Association Between Angiographic Complications and Clinical Outcomes Among Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Impact of a micro-net mesh technology covering stent on coronary microvascular dysfunction in patients with high thrombus burden

BACKGROUND

Highly thrombotic coronary lesions continue to be a serious and clinically significant problem that is not effectively and completely addressed by current technology.

OBJECTIVES

We aimed to investigate whether a micro-net mesh (MNM) technology covering stent could preserve the index of microcirculatory resistance (IMR) after percutaneous coronary intervention (PCI) in patients with high thrombus burden.

METHODS AND RESULTS

Fifty-two patients with non-ST elevation myocardial infarction or ST Elevation Myocardial Infarction and high thrombus burden (TIMI thrombus grade ≥ 3) were randomized into two groups, PCI with a MNM covering stent (MNM group, n = 25) and PCI with any commercially available stent (DES group, n = 27). As the primary endpoint, IMR was measured immediately after PCI using a pressure-temperature sensor-tipped coronary wire. The secondary endpoint was left ventricular ejection fraction (LVEF) at 6 months of follow-up. The IMR in the MNM group was significantly lower in comparison to the DES group (33.2 [21.3, 48.9] vs. 57.2 [39.9, 98.0], p = 0.005). No significant differences were observed in baseline LVEF (54.5 ± 10.2% vs. 53.1 ± 6.87%, p = .57), while LVEF was significantly improved at follow-up in the MNM group (61.1 ± 7.1% vs. 53.9 ± 6.35%, p = .0001).

CONCLUSION

MNM technology significantly improved coronary microvascular dysfunction after PCI in patient with acute coronary syndrome and appears as a useful technological option for thrombus management.

Body Surface Potential Mapping and Left Circumflex Occlusion: Unmasking the Hidden Acute Myocardial Infarction

See Article by Daly et al

Cost implications of intraprocedural thrombotic events and bleeding in percutaneous coronary intervention: Results from the CHAMPION PHOENIX ECONOMICS Study

BACKGROUND

Despite improvements in percutaneous coronary intervention (PCI), intraprocedural thrombotic events (IPTE) and bleeding complications occur and are prognostically important. These have not been included in prior economic studies.

METHODS

PHOENIX ECONOMICS was a substudy of the CHAMPION PHOENIX trial, evaluating cangrelor during PCI. Hospital bills were reviewed from 1,171 patients enrolled at 22 of 63 US sites. Costs were estimated using standard methods including resource-based accounting, hospital billing data, and the Medicare fee schedule. Bleeding and IPTE, defined as abrupt vessel closure (transient or sustained), new/suspected thrombus, new clot on wire/catheter, no reflow, side-branch occlusion, procedural stent thrombosis or urgent need for CABG were identified. Costs were calculated according to whether a complication occurred and type of event. Multivariate analyses were used to estimate the incremental costs of IPTE and postprocedural events.

RESULTS

IPTE occurred in 4.3% and were associated with higher catheterization laboratory and overall index hospitalization costs by $2,734 (95%CI $1,117, $4,351; P = 0.001) and $6,354 (95% CI $4,122, $8,586; P < 0.001), respectively. IPTE were associated with MI (35.4% vs. 3.6%; P < 0.001), out-of-laboratory stent thrombosis (4.2% vs. 0.1%; 0 = 0.005), ischemia driven revascularization (12.5% vs. 0.3%; P < 0.001), but not mortality (2.1% vs. 0.2%; P = 0.12) vs. no procedural thrombotic complication. By comparison, ACUITY minor bleeding increased hospitalization cost by $1,416 (95%CI = 312, $2,519; P = 0.012). ACUITY major bleeding increased cost of hospitalization by $7,894 (95%CI $4,154, $11,635; P < 0.001).

CONCLUSIONS

IPTE and bleeding complications, though infrequent, are associated with substantial increased cost. These complications should be collected in economic assessments of PCI.

