Primary stent implantation compared with primary balloon angioplasty for acute myocardial infarction: a meta-analysis of randomized clinical trials

ST-segment elevation myocardial infarction heart of Charlotte one-year (STEMI HOC-1) study: a prospective study protocol

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) is a clinically distinguishable yet lethal sequela of ischaemic heart disease (IHD). In sub-Saharan Africa (SSA), death due to acute STEMI is increasing. In South Africa, there is a paucity of data available on the clinical outcomes of acute STEMI within one year for individuals treated in the public healthcare sector. This study primarily seeks to determine the one-year all-cause mortality rate of acute STEMI. The study also assesses the value of serum cardiac biomarkers of myocardial damage and serum uric acid in predicting all-cause mortality in STEMI.

METHODS

This is a single-centre observational prospective cohort of all consecutive individuals presenting with an acute STEMI to the Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) in Johannesburg, South Africa. Research data will be sourced on admission through electronic medical records, blood laboratory results and coronary angiography reports, and at follow-up through periodic telephonic interviews and standardised echocardiograms. At least 355 eligible participants will be continuously followed over one year, and clinical outcomes will be measured 30 days, three months, six months and one year after the index hospitalisation.

DISCUSSION

This study provides insights into the demographic, risk factors and clinical profiles of individuals with STEMI in South Africa. Its findings may improve the risk stratification, prognostication, and therapeutic management of STEMI patients in our setting. By comparing the clinical outcomes between the different coronary reperfusion strategies, our results may guide clinicians in providing better patient treatment, particularly in sub-Saharan Africa, where access to percutaneous coronary intervention may be limited. Furthermore, the study offers insights into the routine use of baseline serum uric acid as a potential low-cost prognostic biomarker of all-cause mortality in STEMI. Finally, this study's findings may be of public health significance to local policymakers to aid in reinforcing primary prevention strategies and developing structured referral networks for timely coronary reperfusion of acute STEMI.

Systemic Immune-Inflammation Index and C-Reactive Protein/Albumin Ratio Could Predict Acute Stent Thrombosis and High SYNTAX Score in Acute Coronary Syndrome

Acute stent thrombosis (AST) is associated with increased morbidity and mortality. The main aim of this study was to evaluate the prognostic value of the systemic immune-inflammation index (SII) and C-reactive protein (CRP) to albumin ratio (CAR) in predicting AST and high SYNTAX score in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). The criteria of the Academic Research Consortium were used to determine definite stent thrombosis. A total of 2077 consecutive patients with ACS undergoing PCI were retrospectively enrolled. Platelet, white blood cell and neutrophil counts, as well as SII, CRP, CAR, and peak cardiac troponin I (cTnI) values were significantly higher, whereas the lymphocyte count and albumin values were significantly lower in the AST (+) group compared with the AST (-) group (P < .05). SYNTAX score showed significant positive correlations with SII (r = .429, P < .001) and CRP (r = .402, P < .001). Multivariate logistic regression analysis showed that SII and CAR, as well as age, diabetes mellitus, stent length, and peak cTnI are independent predictors of AST and high SYNTAX score. In conclusion, the SII and CAR are simple, relatively cheap, and reliable inflammatory biomarkers that can predict AST and high SYNTAX scores in ACS.

Management of ST Elevation Myocardial Infarction (STEMI) in Different Settings

ST-segment elevation myocardial infarction (STEMI) is a life-threatening condition that requires emergent, complex, well-coordinated treatment. Although the primary goal of treatment is simple to describe-reperfusion as quickly as possible-the management process is complicated and is affected by multiple factors including location, patient, and practitioner characteristics. Hence, this narrative review will discuss the recommended management and treatment strategies of STEMI in the circumstances.

Cardiac Regeneration: New Insights Into the Frontier of Ischemic Heart Failure Therapy

Ischemic heart disease is the leading cause of morbidity and mortality in the world. While pharmacological and surgical interventions developed in the late twentieth century drastically improved patient outcomes, mortality rates over the last two decades have begun to plateau. Following ischemic injury, pathological remodeling leads to cardiomyocyte loss and fibrosis leading to impaired heart function. Cardiomyocyte turnover rate in the adult heart is limited, and no clinical therapies currently exist to regenerate cardiomyocytes lost following ischemic injury. In this review, we summarize the progress of therapeutic strategies including revascularization and cell-based interventions to regenerate the heart: transiently inducing cardiomyocyte proliferation and direct reprogramming of fibroblasts into cardiomyocytes. Moreover, we highlight recent mechanistic insights governing these strategies to promote heart regeneration and identify current challenges in translating these approaches to human patients.

Drug-coated balloon treatment in coronary artery disease: Recommendations from an Asia-Pacific Consensus Group

Coronary artery disease (CAD) is currently the leading cause of death globally, and the prevalence of this disease is growing more rapidly in the Asia-Pacific region than in Western countries. Although the use of metal coronary stents has rapidly increased thanks to the advancement of safety and efficacy of newer generation drug eluting stent (DES), patients are still negatively affected by some the inherent limitations of this type of treatment, such as stent thrombosis or restenosis, including neoatherosclerosis, and the obligatory use of dual antiplatelet therapy (DAPT) with unknown optimal duration. Drug-coated balloon (DCB) treatment is based on a leave-nothing-behind concept and therefore it is not limited by stent thrombosis and long-term DAPT; it directly delivers an anti-proliferative drug which is coated on a balloon after improving coronary blood flow. At present, DCB treatment is recommended as the first-line treatment option in metal stent-related restenosis linked to DES and bare metal stent. For de novo coronary lesions, the application of DCB treatment is extended further, for conditions such as small vessel disease, bifurcation lesions, and chronic total occlusion lesions, and others. Recently, several reports have suggested that fractional flow reserve guided DCB application was safe for larger coronary artery lesions and showed good long-term outcomes. Therefore, the aim of these recommendations of the consensus group was to provide adequate guidelines for patients with CAD based on objective evidence, and to extend the application of DCB to a wider variety of coronary diseases and guide their most effective and correct use in actual clinical practice.

