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Lee DH, Oh S, Kim MC, Sim DS, Hong YJ, Kim JH, Ahn Y, Han JB, Kim IS, Jeong MH. Comparative treatment outcomes of a single long stent vs. overlapped short stents in acute myocardial infarction. Front Cardiovasc Med 2023; 10:1284396. [PMID: 38179505 PMCID: PMC10766367 DOI: 10.3389/fcvm.2023.1284396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/29/2023] [Indexed: 01/06/2024] Open
Abstract
Objectives There is no consensus regarding the optimal choice between single long stent (SLS) and overlapped double short stents (DSS) in patients with acute myocardial infarction (AMI). Therefore, we aimed to compare treatment outcomes among patients with AMI treated with these two different stenting methods. Methods In total, 537 patients with AMI from a single tertiary center were categorized into two groups: (1) those who received an SLS (stent length ≥38 mm) (n = 254; 47.3%) and (2) those who received overlapped DSS (individual stent lengths <38 mm) (n = 283; 52.7%). The primary outcome was the incidence of major adverse cardiac and cerebrovascular events (MACCEs) within 1 year. Results The mean age of participants was 65.4 years, and 75.0% were male. Patients receiving an SLS had a higher rate of serum creatinine level ≥1.5 mg/dl (16.3% vs. 8.9%, p = 0.009) but a lower rate of hypertension (46.8% vs. 55.8%, p = 0.038), lesser total stent length (38.26 ± 1.31 vs. 45.20 ± 9.25 mm, p < 0.001), total procedure time (41.40 ± 15.74 vs. 53.31 ± 21.75 min, p < 0.001) and total contrast volume (134.13 ± 30.72 vs. 160.57 ± 39.77 ml, p < 0.001) than in those receiving DSS. One-year MACCEs were comparable between the two groups before [hazard ratio (HR), 1.33; 95% confidence interval (CI), 0.80-2.24] and after adjusting for covariates (HR, 1.21; 95% CI, 0.67-2.19). Conclusions Stenting with an SLS demonstrated similar outcomes compared to those achieved when using stenting with overlapped DSS in patients with AMI. Therefore, if the deliverability is acceptable, stenting with an SLS appears to be a safe and effective strategy for AMI treatment.
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Affiliation(s)
- Doo Hwan Lee
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- The Cardiovascular Convergence Research Center of Chonnam National University Hospital Nominated by Korea Ministry for Health and Welfare, Gwangju, Republic of Korea
- Department of Radiological Science, Dongshin University, Naju, Republic of Korea
| | - Seok Oh
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- The Cardiovascular Convergence Research Center of Chonnam National University Hospital Nominated by Korea Ministry for Health and Welfare, Gwangju, Republic of Korea
| | - Min Chul Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- The Cardiovascular Convergence Research Center of Chonnam National University Hospital Nominated by Korea Ministry for Health and Welfare, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Doo Sun Sim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- The Cardiovascular Convergence Research Center of Chonnam National University Hospital Nominated by Korea Ministry for Health and Welfare, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Young Joon Hong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- The Cardiovascular Convergence Research Center of Chonnam National University Hospital Nominated by Korea Ministry for Health and Welfare, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Ju Han Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- The Cardiovascular Convergence Research Center of Chonnam National University Hospital Nominated by Korea Ministry for Health and Welfare, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- The Cardiovascular Convergence Research Center of Chonnam National University Hospital Nominated by Korea Ministry for Health and Welfare, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
| | - Jae Bok Han
- Department of Radiological Science, Dongshin University, Naju, Republic of Korea
| | - In Soo Kim
- Department of Radiological Science, Dongshin University, Naju, Republic of Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Republic of Korea
- The Cardiovascular Convergence Research Center of Chonnam National University Hospital Nominated by Korea Ministry for Health and Welfare, Gwangju, Republic of Korea
- Department of Cardiology, Chonnam National University Medical School, Hwasun, Republic of Korea
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Sang H, Huang J, Jiang B, Guo Q, Nguyen TN, Abdalkader M, Han Q, Zhou S, Tao Z, Mao A, Yan Z, Du J, Jin Y, Huang C, Liu T, Zhao W, Gu G, Wang L, Liu S, Luo S, Pu J, Hu J, Yang J, Li F, Zi W, Hu X, Qiu Z. Association between intravenous tirofiban and intracranial hemorrhage in acute large vessel occlusion stroke: insight from the RESCUE BT randomized placebo-controlled trial. J Neurol 2023; 270:2246-2255. [PMID: 36697890 DOI: 10.1007/s00415-023-11579-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND The aim of this study is to investigate the association between intravenous tirofiban and symptomatic intracranial hemorrhage (SICH) in patients with acute ischemic stroke (AIS) secondary to large vessel occlusion (LVO) receiving endovascular thrombectomy (EVT) within 24 h of time last known well (LKW). METHODS Patients with AIS-LVO who were randomly assigned to receive intravenous tirofiban or placebo before EVT within 24 h of time LKW and had follow-up brain non-contrast computed tomography within 24 h after stopping tirofiban treatment were derived from "RESCUE BT": a multicenter, randomized, placebo-controlled, double-blind trial. All eligible patients were divided into SICH and NO-SICH groups. Subgroup analyses were performed to explore for heterogeneity. RESULTS Of 945 patients included in this cohort, there were 76 (8.0%) in the SICH group and 869 (92.0%) in the NO-SICH group. The incidence of SICH was not higher in patients receiving intravenous tirofiban compared with placebo (adjusted risk ratio (RR), 1.51; 95% confidence interval (CI), 0.97-2.36; P = 0.07). Subgroup analyses showed that age greater than 67-year-old (adjusted RR, 2.18; 95% CI 1.18-4.00), NIHSS greater than 16 (adjusted RR, 1.88; 95% CI 1.06-3.34), and cardioembolism (adjusted RR, 3.73; 95% CI 1.66-8.35) were associated with increased SICH risk. CONCLUSIONS In patients with acute large vessel occlusion stroke, intravenous tirofiban before EVT within 24 h of time from last known well is not associated with increased risk of SICH. Patients who are older, have more severe neurological deficits, or with cardioembolism are at higher risk of SICH with intravenous tirofiban. TRIAL REGISTRATION NUMBER URL: http://www.chictr.org.cn ; Unique identifier: ChiCTR-INR-17014167.
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Affiliation(s)
- Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Bingwu Jiang
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Qifeng Guo
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, 725 Albany St, Neurology 7Th Floor, Boston, MA, 02118, USA
- Department of Radiology, Boston Medical Center, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA, 02118, USA
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, FGH Building, 4th Floor, 820 Harrison Avenue, Boston, MA, 02118, USA
| | - Qin Han
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Simin Zhou
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Zhaojun Tao
- Department of Medical Engineering, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, 310007, China
| | - An Mao
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China
| | - Zhizhong Yan
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, 214000, China
| | - Jie Du
- Department of Neurology, Kaizhou District People's Hospital, Chongqing, 405400, China
| | - Ying Jin
- Department of Neurology, Songyuan Jilin Oilfield Hospital, 138000, Songyuan, China
| | - Chuming Huang
- Department of Neurology, Shantou Central Hospital, Shantou, 515000, China
| | - Tianzhu Liu
- Department of Neurology, Affiliated Hospital of Traditional Chinese Medicine of Southwest Medical University, Luzhou, 646000, China
| | - Wenlong Zhao
- Department of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, 350000, China
| | - Gangfeng Gu
- Department of Neurology, Ya'an People's Hospital, 625000, Ya'an, China
| | - Li Wang
- Department of Neurology, The Third People's Hospital of Zigong, Zigong, 643000, China
| | - Shugai Liu
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, 628000, China
| | - Shiwei Luo
- Department of Neurology, Jieyang People's Hospital, Jieyang, 522000, China
| | - Jie Pu
- Department of Neurology, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, 430000, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China
| | - Xiaogang Hu
- Department of Military Patient Management, The 904th Hospital of The People's Liberation Army, Wuxi, 214000, China.
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), 183 Xinqiao Main Street, Shapingba District, Chongqing, 400037, China.
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, No. 14, Lingyin Road, Xihu District, Hangzhou, 310007, China.
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Chen Q, Meng R, Wu D, Hu J, Tao Z, Xie D, Tian Y, Han Q, Fu Y, Zuo L, Zhang M, Dai W, Deng W, Huang X, Sang H, Feng X, Qiu Z, Wang T, Yuan J. Association of Intravenous Tirofiban with Functional Outcomes in Acute Ischemic Stroke Patients with Acute Basilar Artery Occlusion Receiving Endovascular Thrombectomy. Cerebrovasc Dis 2022; 52:451-459. [PMID: 36481613 PMCID: PMC10568592 DOI: 10.1159/000527483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/05/2022] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION The aim of this study was to test the hypothesis that intravenous tirofiban improves functional outcomes without promoting the risk of intracranial hemorrhage (ICH) in stroke secondary to basilar artery occlusion (BAO) receiving endovascular thrombectomy. METHODS Patients with acute BAO stroke who were treated with endovascular thrombectomy and had tirofiban treatment information were derived from "BASILAR": a nationwide, prospective registry. All eligible patients were divided into tirofiban and no-tirofiban groups according to whether tirofiban was used intravenously. The primary endpoint was the 90-day severity of disability as assessed by the modified Rankin scale score. Safety outcomes were the frequency of ICH and mortality. RESULTS Of 645 patients included in this cohort, 363 were in the tirofiban group and 282 were in the no-tirofiban group. Thrombectomy with intravenous tirofiban reduced the 90-day disability level over the range of the modified Rankin scale (adjusted common odds ratio, 2.08; 95% confidence interval (CI), 1.45-2.97; p < 0.001). The 90-day mortality of patients in the tirofiban group was lower than that in the no-tirofiban group (41.6% vs. 52.1%; adjusted hazard ratio, 0.60; 95% CI, 0.47-0.77; p < 0.001). The frequency of any ICH (6.7% vs. 13.7%; p = 0.004) and symptomatic ICH (4.8% vs. 10.1%; p = 0.01) in the tirofiban group was significantly lower than that in the no-tirofiban group. CONCLUSIONS In patients with acute BAO stroke who underwent endovascular treatment, intravenous tirofiban might be associated with favorable outcome, reduced mortality, and a decreased frequency of ICH.
