the beraprost-treated group 7 and 14 days after stenting (P < 0.05). Over the intermediate term, the intima : media area ratio was significantly lower in the beraprost-treated vein compared with control (P < 0.05). 4. In conclusion, short-term beraprost treatment during stenting suppresses in situ platelet aggregation and SMC proliferation, thus reducing neointimal thickening.

Three-year clinical outcome after primary stenting of totally occluded native coronary arteries: a randomized comparison of bare-metal stent implantation with sirolimus-eluting stent implantation for the treatment of total coronary occlusions (Primary Stenting of Totally Occluded Native Coronary Arteries [PRISON] II study)

BACKGROUND

The purpose of this study was to examine the 3-year clinical outcome in patients enrolled in the Primary Stenting of Totally Occluded Native Coronary Arteries II study.

METHODS

Patients with totally occluded coronary arteries randomized to either sirolimus-eluting Cypher stents (SESs) (Cordis, a Johnson & Joshson Company, Miami Lakes, FL) (100 patients) or bare-metal BxVelocity stents (BMSs) (Cordis) (100 patients) were followed clinically for 3 years.

RESULTS

Between 1 and 3 years, there were infrequent additional clinical events that were equally distributed between the SES and the BMS group. After 3 years, target lesion revascularization was 7% in the SES group versus 27% in the BMS group (P < .001); and target vessel revascularization was seen in 11% in the SES group versus 30% in the BMS group (P = .002). Major adverse cardiac events were noted in 10% of the SES group versus 34% in the BMS group (P < .001). There were no statistically significant differences in death, myocardial infarction, and stent thrombosis according to the Academic Research Consortium criteria between the 2 groups.

CONCLUSIONS

Clinical outcome up to 3 years after implantation of SESs for total coronary occlusions continues to demonstrate a significant reduction in adverse clinical events compared with BMSs without the evidence for either disproportionate late restenosis or late stent thrombosis.

Off-label use of stents: bare-metal versus drug-eluting stents

Drug-eluting stents (DES) became the default strategy for percutaneous revascularization due to their improved intermediate-term outcomes when compared with bare-metal stents (BMS) in the pivotal randomized, controlled trials. The excellent results of DES in on-label or US FDA-approved indications led to extrapolation of the results to more complex situations that were excluded from initial pivotal trials; such as off-label indications. Safety concerns began to grow after reports of increased late thrombosis and possibly associated increased death and myocardial infarction with DES, especially in the off-label situations. Recently, however, several important published registries have calmed some of those uncertainties and reassured the cardiology community of the safety and efficacy of DES compared with BMS. There is an overall poorer outcome with off-label use of any stent (BMS or DES) compared with standard or on-label use. This difference in outcome is most likely related to patient or specific coronary lesion characteristics or comorbidities that predispose an individual to adverse outcomes regardless of the stent type used. It is accepted now that DES use does result in a small increased risk of late thrombosis, but that risk is offset by a significant reduction in restenosis. Overall, the current data suggest that the use of DES in most lesion subsets is at least as safe as and clearly more efficacious than use of BMS in similar situations.

Utility of drug-eluting stents in complex lesions and high-risk patients

Drug-eluting stents represent a breakthrough technology designed to deliver high concentrations of a bioactive agent locally to an atherosclerotic lesion, thereby minimizing systemic side effects of the drug. The safety and efficacy of drug-eluting stents have clearly been demonstrated in noncomplex lesions. This article presents an evidence-based analysis of the current experience with CYPHER sirolimus-eluting stents (Cordis Corp., Miami Lakes, FL) and TAXUS paclitaxel-eluting stents (Boston Scientific, Natick, MA) in a broad spectrum of high-risk and/or complex subsets of patients and lesions, including those with diabetes mellitus, multivessel disease, diffuse disease, very small vessels, lesions in saphenous vein grafts, chronic total occlusions, in-stent restenosis, ostial and bifurcation lesions, unprotected left main disease, and acute myocardial infarction. Emerging data in several of these subsets suggest that drug-eluting stents are safe and effective, and their use may currently be recommended, whereas in other groups of patients and lesions the efficacy and/or safety of drug-eluting stents remains to be determined, thus warranting caution. It is anticipated that penetration of drug-eluting stents will continue to increase, and fewer patients will require surgical revascularization to achieve sustained event-free survival.