Stenting in Primary Percutaneous Coronary Intervention for Acute ST-Segment Elevation Myocardial Infarction

The treatment of ST-segment elevation myocardial infarction (STEMI) has advanced dramatically over the past 30 years since the introduction of reperfusion therapies, such that mechanical reperfusion with primary percutaneous coronary intervention is now the standard of care. With STEMI, as with other forms of acute coronary syndrome, stent deployment in culprit lesions is the dominant form of reperfusion in the developed world and is supported by contemporary guidelines. However, the precise timing of stenting and the extent to which both culprit and non-culprit lesions should be treated continue to be active areas of study. In this review, we revisit key data that support the use of mechanical reperfusion therapy in STEMI patients and explore the optimal timing for and extent of stent implantation in this complex patient group. We also review data surrounding the deleterious effects of untreated residual myocardial ischemia, the importance of complete revascularization, and the recent data exploring culprit-only versus multivessel stenting in the STEMI setting.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI) in 2018

While primary percutaneous coronary intervention (PCI) has significantly contributed to improve the mortality in patients with ST segment elevation myocardial infarction even in cardiogenic shock, primary PCI is a standard of care in most of Japanese institutions. Whereas there are high numbers of available facilities providing primary PCI in Japan, there are no clear guidelines focusing on procedural aspect of the standardized care. Whilst updated guidelines for the management of acute myocardial infarction were recently published by European Society of Cardiology, the following major changes are indicated; (1) radial access and drug-eluting stent over bare metal stent were recommended as Class I indication, and (2) complete revascularization before hospital discharge (either immediate or staged) is now considered as Class IIa recommendation. Although the primary PCI is consistently recommended in recent and previous guidelines, the device lag from Europe, the frequent usage of coronary imaging modalities in Japan, and the difference in available medical therapy or mechanical support may prevent direct application of European guidelines to Japanese population. The Task Force on Primary Percutaneous Coronary Intervention of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) has now proposed the expert consensus document for the management of acute myocardial infarction focusing on procedural aspect of primary PCI.

Cardiac stem cells for myocardial regeneration: promising but not ready for prime time

Remarkable strides have been made in the treatment of ischemic heart disease in decades. As the initial loss of cardiomyocytes associated with myocardial infarction serves as an impetus for myocardial remodeling, the ability to replace these cells with healthy counterparts would represent an effective treatment for many forms of cardiovascular disease. The discovery of cardiac stem cells (that can differentiate into multiple lineages) highlighted the possibility for development of cell-based therapeutics to achieve this ultimate goal. Recent research features cardiac stem cell maintenance, proliferation, and differentiation, as well as direct reprogramming of various somatic cells into cardiomyocytes, all within the context of the holy grail of regeneration of the injured heart. Much work remains to be done, but the future looks bright!

Acute myocardial infarction

Acute myocardial infarction has traditionally been divided into ST elevation or non-ST elevation myocardial infarction; however, therapies are similar between the two, and the overall management of acute myocardial infarction can be reviewed for simplicity. Acute myocardial infarction remains a leading cause of morbidity and mortality worldwide, despite substantial improvements in prognosis over the past decade. The progress is a result of several major trends, including improvements in risk stratification, more widespread use of an invasive strategy, implementation of care delivery systems prioritising immediate revascularisation through percutaneous coronary intervention (or fibrinolysis), advances in antiplatelet agents and anticoagulants, and greater use of secondary prevention strategies such as statins. This seminar discusses the important topics of the pathophysiology, epidemiological trends, and modern management of acute myocardial infarction, focusing on the recent advances in reperfusion strategies and pharmacological treatment approaches.

The History of Primary Angioplasty and Stenting for Acute Myocardial Infarction

The evolution of the management of acute myocardial infarction (MI) has been one of the crowning achievements of modern medicine. At the turn of the twentieth century, MI was an often-fatal condition. Prolonged bed rest served as the principal treatment modality. Over the past century, insights into the pathophysiology of MI revolutionized approaches to management, with the sequential use of surgical coronary artery revascularization, thrombolytic therapy, and percutaneous coronary intervention (PCI) with primary coronary angioplasty, and placement of intracoronary stents. The benefits of prompt revascularization inspired systems of care to provide rapid access to PCI. This review provides a historical context for our current approach to primary PCI for acute MI.

Magnesium as a predictor of acute stent thrombosis in patients with ST-segment elevation myocardial infarction who underwent primary angioplasty

BACKGROUND

Although magnesium (Mg) has been proposed as a useful biomarker for predicting atherothrombosis, the association between Mg and acute stent thrombosis (ST) after primary percutaneous coronary intervention (p-PCI) for ST-segment elevation myocardial infarction (STEMI) has not yet been defined.

OBJECTIVES

We aimed to examine whether admission Mg levels predicted the development of acute ST after p-PCI in STEMI patients.

METHODS AND RESULTS

A total of 2633 patients with STEMI who underwent p-PCI were retrospectively analyzed. Acute ST was defined as thrombosis that occurred in the first (0-1) days following primary coronary stenting, and patients who had undergone p-PCI were divided into two groups: ST group and no-ST group. The cut-off value for Mg obtained by the receiver-operating characteristic curve analysis was less than 1.91 mg/dl for the prediction of acute ST (area under the curve was 0.761; 95% confidence interval, 0.706-0.816; P<0.001; sensitivity, 70%; specificity, 69%). Serum Mg levels were significantly lower in the ST group compared with the no-ST group (median 1.80 mg/dl, interquartile range 1.70-2.00 mg/l vs. median 2.10 mg/dl, interquartile range 1.90-2.20 mg/dl, P<0.001). After multivariable adjustment for clinical, laboratory, and angiographic variables, Mg remained a strong independent predictor for acute ST (odds ratio 5.802, 95% confidence interval, 3.069-10.967; P<0.001).