High-sensitivity cardiac troponin T and prognosis in patients with ST-segment elevation myocardial infarction

BACKGROUND

Evidence on the use of high-sensitivity cardiac troponins (hs-cTn) to risk-stratify patients with ST-segment elevation myocardial infarction (STEMI) is limited.

METHODS

We assessed the prognostic value of preprocedural (admission) and peak postprocedural hs-cTnT in 818 patients with STEMI treated with primary percutaneous coronary intervention (PPCI). Preprocedural and peak postprocedural hs-cTnT was measured. The primary outcome was 3-year all-cause mortality.

RESULTS

The median values of preprocedural and peak postprocedural hs-cTnT were 153ng/L and 1980ng/L. Overall, 134 patients died during the follow-up. There were 85 deaths in patients with preprocedural hs-cTnT >median value and 49 deaths in patients with preprocedural hs-cTnT ≤median value [Kaplan-Meier estimates of mortality, 22.2% and 13.5%; unadjusted hazard ratio (HR)=1.88, 95% confidence interval (CI) 1.32-2.67, p<0.001]. According to peak postprocedural hs-cTnT, there were 84 deaths in patients with postprocedural hs-cTnT >median value and 50 deaths in patients with postprocedural hs-cTnT ≤median value [Kaplan-Meier estimates of mortality, 22.3% and 13.4%; unadjusted HR=1.82 (1.28-2.59), p<0.001]. After adjustment, preprocedural [adjusted HR=1.08 (1.03-1.12), p<0.001] and peak postprocedural hs-cTnT value [adjusted HR=1.06 (1.04-1.08), p<0.001] were independently associated with 3-year mortality (with risk estimates calculated per 70×99th upper reference limit of hs-cTnT). The C statistic of multivariable model increased from 0.868 (0.841-0.895) to 0.872 (0.845-0.898) after incorporation of preprocedural hs-cTnT (p=0.050) and to 0.874 (0.846-0.899) after incorporation of the postprocedural hs-cTnT into the model (p=0.035).

CONCLUSIONS

In conclusion, admission or peak postprocedural hs-cTnT is independently associated with the risk for 3-year mortality in patients with STEMI undergoing PPCI.

Consensus or Controversy?: Evolution of Criteria for Myocardial Infarction After Percutaneous Coronary Intervention

BACKGROUND

The definition and the clinical implications of myocardial infarction (MI) occurring in the setting of percutaneous coronary intervention have been subjects of unresolved controversy. As a result of the use of more sensitive diagnostic tools such as cardiac troponin, the expanding evidence, and the ensuing debate, the definition of procedural MI (pMI) has evolved, leading to several revisions, different proposed definitions, and lack of standardization in randomized clinical trials.

CONTENT

In this review, we will describe the key clinical data on cardiac biomarkers, creatine kinase isoenzyme MB and cTn, in the setting of percutaneous coronary intervention and the main issues that have lead to various consensus documents with a proposed definition of pMI. We will focus on the rationale of the current “Third Universal Definition of Myocardial Infarction” and of the alternative approach proposed by the Society for Cardiovascular Angiography and Interventions.

SUMMARY

The definition of pMI is an evolving field where the Third Universal MI definition represents the best attempt to date to incorporate available evidence along with scientific and clinical judgment into criteria to ensure adequate specificity in the diagnosis and the relevant prognostic significance, while trying to maintain sensitivity. Questions on the recommended criteria and their practical implementation remain, but the Third Universal definition document represents an important milestone toward a better standardization and enhanced consensus on the pMI definition.

Which Intraprocedural Thrombotic Events Impact Clinical Outcomes After Percutaneous Coronary Intervention in Acute Coronary Syndromes?: A Pooled Analysis of the HORIZONS-AMI and ACUITY Trials

OBJECTIVES

This study sought to determine the extent to which individual components of intraprocedural thrombotic events (IPTEs) are associated with adverse events.

BACKGROUND

IPTEs occurring during percutaneous coronary intervention (PCI) are associated with adverse in-hospital and late outcomes in patients with acute coronary syndromes.