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Affiliation(s)
- Qiong Chen
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Guangyang Bay Laboratory, Chongqing Institute for Brain and Intelligence, Chongqing, China
| | - Renliang Meng
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Deping Wu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Huaian Medical District of Jingling Hospital, Medical School of Nanjing University, Huaian, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhaojun Tao
- Department of Medical Engineering, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yan Tian
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qin Han
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Yuan Fu
- Department of Second Outpatient, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Ling Zuo
- Central Sterile Supply Department, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Min Zhang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Weipeng Dai
- Department of Neurology, Jiangmen Central Hospital, Jiangmen, China
| | - Wei Deng
- Department of Neurology, Xiangyang No.1 People’s Hospital, Hubei University of Medicine, Xiangyang, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xinggang Feng
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Tao Wang
- Department of Neurology, The First Affiliated Hospital of Anhui University of Science and Technology (Huainan First People’s Hospital), Huainan, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Department of Neurology, The 925th Hospital of The Chinese People’s Liberation Army, Guiyang, China
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Qiu Z, Li F, Sang H, Luo W, Liu S, Liu W, Guo Z, Li H, Sun D, Huang W, Zhang M, Zhang M, Dai W, Zhou P, Deng W, Zhou Z, Huang X, Lei B, Li J, Yuan Z, Song B, Miao J, Liu S, Jin Z, Zeng G, Zeng H, Yuan J, Wen C, Yu Y, Yuan G, Wu J, Long C, Luo J, Tian Z, Zheng C, Hu Z, Wang S, Wang T, Qi L, Li R, Wan Y, Ke Y, Wu Y, Zhu X, Kong W, Huang J, Peng D, Chang M, Ge H, Shi Z, Yan Z, Du J, Jin Y, Ju D, Huang C, Hong Y, Liu T, Zhao W, Wang J, Zheng B, Wang L, Liu S, Luo X, Luo S, Xu X, Hu J, Pu J, Chen S, Sun Y, Jiang S, Wei L, Fu X, Bai Y, Yang S, Hu W, Zhang G, Pan C, Zhang S, Wang Y, Cao W, Yang S, Zhang J, Guo F, Wen H, Zhang J, Song J, Yue C, Li L, Wu D, Tian Y, Yang J, Lu M, Saver JL, Nogueira RG, Zi W, Yang Q. Effect of Intravenous Tirofiban vs Placebo Before Endovascular Thrombectomy on Functional Outcomes in Large Vessel Occlusion Stroke: The RESCUE BT Randomized Clinical Trial. JAMA 2022; 328:543-553. [PMID: 35943471 PMCID: PMC9364124 DOI: 10.1001/jama.2022.12584] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Tirofiban is a highly selective nonpeptide antagonist of glycoprotein IIb/IIIa receptor, which reversibly inhibits platelet aggregation. It remains uncertain whether intravenous tirofiban is effective to improve functional outcomes for patients with large vessel occlusion ischemic stroke undergoing endovascular thrombectomy. OBJECTIVE To assess the efficacy and adverse events of intravenous tirofiban before endovascular thrombectomy for acute ischemic stroke secondary to large vessel occlusion. DESIGN, SETTING, AND PARTICIPANTS This investigator-initiated, randomized, double-blind, placebo-controlled trial was implemented at 55 hospitals in China, enrolling 948 patients with stroke and proximal intracranial large vessel occlusion presenting within 24 hours of time last known well. Recruitment took place between October 10, 2018, and October 31, 2021, with final follow-up on January 15, 2022. INTERVENTIONS Participants received intravenous tirofiban (n = 463) or placebo (n = 485) prior to endovascular thrombectomy. MAIN OUTCOMES AND MEASURES The primary outcome was disability level at 90 days as measured by overall distribution of the modified Rankin Scale scores from 0 (no symptoms) to 6 (death). The primary safety outcome was the incidence of symptomatic intracranial hemorrhage within 48 hours. RESULTS Among 948 patients randomized (mean age, 67 years; 391 [41.2%] women), 948 (100%) completed the trial. The median (IQR) 90-day modified Rankin Scale score in the tirofiban group vs placebo group was 3 (1-4) vs 3 (1-4). The adjusted common odds ratio for a lower level of disability with tirofiban vs placebo was 1.08 (95% CI, 0.86-1.36). Incidence of symptomatic intracranial hemorrhage was 9.7% in the tirofiban group vs 6.4% in the placebo group (difference, 3.3% [95% CI, -0.2% to 6.8%]). CONCLUSIONS AND RELEVANCE Among patients with large vessel occlusion acute ischemic stroke undergoing endovascular thrombectomy, treatment with intravenous tirofiban, compared with placebo, before endovascular therapy resulted in no significant difference in disability severity at 90 days. The findings do not support use of intravenous tirofiban before endovascular thrombectomy for acute ischemic stroke. TRIAL REGISTRATION Chinese Clinical Trial Registry Identifier: ChiCTR-IOR-17014167.
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Affiliation(s)
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Hongfei Sang
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
- Department of Cardiovascular diseases, The General Hospital of Tibet Military Area Command, Lhasa, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Wenhua Liu
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Zhangbao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Huagang Li
- Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Dong Sun
- Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Wenguo Huang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Min Zhang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Min Zhang
- Department of Neurology, Jiangmen Central Hospital, Jiangmen, China
| | - Weipeng Dai
- Department of Neurology, Jiangmen Central Hospital, Jiangmen, China
| | - Peiyang Zhou
- Department of Neurology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Wei Deng
- Department of Neurology, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, Xiangyang, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Bo Lei
- Department of Cerebrovascular Diseases, Leshan People's Hospital, Leshan, China
| | - Jinglun Li
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Zhengzhou Yuan
- Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Bo Song
- Department of Neurosurgery, Xianyang Hospital of Yan'an University, Xianyang, China
| | - Jian Miao
- Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang, China
| | - Shudong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan, China
| | - Zhenglong Jin
- Department of Neurology, Wuyi Hospital of Traditional Chinese Medicine, Jiangmen, China
| | - Guoyong Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Hongliang Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Yang Yu
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Junxiong Wu
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Chen Long
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Jun Luo
- Department of Neurology, Sichuan Mianyang 404 Hospital, Mianyang, China
| | - Zhenxuan Tian
- Department of Neurology, Sichuan Mianyang 404 Hospital, Mianyang, China
| | - Chong Zheng
- Department of Neurology, Longyan First Affliated Hospital of Fujian Medical University, Longyan, China
| | - Zhizhou Hu
- Department of Neurology, Longyan First Affliated Hospital of Fujian Medical University, Longyan, China
| | - Shouchun Wang
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China
| | - Tao Wang
- Department of Neurology, Huainan First People's Hospital, Huainan, China
| | - Li Qi
- Department of Neurology, The 924th Hospital of The People's Liberation Army, Guilin, China
| | - Rongzong Li
- Department of Neurology, The 924th Hospital of The People's Liberation Army, Guilin, China
| | - Yue Wan
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Yingbing Ke
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Youlin Wu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Xiurong Zhu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Daizhou Peng
- Department of Neurology, Qianxinan People's Hospital, Xingyi, China
| | - Mingze Chang
- Department of Neurology, Xi'an Third Hospital, Xi'an, China
| | - Hanming Ge
- Department of Neurology, Xi'an Third Hospital, Xi'an, China
| | - Zhonghua Shi
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, China
| | - Zhizhong Yan
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, China
| | - Jie Du
- Department of Neurology, Kaizhou District People's Hospital, Kaizhou, China
| | - Ying Jin
- Department of Neurology, Songyuan Jilin Oilfield Hospital, Songyuan, China
| | - Dongsheng Ju
- Department of Neurology, Songyuan Jilin Oilfield Hospital, Songyuan, China
| | - Chuming Huang
- Department of Neurology, Shantou Central Hospital, Shantou, China
| | - Yifan Hong
- Department of Neurology, Shantou Central Hospital, Shantou, China
| | - Tianzhu Liu
- Department of Neurology, Affiliated Hospital of Traditional Chinese Medicine of Southwest Medical University, Luzhou, China
| | - Wenlong Zhao
- Department of Neurology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jian Wang
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Bo Zheng
- Department of Neurology, Ya'an People's Hospital, Ya'an, China
| | - Li Wang
- Department of Neurology, The Third People's Hospital of Zigong, Zigong, China
| | - Shugai Liu
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China
| | - Xiaojun Luo
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China
| | - Shiwei Luo
- Department of Neurology, Jieyang People's Hospital, Jieyang, China
| | - Xinwei Xu
- Department of Neurology, Jieyang People's Hospital, Jieyang, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Jie Pu
- Department of Neurology, Hubei Provincial Hospital of Traditional Chinese Medicine, Wuhan, China
- Department of Neurology, People's Hospital of Wuhan University, Hubei General Hospital, Wuhan, China
| | - Shengli Chen
- Department of Neurology, Chongqing University Three Gorges Central Hospital, Wanzhou, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Shunfu Jiang
- Department of Neurology, Jingdezhen First People's Hospital, Jingdezhen, China
| | - Liping Wei
- Department of Neurointervention, Luoyang Central Hospital, Luoyang, China
| | - Xinmin Fu
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, China
| | - Yongjie Bai
- Department of Neurology, The First Affiliated Hospital of Henan Science and Technology University, Luoyang, China
| | - Shunyu Yang
- Department of Neurology, The First People's Hospital of Yunnan Province, Kunming, China
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Guling Zhang
- Department of Neurology, Danzhai County People's Hospital, Danzhai, China
| | - Chengde Pan
- Department of Neurology, Banan District People's Hospital, Banan, China
| | - Shuai Zhang
- Department of Neurology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yan Wang
- Department of Neurology, The Fifth People's Hospital of Chengdu, Chengdu, China
| | - Wenfeng Cao
- Department of Neurology, Jiangxi Provincial People's Hospital, Nanchang, China
| | - Shiquan Yang
- Department of Neurology, The 902nd Hospital of The People's Liberation Army, Bengbu, China
| | - Jun Zhang
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Fuqiang Guo
- Department of Neurology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Hongbin Wen
- Department of Neurology, Xiangyang Central Hospital, Hubei Arts and Science University, Xiangyang, China
| | - Jinhua Zhang
- Department of Neurology, Sir Run Run Shaw Hospital affiliated to Zhejiang University, Hangzhou, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Deping Wu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Yan Tian
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Mengjie Lu
- School of Public Health, Shanghai JiaoTong University School of Medicine, Shanghai, China
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Centre, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing 400037, China
- Chongqing Institute for Brain and Intelligence, Guangyang Bay Laboratory, Chongqing 400064, China
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5
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The quest for effective pharmacological suppression of neointimal hyperplasia. Curr Probl Surg 2020; 57:100807. [PMID: 32771085 DOI: 10.1016/j.cpsurg.2020.100807] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/22/2020] [Indexed: 12/15/2022]
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6
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Yang M, Huo X, Miao Z, Wang Y. Platelet Glycoprotein IIb/IIIa Receptor Inhibitor Tirofiban in Acute Ischemic Stroke. Drugs 2019; 79:515-529. [PMID: 30838514 DOI: 10.1007/s40265-019-01078-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Tirofiban is a non-peptide selective glycoprotein (GP) IIb/IIIa receptor inhibitor that reversibly inhibits fibrinogen-dependent platelet aggregation and subsequent formation of thrombi, which contribute to the major atherosclerotic complications in the development, progression, and resolution of ischemic stroke. The adjunctive use of tirofiban has been extensively evaluated in progressive stroke, combined intravenous thrombolysis (IVT), and endovascular treatment (EVT) in both preclinical and clinical studies. A body of evidence has been accumulated on the risks and benefits associated with tirofiban in terms of prevention of stroke progression, stent thrombosis, improvement in functional independence, and mortality, especially among high-risk ischemic stroke patients as a further strategy alongside conventional treatment. In general, tirofiban has a favorable tolerability and efficacy profile in the improvement of vascular recanalization and long-term functional outcome, although the optimum dosage, application setting, and precise target patients are not yet well-established. However, its specific inhibition of ongoing platelet aggregation and thrombus formation rather than absolute thrombolysis suggests that tirofiban, one of the most widely used GP IIb/IIIa inhibitors, with high affinity and a short plasma/biologic half-life, may have great potential in the acute treatment of ischemic stroke. Substantial practical progress is likely as our understanding of the mechanism of action and pharmacological actions of tirofiban in atherosclerotic ischemic disease improves. Therefore, we classify and summarize the available findings regarding tirofiban in acute ischemic stroke to stimulate and guide further research and clinical practice.
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Affiliation(s)
- Ming Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 119 Nan Sihuan West Road, Fengtai District, Beijing, 100160, People's Republic of China.,Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
| | - Xiaochuan Huo
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
| | - Zhongrong Miao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, No. 119 Nan Sihuan West Road, Fengtai District, Beijing, 100160, People's Republic of China. .,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China. .,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, People's Republic of China.