CONCLUSION

Serum Mg level is associated independently with the risk of acute ST in patients with STEMI who undergo p-PCI.

The risk factors and prevention of cardiovascular disease: the importance of electrocardiogram in the diagnosis and treatment of acute coronary syndrome

Acute coronary syndrome is a leading cause of emergency medical treatment and hospitalization in Poland. High-speed electrocardiogram (ECG) has shown good accuracy of the initial diagnosis and of the final diagnosis in treated cardiac patients. Initial diagnosis and definitive diagnosis were analyzed statistically (P<0.0001). Although much is said about the prevention of sudden death in heart failure, the elimination of risk factors health care in Poland does not pay due attention to the need for early diagnosis and ECG analysis (at the stage of prevention). This article presents the inclusion of ECG in the prevention process and shows that it allows for early detection of cardiovascular diseases. In Poland, ST-segment elevation myocardial infarction patients are identified in the ambulance that reduces time to door-to-balloon.

Safety and feasibility of a PAclitaxel-eluting balloon angioplasty in Primary Percutaneous coronary intervention in Amsterdam (PAPPA): one-year clinical outcome of a pilot study

AIMS

In primary percutaneous coronary intervention (PPCI), stenting has been shown to reduce the need for repeat target lesion revascularisation (TLR) compared to balloon angioplasty alone, but did not result in a reduction of recurrent myocardial infarction (MI) or cardiac death. Meanwhile, stent-related adverse events such as stent thrombosis continue to be of concern. Our aim was to evaluate the safety and feasibility of drug- coated balloon (DCB) angioplasty without stenting in PPCI.

METHODS AND RESULTS

One hundred patients presenting with ST-elevation MI were prospectively enrolled in this pilot study. They underwent PPCI with DCB angioplasty; additional stenting was allowed only in case of type C to F coronary dissection or residual stenosis >50%. All patients were treated with i.v. bivalirudin. The primary endpoint was the composite of cardiac death, recurrent MI and TLR. A total of 59 patients received treatment with DCB angioplasty alone, whereas additional stenting was required in 41 patients. One-year clinical follow-up was completed in 98 patients. A total of five major adverse cardiac events were reported (5%). Cardiac death was seen in two patients, while three patients underwent TLR.

CONCLUSIONS

This first study of a DCB angioplasty-only strategy in the setting of PPCI showed good one-year clinical results.

Emergent Recanalization with Stenting for Acute Stroke due to Athero-Thrombotic Occlusion of the Cervical Internal Carotid Artery : A Single Center Experience

Objective

The purpose of this study is to demonstrate the technical feasibility and clinical efficacy of emergent carotid angioplasty and stenting (CAS) for acute stroke due to athero-thrombotic occlusion of the cervical internal carotid artery (ICA).

Methods

Review of medical records identified 17 patients who underwent emergent CAS for treatment of athero-thrombotic occlusion of the cervical ICA with acute stroke between 2009 and 2013. Eleven patients (64.7%) presented with concomitant intracranial artery occlusion, which was treated primarily by mechanical thrombectomy after CAS.

Results

Successful revascularization of the cervical ICA with emergent CAS was achieved in all patients. After CAS, intracranial recanalization with Thrombolysis in Cerebral Infarction ≥2b flow was achieved in four of the 11 patients (36.4%). The overall recanalization rate (cervical ICA and intracranial artery) was 10 of 17 patients (58.8%). Symptomatic intracranial hemorrhage occurred in two patients (11.8%), resulting in death. Ten patients (58.8%) showed improvement (decrease in NIHSS score of ≥4 points) at seven days after recanalization. Nine patients (52.9%) showed a favorable outcome (mRS ≤2) at the last follow-up. A favorable outcome (mRS ≤2) was obtained in four of the six patients with isolated cervical ICA occlusion (4/6, 66.7%) and five of 11 patients with intracranial tandem occlusion (5/11, 45.5%).

Conclusion

Emergent CAS for acute stroke due to athero-thrombotic occusion of the cervical ICA showed a good technical feasibility and favorable clinical outcome.

ST-elevation myocardial infarction and myelodysplastic syndrome with acute myeloid leukemia transformation

Acute myocardial infarction and acute myeloid leukemia are rarely reported as concomitant conditions. The management of ST-elevation myocardial infarction (STEMI) in patients who have acute myeloid leukemia is challenging: the leukemia-related thrombocytopenia, platelet dysfunction, and systemic coagulopathy increase the risk of bleeding, and the administration of thrombolytic agents can be fatal. We report the case of a 76-year-old man who presented emergently with STEMI, myelodysplastic syndrome, and newly recognized acute myeloid leukemia transformation. Standard antiplatelet and anticoagulation therapy were contraindicated by the patient's thrombocytopenia and by his reported ecchymosis and gingival bleeding upon admission. He declined cardiac catheterization, was provided palliative care, and died 2 hours after hospital admission. We searched the English-language medical literature, found 8 relevant reports, and determined that the prognosis for patients with concomitant STEMI and acute myeloid leukemia is clearly worse than that for either individual condition. No guidelines exist to direct the management of STEMI and concomitant acute myeloid leukemia. In 2 reports, dual antiplatelet therapy, anticoagulation, and drug-eluting stent implantation were used without an increased risk of bleeding in the short term, even in the presence of thrombocytopenia. However, we think that a more conservative approach--balloon angioplasty with the provisional use of bare-metal stents--might be safer. Simultaneous chemotherapy for the acute myeloid leukemia is crucial. Older age seems to be a major risk factor: patients too frail for emergent treatment can die within hours or days.