METHODS

A total of 6,591 patients who underwent PCI for non-ST-segment elevation acute coronary syndromes/ST-segment elevation myocardial infarction in the ACUITY (Acute Catheterization and Urgent Intervention Triage StrategY) and HORIZONS-AMI (Harmonizing Outcomes with RevascularIZatiON and Stents in Acute Myocardial Infarction) trials underwent detailed frame-by-frame core laboratory angiographic analysis to assess for IPTEs. The associations of IPTE components with death, major bleeding, and major adverse cardiac events at 30 days were assessed using univariable analyses and multivariable models.

RESULTS

The overall incidence of IPTEs was 7.7%, with a greater incidence in ST-segment elevation myocardial infarction patients (12.2%) compared with non-ST-segment elevation acute coronary syndromes patients (3.5%). Specific components of IPTEs included no-reflow/slow reflow in 58.0%, new/worsened thrombus in 35.3%, distal embolization in 34.9%, abrupt closure in 19.8%, and intraprocedural stent thrombosis (IPST) in 9.5% of patients. Each IPTE component was independently associated with 30-day death, major bleeding, and MACE in multivariable models, with the strongest association observed for IPST (MACE hazard ratio: 7.51 [95% confidence interval: 4.36 to 12.94]).

CONCLUSIONS

The occurrence of IPTEs is not infrequent among high-risk acute coronary syndromes patients undergoing PCI, and each IPTE component was associated with subsequent adverse events. Although IPST represented <10% of IPTE events overall, it was the component with the strongest association with adverse events.

Impact of intraprocedural thrombotic events on short- and long-term outcomes following percutaneous coronary intervention. Evidence from a meta-analysis

BACKGROUND

Data regarding the effects of intraprocedural thrombotic events (IPTE) are scarce. Hence we aim to perform a meta-analysis to examine the outcomes of IPTE compared to non-IPTE during PCI.

METHODS

We performed a literature search of all published full-length articles of studies that reported data on patients with IPTE compared with non-IPTE during PCI. We calculated odd ratios via random effects model.

RESULTS

A total of 26,697 patients, of which 1572 patients had IPTE, were included in this analysis. In-hospital, IPTE was associated with higher mortality (odds ratio (OR) 5.36, 95% confidence interval (CI) [2.31, 12.41]; p<0.0001), myocardial infarction (MI) and major bleeding compared to non-IPTE. At 30 days, IPTE was also associated with higher mortality (OR 4.57, 95% CI [2.43, 8.60]; p<0.0001), MI, repeat revascularization, stent thrombosis and major bleeding compared to non-IPTE group. IPTE was also associated with higher long-term mortality (OR 2.19, 95% CI [1.35, 3.53]; p=0.001). Among IPTE patients, intraprocedural stent thrombosis was associated with greater odds of MI compared to both no reflow and distal embolization events.

CONCLUSION

IPTE during PCI is associated with more adverse ischemic events, including mortality, during the index hospitalization, at 30 days and long-term.

Evaluation of early interventional treatment opportunity of the elderly & high-risk patients with non-ST segment elevation acute myocardial infarction

Objective:

To investigate the effect of treatment on prognosis of patients with different timing of early interventional treatment for non-ST segment elevation acute myocardial infarction (NSTEMI).

Methods:

Forty two cases above 75 years old, diagnosed with high-risk on NSTEMI, were selected in cardiology department of Xinxiang central hospital. They were randomly divided into two groups: 22 in group A and 20 in group B. Group A was performed PCI surgery within 12 hours after the onset while group B from 12 to 24 hour after the onset. Major adverse cardiovascular events (including death, heart failure readmission rates after ischemia, malignant arrhythmias, again target vessel revascularization) and bleeding data were recorded at the three terms of hospitalization, one month after the onset and six months after the onset.

Results:

Angina, malignant arrhythmia and heart failure during hospitalization can be reduced after interventional treatment carried out within 12 hours after the onset. Readmission rates after ischemia, heart failure and the incidence of death can be significantly reduced after interventional treatment carried out during 1-6 month after the onset with no significant increase in bleeding rate.

