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Osman M, Benjamin MM, Balla S, Kheiri B, Bianco C, Sengupta PP, Daggubati R, Malla M, Liu SV, Mamas M, Patel B. Index Admission and Thirty-Day Readmission Outcomes of Patients With Cancer Presenting With STEMI. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 35:121-128. [PMID: 33888417 PMCID: PMC8521583 DOI: 10.1016/j.carrev.2021.04.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/30/2021] [Accepted: 04/12/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND National-level data of cancer patients' readmissions after ST-segment elevation myocardial infarction (STEMI) are lacking. OBJECTIVES The primary aim of this study was to compare the rates and causes of 30-day readmissions in patients with and without cancer. METHODS Among patients admitted with STEMI in the United States National Readmission Database (NRD) from October 2015-December 2017, we identified patients with the diagnosis of active breast, colorectal, lung, or prostate cancer. The primary endpoint was the 30-day unplanned readmission rate. Secondary endpoints included in-hospital outcomes during the index admission and causes of readmissions. A propensity score model was used to compare the outcomes of patients with and without cancer. RESULTS A total of 385,522 patients were included in the analysis: 5956 with cancer and 379,566 without cancer. After propensity score matching, 23,880 patients were compared (Cancer = 5949, No Cancer = 17,931). Patients with cancer had higher 30-day readmission rates (19% vs. 14%, p < 0.01). The most common causes for readmission among patients with cancer were cardiac (31%), infectious (21%), oncologic (17%), respiratory (4%), stroke (4%), and renal (3%). During the first readmission, patients with cancer had higher adjusted rates of in-hospital mortality (15% vs. 7%; p < 0.01) and bleeding complications (31% vs. 21%; p < 0.01), compared to the non-cancer group. In addition, cancer (OR 1.5, 95% CI 1.2-1.6, p < 0.01) was an independent predictor for 30-day readmission. CONCLUSIONS About one in five cancer patients presenting with STEMI will be readmitted within 30 days. Cardiac causes predominated the reason for 30-day readmissions in patients with cancer.
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Affiliation(s)
- Mohammed Osman
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Mina M. Benjamin
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Sudarshan Balla
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Babikir Kheiri
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Christopher Bianco
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Partho P. Sengupta
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Ramesh Daggubati
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Midhun Malla
- Division of Oncology, West Virginia University, School of Medicine, Morgantown, WV, USA
| | - Stephen V. Liu
- Division of Oncology, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Mamas Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, United Kingdom,Royal Stoke University Hospital, Stoke-on-Trent, United Kingdom
| | - Brijesh Patel
- Division of Cardiology, West Virginia University School of Medicine, Morgantown, WV, USA,Corresponding author at: WVU Heart & Vascular Institute, West Virginia University, One Medical Center Drive, Box 8003, Morgantown, WV 26506., USA.
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O'Fee K, Deych E, Ciani O, Brown DL. Assessment of Nonfatal Myocardial Infarction as a Surrogate for All-Cause and Cardiovascular Mortality in Treatment or Prevention of Coronary Artery Disease: A Meta-analysis of Randomized Clinical Trials. JAMA Intern Med 2021; 181:1575-1587. [PMID: 34694318 PMCID: PMC8546625 DOI: 10.1001/jamainternmed.2021.5726] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Although nonfatal myocardial infarction (MI) is associated with an increased risk of mortality, evidence validating nonfatal MI as a surrogate end point for all-cause or cardiovascular (CV) mortality is lacking. OBJECTIVE To examine whether nonfatal MI may be a surrogate for all-cause or CV mortality in patients with or at risk for coronary artery disease. DATA SOURCES In this meta-analysis, PubMed was searched from inception until December 31, 2020, for randomized clinical trials of interventions to treat or prevent coronary artery disease reporting mortality and nonfatal MI published in 3 leading journals. STUDY SELECTION Randomized clinical trials including at least 1000 patients with 24 months of follow-up. DATA EXTRACTION AND SYNTHESIS Trial-level correlations between nonfatal MI and all-cause or CV mortality were assessed for surrogacy using the coefficient of determination (R2). The criterion for surrogacy was set at 0.8. Subgroup analyses based on study subject (primary prevention, secondary prevention, mixed primary and secondary prevention, and revascularization), era of trial (before 2000, 2000-2009, and 2010 and after), and follow-up duration (2.0-3.9, 4.0-5.9, and ≥6.0 years) were performed. MAIN OUTCOMES AND MEASURES All-cause or CV mortality and nonfatal MI. RESULTS A total of 144 articles randomizing 1 211 897 patients met the criteria for inclusion. Nonfatal MI did not meet the threshold for surrogacy for all-cause (R2 = 0.02; 95% CI, 0.00-0.08) or CV (R2 = 0.11; 95% CI, 0.02-0.27) mortality. Nonfatal MI was not a surrogate for all-cause mortality in primary (R2 = 0.01; 95% CI, 0.001-0.26), secondary (R2 = 0.03; 95% CI, 0.00-0.20), mixed primary and secondary prevention (R2 = 0.001; 95% CI, 0.00-0.08), or revascularization trials (R2 = 0.21; 95% CI, 0.002-0.50). For trials enrolling patients before 2000 (R2 = 0.22; 95% CI, 0.08-0.36), between 2000 and 2009 (R2 = 0.02; 95% CI, 0.00-0.17), and from 2010 and after (R2 = 0.01; 95% CI, 0.00-0.09), nonfatal MI was not a surrogate for all-cause mortality. Nonfatal MI was not a surrogate for all-cause mortality in randomized clinical trials with 2.0 to 3.9 (R2 = 0.004; 95% CI, 0.00-0.08), 4.0 to 5.9 (R2 = 0.06; 95% CI, 0.001-0.16), or 6.0 or more years of follow-up (R2 = 0.30; 95% CI, 0.01-0.55). CONCLUSIONS AND RELEVANCE The findings of this meta-analysis do not appear to establish nonfatal MI as a surrogate for all-cause or CV mortality in randomized clinical trials of interventions to treat or prevent coronary artery disease.