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7
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Yong CM, Sundaram V, Abnousi F, Olivier CB, Yang J, Stone GW, Steg PG, Michael Gibson C, Hamm CW, Price MJ, Deliargyris EN, Prats J, White HD, Harrington RA, Bhatt DL, Mahaffey KW. The efficacy and safety of cangrelor in single vessel vs multivessel percutaneous coronary intervention: Insights from CHAMPION PHOENIX. Clin Cardiol 2019; 42:797-805. [PMID: 31254472 PMCID: PMC6727881 DOI: 10.1002/clc.23221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/18/2019] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND The intravenous, rapidly acting P2Y12 inhibitor cangrelor reduces the rate of ischemic events during PCI with no significant increase in severe bleeding. However, the efficacy and safety of cangrelor compared with clopidogrel in patients treated with single vessel (SV)-percutaneous coronary intervention (PCI) or multivessel (MV)-PCI remains unexplored. METHODS We studied the modified intention-to-treat population of patients from the CHAMPION PHOENIX trial who were randomized to either cangrelor or clopidogrel. We used logistic regression and propensity score matching to evaluate the effect of cangrelor compared with clopidogrel on the primary efficacy outcome (composite of death, myocardial infarction, ischemia-driven revascularization, or stent thrombosis) at 48 hours. The safety outcome was moderate or severe Global Utilization of Streptokinase and tPA for Occluded Arteries bleeding at 48 hours. HYPOTHESIS Cangrelor is as efficacious and safe as clopidogrel in both SV and MV PCI. RESULTS Among 10 854 patients, 9204 (85%) underwent SV- and 1650 (15%) MV-PCI. After adjustment, cangrelor was associated with similar reductions vs clopidogrel in the primary efficacy outcome in patients undergoing SV-PCI (4.5% vs 5.2%; odds ratio [OR] 0.81 [0.66-0.98]) or MV-PCI (6.1% vs 9.8%, OR 0.59 [0.41-0.85]; Pint 0.14). Similar results were observed after propensity score matching (SV-PCI: 5.5% vs 5.9%, OR 0.93 [0.74-1.18]; MV-PCI: 6.2% vs 8.9%, OR 0.67 [0.44-1.01]; Pint 0.17). There was no evidence of heterogeneity in the treatment effect of cangrelor compared with clopidogrel for the safety outcome. CONCLUSIONS In patients undergoing SV- or MV-PCI, cangrelor was associated with similar relative risk reductions in ischemic complications and no increased risk of significant bleeding compared with clopidogrel, which highlights the expanding repertoire of options for use in complex PCI.
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Affiliation(s)
- Celina M. Yong
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare SystemPalo AltoCalifornia,Division of Cardiovascular MedicineStanford University School of MedicineStanfordCalifornia
| | - Vandana Sundaram
- Quantitative Sciences Unit, Department of MedicineStanford University School of MedicineStanfordCalifornia
| | - Freddy Abnousi
- Division of Cardiology, Veterans Affairs Palo Alto Healthcare SystemPalo AltoCalifornia
| | - Christoph B. Olivier
- Stanford Center for Clinical Research (SCCR)Department of Medicine, Stanford University School of MedicineStanfordCalifornia,Department of Cardiology and Angiology IHeart Center Freiburg University, Faculty of Medicine, University of FreiburgFreiburgGermany
| | - Jaden Yang
- Quantitative Sciences Unit, Department of MedicineStanford University School of MedicineStanfordCalifornia
| | - Gregg W. Stone
- Cardiovascular Research FoundationColumbia University Medical CenterNew YorkNew York
| | - Philippe G. Steg
- DHU (Département Hospitalo‐Universitaire)‐FIRE (Fibrosis, Inflammation, REmodelling), Hôpital Bichat, AP‐HPb (Assistance Publique‐Hôpitaux de Paris)Université Paris‐Diderot, Sorbonne‐Paris Cité, and FACT (French Alliance for Cardiovascular clinical Trials), an F‐CRIN network, INSERM U‐1148ParisFrance,NLHI, ICMSRoyal Brompton Hospital, Imperial CollegeLondonUK
| | - C. Michael Gibson
- Beth Israel Deaconess Medical Center, Division of CardiologyHarvard Medical School, BostonBostonMassachusetts
| | | | - Matthew J. Price
- Scripps Clinic and Scripps Translational Science InstituteLa JollaCalifornia
| | | | | | - Harvey D. White
- Auckland City HospitalUniversity of AucklandAucklandNew Zealand
| | - Robert A. Harrington
- Stanford Center for Clinical Research (SCCR)Department of Medicine, Stanford University School of MedicineStanfordCalifornia
| | - Deepak L. Bhatt
- Brigham and Women's Hospital Heart & Vascular CenterHarvard Medical SchoolBostonMassachusetts
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research (SCCR)Department of Medicine, Stanford University School of MedicineStanfordCalifornia
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8
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Kretzschmar D, Jung C, Otto S, Utschig S, Hartmann M, Lehmann T, Yilmaz A, Pörner TC, Figulla HR, Ferrari M. Detection of coronary microembolization by Doppler ultrasound in patients with stable angina pectoris during percutaneous coronary interventions under an adjunctive antithrombotic therapy with abciximab: design and rationale of the High Intensity Transient Signals ReoPro (HITS-RP) study. Cardiovasc Ultrasound 2012; 10:21. [PMID: 22613136 PMCID: PMC3407765 DOI: 10.1186/1476-7120-10-21] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2012] [Accepted: 05/21/2012] [Indexed: 12/23/2022] Open
Abstract
Background Embolization of atherosclerotic debris from the rupture of a vulnerable atherosclerotic plaque occurs iatrogenically during percutaneous coronary interventions (PCI) and can induce myocardial necrosis. These microembolizations are detected as high intensity transient signals (HITS) using intracoronary Doppler technology. Presentation of the hypothesis In the presented study we will test if abciximab (ReoPro®) infusion reduces high intensity transient signals in patients with stable angina pectoris undergoing PCI in comparison to standard therapy alone. Testing the hypothesis The High Intensity Transient Signals ReoPro® (HITS-RP) study will enroll 60 patients. It is a prospective, single center, randomized, double-blinded, controlled trial. The study is designed to compare the efficacy of intravenous abciximab administration for reduction of microembolization during elective PCI. Patients will be randomized in a 1:1 fashion to abciximab or placebo infusion. The primary end point of the HITS-RP-Study is the number of HITS during PCI measured by intracoronary Doppler wire. Secondary endpoints are bleeding complications, elevation of cardiac biomarkers or ECG changes after percutaneous coronary interventions, changes in coronary flow velocity reserve, hs-CRP elevation, any major adverse cardio-vascular event during one month follow-up. Implications of the hypothesis The HITS-RP-Study addresses important questions regarding the efficacy of intravenous abciximab administration in reducing microembolization and periprocedural complications in stable angina pectoris patients undergoing PCI. Trial registration The trial is registered under http://www.drks-neu.uniklinik-freiburg.de/drks_web/:DRKS00000603.
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Affiliation(s)
- Daniel Kretzschmar
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, Erlanger Allee 101, D-07740, Jena, Germany.
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9
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Clopidogrel use before renal artery angioplasty with/without stent placement resulted in tertiary procedure risk reduction. J Vasc Surg 2012; 56:416-23. [PMID: 22560231 DOI: 10.1016/j.jvs.2012.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Revised: 12/12/2011] [Accepted: 01/06/2012] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Contrary to coronary artery literature, the effect of preprocedural clopidogrel on renal artery restenosis (RAR) has not been characterized. This study was designed to evaluate the effect of preprocedural clopidogrel on target vessel revascularization (TVR), reintervention, and restenosis for patients who underwent recurrent renal artery angioplasty. METHODS A retrospective analysis of patients treated for RAR in a single tertiary center from January 1999 to December 2009 was conducted. Patients were divided into preadmission use of (1) clopidogrel or (2) aspirin only (acetylsalicylic acid [ASA]) for the initial procedure. TVR was defined as occurrence of a tertiary procedure for symptomatic RAR. Rate of freedom from event (ie, tertiary restenosis and TVR) was analyzed using Kaplan-Meier method. RESULTS Eighty-eight interventions were performed on 77 patients with RAR; 66% were females with average (mean ± SEM) age and body mass index of 68.8 ± 1.1 and 28.6 ± 0.8, respectively. Comorbidities included 96% chronic hypertension, 33% diabetes, 76% hyperlipidemia, 20% renal insufficiency, 39% tobacco use, 58% coronary artery disease, and 51% peripheral vascular disease. Clopidogrel use increased significantly during the index procedure from admission 35.2% to discharge 97.7% (P < .001, McNemar test). There was a trend toward risk reduction of a tertiary intervention (23%) for patients admitted on clopidogrel compared with ASA (P = .052). Likewise, there was a trend (P = .051) toward increased freedom from a tertiary intervention, with cumulative freedom at 8 years 93.5% for clopidogrel vs 61% for ASA. No differences were found for restenosis. CONCLUSIONS The use of preprocedural clopidogrel was associated with a possible risk reduction of TVR reintervention, but this finding needs to be validated in randomized clinical trial.
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10
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Usefulness of transient and persistent no reflow to predict adverse clinical outcomes following percutaneous coronary intervention. Am J Cardiol 2012; 109:478-85. [PMID: 22176999 DOI: 10.1016/j.amjcard.2011.09.037] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 09/30/2011] [Accepted: 09/30/2011] [Indexed: 11/20/2022]
Abstract
The no reflow phenomenon is reported to occur in >2% of all percutaneous coronary interventions (PCIs) and portends a poor prognosis. We analyzed data from 5,286 consecutive patients who underwent PCI from the Melbourne Interventional Group (MIG) registry from April 2004 through January 2008 who had 30-day follow-up completed. Patients without no reflow (normal reflow, n = 5,031) were compared to 255 (4.8%) with no reflow (n = 217 for transient no reflow, n = 38 for persistent no reflow). Patients with transient or persistent no reflow were more likely to present with ST-elevation myocardial infarction (MI) or cardiogenic shock (p <0.0001 for the 2 comparisons). They were also more likely to have complex lesions (American College of Cardiology/American Heart Association type B2/C), have lesions within a bypass graft, require an intra-aortic balloon pump, receive glycoprotein IIb/IIIa inhibition, and have a longer mean stent length (p <0.0001 for all comparisons). In-hospital outcomes were significantly worse in those patients with transient or persistent no reflow, with increased death, periprocedural MI, renal impairment, and major adverse cardiac events (p <0.0001 for all comparisons). Similarly, transient and persistent no reflow portended worse 30-day clinical outcomes, with a progressive increase in mortality (normal reflow 1.7% vs transient no reflow 5.5% vs persistent no reflow 13.2%, p <0.0001), MI, target vessel revascularization, and major adverse cardiac events (p <0.0001 for all comparisons) compared to patients with normal flow. In conclusion, transient or persistent no reflow complicates approximately 1 in 20 PCIs and results in stepwise increases in in-hospital and 30-day adverse outcomes.