Synergistic effect of thrombus aspiration and abciximab in primary percutaneous coronary intervention

BACKGROUND

Previous studies failed to assess the individual prognostic role of thrombus aspiration (TA) or abciximab in primary percutaneous coronary intervention (pPCI), due their prevalent combined use.

METHODS AND RESULTS

A total of 644 consecutive ST-segment elevation myocardial infarction patients treated with pPCI were included in this retrospective registry from January 2006 to December 2008. Patients were divided in: (a) Group 1, with conventional pPCI; (b) Group 2, with pPCI and abciximab; (c) Group 3, with pPCI and TA; (d) Group 4, with pPCI and abciximab plus TA. Primary end point was the composite of major adverse cardiovascular events (MACEs, defined as overall mortality, myocardial infarction, target vessel revascularization, and major bleedings) at 1 year. Baseline clinical and angiographic characteristics were not different among the groups, with the exception of a younger age in group 4. The two groups of patients treated with TA (group 3 and 4) received more frequently direct stenting (P < 0.001 vs. group 1 for both), presented higher rate of end-procedural TIMI flow grade 3 (P < 0.001 vs. group 1 for both), and lower rate of no-reflow (P = 0.016 and P < 0.001 vs. group 1, respectively). Patients of group 2 presented a borderline nonsignificant trend toward higher rate of end-procedural TIMI flow grade 3 (P = 0.083 vs. group 1). MACEs at 1 year were 43 (29%) in group 1 versus 25 (22%) in group 2 versus 24 (19%) in group 3 versus 32 (13%) in group 4 (log-rank P = 0.001). At the multivariate Cox regression analysis, combined TA plus abciximab in group 4 [hazard ratio (HR): 0.48, confidence interval (CI) 95% 0.28-0.84, P = 0.01] and a higher left ventricular ejection fraction (HR: 0.97, CI 95% 0.95-0.98, P < 0.001) were significantly associated with lower MACE rate.

CONCLUSIONS

The combination of pharmacologic and mechanic antithrombotic treatment during pPCI was associated with better 1-year clinical outcome.

Intracoronary versus intravenous administration of abciximab in patients with acute coronary syndrome: a meta-analysis

BACKGROUND

Abciximab is a widely used adjunctive therapy for acute coronary syndrome (ACS). However, the effect of intracoronary (i.c.) administration of abciximab on cardiovascular events remains unclear when compared with intravenous (i.v.) therapy.

METHODOLOGY AND PRINCIPAL FINDINGS

We systematically searched the Medline, Embase, and Cochrane Central Register of Controlled Trials databases and reference lists of articles and proceedings of major meetings for obtaining relevant literature. All eligible trials included ACS patients who received either i.c. administration of abciximab or i.v. therapy. The primary outcome was major cardiovascular events, and secondary outcomes included total mortality, reinfarction, and any possible adverse events. Of 660 identified studies, we included 9 trials reporting data on 3916 ACS patients. Overall, i.c. administration of abciximab resulted in 45% reduction in relative risk for major cardiovascular events (RR; 95% confidence interval [CI], 24-60%), 41% reduction in RR for reinfarction (95% CI, 7-63%), and 44% reduction in RR for congestive heart failure relative to i.v. therapy (95% CI, 8-66%); however, compared to i.v. therapy, i.c. administration of abciximab had no effect on total mortality (RR, 0.69; 95% CI, 0.45-1.07). No other significant differences were identified between the effect of i.c. abciximab administration and i.v. therapy.

CONCLUSIONS/SIGNIFICANCE

I.c. administration of abciximab can reduce the risk of major cardiovascular events, reinfarction, and congestive heart failure when compared with i.v. therapy.

Stenting in Acute STEMI Intervention

Stenting in acute myocardial infarction (AMI) has the benefits of achieving acute optimal angiographic results and correcting residual dissection to decrease the incidence of restenosis and reocclusion. Studies have shown that percutaneous transluminal coronary angioplasty for primary treatment after AMI is superior to thrombolytic therapy regarding the restoration of normal coronary blood flow. Coronary stenting improves initial success rates, decreases the incidence of abrupt closure, and is associated with a reduced rate of restenosis. In the presence of thrombus-containing lesions, coronary stenting constitutes an effective therapeutic strategy, either after failure of initial angioplasty or electively as the primary procedure.

The rise of cardiovascular medicine

Modern cardiology was born at the turn of the nineteenth to twentieth centuries with three great discoveries: the X ray, the sphygmomanometer, and the electrocardiograph. This was followed by cardiac catheterization, which led to coronary angiography and to percutaneous coronary intervention. The coronary care units and early reperfusion reduced the early mortality owing to acute myocardial infarction, and the discovery of coronary risk factors led to the development of Preventive Cardiology. Other major advances include several cardiac imaging techniques, the birth and development of cardiac surgery, and the control of cardiac arrhythmias. The treatment of heart failure, although greatly improved, remains a challenge. Current cardiology practice is evidence-based and global in scope. Research and practice are increasingly conducted in cardiovascular centres and institutes. It is likely that in the future, a greater emphasis will be placed on prevention, which will be enhanced by genetic information.

The treatment of acute myocardial infarction: the Past, the Present, and the Future

Since Herrick's description of the clinical picture of acute myocardial infarction exactly one century ago (1912), there have been three phases of therapy: Phase 1 (1912-1961, bed rest and 'expectant' treatment); Phase 2 (1961-1974, the coronary care unit); and Phase 3 (1975-present, myocardial reperfusion). We are now on the cusp of Phase 4, which comprises efforts to reduce myocardial perfusion injury as well as regenerative medicine.