Reperfusion strategies in ST-elevation myocardial infarction--current status and perspectives for early and pre-hospital treatment

The latest guidelines on the emergency care of acute ST-elevation myocardial infarction were published by the European Resuscitation Council at the end of 2005. Since then, numerous studies have been presented, which have led to important conclusions. Among pharmacological interventions, the opinion on adjuncts to anticoagulant treatment in the area of thrombolysis as well as in primary coronary intervention seems to be moving away from unfractionated heparin towards low molecular weight heparin, and possibly even factor Xa-specific pentasaccharide or the direct antithrombin bivalirudin. Clopidogrel has developed to become an accepted standard alongside aspirin in thrombolytic therapy of ST-elevation myocardial infarction, even if some questions still remain open. The promising idea of "facilitated percutaneous coronary intervention" has shown itself to at least be problematic if performed immediately and routinely after thrombolysis; "rescue" intervention in the event of ineffective thrombolysis is, on the other hand, useful and effective. Apparently, a more individualistic approach is required, which combines new therapeutic options and patients' conditions on the one side with regional resources on the other, to produce an optimal and timely strategy, remembering that one size does not fit all.

Shifting from pharmacological to systematic mechanical reperfusion therapy for acute myocardial infarction via a cooperating network: impact on reperfusion rate and in-hospital mortality

BACKGROUND

Primary percutaneous transluminal coronary angioplasty is the preferred reperfusion strategy for acute ST-elevation myocardial infarction in selected settings. Limited data are available about the clinical impact of the implementation of a systematic primary angioplasty infarct reperfusion program in the real world.

METHODS AND RESULTS

We organized a comprehensive district network allowing the coordinated and timely transfer of patients with acute ST-elevation myocardial infarction to the hub hospital with catheterization facilities in order to expand the use of mechanical reperfusion. Implementation of the network resulted in increased numbers of patients receiving reperfusion therapies (from 57.5% to 74.1%; P < 0.001). In addition, the proportion of elderly individuals (those aged > or = 75 years) who received a reperfusion therapy significantly increased (from 25.7% to 66.3%; P < 0.001). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 42.5% to 25.9%. Primary percutaneous transluminal coronary angioplasty usage increased from 24.5% to 73.1% (P < 0.001). As a consequence, in-hospital mortality decreased from 13.5% before establishment of the network to 6.0% (P = 0.016), and major adverse cardiac events decreased from 17.5% to 7.8% (P = 0.005).

CONCLUSIONS

Implementation of a systematic primary angioplasty infarct reperfusion program improves reperfusion rate and reduces in-hospital mortality and total major adverse cardiovascular events.

Clinical trials update from the European Society of Cardiology Congress in Vienna, 2007: PROSPECT, EVEREST, ARISE, ALOFT, FINESSE, Prague-8, CARESS in MI and ACUITY

The Clinical Trials described in this article were presented at the Hotline and Clinical Trial Update Sessions of the European Society of Cardiology Congress held in September 2007 in Vienna, Austria. The sessions chosen for this article represent the scope of interest of Cardiovascular Drugs and Therapy. The presentations should be considered preliminary, as further analyses could alter the final publication of the results of these studies. PROSPECT evaluated echocardiographic criteria for optimal selection of patients with moderate to severe heart failure who may benefit from cardiac resynchronisation therapy, however concluded that no single echocardiographic measure can be recommended. EVEREST found that tolvaptan, a vasopressin V(2) antagonist, resulted in early weight reduction and improvement of dyspnoea in patients with acute heart failure, but lacked long term improvement. In ARISE, the anti-oxidant succinobucal did not affect the primary outcome in high risk cardiovascular patients, but improved the combination of cardiovascular death, myocardial infarction and stroke, and diabetic control in diabetics. ALOFT showed that the addition of the renin inhibitor aliskiren to an ACE inhibitor or ARB and a beta-blocker leads to favourable effects on neurohormonal actions in heart failure. FINESSE markedly improved coronary patency before PCI with half-dose reteplase/abciximab in STEMI patients, however without significantly improving short-term outcome. The Prague-8 Study evaluated whether routine clopidogrel administered >6 h pre-angiography would be a safe way to achieve therapeutic drug levels in case a follow-up intervention would be considered immediately, but appeared not justified because of bleeding complications. CARESS in MI showed that high risk patients with evolving STEMI who undergo thrombolytic therapy should undergo PCI early after the thrombolysis. Finally, the ACUITY trial found that in moderate or high risk Non ST elevation ACS patients triaged to PCI, coronary artery bypass graft (CABG) surgery, or medical management, bivalirudin, with or without associated GPIIb/IIIa inhibitor therapy, resulted in a marked reduction of bleeding at 30 days whilst preserving the ischemic and mortality benefit at 1 year follow up.