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11
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Kaluski E. The Role of Glycoprotein IIb/IIIa Inhibitors- A Promise Not Kept? Curr Cardiol Rev 2011; 4:84-91. [PMID: 19936282 PMCID: PMC2779356 DOI: 10.2174/157340308784245793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Revised: 05/17/2007] [Accepted: 05/30/2007] [Indexed: 11/22/2022] Open
Abstract
For over one decade Glycoproteins IIb/IIIa inhibitors (GPI) have been administered to prevent coronary artery thrombosis. Initially these agents were used for acute coronary syndromes and subsequently as adjunctive pharmacotherapy for percutaneous coronary interventions (PCIs). Most benefit of GPI emerged from reduction of ischemic events: mostly non-q-wave myocardial infarctions (NQWMIs) during PCI. However, individual randomized clinical trials could not demonstrate that any of these agents could significantly reduce mortality in any clinical subset of patients. Studies of employing prolonged oral GPI administration resulted in excessive death. The non-homogenous statistically-significant reduction of ischemic endpoints was accompanied by an excess of bleeding, vascular complications, and thrombocytopenia. The clinical and ecomomic burden of major bleeding and thrombocytopenia is substantial. The ACUITY trial has initiate a new debate regarding the efficacy and safety of GPI. Selective “patient-tailored” use of GPI limited to moderate-high risk PCI patients with low bleeding propensity is suggested. Research of new algorithms emphasizing abbreviated GPI administration, careful access site and bleeding surveillance, in conjunction with lower doses of unfractionated heparin or new and safer anti-thrombins may further enhance patient safety.
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Affiliation(s)
- Edo Kaluski
- Department of Cardiology, University Medical Center, University of Medicine and Dentistry, Newark, NJ, USA
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12
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Butler MJ, Chan W, Taylor AJ, Dart AM, Duffy SJ. Management of the no-reflow phenomenon. Pharmacol Ther 2011; 132:72-85. [PMID: 21664376 DOI: 10.1016/j.pharmthera.2011.05.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2011] [Accepted: 05/12/2011] [Indexed: 01/03/2023]
Abstract
The lack of reperfusion of myocardium after prolonged ischaemia that may occur despite opening of the infarct-related artery is termed "no reflow". No reflow or slow flow occurs in 3-4% of all percutaneous coronary interventions, and is most common after emergency revascularization for acute myocardial infarction. In this setting no reflow is reported to occur in 30% to 40% of interventions when defined by myocardial perfusion techniques such as myocardial contrast echocardiography. No reflow is clinically important as it is independently associated with increased occurrence of malignant arrhythmias, cardiac failure, as well as in-hospital and long-term mortality. Previously the no-reflow phenomenon has been difficult to treat effectively, but recent advances in the understanding of the pathophysiology of no reflow have led to several novel treatment strategies. These include prophylactic use of vasodilator therapies, mechanical devices, ischaemic postconditioning and potent platelet inhibitors. As no reflow is a multifactorial process, a combination of these treatments is more likely to be effective than any of these alone. In this review we discuss the pathophysiology of no reflow and present the numerous recent advances in therapy for this important clinical problem.
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Affiliation(s)
- Michelle J Butler
- Department of Cardiovascular Medicine, the Alfred Hospital, Melbourne, Australia
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13
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Heller E, Dangas GD. Heparin, LMWH, GIIb/IIIa, and Direct Thrombin Inhibitors. Interv Cardiol 2011. [DOI: 10.1002/9781444319446.ch9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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14
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Knauer K, Huber R. Fibrinolysis and Beyond: Bridging the Gap between Local and Systemic Clot Removal. Front Neurol 2011; 2:7. [PMID: 21373206 PMCID: PMC3044492 DOI: 10.3389/fneur.2011.00007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2010] [Accepted: 02/02/2011] [Indexed: 11/13/2022] Open
Abstract
Recanalization methods in ischemic stroke have been progressively expanded over the past years. In addition the continuous development of specialized mechanical devices for thrombectomy a broad spectrum of new drugs has been tested: Both options, novel drugs as well as new devices, can be employed independently of each other, but in most cases a combination of the two with the standard treatment of intravenous fibrinolysis is applied. Until recently, a large number of case series have been performed to investigate the effects of various drugs and interventions, but only a few trials have been conducted to determine the optimal conditions for combining both procedures. This review surveys the different systemic and endovascular vessel reopening practices and their major bridging techniques.
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Affiliation(s)
- K Knauer
- Department of Neurology, University of Ulm Ulm, Germany
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15
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Park SJ, Kim YH. Percutaneous coronary intervention for unprotected left main coronary artery stenosis. World J Cardiol 2010; 2:78-88. [PMID: 21160702 PMCID: PMC2998877 DOI: 10.4330/wjc.v2.i4.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2010] [Revised: 04/05/2010] [Accepted: 04/09/2010] [Indexed: 02/07/2023] Open
Abstract
Hemodynamically significant left main coronary artery stenosis (LMCA) is found in around 4% of diagnostic coronary angiograms and is known as unprotected LMCA stenosis if the left coronary artery and left circumflex artery has no previous patent grafts. Previous randomized studies have demonstrated a significant reduction in mortality when revascularization by coronary artery bypass graft (CABG) surgery was undertaken compared with medical treatment. Therefore, current practice guidelines do not recommend percutaneous coronary intervention (PCI) for such a lesion because of the proven benefit of surgery and high rates of restenosis with the use of bare metal stents. However, with the advent of drug-eluting stents (DES), the long term outcomes of PCI with DES to treat unprotected LMCA stenoses have been acceptable. Therefore, apart from the current guidelines, PCI for treatment of unprotected LMCA stenosis is often undertaken in individuals who are at a very high risk of CABG or refuse to undergo a sternotomy. Future randomized studies comparing CABG vs PCI using DES for treatment of unprotected LMCA stenosis would be a great advance in clinical knowledge for the adoption of appropriate treatment.
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Affiliation(s)
- Seung-Jung Park
- Seung-Jung Park, Young-Hak Kim, Cardiac Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul 138-736, South Korea
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16
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Park SJ, Kim YH. Percutaneous Coronary Intervention for Unprotected Left Main Coronary Artery Stenosis. Cardiol Clin 2010; 28:81-95. [DOI: 10.1016/j.ccl.2009.09.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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17
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Heusch G, Kleinbongard P, Böse D, Levkau B, Haude M, Schulz R, Erbel R. Coronary microembolization: from bedside to bench and back to bedside. Circulation 2009; 120:1822-36. [PMID: 19884481 DOI: 10.1161/circulationaha.109.888784] [Citation(s) in RCA: 321] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Coronary microembolization from the erosion or rupture of a vulnerable atherosclerotic plaque occurs spontaneously in acute coronary syndromes and iatrogenically during percutaneous coronary interventions. Typical consequences of coronary microembolization are microinfarcts with an inflammatory response, contractile dysfunction, and reduced coronary reserve. Apart from transient elevations of creatine kinase and troponin, microemboli can be visualized by intracoronary Doppler and the resulting microinfarcts by late-enhancement nuclear magnetic resonance. Statins, antiplatelet agents, and coronary vasodilators protect against microembolization and microinfarction when started before percutaneous coronary interventions. Distal protection devices can retrieve atherothrombotic debris and prevent its embolization into the microcirculation, but their effect on clinical outcome has been disappointing so far, except for saphenous vein bypass grafts. Devices for aspiration of thrombi and thrombus-derived vasoconstrictor, thrombogenic, and inflammatory substances, however, reduce thrombus burden, improve perfusion, and provide protection in patients with acute myocardial infarction.
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Affiliation(s)
- Gerd Heusch
- Institut für Pathophysiologie, Universitätsklinikum Essen, Essen, Germany.
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18
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Park SJ, Kim YH. Percutaneous coronary intervention for unprotected left main coronary artery stenosis. Interv Cardiol 2009. [DOI: 10.2217/ica.09.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Tan ES, Jessurun G, Deurholt W, van der Vleuten P, van den Heuvel A, Ebels T, Zijlstra F, Tio R. Differences between early, intermediate, and late angioplasty after coronary artery bypass grafting. Crit Pathw Cardiol 2008; 7:239-244. [PMID: 19050420 DOI: 10.1097/hpc.0b013e3181894550] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The aim of the present study was to identify patients with recurrent ischemia after coronary artery bypass surgery (CABG) treated by percutaneous coronary intervention (PCI). Graft failure after CABG may be managed conservatively or treated by surgery or PCI. We thought to investigate clinical, angiographic, and procedural characteristics in relation to clinical outcome. This was a retrospective single-center study. Patients who underwent revascularization by PCI with a previous CABG were analyzed. Patients were divided in 3 groups, depending on interval between CABG and index PCI: group 1, interval <72 hours; group 2, interval between 72 hours and 1 year; group 3, interval >1 year. Two hundred twenty-one patients were studied. Clinical characteristics and survival curves were comparable in groups 2 and 3. Postoperative creatine kinase MB and troponin values were significantly higher in group 1 (P = 0.000). From group 1, significantly more patients (10.5%) required emergency CABG after the index PCI than compared with group 2 (2.1%) and group 3 (0%), (P = 0.003). There were more off-pump CABGs in group 1 than in the other 2 groups. Group 1 received less PCIs in native ungrafted vessels compared with the other 2 groups. Mortality in group 1 (18.4%) was higher than in the other 2 groups (7.4 and 4.5%, respectively; P < 0.05). Mortality in group 1 was higher in the acute phase of follow-up. PCI performed less than 72 hours after CABG is feasible but accompanied by a higher mortality and redo CABG. This outcome is probably related to the high-risk patient category.
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Affiliation(s)
- Eng-Shiong Tan
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
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Mandava P, Thiagarajan P, Kent TA. Glycoprotein IIb/IIIa antagonists in acute ischaemic stroke: current status and future directions. Drugs 2008; 68:1019-28. [PMID: 18484795 DOI: 10.2165/00003495-200868080-00001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Glycoprotein (GP) IIb/IIIa receptors on the surface of platelets play a critical role in thrombosis. Intravenous GP IIb/IIIa antagonists abciximab, tirofiban and eptifibatide have demonstrated efficacy in acute coronary syndromes when combined with heparin, aspirin, clopidogrel and percutanous coronary interventions. Results have been less consistent in acute ischaemic stroke. Preclinical data support the potential benefit of these agents both in the microcirculation and in aiding clot lysis. While phase I and II trials of abciximab as the sole agent employing dosages comparable with those used in coronary syndromes were promising, the pivotal phase III trial was abandoned because of an unfavourable benefit-to-risk ratio. New preliminary platelet inhibition measurements from our group suggest that cardiac dosages were likely to be too high for stroke patients. Exploration of lower dosages of abciximab and potentiation with time-limited weight-based heparin along with platelet aggregation inhibition measurement is continuing on a smaller scale. At present, the most common usage of GP IIb/IIIa antagonists in stroke are as adjunctive agents to thrombolysis by intravenous and intra-arterial routes. Substantial progress is likely to require a better understanding of the mechanism of actions and unique pharmacology of GP IIb/IIIa antagonists in ischaemic stroke.
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Affiliation(s)
- Pitchaiah Mandava
- Michael E. DeBakey VA Medical Center and Department of Neurology, Baylor College of Medicine, Houston, Texas 77030, USA.
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Kaluski E, Haider B, Milo-Cotter O, Klapholz M. Glycoprotein IIb/IIIa inhibitors: questioning indications and treatment algorithms. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2007; 8:281-8. [PMID: 18053951 DOI: 10.1016/j.carrev.2007.03.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2007] [Accepted: 03/30/2007] [Indexed: 11/27/2022]
Abstract
Glycoprotein inhibitors (GPI) are viewed as beneficial adjunctive pharmacotherapy agents for percutaneous coronary interventions (PCIs). The major benefit of GPI is derived from the reduction of ischemic events (mostly non-Q-wave myocardial infarctions) during PCI. There is no single randomized clinical trial demonstrating that any of these agents significantly reduces mortality in any clinical subset of patients. Studies of sustained oral GPI resulted in excessive death and myocardial infarctions. Reduction of ischemic end points was counteracted by excessive bleeding, vascular complications, and thrombocytopenia. These complications bear considerable medical and economic impact. The Acute Catheterization and Early Intervention Triage Strategy trial demonstrated that GPI, when added to heparin, enoxaparine, or bivalirudin, do not reduce mortality or ischemic events but significantly increase bleeding complications. Major bleeding resulted in threefold mortality at 1 year. In view of available data, the use of GPI should be limited to moderate-risk to high-risk PCI patients with low bleeding propensity. Protocols of abbreviated GPI administration and careful bleeding surveillance, in conjunction with lower doses of unfractionated heparin or new and possibly safer antithrombins, can potentially improve patient safety.