A meta-analytic overview of thrombectomy during primary angioplasty

INTRODUCTION

Even though primary angioplasty restores TIMI 3 flow in more than 90% of STEMI patients, the results in terms of myocardial perfusion are still unsatisfactory in a relatively large proportion of patients. Great interest has been focused in the last years on distal embolization as major determinant of poor reperfusion and clinical outcome after primary angioplasty. The aim of this article is to perform an updated meta-analysis of thrombectomy devices in STEMI patients undergoing primary angioplasty.

METHODS

The literature was scanned by formal searches of electronic databases (MEDLINE, Pubmed) from January 1990 to December 2010, the scientific session abstracts (from January 1990 to December 2010) and oral presentation and/or expert slide presentations (from January 2002 to December 2010) (on TCT, AHA, ESC, ACC and EuroPCR websites). No language restrictions were enforced.

RESULTS

A total of 21 randomized trials were finally included in the meta-analysis, involving 4514 patients (2270 or 50.3% randomized to thrombectomy and 2244 or 49.7% to standard angioplasty). Overall thrombectomy did not reduce 30-day mortality, with more benefits observed only with manual thrombectomy. No difference was observed in the 30-day reinfarction rate, whereas a trend in higher risk of stroke was observed with thrombectomy (p=0.06). Manual but not mechanical thrombectomy significantly improved postprocedural TIMI 3 flow, however, both devices significantly improved myocardial reperfusion as evaluated by ST-segment resolution. By meta-regression analysis a linear relationship was observed between benefits from thrombectomy in ST-segment resolution and in the presence of thrombus at baseline angiography (p=0.0016).

CONCLUSIONS

The present meta-analysis has demonstrated that, among patients with STEMI, manual thrombectomy significantly improved myocardial perfusion, with a trend in short-term mortality benefits, whereas mechanical thrombectomy, despite the benefits in myocardial perfusion, did not impact on short-term survival. However, the benefits in myocardial perfusion were significantly related to prevalence of coronary thrombus. In light of the observed higher risk of stroke, thrombectomy cannot be routinely recommended, but should be used in case of evident intracoronary thrombus. Mechanical thrombectomy devices may be considered as well to further improve reperfusion and facilitate optimal stent implantation, especially in the presence of large thrombus burden.

Carotid artery stenting in acute stroke

OBJECTIVES

The purpose of this study is to demonstrate the technical success of carotid artery stenting in acute extracranial internal carotid artery (ICA) occlusion as well as the benefit in clinical outcome.

BACKGROUND

Stroke caused by acute occlusion of the ICA is associated with a significant level of morbidity and mortality. For this type of lesion, treatment with standard intravenous thrombolysis alone leads to a good clinical outcome in only 17% of the cases, with a death rate as high as 55%. Recanalization of the occluded ICA can lead to an improvement in acute symptoms of stroke, prevent possible deterioration, and reduce long-term stroke risk. At present, there is no consensus treatment for patients with acute ischemic stroke presenting with severe clinical symptoms due to atherosclerotic occlusion of the extracranial ICA.

METHODS

Carotid artery stenting was performed in 22 patients with acute atherosclerotic extracranial ICA occlusion within 6 h of stroke symptom onset. In 18 patients, there was an additional intracranial occlusion at the level of the terminal segment of the ICA (n = 4) and at the level of the middle cerebral artery (n = 14). Intracranial occlusions were either treated with the Penumbra system or the Solitaire stent-based recanalization system, or a combination of mechanical recanalization and intra-arterial thrombolysis. Recanalization results were assessed by angiography immediately after the procedure. The neurologic status was evaluated before and after the treatment with a follow-up as long as 90 days using the National Institutes of Health Stroke Scale and the modified Rankin Scale.

RESULTS

Successful revascularization of extracranial ICA with acute stent implantation was achieved in 21 patients (95%). There was no acute stent thrombosis. After successful recanalization of the origin of the ICA, the intracranial recanalization with Thrombolysis In Myocardial Infarction flow grade 2/3 was achieved in 11 of the 18 patients (61%). The overall recanalization rate (extracranial and intracranial) was 14 of 22 patients (63%). Nine patients (41%) had a modified Rankin Scale score of ≤2 at 90 days. The mortality rate was 13.6% at 90 days.

CONCLUSIONS

Carotid artery stenting in acute atherosclerotic extracranial ICA occlusion with severe stroke symptoms is feasible, safe, and useful within the first 6 h after symptom onset.

Comparison of paclitaxel-, sirolimus-, and zotarolimus-eluting stents in patients with acute ST-segment elevation myocardial infarction and metabolic syndrome

BACKGROUND

The purpose of the present study was to compare the efficacy and safety of paclitaxel-eluting stent (PES), sirolimus-eluting stent (SES), and zotarolimus-eluting stent (ZES) in primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction (STEMI) with metabolic syndrome (MS).

METHODS AND RESULTS

Using data from Korea Acute Myocardial Infarction Registry (KAMIR; November 2005-December 2007), a total of 1,768 MS patients with STEMI who underwent primary PCI were enrolled: The PES group was 634, SES group, 906, and ZES group, 228. The primary endpoint was major adverse cardiac event (all-cause death, re-myocardial infarction, target lesion revascularization) during 12 months follow-up. At 12 months, the cumulative incidence of primary endpoint in the PES, SES, and ZES groups was 10.9%, 9.1%, and 11.0%, respectively (P=0.086). Incidence of death, recurrent myocardial infarction, or target lesion revascularization did not differ among the 3 groups. There were 7 episodes of acute (0.3% in PES group, 0.4% in SES group, and 0.4% in ZES group, respectively, P=0.773) and 18 episodes of cumulative stent thrombosis including late stent thrombosis (0.9% in PES group, 1.0% in SES group, and 1.3% in ZES group, respectively, P=0.448).