A randomized comparison of sirolimus-eluting stent implantation with zotarolimus-eluting stent implantation for the treatment of total coronary occlusions: rationale and design of the PRImary Stenting of Occluded Native coronary arteries III (PRISON III) study

Primary intracoronary drug-eluting stent placement after the successful crossing of total coronary occlusions decreases restenosis rate at long-term follow-up compared with bare-metal stent implantation. The PRISON II trial was the first randomized study to show the safety and efficacy of sirolimus-eluting stents in patients with totally occluded native coronary arteries. The sirolimus-eluting stent is superior to the bare-metal stent in treating patients with total coronary occlusions, with significant reduction in angiographic binary in-stent and in-segment restenosis resulting in significantly reduced need for target lesion and target vessel revascularization. Whether sirolimus-eluting stents are superior to other drug-eluting stents in total coronary occlusions is unknown. In this prospective, randomized trial, sirolimus-eluting stent implantation will be compared with zotarolimus-eluting stent implantation for the treatment of total coronary occlusions. A total of 300 patients will be followed for up to 5 years with angiographic follow-up at 8 months. Quantitative coronary analysis will be performed by an independent core laboratory. The primary end point will be in-segment late luminal loss at 8 months angiographic follow-up.

Reperfusion strategies for ST-elevation myocardial infarction

Management of ST-elevation myocardial infarction requires rapid, sustained and early restoration of flow in the infarct-related artery to minimize myocardial damage and to improve clinical outcomes. Primary percutaneous coronary intervention (PCI) is the preferred therapy but is limited by restricted availability and delays in implementation. Fibrinolytic administration is widely available but is limited by its failure to achieve Thrombolysis in Myocardial Infarction grade 3 flow in many patients, re-infarction, and intracranial hemorrhage. A combination approach to reperfusion--facilitated PCI--involves the administration of a pharmacologic agent to improve reperfusion with PCI. The evidence supporting facilitated PCI varies according to the pharmacologic regimen at this time.

Current incidence and clinical outcomes of bivalirudin administration among patients undergoing primary coronary intervention for stent thrombosis elevation acute myocardial infarction

BACKGROUND

Multiple antithrombotic options are available for patients undergoing primary percutaneous coronary interventions for stent thrombosis elevation acute myocardial infarction. Current utilization and outcomes of antithrombotic agents for primary percutaneous coronary intervention, including bivalirudin, have not been defined.

METHODS

A total of 84 471 patients were reported from 439 hospitals to the National Registry of Myocardial Infarction-5 registry between April 2004 and June 2005. Consecutive patients undergoing primary percutaneous coronary interventions for stent thrombosis elevation acute myocardial infarction (n=7629 at 231 United States percutaneous coronary intervention capable hospitals) comprised the population analyzed. We examined antithrombotic strategies and the occurrence of adverse cardiac events stratified according to the use of bivalirudin. Logistic regression was performed to control for differences between three antithrombotic therapy treatment groups.

RESULTS

Glycoprotein IIbIIIa inhibitors were used nearly ubiquitously, but given prior to percutaneous coronary interventions in only 36% of patients. Less than one-quarter of patients received clopidogrel prior to percutaneous coronary interventions. Bivalirudin was used in 4.2% of patients (n=320) undergoing primary percutaneous coronary intervention during this time period. Patients treated with bivalirudin were more likely to be elderly (P=0.03), have a history of prior bleeding (P=0.003) and stroke (P=0.06). Major adverse events and bleeding complications were similar in antithrombotic therapy groups (bleeding: bivalirudin 7.8% versus nonbivalirudin 7.5%, P=0.85). The adjusted outcomes were also similar after confining the analysis to bivalirudin patients who had not received any glycoprotein IIbIIIa inhibitors (n=143).