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Affiliation(s)
- Edo Kaluski
- Department of Cardiology, University Medical Center, University of Medicine and Dentistry, Newark, NJ 07101, USA.
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Christov A, Korol RM, Dai E, Liu L, Guan H, Bernards MA, Cavers PB, Susko D, Lucas A. In Vivo Optical Analysis of Quantitative Changes in Collagen and Elastin During Arterial Remodeling¶. Photochem Photobiol 2007. [DOI: 10.1111/j.1751-1097.2005.tb00208.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
This article outlines the antiplatelet and antithrombotic therapy used in contemporary percutaneous coronary interventions. It is a comprehensive review of past and present pharmacologic agents and includes a discussion of the more promising potential future therapies. The clinical trials that provide the basis for the current standard of care are provided, as are ongoing trials that will likely shape the future standard. This article is not intended to provide a detailed discussion of precise mechanistic or structural features of each agent but to serve as a practical clinical guide to the interventionalist when choosing specific pharmacotherapies for specific patients in the catheterization laboratory.
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Affiliation(s)
- Nitin Barman
- Interventional Cardiology, Mount Sinai Hospital, One Gustave L. Levy Place, New York, NY 10029, USA
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Denvir MA, Lee AJ, Rysdale J, Prescott RJ, Eteiba H, Starkey IR, Pell JP, Walker A. Effects of changing clinical practice on costs and outcomes of percutaneous coronary intervention between 1998 and 2002. Heart 2006; 93:195-9. [PMID: 16849373 PMCID: PMC1861374 DOI: 10.1136/hrt.2006.090134] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
AIM To assess the effect of changing clinical practice on the costs and outcomes of percutaneous coronary intervention (PCI) between 1998 and 2002. SETTING Two tertiary interventional centres. PATIENTS Consecutive patients undergoing PCI over a 12-month period between 1998 and 2002. DESIGN Comparative observational study of costs and 12-month clinical outcomes of consecutive PCI procedures in 1998 (n = 1047) and 2002 (n = 1346). Clinical data were recorded in the Scottish PCI register. Repeat PCI, coronary artery bypass graft and mortality were obtained by record linkage. Costs of equipment were calculated using a computerised bar-code system and standard National Health Service reference costs. RESULTS Between 1998 and 2002, the use of bare metal stents increased from 44% to 81%, and the use of glycoprotein IIB/IIIA inhibitors increased from 0% to 14% of cases. During this time, a significant reduction was observed in repeat target-vessel PCI (from 8.4% to 5.1%, p = 0.001), any repeat PCI (from 11.7% to 9.2%, p = 0.05) and any repeat revascularisation (from 15.1% to 11.3%, p = 0.009) within 12 months. Significantly higher cost per case in 2002 compared with 1998 (mean (standard deviation) 2311 pounds (1158) v 1785 pounds (907), p<0.001) was mainly due to increased contribution from bed-day costs in 2002 (45.0% (16.3%) v 26.2% (12.6%), p = 0.01) associated with non-elective cases spending significantly longer in hospital (6.22 (4.3) v 4.6 (4.3) days, p = 0.01). CONCLUSIONS Greater use of stents and glycoprotein IIb/IIIa inhibitors between 1998 and 2002 has been accompanied by a marked reduction in the need for repeat revascularisation. Longer duration of hospital stay for non-elective cases is mainly responsible for increasing costs. Strategies to reduce the length of stay could considerably reduce the costs of PCI.
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Affiliation(s)
- M A Denvir
- Centre for Cardiovascular Research, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK.
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25
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Abstract
The acute coronary syndrome comprises unstable angina, non-ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction. A successful and stable revascularisation of the infarct related vessel, and the prevention of the loss of myocardium are the main therapeutic targets, as cardiovascular mortality and long term quality of life are essentially determined by left ventricular function. The clinical diagnosis comprises clinical symptoms, ECG-changes, and cardiac troponins. Early percutaneous coronary intervention (PCI) has become the most common method of coronary revascularisation. If PCI is not available, systemic thrombolysis is an alternative after exclusion of contraindications. Parenteral anticoagulation with intravenous or subcutaneous heparines, antithrombotic therapy and HMG-CoA reductase inhibitors are the common secondary drug therapy. Moreover, to prevent left ventricular remodelling ACE-inhibitors, angiotension 2-receptor antagonists, and beta-blocker are indicated.
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Affiliation(s)
- M Kelm
- Klinik für Kardiologie, Pneumologie und Angiologie, Medizinische Klinik und Poliklinik B, Heinrich-Heine-Universität Düsseldorf.
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Nordmann AJ, Bucher H, Hengstler P, Harr T, Young J. Primary stenting versus primary balloon angioplasty for treating acute myocardial infarction. Cochrane Database Syst Rev 2005:CD005313. [PMID: 15846752 DOI: 10.1002/14651858.cd005313] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Balloon angioplasty following myocardial infarction (MI) reduces death, non-fatal MI and stroke compared to thrombolytic reperfusion. However up to 50% of patients experience restenosis and 3% to 5% recurrent myocardial infarction. Therefore, primary stenting may offer additional benefits compared to balloon angioplasty in patients with acute myocardial infarction. OBJECTIVES To examine whether primary stenting compared to primary balloon angioplasty reduces clinical outcomes in patients with acute myocardial infarction. SEARCH STRATEGY We searched MEDLINE, EMBASE, Pascal, Index medicus and The Cochrane Controlled Trials Register (The Cochrane Library) from 1979 to March 2002. SELECTION CRITERIA Randomised controlled trials of primary stenting or balloon angioplasty prior to the invasive procedure; intervention in native coronary arteries within 24 hours after onset of symptoms of myocardial infarction; report of death or reinfarction; and follow-up of at least 1 month. Trials were excluded when randomisation occurred after an invasive procedure and if they exclusively included patients with cardiogenic shock. DATA COLLECTION AND ANALYSIS Two reviewers independently selected and extracted data from identified trials. Outcomes included mortality, reinfarction, coronary artery bypass grafting, target vessel revascularization, need for vascular repair or blood transfusion. Peto odds ratios were calculated. To explore the stability of the overall treatment effect various sensitivity analyses were performed. MAIN RESULTS We included nine trials of 4433 participants. Odds ratios for mortality after stenting compared to balloon angioplasty at 30 days, 6 and 12 months were 1.16 (95% CI 0.78 to 1.73), 1.27 (95% CI 0.89 to 1.83), and 1.06 (95% CI 0.77 to 1.45). At 30 days, 6 and 12 months odds ratios for reinfarction after stenting compared to balloon angioplasty were 0.52 (95% CI 0.31 to 0.87), 0.67 (95% CI 0.45 to 1.00), and 0.67 (95% CI 0.45-0.98) and odds ratio for target vessel revascularization after stenting compared to balloon angioplasty were 0.45 (95%CI 0.34 to 0.60), 0.42 (95% CI 0.35 to 0.51), and 0.47 (95% CI 0.38 to 0.57). The odds ratio for post-interventional bleeding complications after stenting compared to balloon angioplasty was 1.34 (95% CI 0.95 to 1.88; test of heterogeneity p > 0.1). AUTHORS' CONCLUSIONS There is no evidence to suggest that primary stenting reduces mortality when compared to balloon angioplasty. Stenting seems to be associated with a reduced risk of reinfarction and target vessel revascularization, but potential confounding due to unbalanced post-interventional antithrombotic/anticoagulant therapies can not be ruled out on basis of this review.
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Affiliation(s)
- A J Nordmann
- Basel Institute for Clinical Epidemiology, University Hospital Basel, Hebelstrasse 10, Basel, Switzerland, 4031.
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McDonald SB, Renna M, Spitznagel EL, Avidan M, Hogue CW, Moon MR, Barzilai B, Saleem R, McDonald JM, Despotis GJ. Preoperative use of enoxaparin increases the risk of postoperative bleeding and re-exploration in cardiac surgery patients. J Cardiothorac Vasc Anesth 2005; 19:4-10. [PMID: 15747262 DOI: 10.1053/j.jvca.2004.11.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The purpose of this study was to investigate if the preoperative use of new platelet inhibitors and low-molecular-weight heparins may contribute to bleeding after cardiac surgery. DESIGN Retrospective data review. SETTING University teaching hospital. PARTICIPANTS One hundred eleven patients divided in 5 groups. INTERVENTIONS Patients were grouped according to preoperative antithrombotic regimen: group 1, control, no agents (n=55); group 2, clopidogrel (n=9); group 3, enoxaparin (n=17); group 4, any GP IIb/IIIa inhibitor (n=14); and group 5, any drug combination (n=15). Data included cumulative mediastinal chest tube drainage, allogeneic blood transfusions, total blood donor exposures, and re-exploration. MEASUREMENTS AND MAIN RESULTS Use of any drug (groups 2-5) resulted in greater total blood transfusions and donor exposure (p=0.0003) than control, especially red cells (p=0.002) and platelets (p=0.006). A greater percentage of patients on enoxaparin required mediastinal re-exploration for nonsurgical bleeding versus control (3/17 v 0/55, p=0.001). The use of enoxaparin was associated with significantly higher chest tube output after the first 24 hours postoperatively (p=0.048). CONCLUSION Newer antithrombotic agents were associated with greater transfusion rates and total donor exposures. Enoxaparin use was associated with greater overall blood loss and with higher incidence of mediastinal re-exploration. The relative risk-benefit ratio of reduced periprocedure morbidity versus increased bleeding complications has yet to be determined.
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Affiliation(s)
- Susan B McDonald
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO 63110, USA
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Christov A, Korol RM, Dai E, Liu L, Guan H, Bernards MA, Cavers PB, Susko D, Lucas A. In Vivo Optical Analysis of Quantitative Changes in Collagen and Elastin During Arterial Remodeling¶. Photochem Photobiol 2005. [DOI: 10.1562/2004-03-10-ra-107.1] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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López-Mínguez JR, Fuentes ME, Doblado M, Merchán A, Martínez A, González R, Alonso R, Alonso F. [Prognostic role of systemic hypertension and diabetes mellitus in patients with unstable angina undergoing coronary stenting]. Rev Esp Cardiol 2004; 56:987-94. [PMID: 14563293 DOI: 10.1016/s0300-8932(03)76996-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- José R López-Mínguez
- Unidad de Hemodinámica y Cardiología Intervencionista, Hospital Universitario Infanta Cristina, Badajoz, España.