CONCLUSIONS

Implantation of SES, PES, and ZES in MS patients with STEMI undergoing primary PCI provided comparable clinical outcomes in patients enrolled in KAMIR.

Comparison of sirolimus- and paclitaxel-eluting stents in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a meta-analysis of randomized trials

BACKGROUND

It has been reported that sirolimus-eluting stents (SES) and paclitaxel-eluting stents (PES) have been more effective than bare-metal stents in reducing restenosis and cardiac events in a broad range of patients with coronary artery disease. However, it is unknown whether there might be differences between these two drug-eluting stents in terms of efficacy and safety in the setting of acute ST-segment elevation myocardial infarction (STEMI).

HYPOTHESIS

The aim of the present study was to compare SES with PES in patients with acute STEMI undergoing primary percutaneous coronary intervention (PCI).

METHODS

The published research was scanned by formal searches of electronic databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials) from January 2001 to February 2010. Internet-based sources of information on the results of clinical trials in cardiology were also searched.

RESULTS

A total of 4 randomized trials were included in the present meta-analysis, involving 1105 patients (550 in the SES group, 555 in the PES group). SES were significantly more effective in the reduction of angiographic binary (≥50%) restenosis (4.0% vs 9.6%, odds ratio 0.38, 95% confidence interval 0.19 to 0.74, P = 0.004) compared to PES. The differences between SES and PES were not statistically significant with respect to target vessel revascularization (TVR), stent thrombosis, cardiac death, and myocardial infarction.

CONCLUSIONS

SES are superior to PES in reducing the incidence of restenosis in patients undergoing primary PCI for STEMI, with nonsignificant differences in terms of TVR, cardiac death, myocardial infarction, and stent thrombosis.

Drug-eluting stents during ST-segment elevation acute myocardial infarction: a critical analysis

Primary percutaneous coronary intervention is the preferred reperfusion therapy for ST-segment elevation acute myocardial infarction patients within 12 hours of symptom-onset. Routine stent implantation during the procedure significantly reduces the rate of target vessel revascularization, although restenosis still represents a current limitation of the technique. Drug-eluting stents were developed to treat and prevent coronary restenosis. Randomized trials, meta-analysis, and registries proved their efficacy and safety in different clinical situations, including acute myocardial infarction. However, the increased risk of late stent thrombosis associated with drug-eluting stents during primary percutaneous coronary interventions encourages a careful analysis to identify which patients most benefit from them, as well as those where a prolonged dual antiplatelet therapy does not represent a limiting factor.

Selective drug-eluting stent implantation for high-risk patients with acute ST-elevation myocardial infarction: rationale and safety

BACKGROUND

A selective policy of drug-eluting stent (DES) implantation in ST-elevation myocardial infarction (STEMI) patients at high risk of restenosis may maximize the benefit from restenosis reduction and minimize risk from late stent thrombosis (LaST).

OBJECTIVES

We sought to prospectively determine the safety of selective DES implantation for long lesions (>20 mm), small vessels (<2.5 mm) and diabetic patients in patients with STEMI using a prospective single-center registry.

METHODS

A total of 252 patients who underwent primary PCI between January 2005 and December 2006 were included: 126 consecutive patients receiving DES were compared with 126 age-, sex-, and vessel-matched controls with STEMI who received bare-metal stents. Composite major adverse cardiovascular events (MACE) (death, AMI, and target vessel revascularization) were used as the primary outcome measure.

RESULTS

Baseline clinical and angiographic characteristics and outcomes were similar between groups except for the prespecified diabetes, lesion length, and maximum stent diameter. Long-term outcomes at a median follow up of 34 ± 6 months showed significant reductions in reinfarction (2% vs. 11%, P = 0.03), target vessel revascularization (TVR) (10% vs. 24%, P = 0.02), and composite MACE (18% vs. 31%, P = 0.03) with DES, with no excess of death (9% vs. 7%, P = NS) or LaST (2% vs. 1%, P = NS). In a Cox multivariate model, clopidogrel cessation at long-term follow-up was the most powerful predictor of hierarchical MACE (HR: 5.165; 95%CI: 2.019-13.150, P = 0.001).

CONCLUSIONS

Selective DES implantation in patients with high-risk STEMI appears safe, and exposes fewer patients to the risk of LaST. A randomized comparison of selective versus routine DES use in patients with STEMI should be considered.

Predictive value of ST resolution analysis performed immediately versus at ninety minutes after primary percutaneous coronary intervention

ST segment resolution (STR) predicts epicardial and microvascular reperfusion after primary percutaneous coronary intervention (PPCI) or thrombolysis for ST-elevation myocardial infarction. Immediate restoration of epicardial coronary flow, with improved microvascular perfusion, is much more likely with PPCI. However, the predictive value of immediate STR compared to 90 minutes after PPCI remains unknown. In 622 consecutive patients with ST-elevation myocardial infarction (mean age 59 +/- 13 years), 217 had complete STR immediately after PPCI (group A), 188 had complete STR only at 90 minutes (group B), and 217 had incomplete STR at either point (group C). The primary end point was mortality and adverse cardiovascular events ([MACE] death, nonfatal repeat myocardial infarction, and heart failure). Group A had a greater left ventricular ejection fraction (53%, 47%, and 46%, p <0.001) and lower all-cause mortality (1.8%, 3.2%, and 6%, p = 0.07), lower heart failure (1.8%, 4.3%, and 7.8%, p <0.001), and MACE (5.1%, 9.6%, and 16.1%, p = 0.001) at 30 days compared to groups B and C, respectively. The rate of MACE at 1 year was 7.6%, 17.1%, and 20.2% in groups A, B, and C, respectively (p <0.001). Immediate STR independently predicted MACE (adjusted hazard ratio 0.36, 95% confidence interval 0.21 to 0.61, p = 0.001, group A vs C), and STR at 90 minutes did not. In conclusion, STR analysis performed immediately after PPCI provided superior differentiation for adverse cardiovascular events compared to STR at 90 minutes. Immediate STR should be the contemporary goal of reperfusion with PPCI.