CONCLUSIONS

Contemporary primary percutaneous coronary intervention includes mainly clopidogrel and eptifibatide initiated at the time of percutaneous coronary intervention. Patients who received bivalirudin were at higher risk and had similar adjusted outcomes as patients in the nonbivalirudin group. Optimization of primary percutaneous coronary intervention pharmacology requires future randomized clinical trials, examining the timing and type of adjunctive antithrombotic agents.

Devices for chronic occlusion

Interventional cardiology has advanced into domains once believed to be beyond the reach of percutaneous procedures. As technologic advances continue to push the limits of the interventionalist's capabilities, several areas still exert considerable resistance to this forward momentum. These technically difficult frontiers include bifurcated lesions, small-vessel disease, multivessel disease, diffuse disease, and chronic total occlusions.

Off-Pump Revascularization of Chronically Occluded Left Anterior Descending Artery Through Left Anterior Small Thoracotomy: Early and Late Angiographic and Clinical Follow-Up

BACKGROUND

The aim of this retrospective study was to evaluate the safety and efficacy of left anterior small thoracotomy for treatment of isolated chronic total occlusion of the left anterior descending artery.

METHODS

From November 21, 1994, to December 31, 2002, 143 patients with isolated left anterior descending artery chronic occlusion underwent off-pump surgery through left anterior small thoracotomy. Safety was evaluated analyzing 30-day mortality, major adverse cardiac events, and major complications; efficacy was evaluated analyzing 6-month angiographic results and 12-month survival, freedom from cardiac death, freedom from acute myocardial infarction, either in all areas or in the grafted one, freedom from redo or percutaneous coronary intervention, freedom from target vessel revascularization, and freedom from major adverse cardiac events and from any event. Eight-year outcome was reported as well.

RESULTS

Thirty-day mortality was 0.7% (1 patient). No patient experienced acute myocardial infarction, cerebrovascular accident, or urgent repeat revascularization. One-year survival was 98.6% +/- 0.7%; freedom from cardiac death was 99.3% +/- 0.7%; freedom from acute myocardial infarction in either all areas or in the grafted one was 100%; freedom from redo or percutaneous coronary intervention or from target vessel revascularization was 99.3% +/- 0.7%, and freedom from major adverse cardiac events or any event was 97.9% +/- 1.2%. Eight-year survival was 94.9% +/- 1.9%; freedom from cardiac death was 96.3% +/- 1.6%, from acute myocardial infarction in all or in the grafted area 99.2% +/- 0.8%, from redo or percutaneous coronary intervention 94.4% +/- 2.1, from target vessel revascularization 97.8% +/- 1.3%, from major adverse cardiac events 92.8% +/- 2.2%, and from any event 89.5% +/- 2.7%. Six months after surgery, 56% of survivors underwent angiographic control, showing a patency rate of 98.2%.

CONCLUSIONS

In our experience, left anterior small thoracotomy operation can be considered a suitable choice for treatment of left anterior descending artery chronic occlusion.

Clinical effectiveness of bare-metal stenting compared with balloon angioplasty in total coronary occlusions: insights from a systematic overview of randomized trials in light of the drug-eluting stent era

BACKGROUND

We sought to compare, using meta-analytic techniques, bare-metal stent versus balloon angioplasty in the percutaneous treatment of total coronary occlusions by means of a quantitative systematic review and to indicate new avenues for future treatments.

METHODS

MEDLINE and CENTRAL were searched. Inclusion criteria were random allocation, prospective comparison, and intention to treat. Random-effect odds ratios (ORs) with 95% confidence intervals (CIs) for death, myocardial infarction (MI), repeated revascularization, major adverse cardiac events (MACE), and angiographic restenosis and reocclusion were computed.