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Ibbotson T, McGavin JK, Goa KL. Abciximab: an updated review of its therapeutic use in patients with ischaemic heart disease undergoing percutaneous coronary revascularisation. Drugs 2003; 63:1121-63. [PMID: 12749745 DOI: 10.2165/00003495-200363110-00014] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
UNLABELLED Abciximab (Reopro) is an antibody fragment that dose-dependently inhibits platelet aggregation and leucocyte adhesion by binding to the glycoprotein (GP) IIb/IIIa, vitronectin and Mac-1 receptors. Abciximab (0.25 mg/kg bolus plus infusion of 0.125 micro g/kg/min for 12 hours) showed greater efficacy than tirofiban in reducing the 30-day composite endpoint of death, nonfatal myocardial infarction (MI) or urgent target-vessel revascularisation in the randomised, double-blind TARGET study in patients scheduled for stent placement. In addition, the beneficial effects of treatment with abciximab previously observed in the randomised, multicentre, placebo-controlled EPILOG and EPISTENT studies have been maintained to 1 year, with a significantly reduced incidence of ischaemic complications relative to placebo consistently observed across a range of subgroups including age, sex, bodyweight and indication for revascularisation. The incidence of the composite endpoint was reduced in patients presenting with acute MI of <48 hours' duration in comparison with either fibrinolytic therapy or stenting alone in the randomised STOPAMI and ADMIRAL trials, primarily because of a reduced requirement for urgent repeat revascularisation and reduced incidence of mortality. In the randomised, nonblind, multicentre CADILLAC trial in patients with acute myocardial infarction (MI), stenting alone was superior to percutaneous transluminal coronary angioplasty (PTCA) and stenting alone was not inferior to PTCA plus abciximab. Recent large randomised, multicentre studies (ASSENT-3 and GUSTO-V) have shown higher efficacy (on various ischaemic endpoints) of abciximab in combination with either a reduced dose of tenecteplase or reteplase compared with the fibrinolytic drug alone. TIMI grade 3 flow rates at 60 and 90 minutes in the TIMI-14 and SPEED trials were higher in patients who received abciximab in combination with either alteplase or reteplase than abciximab alone and were similar to that seen with the full-dose fibrinolytic alone. In the randomised, multicentre GUSTO IV-ACS study, no significant differences in any of the ischaemic endpoints at either 7 or 30 days in patients with acute coronary syndromes who were not scheduled to undergo early revascularisation (within 12 hours of end of infusion) were apparent between those who received abciximab (bolus and either 24- or 48-hour infusion) and those who received placebo in addition to aspirin and heparin. The most common adverse events associated with the use of abciximab are bleeding complications and thrombocytopenia, although the risk of major bleeding can be limited through adhering to current administration protocols. Treatment costs are generally higher in both stent plus abciximab and angioplasty plus abciximab groups than stent plus placebo, primarily because of the acquisition cost of abciximab. Abciximab appeared most cost beneficial in high-risk patients undergoing elective percutaneous coronary revascularisation; among lower risk patients, abciximab therapy has been associated with higher total in-hospital and 6-month medical costs than eptifibatide. CONCLUSION The GP IIb/IIIa receptor antagonist abciximab, when used with aspirin and heparin, has demonstrated efficacy in reducing the short- and long-term risk of ischaemic complications in patients with ischaemic heart disease undergoing percutaneous coronary intervention, when used with aspirin and heparin. High-risk patients (including those with diabetes mellitus) derive particular benefits from abciximab treatment. Abciximab remains an important therapeutic option for the prevention of complications in patients with ischaemic heart disease.
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Affiliation(s)
- Tim Ibbotson
- Adis International Limited, Mairangi Bay, Auckland, New Zealand
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Sim DS, Jeong MH, Kim W, Rhew JY, Yum JH, Kim JH, Cho JG, Ahn YK, Park JC, Ahn BH, Kim SH, Kang JC. Long-term clinical benefits of a platelet glycoprotein IIb/IIIa receptor blocker, abciximab (ReoPro), in high-risk diabetic patients undergoing percutaneous coronary intervention. Korean J Intern Med 2003; 18:129-37. [PMID: 14619381 PMCID: PMC4531627 DOI: 10.3904/kjim.2003.18.3.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND High-risk percutaneous coronary interventions (PCIs) are associated with a high complication rate, a low procedural success rate and a high restenosis rate, especially in diabetics. We sought to determine whether abciximab (ReoPro) therapy affects long-term clinical outcomes of Korean patients with diabetes undergoing high-risk PCI. METHODS One hundred and nineteen patients with 152 lesion sites were administered ReoPro among 2,231 patients who underwent PCI at Chonnam National University Hospital from March 1999 to Feb 2001. These 119 patients were divided into two groups, 30 were allocated to a diabetic group (Group 1, 57.7 +/- 8.2 years, 22 male), and 89 to a non-diabetic group (Group II, 59.6 +/- 10.8 years, 68 male). Early and long-term clinical outcomes after PCI were analyzed. RESULTS In terms of clinical diagnosis, the number of acute myocardial infarctions in Group I was 25 (83.3%) and 76 in Group II (85.4%). As for risk factors, target artery lesions, and ACC/AHA types, no differences were found between the two groups. The number of patients with total occlusion was 21 (55.3%) and 62 (53.9%), and the number with a thrombus-containing lesion was 28 (93.3%) and 88 (98.9%) in Groups I and II, respectively. The procedure was successful in 27 (90.0%) in Group I, and in 80 (89.9%) in Group II, and no differences were evident between the two groups in terms of bleeding complications. No major adverse cardiac events (MACE), including myocardial infarction, repeat revascularization or cardiac death, were observed in Group I, but 8 cases of MACE occurred in Group II during hospitalization. Clinical follow-up was performed in 116 patients (97.5%) over 18.5 +/- 6.7 (5-28) months. The number of overall MACEs was 10 (3.3%) in Group I and 14 (15.7%) in Group II (p = 0.038). CONCLUSION ReoPro used in high-risk PCI in diabetics was effective in terms of early clinical outcomes, but its long-term clinical benefits were not proven.
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Affiliation(s)
| | - Myung Ho Jeong
- Correspondence to: Myung Ho Jeong, M.D., Ph.D., FACC, FESC, FSCAI, Chief of Cardiovascular Medicine, Director of Cardiac Catheterization Laboratory, The Heart Center of Chonnam National University Hospital, Hakdong 8, Dongku, Gwangju, 501-757, Korea, Tel : 82-62-220-6243, Fax : 82-62-228-7174, E-mail:
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Lemos PA, Lee CH, Degertekin M, Saia F, Tanabe K, Arampatzis CA, Hoye A, van Duuren M, Sianos G, Smits PC, de Feyter P, van der Giessen WJ, van Domburg RT, Serruys PW. Early outcome after sirolimus-eluting stent implantation in patients with acute coronary syndromes: insights from the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. J Am Coll Cardiol 2003; 41:2093-9. [PMID: 12798587 DOI: 10.1016/s0735-1097(03)00429-7] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study evaluated the early outcomes of patients with acute coronary syndromes (ACS) treated with sirolimus-eluting stents (SES). BACKGROUND The safety of SES implantation in patients with a high risk for early thrombotic complications is currently unknown. METHODS Sirolimus-eluting stents have been utilized as the device of choice for all percutaneous procedures in our institution, as part of the Rapamycin-Eluting Stent Evaluated At Rotterdam Cardiology Hospital (RESEARCH) registry. After four months of enrollment, 198 patients with ACS had been treated exclusively with SES (64% of those treated in the period) and were compared with a control group composed of 301 consecutive patients treated with bare stents in the same time period immediately before this study. The incidence of major adverse cardiac events (MACE) during the first month was evaluated (death, nonfatal myocardial infarction [MI], or re-intervention). RESULTS Compared with control patients, patients treated with SES had more primary angioplasty (95% vs. 77%; p < 0.01), more bifurcation stenting (13% vs. 5%; p < 0.01), less previous MI (28% vs. 45%; p < 0.01), and less glycoprotein IIb/IIIa inhibitor utilization (27% vs. 42%; p < 0.01). The 30-day MACE rate was similar between both groups (SES 6.1% vs. control patients 6.6%; p = 0.8), with most complications occurring during the first week. Stent thrombosis occurred in 0.5% of SES patients and in 1.7% of control patients (p = 0.4). In multivariate analysis, SES utilization did not influence the incidence of MACE (odds ratio 1.0 [95% confidence interval: 0.4 to 2.2]; p = 0.97). CONCLUSIONS Sirolimus-eluting stent implantation for patients with ACS is safe, with early outcomes comparable with bare metal stents.
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Affiliation(s)
- Pedro A Lemos
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Dr Molewaterplein 40, NL-3015 GD Rotterdam, the Netherlands
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Sayen MR, Gustafsson AB, Sussman MA, Molkentin JD, Gottlieb RA. Calcineurin transgenic mice have mitochondrial dysfunction and elevated superoxide production. Am J Physiol Cell Physiol 2003; 284:C562-70. [PMID: 12397029 DOI: 10.1152/ajpcell.00336.2002] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Introduction of the constitutively active calcineurin gene into neonatal rat cardiomyocytes by adenovirus resulted in decreased mitochondrial membrane potential (P < 0.05). Infection of H9c2 cells with calcineurin adenovirus resulted in increased superoxide production (P < 0.001). Transgenic mice with cardiac-specific expression of a constitutively active calcineurin cDNA (CalTG mice) exhibit a two- to threefold increase in heart size that progresses to heart failure. We prepared mitochondria enriched for the subsarcolemmal population from the hearts of CalTG mice and transgene negative littermates (control). Intact, well-coupled mitochondria prepared from one to two mouse hearts at a time yielded sufficient material for functional studies. Mitochondrial oxygen consumption was measured with a Clark-type oxygen electrode with substrates for mitochondrial complex II (succinate) and complex IV [tetramethylpentadecane (TMPD)/ascorbate]. CalTG mice exhibited a maximal rate of electron transfer in heart mitochondria that was reduced by approximately 50% (P < 0.002) without a loss of respiratory control. Mitochondrial respiration was unaffected in tropomodulin-overexpressing transgenic mice, another model of cardiomyopathy. Western blotting for mitochondrial electron transfer subunits from mitochondria of CalTG mice revealed a 20-30% reduction in subunit 3 of complex I (ND3) and subunits I and IV of cytochrome oxidase (CO-I, CO-IV) when normalized to total mitochondrial protein or to the adenine nucleotide transporter (ANT) and compared with littermate controls (P < 0.002). Impaired mitochondrial electron transport was associated with high levels of superoxide production in the CalTG mice. Taken together, these data indicate that calcineurin signaling affects mitochondrial energetics and superoxide production. The excessive production of superoxide may contribute to the development of cardiac failure.
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Affiliation(s)
- M R Sayen
- The Scripps Research Institute, La Jolla, California 92037, USA
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Ajani AE, Waksman R, Cheneau E, Leborgne L, Pinnow E, Canos DA, Satler LF, Pichard AD, Kent KM, Lindsay J. Impact of intracoronary radiation on in-stent restenosis involving ostial lesions. Catheter Cardiovasc Interv 2003; 58:175-80. [PMID: 12552539 DOI: 10.1002/ccd.10388] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
The aim of this study was to compare 6-month clinical outcomes of patients with in-stent restenosis (ISR) involving the ostium treated with intracoronary radiation therapy (IRT) compared to placebo therapy, and also to nonostial lesions treated with IRT. Coronary interventions in ostial lesions have a high rate of recurrence of restenosis. The impact of IRT on ostial ISR has been inadequately characterized. We assessed patients enrolled in gamma (192-iridium) and beta (90-yttrium, 32-phosphorus) radiation trials for ISR at the Washington Hospital Center. Of patients receiving IRT, 105 (8%) patients had ostial ISR and 1,289 (92%) patients had nonostial ISR. Twenty-seven patients had ostial ISR and received placebo therapy. Baseline demographic and angiographic and procedural details were similar, except ostial IRT patients had a trend toward shorter lesions (15.4 +/- 10.8 vs. 24.1 +/- 12.2 mm; P < 0.001) and had a higher rate of saphenous vein graft disease (46% vs. 19%; P < 0.001) compared to nonostial IRT patients. At 6 months, ostial lesions treated with IRT for ISR had a reduced rate of target lesion revascularization (TLR) compared to ostial lesions treated with placebo (15% vs. 43%; P = 0.004). Outcomes at 6 months were similar for the ostial and nonostial IRT groups including TLR (15% vs. 14%; P = 0.80) and composite major adverse cardiac events (18% vs. 15%; P = 0.46). Intracoronary radiation therapy is effective for ostial in-stent restenotic lesions and should be comfortably used for this challenging anatomic location.