Conclusion:

In the treatment of elderly patients with NSTEMI, early interventional treatment is safe and effective.

Plaque Characterization to Inform the Prediction and Prevention of Periprocedural Myocardial Infarction During Percutaneous Coronary Intervention: The CANARY Trial (Coronary Assessment by Near-infrared of Atherosclerotic Rupture-prone Yellow)

OBJECTIVES

This study sought to determine whether pre-percutaneous coronary intervention (PCI) plaque characterization using near-infrared spectroscopy identifies lipid-rich plaques at risk of periprocedural myonecrosis and whether these events may be prevented by the use of a distal protection filter during PCI.

BACKGROUND

Lipid-rich plaques may be prone to distal embolization and periprocedural myocardial infarction (MI) in patients undergoing PCI.

METHODS

Patients undergoing stent implantation of a single native coronary lesion were enrolled in a multicenter, prospective trial. Near-infrared spectroscopy and intravascular ultrasound were performed at baseline, and lesions with a maximal lipid core burden index over any 4-mm length (maxLCBI4mm) ≥600 were randomized to PCI with versus without a distal protection filter. The primary endpoint was periprocedural MI, defined as troponin or a creatine kinase-myocardial band increase to 3 or more times the upper limit of normal.

RESULTS

Eighty-five patients were enrolled at 9 U.S. sites. The median (interquartile range) maxLCBI4mm was 448.4 (274.8 to 654.4) pre-PCI and decreased to 156.0 (75.6 to 312.6) post-PCI (p < 0.0001). Periprocedural MI developed in 21 patients (24.7%). The maxLCBI4mm was higher in patients with versus without MI (481.5 [425.6 to 679.6] vs. 371.5 [228.9 to 611.6], p = 0.05). Among 31 randomized lesions with maxLCBI4mm ≥600, there was no difference in the rates of periprocedural MI with versus without the use of a distal protection filter (35.7% vs. 23.5%, respectively; relative risk: 1.52; 95% confidence interval: 0.50 to 4.60, p = 0.69).

CONCLUSIONS

Plaque characterization by near-infrared spectroscopy identifies lipid-rich lesions with an increased likelihood of periprocedural MI after stent implantation, presumably due to distal embolization. However, in this pilot randomized trial, the use of a distal protection filter did not prevent myonecrosis after PCI of lipid-rich plaques.

Varying definitions for periprocedural myocardial infarction alter event rates and prognostic implications

BACKGROUND

Periprocedural myocardial infarction (PMI) has had several definitions in the last decade, including the Society for Cardiovascular Angiography and Interventions (SCAI) definition, that requires marked biomarker elevations congruent with surgical PMI criteria.

METHODS AND RESULTS

The aim of this study was to examine the definition-based frequencies of PMI and whether they influenced the reported association between PMI and increased rates of late death/ myocardial infarction (MI). We studied 742 patients; 492 (66%) had normal troponin T (TnT) levels and 250 (34%) had elevated, but stable or falling, TnT levels. PMI, using the 2007 and the 2012 universal definition, occurred in 172 (23.2%) and in 99 (13.3%) patients, respectively, whereas 19 (2.6%) met the SCAI PMI definition (P<0.0001). Among patients with PMI using the 2012 definition, occlusion of a side branch ≤1 mm occurred in 48 patients (48.5%) and was the most common angiographic finding for PMI. The rates of death/MI at 2 years in patients with, compared to those without, PMI was 14.7% versus 10.1% (P=0.087) based on the 2007 definition, 16.9% versus 10.3% (P=0.059) based on the 2012 definition, and 29.4% versus 10.7% (P=0.015) based on the SCAI definition.

CONCLUSION

In this study, PMI, according to the SCAI definition, was associated with more-frequent late death/MI, with ≈20% of all patients, who had PMI using the 2007 universal MI definition, not having SCAI-defined PMI. Categorizing these latter patients as SCAI-defined no PMI did not alter the rate of death/MI among no-PMI patients.