RESULTS

Nine trials (1409 patients) were included. Death rate was not different in the 2 groups, 0.4% after stenting versus 0.7% after balloon angioplasty (OR 0.72, 95% CI 0.21-2.50). MI rate was significantly increased after stenting (6.7% vs 3.4%, OR 2.06, 95% CI 1.22-3.46), mainly because of a higher rate of periprocedural non-Q-wave MI. By contrast, the risk of repeated revascularization was significantly reduced by stenting (17% vs 32%, OR 0.41, 95% CI 0.31-0.53). This yielded to an overall reduction in the rate of MACE after stenting (23.2% vs 35.4%, OR 0.49, 95% CI 0.36-0.68). Angiographic restenosis and reocclusion were also decreased by stent (41.1% vs 60.9%, OR 0.36, 95% CI 0.23-0.57; 6.8% vs 16%, OR 0.36, 95% CI 0.22-0.59, respectively).

CONCLUSIONS

In total coronary occlusions, stenting yields an important benefit over balloon angioplasty in reduction of MACE, repeated revascularizations, and angiographic restenosis and reocclusion. However, these events remain frequent. Moreover, the finding of an increased rate of periprocedural minor myocardial damage after stenting casts caution. New strategies aimed to reduce the need of repeated revascularizations and periprocedural MIs should be further investigated.

Subgroup analyses in therapeutic cardiovascular clinical trials: are most of them misleading?

BACKGROUND

Treatment decisions in clinical cardiology are directed by results from randomized clinical trials (RCTs). We studied the appropriateness of the use and interpretation of subgroup analysis in current therapeutic cardiovascular RCTs.

METHODS

We reviewed main reports of phase 3 cardiovascular RCTs with at least 100 patients, published in 2002 and 2004, and from major journals (Circulation, J Am Coll Cardiol, Am Heart J, Am J Cardiol, N Engl J Med, Lancet, JAMA, BMJ, Ann Intern Med). Information on subgroups included prespecification, number, interaction test use, significant subgroups found, and emphasis on findings. We examined appropriateness of reporting and differences according to sample size, overall trial result, and CONSORT adoption.

RESULTS

We selected 63 RCTs, with a median of 496 (range 100-15,245) patients. Thirty-nine RCTs were reported with subgroup analyses and 26 with > 5 subgroups. No trial was specifically powered to detect subgroup effects, and only 14 RCTs were reported with fully prespecified subgroups. Only 11 RCTs were reported with interaction tests. Furthermore, 21 RCTs were reported with claims of significant subgroups and 15 with equal or more emphasis to subgroups than to the overall results. Subgroup analyses in large RCTs (> 500 patients) were reported more often than in small ones (24/30 vs 15/33, P = .005). No differences were found according to overall result (positive/negative) or CONSORT adoption.

CONCLUSIONS

Subgroup analyses in recent cardiovascular RCTs were reported with several shortcomings, including a lack of prespecification and testing of a large number of subgroups without the use of the statistically appropriate test for interaction. Reporting of subgroup analysis needs to be substantially improved because emphasis on these secondary results may mislead treatment decisions.

Guidelines for percutaneous coronary interventions. The Task Force for Percutaneous Coronary Interventions of the European Society of Cardiology