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Affiliation(s)
- Andrew E Ajani
- Cardiovascular Research Institute, Washington Hospital Center, Washington, DC, USA
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Drenth DJ, Veeger NJGM, Winter JB, Grandjean JG, Mariani MA, Boven van AJ, Boonstra PW. A prospective randomized trial comparing stenting with off-pump coronary surgery for high-grade stenosis in the proximal left anterior descending coronary artery: three-year follow-up. J Am Coll Cardiol 2002; 40:1955-60. [PMID: 12475455 DOI: 10.1016/s0735-1097(02)02536-6] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES This study was done to identify the best treatment for an isolated high-grade stenosis of the proximal left anterior descending coronary artery (LAD). BACKGROUND Percutaneous transluminal coronary angioplasty with stenting (PCI) and off-pump coronary artery bypass grafting (surgery) are used to treat single-vessel disease of a high-grade stenosis of the proximal LAD. Midterm results of both treatments are compared in this prospective randomized study. METHODS In a single-center prospective trial, we randomly assigned 102 patients with a high-grade stenosis of the proximal LAD (American College of Cardiology/American Heart Association classification type B2 or C) to PCI (n = 51) or surgery (n = 51). Primary composite end point was freedom from Major Adverse Cardiac and Cerebrovascular Events (MACCE) at follow-up, including death, myocardial infarction, cerebrovascular accident, and repeat target vessel revascularization (TVR). Secondary end points were angina pectoris class and need for antianginal medication at follow-up. Analysis was by intention-to-treat (ITT) and received treatment (RT). RESULTS Mean follow-up time was three years (90% midrange, two to four years). Incidence of MACCE was 23.5% after PCI and 9.8% after surgery; p = 0.07 ITT (24.1% vs. 8.3%; p = 0.04 RT). After surgery a significantly lower angina pectoris class (p = 0.02) and need for antianginal medication (p = 0.01) was found compared to PCI. Target vessel revascularization was 15.7% after PCI and 4.1% after surgery (p = 0.09). CONCLUSIONS At three-year follow-up (range, two to four years), a trend in favor of surgery is observed in regard to MACCE-free survival with a significantly lower angina pectoris status and significantly lower need for antianginal medication.
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Affiliation(s)
- Derk J Drenth
- Thoraxcentre of the Groningen University Hospital, Groningen, The Netherlands
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36
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Mukherjee D, Gurm H, Tang WHW, Roffi M, Wolski K, Moliterno DJ, Guetta V, Ardissinio D, Bode C, Steg G, Lincoff AM, Topol EJ. Outcome of acute myocardial infarction in patients with prior coronary artery bypass grafting treated with combination reduced fibrinolytic therapy and abciximab. Am J Cardiol 2002; 90:1198-203. [PMID: 12450598 DOI: 10.1016/s0002-9149(02)02834-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
ST-segment elevation acute myocardial infarction (AMI) in patients who have undergone previous coronary artery bypass grafting (CABG) is associated with low reperfusion rates and poor outcome after fibrinolytic therapy. The efficacy of a combination strategy (reduced fibrinolytic plus platelet glycoprotein IIb/IIIa agent) in this setting is unknown. In the Global Use of Streptokinase and TPA for Occluded coronary arteries V (GUSTO V) trial, 553 patients with a history of CABG were treated with standard-dose reteplase (n = 273), or half-dose reteplase and full-dose abciximab (n = 280) in the first 6 hours of evolving ST-segment elevation MI. Mortality at 30 days was significantly higher in patients who underwent prior CABG compared with patients with no prior CABG (odds ratio [OR] 1.64, 95% confidence interval [CI] 1.21 to 2.24, p = 0.001). In patients who underwent prior CABG, mortality at 7 days was reduced 15% with combination therapy compared with reteplase alone, which was not statistically significant (OR 0.85, 95% CI 0.40 to 1.81, p = 0.66). Patients who underwent prior CABG treated with the combination therapy had fewer episodes of recurrent ischemia (OR 0.60, 95% CI 0.37 to 0.96, p = 0.02), high degree atrioventricular block (OR 0.17, 95% CI 0.02 to 0.82, p = 0.01), and ventricular tachycardia (OR 0.29, 95% CI 0.07 to 0.96, p = 0.04). There was a trend toward reduced urgent revascularization (OR 0.61, 95% CI 0.36 to 1.03, p = 0.06) but no significant difference in reinfarction (OR 0.61, 95% CI 0.31 to 1.52, p = 0.40). In the GUSTO V trial, patients who underwent prior CABG had significantly higher event rates compared with patients without CABG. As in the overall trial, combination therapy in patients who underwent prior CABG led to a consistent reduction in key secondary complications of AMI, including recurrent ischemia and a trend toward reduced urgent revascularization.
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Wilensky RL, Selzer F, Johnston J, Laskey WK, Klugherz BD, Block P, Cohen H, Detre K, Williams DO. Relation of percutaneous coronary intervention of complex lesions to clinical outcomes (from the NHLBI Dynamic Registry). Am J Cardiol 2002; 90:216-21. [PMID: 12127606 DOI: 10.1016/s0002-9149(02)02457-8] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Advances in percutaneous coronary intervention (PCI) have reduced complications but expanded indications. We used the National Heart, Lung, and Blood Insitute Dynamic Registry to determine clinical outcomes up to 1 year after PCI in 2,839 patients with at least 1 treated complex lesion (defined as a lesion showing evidence of thrombus, calcification, bifurcation or ostial location, or chronic occlusion) and 1,790 patients with only simple lesions treated. Complex lesion interventions were associated (p <0.05) with more sustained major dissections, distal embolization, side branch occlusion, and persistent flow reduction. Patients with treated complex lesions had a lower procedural success rate (93.8% vs 97.3%, p <0.001) and increased in-hospital rates (p <0.001) of death (2.0% vs 0.6%), death/myocardial infarction [MI] (5.2% vs 2.4%), or death/MI/coronary artery bypass graft [CABG] surgery (6.5% vs 2.9%). After adjustment for potential confounders, patients treated for multiple complex lesions were more likely to experience the in-hospital combined end points of death/MI (odds ratio 3.22, 95% confidence interval 2.10 to 4.92), or death/MI/CABG (odds ratio 2.55, 95% confidence interval 1.71 to 3.80). At 1 year, patients with treated complex lesions were more likely (p <0.001) to die (6.2% vs 3.7%), suffer death/MI (11.7% vs 7.5%), or death/MI/CABG/repeat PCI (27.2% vs 23.4%). Patients treated for multiple complex lesions were approximately 50% more likely to die or to have major adverse events than with patients only treated for simple lesions. An increased in-hospital adverse clinical event rate was independently noted for thrombotic, bifurcation, and calcified lesions, and bifurcation lesions had worse long-term event rates.
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Affiliation(s)
- Robert L Wilensky
- Cardiovascular Division, University of Pennsylvania, Philadelphia 19104, USA.
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38
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Drenth DJ, Winter JB, Veeger NJGM, Monnink SHJ, van Boven AJ, Grandjean JG, Mariani MA, Boonstra PW. Minimally invasive coronary artery bypass grafting versus percutaneous transluminal coronary angioplasty with stenting in isolated high-grade stenosis of the proximal left anterior descending coronary artery: six months' angiographic and clinical follow-up of a prospective randomized study. J Thorac Cardiovasc Surg 2002; 124:130-5. [PMID: 12091818 DOI: 10.1067/mtc.2002.122525] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to compare minimally invasive coronary artery bypass grafting (surgical intervention) with percutaneous transluminal coronary angioplasty with primary stenting (stenting) in patients having an isolated high-grade stenosis (American College of Cardiology/American Heart Association classification type B2 or C) of the proximal left anterior descending coronary artery. At 6 months, both procedures were compared on the basis of quantitative angiography and clinical outcome. METHODS Both treatments were compared in a single-center, prospective, randomized study. The primary end point of this study was quantitative angiographic outcome at 6 months. The secondary end point was 6-month clinical outcome. Statistical analysis was performed in accordance with the intention-to-treat principle. RESULTS From March 1997 to September 1999, patients with angina pectoris caused by an isolated high-grade stenosis of the proximal left anterior descending coronary artery were randomly assigned to surgical intervention (n = 51) or stenting (n = 51). At 6 months, quantitative coronary angiography showed an anastomotic stenosis rate of 4% after surgical intervention and a restenosis rate of 29% after stenting (P <.001). Periprocedural events did not significantly differ between surgical intervention and stenting. After surgical intervention, 2 patients died; no patients died after stenting. After 6 months, no significant difference was found for major adverse cardiac or cerebral events and need for repeat target vessel revascularization. After 6 months, return of angina pectoris, physical work capacity, and use of antianginal drugs did not significantly differ between treatments. CONCLUSIONS After 6 months, surgical intervention had a significantly better angiographic outcome than stenting in patients with an isolated high-grade stenosis of the proximal left anterior descending coronary artery. Clinical outcome did not significantly differ between treatments.
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Affiliation(s)
- Derk J Drenth
- Thoraxcentre of the Groningen University Hospital, Groningen, The Netherlands
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Abstract
BACKGROUND Current antiplatelet regimens fail to prevent the majority of recurrent strokes. Asymptomatic circulating emboli can be detected by transcranial Doppler ultrasound, are frequent in patients with symptomatic carotid stenosis, and predict recurrent stroke risk. S-nitrosoglutathione (GSNO) is a nitric oxide donor that appears to have relative platelet specificity. We evaluated its effectiveness in reducing embolization in patients with symptomatic carotid stenosis who already were taking aspirin. METHODS AND RESULTS Twenty patients with > or =50% internal carotid artery stenosis and with > or =3 embolic signals detected during a half-hour screening recording were recruited. All had taken aspirin for at least 7 days. They were randomly assigned in a double-blind fashion to either GSNO (4.4 mmol/kg per minute) or saline placebo for 90 minutes. Transcranial Doppler recordings were made from the ipsilateral middle cerebral artery for 1 hour before treatment and at 0 to 3, 6, and 24 hours after treatment. Before treatment, the mean (range) of embolic signals per hour was 6.9 (3 to 13) in the GSNO group and 7.3 (4 to 12) in the placebo group (P=0.68). GSNO resulted in a rapid reduction in the frequency of embolic signals of 84% at 0 to 3 hours, 95% at 6 hours, and 100% at 24 hours (P<0.0001, P=0.003, and P<0.0001 versus placebo, respectively). CONCLUSIONS Continued embolization is common in patients with carotid stenosis despite aspirin therapy. GSNO was highly effective in rapidly reducing the frequency of embolic signals in this patient group. Despite its short administration time and its short half-life, it resulted in therapeutic effects lasting 24 hours.