Angiographic outcomes with early eptifibatide therapy in non-ST-segment elevation acute coronary syndrome (from the EARLY ACS Trial)

Early administration of glycoprotein IIbIIIa inhibitors results in improved angiographic parameters, including thrombolysis in myocardial infarction (TIMI) flow grade, corrected TIMI frame count, and TIMI myocardial perfusion grade (TMPG) among patients with ST-segment elevation myocardial infarction. Whether the same is true in the setting of non-ST-segment elevation acute coronary syndrome is unknown. The goal of the early glycoprotein IIbIIIa inhibition in non-ST-segment elevation acute coronary syndrome (EARLY ACS) angiographic substudy was to compare angiographic outcomes among patients with non-ST-segment elevation acute coronary syndrome who were administered early routine versus delayed provisional eptifibatide. Of 9,406 patients in the EARLY ACS trial, 2,066 patients were included in the angiographic substudy (early routine eptifibatide [n=1,042] or early placebo [n=1,024] with delayed provisional eptifibatide after angiography and before percutaneous coronary intervention [PCI]). The angiographic substudy primary end point was the incidence of TMPG 3 before and after PCI. TMPG 3 before (43.7% vs 44.9%, p=0.58) and after PCI (52.4% vs 50.1%, p=0.73) was similar for early routine versus delayed provisional eptifibatide, respectively. Angiographic procedural complications consisting of a composite of loss of side branch, abrupt vessel closure, distal embolization, and no reflow occurred less frequently in early routine group versus delayed provisional group (9.3% vs 13.6%, respectively, p=0.01). In the EARLY ACS angiographic substudy, the use of early routine eptifibatide resulted in fewer angiographic procedural complications. These data provide support for the use of eptifibatide in the catheterization laboratory during high-risk cases merely to prevent angiographic procedural complications.

Association between intraprocedural thrombotic events and adverse outcomes after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (a Harmonizing Outcomes With RevasculariZatiON and Stents in Acute Myocardial Infarction [HORIZONS-AMI] Substudy)

The present study sought to determine the extent to which adverse angiographic events encountered during percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) are associated with adverse clinical outcomes. Patients with STEMI represent a cohort at particularly high risk of intraprocedural thrombotic events (IPTEs). The overall frequency and implications of IPTEs occurring in patients with STEMI have not been systematically quantified in previous studies. A total of 3,163 patients undergoing primary percutaneous coronary intervention with stent implantation for STEMI in the Harmonizing Outcomes with RevasculariZatiON and Stents in Acute Myocardial Infarction (HORIZONS-AMI) trial underwent detailed frame-by-frame core laboratory angiographic analysis to assess IPTEs. The clinical outcomes at 30 days were compared between the patients with and without IPTEs. IPTEs, defined as the development of new or increasing thrombus, abrupt vessel closure, no reflow, slow reflow, and distal embolization at any point during the procedure, occurred in 386 patients (12.2%). The independent predictors of IPTE were thrombus at baseline, lesion length, and randomization to bivalirudin; the patients with IPTEs were also more likely to receive bailout glycoprotein IIb/IIIa inhibitors and unplanned thrombectomy. Compared with patients without IPTEs, the patients with IPTEs had higher 30-day rates of composite major adverse cardiovascular events (death, myocardial infarction, ischemic target vessel revascularization, and stroke; 7.8% vs 4.2%, p = 0.002), major bleeding not related to coronary artery bypass grafting (11.8% vs 6.5%, p <0.001), and all-cause death (4.2% vs 1.8%, p = 0.002). On multivariate analysis, IPTEs were independently associated with 30-day major adverse cardiovascular events, major bleeding, and death. In conclusion, the development of IPTEs in patients undergoing primary percutaneous coronary intervention for STEMI was associated with subsequent adverse outcomes, including major adverse cardiovascular events, major bleeding, and death. Additional studies of strategies to decrease the occurrence of IPTEs are warranted.