Drug-eluting stents for the treatment of acute myocardial infarction: the view to the HORIZONS

Drug-eluting stents (DES) offer an attractive option for the treatment of acute thrombotic lesions during acute ST-elevation myocardial infarction (STEMI) due to their ability to inhibit restenosis. Several randomised trials have demonstrated the efficacy of DES in reducing target vessel revascularisation (TVR) in this setting. However, several registries of real-world patients receiving DES for STEMI have raised long-term safety concerns about DES use in this patient subset. Given the inherent limitations of registry data, this issue is likely to remain unresolved until further data is made available from large-scale ongoing trials with long-term follow-up such as the HORIZONS-AMI trial.

Comparison of the efficacy and safety of zotarolimus-, sirolimus-, and paclitaxel-eluting stents in patients with ST-elevation myocardial infarction

Drug-eluting stents (DESs) are increasingly used for treatment of acute ST-segment elevation myocardial infarction (STEMI), but there are few comparisons of outcomes of various types of DES. We compared the efficacy and safety of zotarolimus-eluting stents (ZESs), sirolimus-eluting stents (SESs), and paclitaxel-eluting stents (PESs) in primary intervention for STEMI. This multicenter, prospectively randomized ZEST-AMI trial included 328 patients at 12 medical centers who were randomly assigned to ZES (n = 108), SES (n = 110), or PES (n = 110) deployment. The primary end point was major adverse cardiac events (death, MI, and ischemia-driven target vessel revascularization) at 12 months. Secondary end points included the individual components of the primary end point, late loss, angiographic restenosis, and stent thrombosis. Baseline clinical and angiographic characteristics were well matched. In-segment late loss (0.28 +/- 0.42 vs 0.46 +/- 0.48 vs 0.47 +/- 0.50 mm, respectively, p = 0.029) and restenosis rate (2.7% vs 15.9% vs 12.3%, respectively, p = 0.027) at 8 months were lowest in the SES group compared to the ZES and PES groups. At 12 months, cumulative incidence rates of primary end points in the ZES, SES, and PES groups were 11.3%, 8.2%, and 8.2%, respectively (p = 0.834). There were 2 acute (in the SES group) and 5 subacute (2 in the SES group and 3 in the PES group) stent thromboses. Incidence of death, recurrent MI, or ischemia-driven target vessel revascularization did not differ among the 3 groups. In conclusion, despite the difference in restenosis rate, the efficacy and safety of the 3 different DESs showed similar, acceptable results in the treatment of STEMI.

Early Stent Thrombosis in Patients Undergoing Primary Coronary Stenting for Acute Myocardial Infarction: Incidence, a Simple Risk Score, and Prognosis

Background: One of the major concerns remaining in the treatment with stenting of patients with acute myocardial infarction (AMI) is the occurrence of stent thrombosis (ST). The aim of the current study is to investigate the incidence, predictors, and long-term outcomes of early ST after primary coronary stenting for AMI in a large population. Methods: We reviewed 1960 consecutive patients (mean age 56 ± 11.6 years, 1658 males) treated with primary coronary stenting for AMI between 2003 and 2008. All clinical, angiographic, and follow-up data were retrospectively collected. Early ST was defined as thrombosis that occurred in the first 30 days after primary coronary stenting. Results: Early ST was observed in 89 (4.5%) patients. Five variables, selected from the multivariate analysis, were weighted proportionally to their respective odds ratio (OR) for early ST (premature clopidogrel therapy discontinuation [10 points], stent diameter ≤3 mm [5 points], current smoker [4 points], diabetes mellitus [DM; 3 points], and age >65 years [2 points]). Three strata of risks were defined (low risk, score 0-4; intermediate risk, score 5-12; and high risk, score 13-24) and had a strong association with early ST and long-term cardiovascular mortality. Long-term cardiovascular mortality was 5-fold more in patients with early ST than that without ST (24.1% vs 4.7%, respectively, P < .001). Conclusions: Early ST after primary coronary stenting in AMI is strongly related with increased long-term cardiovascular mortality. Premature clopidogrel therapy discontinuation is the most powerful predictor of early ST.

Drug-eluting stents versus bare-metal stents in diabetic patients with ST-segment elevation acute myocardial infarction: a pooled analysis of individual patient data from seven randomized trials

INTRODUCTION AND OBJECTIVES

The performance of drug-eluting stents (DESs) in high-risk patients with diabetes and acute ST-elevation myocardial infarction (STEMI) who have undergone primary angioplasty has not been previously studied. The objective was to evaluate the efficacy and safety of DESs in diabetic patients with STEMI.

METHODS

We performed a pooled analysis of individual patient data from seven randomized trials that compared DESs (i.e., sirolimus- or paclitaxel-eluting stents) with bare-metal stents (BMSs) in patients with STEMI. The analysis involved 389 patients with diabetes mellitus from a total of 2476 patients. The outcomes of interest were target-lesion revascularization, stent thrombosis, death and the composite endpoint of death or recurrent myocardial infarction during a follow-up of 12-24 months.

