One-year outcome after percutaneous coronary intervention for stable and unstable angina pectoris with or without application of general usage of stents in unselected European patient groups

Restenosis after Percutaneous Coronary Intervention (PCI): Experiences from the Patients' Perspective

BACKGROUND

PCI has been established as an effective treatment for coronary artery disease. Restenosis is a recurrence of a significant narrowing in the treated vessel. Although a part of the investigative and research funding is invested in the prevention and resolving the restenosis problem, little is known about its clinical significance apart from further revascularisation.

AIM

The intention of this study was to clarify the patients perspective of what it means to suffer from documented restenosis after PCI.

METHOD

Patients interviewed had undergone PCI. Data collection and analysis was done simultaneously according to Grounded Theory methodology and continued until new interviews provided no additional information.

RESULTS

"Living with uncertainty" was identified as the core category, and the central focus in the data explains what it means to patients' to suffer from restenosis. The core category was further illuminated in four additional categories labelled "fighting for access to care", "moderating health threats", "trying to understand" and "controlling relatives anxiety".

CONCLUSION

Patients' perceptions of illness and illness-related events, such as symptoms, diagnosis, treatment and prognosis, are considerably affected by uncertainty. This infiltrates their struggle to acquire the care needed, their endeavour to comprehend and moderate health threats, and caring for their family.

Predictors of diffuse-type in-stent restenosis following drug-eluting stent implantation

Diffuse-type in-stent restenosis (ISR) is known to be associated with a higher rate of restenosis than focal-type ISR. Therefore, it is clinically important to identify the determinants of diffuse-type ISR following drug-eluting stent (DES) implantation. We investigated the clinical, procedural and angiographic variables for predicting diffuse-type ISR following DES implantation. A total of 173 ISR lesions in 159 patients (diffuse-type: 61 lesions, focal-type: 112 lesions) following DES implantation from February 2003 to May 2008 were included in this study. Clinical, procedural and quantitative coronary angiographic variables were analyzed to determine predictors of diffuse-type ISR following DES implantation. Univariate analysis showed that the absence of hypertension [odds ratio (OR), 0.493; 95% confidence interval (CI), 1.025-4.103, P=0.042], use of a paclitaxel-eluting stent (PES) (OR, 3.318; 95% CI, 1.730-6.365, P<0.001) and smaller post-stenting minimal luminal diameter (MLD; OR, 0.368, 95% CI, 0.168-0.808, P=0.013) were significantly associated with diffuse-type ISR. However, use of a PES (OR, 3.957; 95% CI, 1.977-7.922, P<0.001) and smaller post-stenting MLD (OR, 0.320; CI, 0.140-0.731, P=0.007) were only independent predictors of diffuse-type ISR by multivariate analysis. Diabetes was not a predictor of diffuse-type ISR. The use of a PES and the post-stenting MLD were related to diffuse-type ISR following DES implantation.

Rationale and design of the Randomized Intervention with CPAP in Coronary Artery Disease and Sleep Apnoea--RICCADSA trial

RATIONALE

Obstructive sleep apnoea (OSA) is common in coronary artery disease (CAD) and a possible cause of increased mortality. To date, there is a lack of randomized controlled trials to draw the conclusion that all CAD patients should be investigated for OSA and subsequently be treated with continuous positive airway pressure (CPAP).

OBJECTIVE

The Randomized Intervention with CPAP in CAD and OSA (RICCADSA) trial is designed to address if CPAP treatment reduces the combined rate of new revascularization, myocardial infarction, stroke and cardiovascular mortality over a 3-year period in CAD patients with OSA. Secondary outcomes include cardiovascular biomarkers, cardiac function and maximal exercise capacity at 3-month- and 1-year follow-ups.

PATIENTS AND METHODS

A sample of 400 CAD patients (100 non-sleepy OSA patients randomized to CPAP, 100 to non-CPAP; 100 sleepy OSA patients on CPAP, and 100 CAD patients without OSA) will be included. So far, 240 patients have been enrolled in the trial since December 31, 2005.

CONCLUSION

The RICCADSA trial will contribute to defining the impact of CPAP on prognosis of CAD patients with OSA.