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Affiliation(s)
- Zoltan Kaposzta
- Clinical Neuroscience, St George's Hospital Medical School, London, UK
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40
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Serruys PW, Foley DP, Suttorp MJ, Rensing BJWM, Suryapranata H, Materne P, van den Bos A, Benit E, Anzuini A, Rutsch W, Legrand V, Dawkins K, Cobaugh M, Bressers M, Backx B, Wijns W, Colombo A. A randomized comparison of the value of additional stenting after optimal balloon angioplasty for long coronary lesions: final results of the additional value of NIR stents for treatment of long coronary lesions (ADVANCE) study. J Am Coll Cardiol 2002; 39:393-9. [PMID: 11823075 DOI: 10.1016/s0735-1097(01)01760-0] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVES We sought to investigate the clinical benefit of additional stent implantation after achieving an optimal result of balloon angioplasty (BA) in long coronary lesions (>20 mm). BACKGROUND Long coronary lesions are associated with increased early complications and late restenosis after BA. Stenting improves the early outcome, but stent restenosis is also related to both lesion length and stent length. METHODS A total of 437 patients with a single native lesion 20 to 50 mm in length were included and underwent BA, using long balloons matched to lesion length and vessel diameter (balloon/artery ratio 1.1) to achieve a diameter stenosis (DS) <30% by on-line quantitative coronary angiography (QCA). "Bail-out stenting" was performed for flow-limiting dissections or >50% DS. Patients in whom an optimal BA result was achieved were randomized to additional stenting (using NIR stents) or no stenting. The primary end point was freedom from major adverse cardiac events (MACE) at nine months, and core laboratory QCA was performed on serial angiograms. RESULTS Bailout stenting was necessary in 149 patients (34%) and was associated with a significantly increased risk of peri-procedural infarction (p < 0.02). Among the 288 randomized patients, the mean lesion length was 27+/-9 mm, and the vessel diameter was 2.78+/-0.52 mm. The procedural success rate was 90% for the 143 patients assigned to BA alone (control group), as compared with 93% in the 145 patients assigned to additional stenting (stent group), which resulted in a superior early minimal lumen diameter (0.54 mm, p < 0.001) and led to reduced angiographic restenosis (27% vs. 42%, p = 0.022). Freedom from MACE at nine months was 77% in both groups. CONCLUSIONS A strategy of provisional stenting for long coronary lesions led to bailout stenting in one-third of patients, with a threefold increase in peri-procedural infarction. Additional stenting yielded a lower angiographic restenosis rate, but no reduction in MACE at nine months.
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41
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Bhatt DL, Bertrand ME, Berger PB, L'Allier PL, Moussa I, Moses JW, Dangas G, Taniuchi M, Lasala JM, Holmes DR, Ellis SG, Topol EJ. Meta-analysis of randomized and registry comparisons of ticlopidine with clopidogrel after stenting. J Am Coll Cardiol 2002; 39:9-14. [PMID: 11755280 DOI: 10.1016/s0735-1097(01)01713-2] [Citation(s) in RCA: 260] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We sought to determine whether clopidogrel is at least as efficacious as ticlopidine. BACKGROUND Several trials have supported the enhanced safety and tolerability of clopidogrel compared with ticlopidine after coronary stent deployment. However, none of these individual trials were powered to detect possible differences in the efficacy for reducing ischemic end points. METHODS Published data from trials and registries that compared clopidogrel with ticlopidine in patients receiving coronary stents were pooled, and a formal meta-analysis was performed. The rate of 30-day major adverse cardiac events (MACE), as defined in each trial, was used as the primary end point. RESULTS There were a total of 13,955 patients. The pooled rate of major adverse cardiac events was 2.10% in the clopidogrel group and 4.04% in the ticlopidine group. After adjustment for heterogeneity in the trials, the odds ratio (OR) of having an ischemic event with clopidogrel, as compared with ticlopidine, was 0.72 (95% confidence interval [CI] 0.59 to 0.89, p = 0.002). Mortality was also lower in the clopidogrel group compared with the ticlopidine group-0.48% versus 1.09% (OR 0.55, 95% CI 0.37 to 0.82; p = 0.003). CONCLUSIONS Based on all available evidence from randomized clinical trials or registries, clopidogrel, in addition to better tolerability and fewer side effects, is at least as efficacious as ticlopidine in reducing MACE. This finding may be due to the more rapid onset of an antiplatelet effect seen with the loading dose of clopidogrel, which was used in most of these studies, or to better patient compliance with clopidogrel therapy. Therefore, clopidogrel plus aspirin should replace ticlopidine plus aspirin as the standard antiplatelet regimen after stent deployment.
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Affiliation(s)
- Deepak L Bhatt
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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42
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Abstract
Restenosis rates after coronary stent implantation in complex lesions are between 30 and 50%. Neointimal hyperplasia promoted by complex interaction between cellular and acellular elements, such as cytokines and growth factors, is thought to be the primary process responsible for restenosis. The risk of in-stent restenosis is increased in patients with a history of restenosis after percutaneous transluminal coronary angioplasty, in long lesions, in total occlusions, in patients with diabetes mellitus, in small vessels, in the proximal parts of the left anterior descending coronary artery and in cases of stent oversizing. In-stent restenosis represents a serious economic burden on society because treatment strategies include expensive approaches such as cutting-balloon angioplasty, rotational atherectomy and brachytherapy. A number of pharmacological agents, including ACE inhibitors, have been unsuccessful in preventing restenosis. Alternative procedures such as brachytherapy, radioactive stents and drug-eluting stents are under evaluation. Although sirolimus- or paclitaxel-eluting stents have been associated with very low restenosis rates over durations of 6 to 12 months, the long-term efficacy and tolerability of this approach is currently being investigated. Although ACE inhibitors have failed in reducing restenosis rates, the selective angiotensin II type 1 (AT(1)) receptor antagonist valsartan has shown encouraging results in the single-center Valsartan for Prevention of Restenosis after Stenting of Type B2/C lesions trial (ValPREST). The ValPREST trial is the first randomized, placebo-controlled study to have evaluated the effect of an angiotensin receptor antagonist on in-stent restenosis in a moderate number of patients. Compared with ACE inhibitors, angiotensin receptor blockers exert additional effects on the pathophysiological processes which lead to restenosis. Angiotensin receptor antagonists may affect several mechanisms involved in neointimal hyperplasia such as decreasing circulating cytokine and growth factor levels and reducing neutrophil activation, especially after stenting in acute coronary syndromes, but the results need to be confirmed in a large multicenter trial. The question whether long-term therapy, with an oral angiotensin receptor antagonist, is cost-effective and whether angiotensin receptor antagonists should be used as an add-on therapy to drug-eluting stents, requires clarification.
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Affiliation(s)
- Stefan Peters
- Klinikum Dorothea Christiane Erxleben Quedlinburg, Academic Teaching Hospital of the University Hospital Magdeburg, Quedlinburg, Germany.
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Singh M, Berger PB, Ting HH, Rihal CS, Wilson SH, Lennon RJ, Reeder GS, Bresnahan JF, Holmes DR. Influence of coronary thrombus on outcome of percutaneous coronary angioplasty in the current era (the Mayo Clinic experience). Am J Cardiol 2001; 88:1091-6. [PMID: 11703950 DOI: 10.1016/s0002-9149(01)02040-9] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Earlier studies documented an increased risk of percutaneous coronary intervention (PCI) in patients with angiographic evidence of thrombus. With newer antiplatelet agents and stents, it is not known whether thrombus is a risk factor after PCI. This study examines whether outcome of PCI in patients with thrombus has improved, and whether thrombus is associated with adverse outcome after PCI in the current era. This single-institution retrospective analysis of PCI in 7,184 patients was divided into 2 periods: group I, 1990 to 1995 (n = 3,640), and group II, 1996 to 1999 (n = 3,544). The groups were subdivided according to the presence or absence of angiographic thrombus before PCI. We compared the outcome of PCI for patients with and without thrombus in group II. A comparison was made in the 2 groups in patients with angiographic thrombus. Procedural success improved in group II compared with group I patients with thrombus (93% vs 88%, p <0.001). There was significant reduction in abrupt closure in the recent era in patients with thrombus (4% vs 7%, p = 0.01). In group II, procedural success remained lower in patients with (93% vs 96%) than without thrombus (p <0.001). After adjusting for the significant univariate characteristics of group II patients, thrombus remained an independent predictor of Q-wave infarction (odds ratio 3.78; 95% confidence interval [CI], 1.8 to 8.0; p <0.0013) and the composite end point of death, Q-wave infarction, and emergency bypass surgery (odds ratio 2.37; 95% CI 1.4 to 4.1; p = 0.002). There was a trend toward increased in-hospital death among patients with thrombus (odds ratio 2.06; 95% CI 0.9 to 4.8; p = 0.09). The 1-year outcome after successful PCI was similar for those with and without thrombus. Despite improvement in the outcome of patients with thrombus undergoing PCI in recent years, thrombus is still an independent predictor of adverse in-hospital outcomes after PCI.
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Affiliation(s)
- M Singh
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA
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44
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Foley DP, Kererakes D, te Riele JA, Nishimura N, Veldhof S, Fink S, Yeung A, van Hoogenhuyze D, Lansky AM, van Es GA, Kutryk MJ, Serruys PW. Acute and 6-month clinical and angiographic outcome after implantation of the ACS Duet stent for single-vessel coronary artery disease: final results of the European and US ACS Multi-link Duet Registry. Catheter Cardiovasc Interv 2001; 54:25-33. [PMID: 11553944 DOI: 10.1002/ccd.1233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The aim of the study was to determine the safety and efficacy of the second-generation ACS Multi-Link Duet coronary stent system for the treatment of single, symptomatic, de novo, native coronary artery lesions. Between February and June 1998, 427 patients (69.3% male, 51.5% class 3 or 4 angina, 20.1% diabetic, 43.6% hyperlipidemia) were included at 38 centers in this prospective observational study. All patients received ticlopidine 500 mg/day for 1 month and aspirin > or =100 mg/day. The Duet stent was available in 8, 18, and 28 mm length and 3.0, 3.5, and 4.0 mm diameter. After adequate predilatation, stents were successfully implanted, at up to 16 atm, in 99.3% of patients. Mean vessel diameter by core laboratory quantitative coronary angiography was 3.0 +/- 0.53 mm and postprocedural minimum luminal diameter was 2.79 +/- 0.43 mm (12% +/- 9.3% diameter stenosis). At 30 days, 96.7% of patients were event-free and at 6 months 88.1% remained free of major adverse cardiac events. The restenosis rate was 18.1%. The ACS Duet stent was safely implanted in >99% of target lesions by a diverse group of international investigators. With late outcomes at least comparable to the best published results, this stent platform provides safe and effective percutaneous treatment of obstructive coronary artery disease. Cathet Cardiovasc Intervent 2001;54:25-33.
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Affiliation(s)
- D P Foley
- Department of Interventional Cardiology Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands.
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Bhatt DL, Topol EJ. Debate: PCI or CABG for multivessel disease? Viewpoint: No clear winner in an unfair fight. CURRENT CONTROLLED TRIALS IN CARDIOVASCULAR MEDICINE 2001; 2:260-262. [PMID: 11806809 PMCID: PMC64821 DOI: 10.1186/cvm-2-6-260] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The Arterial Revascularization Therapy Study (ARTS) and the Stent or Surgery (SoS) trial each randomized patients with multivessel disease to either stenting or bypass surgery. The ARTS showed no difference in mortality between the two strategies, other than in diabetic patients, who fared better with surgery. The SoS trial demonstrated increased mortality in the stent arm, a difference that was not attributable to diabetes. Both trials found that the rates of repeat revascularization were lower with surgery, although the rate with stenting was much lower than had been seen in previous trials of angioplasty. Use of antiplatelet therapy such as intravenous glycoprotein IIb/IIIa inhibitors, especially with their pronounced effects in diabetics and in those with multivessel disease, could potentially equalize the playing field or perhaps even tip the balance in favor of percutaneous intervention.
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