RESULTS

Overall, 206 diabetic patients received a DES and 183, a BMS. The risk of target-lesion revascularization was significantly lower in patients treated with a DES compared to those treated with a BMS (hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.23-0.88; P=.02). There was no significant difference in the risk of stent thrombosis between those treated with a DES or a BMS (HR 0.33, 95% CI 0.09-1.13; P=.08). Similarly, the risk of the combined endpoint of death or myocardial infarction was not significantly different between patients treated with a DES or a BMS (HR 0.64, 95% CI 0.36-1.13; P=.12).

CONCLUSIONS

Compared with BMSs, DES use improved clinical outcomes in diabetic patients undergoing primary angioplasty for STEMI: the need for reintervention was reduced, with no increase in mortality or myocardial infarction.

Two year follow-up after primary PCI with a paclitaxel-eluting stent versus a bare-metal stent for acute ST-elevation myocardial infarction (the PASSION trial): a follow-up study

AIMS

This follow-up study was performed to assess the long-term effects of paclitaxel-eluting stents (PES) compared with bare-metal stents (BMS) in patients who had undergone a percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI).

METHODS AND RESULTS

The PASSION trial randomly assigned 619 patients with STEMI to receive either a PES or BMS. The composite endpoint for the follow-up study was the occurrence of the combination of cardiac death, recurrent myocardial infarction, target lesion revascularisation (TLR) or stent thrombosis at two years. A trend towards a lower rate of the composite endpoint was observed in the PES compared to the BMS group (hazard ratio [HR] 0.70; 95% C.I. 0.45-1.09). This was driven by a reduced TLR in favour of PES (HR 0.60; 95% C.I. 0.34-1.09). Angiographically proven stent thrombosis at two years did not differ significantly between groups (2.1% in the PES group versus 1.4%; HR 1.48; 95% C.I. 0.42-5.23).

CONCLUSIONS

PES implantation for STEMI did not significantly improve clinical outcome at two years after the index event, although there was a trend towards a lower rate of target-lesion revascularisation. The rate of stent thrombosis did not differ significantly between groups.

Routine stenting vs. balloon angioplasty in ST-segment elevation myocardial infarction due to proximal left anterior descending coronary artery occlusion

BACKGROUND

Primary angioplasty has been shown to improve the outcome in selected patients with ST-segment elevation myocardial infarction. However, no data have been reported of patients with proximal left anterior descending artery occlusion. In the Zwolle-6 randomized trial, a total of 1683 consecutive patients with ST-segment elevation myocardial infarction were randomized to stenting or balloon angioplasty without any exclusion criteria. The aim of this substudy was to investigate the benefits of coronary stenting as compared to balloon angioplasty in patients with proximal left anterior descending artery occlusion.

METHODS

From April 1997 to October 2001, among a total of 1683 consecutive patients with ST-segment elevation myocardial infarction randomized to stenting or balloon angioplasty before the initial angiography, a total of 218 patients underwent primary angioplasty of proximal left anterior descending artery occlusion. One-year follow-up data were available from all patients.

RESULTS

A total of 107 patients were randomized to stent and 111 patients to balloon angioplasty. The cross-over rates from balloon to stent and stent to balloon were 35.1 and 13.1%, respectively (P<0.0001). The groups were comparable in terms of postprocedural thrombolysis in myocardial infarction flow, myocardial blush grade, distal embolization, and ST-segment resolution. Stenting was associated with benefits in terms of restenosis (27.6 vs. 53.8%, P=0.03) and target vessel revascularization (15.0 vs. 24.3%, P=0.081), whereas no difference was observed in mortality (11.2 vs. 13.5%, P>0.1) and reinfarction (11.2 vs. 8.1%, P>0.1) as compared with balloon angioplasty.

CONCLUSION

As compared with balloon angioplasty, routine stenting does reduce angiographic restenosis, without significant benefits in terms of death and reinfarction among patients undergoing primary angioplasty for ST-segment elevation myocardial infarction due to proximal left anterior descending artery occlusion.

Comparison of six-month outcomes for primary percutaneous revascularization for acute myocardial infarction with drug-eluting versus bare metal stents (from the APEX-AMI study)

We evaluated the use and outcomes of drug-eluting stents (DESs) and bare metal stents (BMSs) in a large primary percutaneous coronary intervention (PCI) acute ST-elevation myocardial infarction (MI) trial. Recently concerns have been raised with "off-label" use of DESs for short- and long-term clinical outcomes. Limited randomized data exist evaluating DESs versus BMSs in ST-elevation MI. Patients (n=5,745) in the Assessment of Pexelizumab in Acute Myocardial Infarction (APEX-AMI) trial were categorized by stent type used. Baseline variables and clinical outcomes were collected at 90 days and 6 months. Outcomes by stent type were adjusted for using conventional multivariable predictors of 90-day mortality (age, anterior location, total ST-segment deviation, and Killip class), time to PCI, and Thrombolysis In Myocardial Infarction grade flow. Stents were deployed (at the investigator's discretion) in 5,124 patients (89.2%) with acute MI, with DES use in 2,221 (43.3%) and BMS use in 2,903 (56.7%). Patients receiving DESs were younger (median 59 vs 63 years of age, p<0.001), had left anterior descending coronary artery PCI (57.9% vs 48.1%, p<0.001), and often were treated in the United States (58.2%). DES-treated patients had a lower adjusted mortality at 90 days (hazard ratio 0.73, 95% confidence interval [CI] 0.54 to 0.99, p=0.046) and trended toward lower mortality (hazard ratio 0.77, 95% CI 0.58 to 1.03, p=0.084) and recurrent MI (hazard ratio 0.81, 95% CI 0.59 to 1.11, p=0.186) at 6 months compared with BMSs. In conclusion, in this observational analysis of stent use from a large primary percutaneous intervention for acute MI trial, DESs appear as safe as BMSs with similar 6-month clinical outcomes with regard to death and recurrent MI.