Comparison of angiographic patterns of in-stent restenosis between sirolimus- and paclitaxel-eluting stent

BACKGROUND

Angiographic pattern of in-stent restenosis (ISR) after drug-eluting stent (DES) implantation was known to be different to that after bare metal stent (BMS) implantation. But the different angiographic patterns of ISR and its prognosis between sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES) has not been properly addressed in large scale studies.

OBJECTIVES AND METHODS

We evaluated the angiographic pattern of ISR and their subsequent clinical outcomes in 177 ISR lesions of 163 consecutive patients previously treated with SES (n=97) or PES (n=80) from February 2003 to April 2005.

RESULTS

In angiographic ISR pattern, diffuse ISR was more common in PES implantation (SES vs PES; 23.7% vs 48.7%, p=0.001) mainly because of higher incidence of diffuse intrastent ISR (8.2% vs 33.8%, p<0.001, respectively) whereas focal ISR was more common in SES implantation (76.3% vs 51.3%, p=0.001, respectively) mainly because of higher incidence of focal margin ISR (27.8% vs 2.5%, p<0.001, respectively). Among 177 ISR lesions, clinically driven target lesion revascularization (TLR) was performed in 53.6% in SES implantation and 56.3% in PES implantation (p=0.725).

CONCLUSION

Angiographic pattern of ISR differed after SES and PES implantation, but their subsequent TLR rate was similar to both types of DES.

Impact of Stable Versus Unstable Coronary Artery Disease on 1-Year Outcome in Elective Patients Undergoing Multivessel Revascularization With Sirolimus-Eluting Stents

OBJECTIVES

We sought to evaluate the impact of unstable coronary artery disease (CAD) on short- and mid-term outcomes in patients with multivessel disease treated by multiple sirolimus-eluting stents (SES) as part of ARTS II (Arterial Revascularization Therapies Study Part II).

BACKGROUND

The differential safety/efficacy profile of SES when implanted in patients with unstable angina (UA) in comparison with stable angina (SA) undergoing multivessel intervention is largely unknown.

METHODS

Between February 2003 and November 2003, 607 patients at 45 participating centers were treated; 221 of them (36%) presented with UA.

RESULTS

At 30 days, the cumulative rate of death, myocardial infarction-defined as any creatine kinase (CK)/CK-myocardial band elevation beyond the upper limit of normal-cerebrovascular accident, and repeat revascularization (i.e., major adverse cardiac and cerebrovascular events [MACCEs]) was 19.9% in both groups. Angiographic subacute stent occlusion was documented in 1 (0.5%) and 4 (1%) patients in the UA and SA groups, respectively. At 1 year, the cumulative incidence of MACCEs was 27.1% in the UA and 24.9% in the SA group (p = 0.56). Two late occlusions occurred, both in the SA group. After adjustment for baseline and procedural characteristics, the presence of UA was not identified as an independent predictor of MACCE (hazard ratio 0.94; 95% confidence interval 0.41 to 2.12; p = 0.88). These findings remained consistent after increasing the CK/CK-myocardial band threshold to define periprocedural myocardial infarction up to at least 3 or 5 times the upper limit of normal.

CONCLUSIONS

In ARTS II, an unstable clinical presentation did not exert a negative impact on short- and mid-term outcome after SES implantation for multivessel disease. (ARTS II Trial; ; NCT00235170).

Safety and efficacy with drug-eluting stent in ST-segment elevation and non-ST-segment elevation myocardial infarction

BACKGROUND

Drug-eluting stents (DES) have been shown to reduce the need for repeat revascularization compared with bare metal stents (BMS). However, there is little information regarding the safety and long-term efficacy of DES in patients with acute myocardial infarction (AMI).

HYPOTHESIS

The aim of this study was to evaluate the safety and efficacy of DES in patients with AMI.

METHODS

Data from 211 consecutive patients with AMI treated with DES were compared with those from 228 consecutive patients with AMI treated with BMS. All patients were treated within 7 days of symptom onset. The incidence of major adverse cardiovascular events ([MACE]: death, reinfarction, and target vessel revascularization) was evaluated at 30 days and 1 year.