In patients with stable CAD, PCI can be considered a valuable initial mode of revascularization in all patients with objective large ischaemia in the presence of almost every lesion subset, with only one exception: chronic total occlusions that cannot be crossed. In early studies, there was a small survival advantage with CABG surgery compared with PCI without stenting. The addition of stents and newer adjunctive medications improved the outcome for PCI. The decision to recommend PCI or CABG surgery will be guided by technical improvements in cardiology or surgery, local expertise, and patients' preference. However, until proved otherwise, PCI should be used only with reservation in diabetics with multi-vessel disease and in patients with unprotected left main stenosis. The use of drug-eluting stents might change this situation. Patients presenting with NSTE-ACS (UA or NSTEMI) have to be stratified first for their risk of acute thrombotic complications. A clear benefit from early angiography (<48 h) and, when needed, PCI or CABG surgery has been reported only in the high-risk groups. Deferral of intervention does not improve outcome. Routine stenting is recommended on the basis of the predictability of the result and its immediate safety. In patients with STEMI, primary PCI should be the treatment of choice in patients presenting in a hospital with PCI facility and an experienced team. Patients with contra-indications to thrombolysis should be immediately transferred for primary PCI, because this might be their only chance for quickly opening the coronary artery. In cardiogenic shock, emergency PCI for complete revascularization may be life-saving and should be considered at an early stage. Compared with thrombolysis, randomized trials that transferred the patients for primary PCI to a 'heart attack centre' observed a better clinical outcome, despite transport times leading to a significantly longer delay between randomization and start of the treatment. The superiority of primary PCI over thrombolysis seems to be especially clinically relevant for the time interval between 3 and 12 h after onset of chest pain or other symptoms on the basis of its superior preservation of myocardium. Furthermore, with increasing time to presentation, major-adverse-cardiac-event rates increase after thrombolysis, but appear to remain relatively stable after primary PCI. Within the first 3 h after onset of chest pain or other symptoms, both reperfusion strategies seem equally effective in reducing infarct size and mortality. Therefore, thrombolysis is still a viable alternative to primary PCI, if it can be delivered within 3 h after onset of chest pain or other symptoms. Primary PCI compared with thrombolysis significantly reduced stroke. Overall, we prefer primary PCI over thrombolysis in the first 3 h of chest pain to prevent stroke, and in patients presenting 3-12 h after the onset of chest pain, to salvage myocardium and also to prevent stroke. At the moment, there is no evidence to recommend facilitated PCI. Rescue PCI is recommended, if thrombolysis failed within 45-60 min after starting the administration. After successful thrombolysis, the use of routine coronary angiography within 24 h and PCI, if applicable, is recommended even in asymptomatic patients without demonstrable ischaemia to improve patients' outcome. If a PCI centre is not available within 24 h, patients who have received successful thrombolysis with evidence of spontaneous or inducible ischaemia before discharge should be referred to coronary angiography and revascularized accordingly--independent of 'maximal' medical therapy.

Primary stenting of occluded native coronary arteries II--rationale and design of the PRISON II study: a randomized comparison of bare metal stent implantation with sirolimus-eluting stent implantation for the treatment of chronic total coronary occlusions

Primary intracoronary stent placement after successfully crossing chronic total occlusions (CTO) decreases the high restenosis rate at long-term follow-up compared with conventional balloon angioplasty. Several studies have shown the efficacy of sirolimus-eluting stents in selected groups of patients. Whether sirolimus-eluting stents are superior to bare metal stents in CTO is unknown. In this prospective randomized trial, bare metal stent implantation will be compared with sirolimus-eluting stent implantation for the treatment of CTO. A total of 200 patients will be followed up for 12 months with angiographic follow-up at 6 months. Quantitative coronary analysis will be performed by an independent core laboratory. The primary end point is the binary angiographic restenosis and reocclusion rate.

Prevention of lesion recurrence in chronic total coronary occlusions by paclitaxel-eluting stents

OBJECTIVES

The aim of this research was to assess the efficacy of paclitaxel-eluting stents in chronic total coronary occlusions (CTO).

BACKGROUND

Percutaneous coronary interventions for CTOs are characterized by a high target vessel failure rate.

METHODS

In 48 consecutive patients, paclitaxel-eluting stents (Taxus, Boston Scientific Corp., Natick, Massachusetts) were implanted after successful recanalization of a CTO (duration >2 weeks). Patients underwent an angiography after 6 months and were followed clinically for 12 months. They were compared with 48 lesion- and risk-matched patients with CTOs treated with bare metal stents (BMS). Primary clinical end point was the one-year incidence of major adverse cardiac events (MACE) (death, myocardial infarction, repeat revascularization); secondary end points were the rate of restenosis and re-occlusion.

RESULTS

In-hospital MACE was 4.2% with Taxus, and 2.1% with BMS (p = NS). The one-year MACE rate was 12.5% in the Taxus group, and 47.9% in the BMS group (p < 0.001), which was due to a reduced need for repeat revascularization. The angiographic restenosis rate was 8.3% with Taxus versus 51.1% with BMS (p < 0.001). There was only one late re-occlusion with Taxus (2.1%) as compared with 23.4% with BMS (p < 0.005). The late loss was reduced in the Taxus group by 84% as compared with BMS. All nonocclusive restenoses in the Taxus group were focal and successfully treated by implanting an additional Taxus stent.

CONCLUSIONS

The treatment of CTOs with a paclitaxel-eluting stent drastically reduces MACE and restenosis, and almost eliminates re-occlusion, which is typically frequent with BMS in CTOs. Chronic total coronary occlusion should be a preferred indication for drug-eluting stents.