RESULTS

Baseline clinical and angiographic characteristics were similar for both stent groups. However, patients who received DES had longer lesion lengths (23.0 +/- 12.7 vs. 18.8 +/- 10.6 mm, respectively; p < 0.001) and smaller reference diameters (2.97 +/- 0.52 vs. 3.19 +/- 0.63 mm, respectively, p < 0.001). At 30 days, the incidence rates of MACE (DES vs. BMS: 2.2 vs. 1.9%, p = 1.000) and stent thrombosis (BMS vs. DES: 0.9 vs. 1.7%; p = 0.434) did not differ significantly between the groups. At 1 year, patients with DES had a lower rate of MACE (BMS vs. DES: 14.0 vs. 6.6%; p = 0.011) primarily due to a lower target vessel revascularization rate (BMS vs. DES: 9.6 vs. 4.8%; p = 0.028).

CONCLUSIONS

The DES appear to be superior to the BMS in reducing the risk of MACE in patients with AMI.

Outcomes with the paclitaxel-eluting stent in patients with acute coronary syndromes

OBJECTIVES

We sought to investigate the outcomes of paclitaxel-eluting stent implantation in patients with unstable angina or non-ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention (PCI).

BACKGROUND

Whether the paclitaxel-eluting stent is safe and effective in patients with acute coronary syndromes (ACS) is unknown.

METHODS

In the TAXUS-IV trial, 1,314 patients with stable or unstable ischemic syndromes undergoing PCI were randomized to treatment with either the slow-release, polymer-based, paclitaxel-eluting TAXUS stent or a bare-metal EXPRESS stent (Boston Scientific Corp., Natick, Massachusetts). The results were stratified by the acuity of the presenting clinical syndrome.

RESULTS

Acute coronary syndromes were present in 450 patients (34.2%), 237 of whom were assigned to paclitaxel-eluting stents and 213 to bare-metal stents. The baseline and procedural characteristics were well matched between the groups. Clinical outcomes at 30 days were similar with both stents. At one-year follow-up, patients with ACS assigned to the paclitaxel-eluting stent compared to the control stent had strikingly lower rates of target lesion revascularization (TLR) (3.9% vs. 16.0%, p < 0.0001) and major adverse cardiac events (11.1 vs. 21.7%, p = 0.002). By multivariate analysis, ACS was an independent predictor of in-stent restenosis in the cohort treated with bare-metal stents (hazard ratio [HR] = 2.03 [95% confidence interval (CI) 1.05 to 3.92], p = 0.035), while among patients randomized to the paclitaxel-eluting stents, ACS was an independent predictor of freedom from restenosis (HR = 0.27 [95% CI 0.08 to 0.97], p = 0.04).

CONCLUSIONS

The use of the paclitaxel-eluting TAXUS stent was safe in patients with unstable ischemic syndromes, and was associated with marked reduction of ischemia-driven TLR and adverse cardiac events at one year.

[Prognostic role of systemic hypertension and diabetes mellitus in patients with unstable angina undergoing coronary stenting]

BACKGROUND AND OBJECTIVES

The adverse effects of systemic hypertension and diabetes mellitus in coronary patients are well known, although their long-term prognostic influence on patients with unstable angina (UA) undergoing percutaneous coronary intervention (PCI) with coronary stenting is uncertain. The aim of this study was to determine the influence of these pathologies in this population at 3-year follow-up.

PATIENTS AND METHOD

We studied 279 consecutive patients with UA who underwent coronary stenting. 129 (46.2%) of them had hypertension and 60 (24.7%) had diabetes. Clinical follow-up was obtained in 92.14% after 3 years.

RESULTS

Although the need for new PCI at the target lesion was higher for patients with hypertension and diabetes (12.1 vs 8.4%; p=0.31, and 14.5 vs 8.6%; p=0.16, respectively), the differences were not significant with respect to the control groups. Multivariate analysis showed hypertension (OR=4.71; CI 95%, 1.01-42.2; p=0.04) and ejection fraction (OR=0.95; CI 95%, 0.91-0.99; p=0.03) to be predictors of mortality, and diabetes to be a predictor of myocardial infarction and infarction resulting in death (OR=3.01; CI 95%, 1.13-8.02; p=0.02, and OR=2.68; CI 95%, 1.03-6.95; p=0.04, respectively).

CONCLUSIONS

Hypertension was the only independent long-term predictor of mortality in our series of patients with UA who underwent coronary stenting. Diabetes was the only predictor of myocardial infarction or for the combined event of infarction and death. Risk of myocardial infarction was threefold as high in this diabetic patient population, and was the main cause of mortality.