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Affiliation(s)
- Kevin O'Fee
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Elena Deych
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.,Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Oriana Ciani
- Center for Research in Health and Social Care Management, SDA Bocconi, Milan, Italy.,University of Exeter College of Medicine and Health, Exeter, United Kingdom
| | - David L Brown
- Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.,Cardiovascular Division, Washington University School of Medicine in St Louis, St Louis, Missouri
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Szummer K, Jernberg T, Wallentin L. From Early Pharmacology to Recent Pharmacology Interventions in Acute Coronary Syndromes. J Am Coll Cardiol 2019; 74:1618-1636. [DOI: 10.1016/j.jacc.2019.03.531] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 03/27/2019] [Accepted: 03/31/2019] [Indexed: 10/26/2022]
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Microcatheter-Facilitated Primary Angioplasty in ST-Segment Elevation Myocardial Infarction. Can J Cardiol 2018; 34:23-30. [PMID: 29275878 DOI: 10.1016/j.cjca.2017.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 10/09/2017] [Accepted: 11/06/2017] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Direct stenting is the best method for achieving reperfusion in primary percutaneous coronary intervention (PPCI). We hypothesized that the use of a microcatheter (MC) during PPCI when Thrombolysis in Myocardial Infarction (TIMI) flow ≤ 1 after wire crossing would allow visualization of the downstream artery with an optimal TIMI 3 flow at the end of the procedure. METHODS In this pilot study, PPCI patients with TIMI flow ≤ 1 after wire crossing formed the MC group (n = 60); the MC was positioned in the distal part of the culprit artery and a small amount of contrast was injected through it to determine stent size and length to treat the culprit lesion. The MC group was compared with previous consecutive patients treated using standard PPCI (n = 94; similar characteristics except for the rate of previous percutaneous coronary intervention). RESULTS In the MC group, downstream arteries were visualized in 98% of cases and direct stenting was achieved in 72% vs 31% (P < 0.0001). Final TIMI 3 flow was similar in both groups (97%). There was less manual thrombectomy (20% vs 63%; P < 0.001) and bailout glycoprotein IIb/IIIa inhibitor use (6.7% vs 29.8%; P < 0.002). The incidence of major adverse events (death, shock, severe arrhythmia) and left ventricular ejection fraction were similar. The peak cardiac enzymes level was significantly lower in the MC group. CONCLUSIONS The MC strategy appears feasible and safe. It could allow exploring new strategies on the basis of more systematic direct stenting and prepared reperfusion by injecting drugs through the MC before reperfusion.
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Abstract
The evolution of the management of acute myocardial infarction (MI) has been one of the crowning achievements of modern medicine. At the turn of the twentieth century, MI was an often-fatal condition. Prolonged bed rest served as the principal treatment modality. Over the past century, insights into the pathophysiology of MI revolutionized approaches to management, with the sequential use of surgical coronary artery revascularization, thrombolytic therapy, and percutaneous coronary intervention (PCI) with primary coronary angioplasty, and placement of intracoronary stents. The benefits of prompt revascularization inspired systems of care to provide rapid access to PCI. This review provides a historical context for our current approach to primary PCI for acute MI.
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Goswami NJ, Moody JM, Bailey SR. Percutaneous Mechanical Reperfusion During Acute Myocardial Infarction. J Intensive Care Med 2016. [DOI: 10.1177/0885066602017004002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The treatment of acute myocardial infarction has progressed from bedrest to mechanical, catheter-based reperfusion. The authors review the use of percutaneous coronary intervention (PCI) as a primary treatment for acute myocardial infarction and the use of adjunctive agents. The most recent American College of Cardiology/ American Heart Association (ACC/AHA) guidelines for the use of PCI in ST segment elevation myocardial infarction (MI) advocate the use of PCI as primary therapy at those centers in which the procedure can be performed within accepted standards. Because a majority of hospitals (80%) do not have the capability of performing primary PCI, most patients are treated with thrombolytic therapy. PCI should be considered in those patients treated with thrombolytic therapy who have persistent or recurrent ischemia and/or cardiogenic shock. For patients with non-ST elevation MI, the use of an invasive strategy (early angiography and PCI if needed) has recently shown to be beneficial. Although revascularization is the basis of the acute therapy of MI, additional pharmacologic therapy in the acute setting is now recognized as a key to favorable long-term outcome.
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Affiliation(s)
- Nilesh J. Goswami
- Department of Medicine/Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, TX
| | - Joe M. Moody
- Department of Medicine/Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, TX,
| | - Steven R. Bailey
- Department of Medicine/Division of Cardiology, University of Texas Health Science Center at San Antonio, San Antonio, TX
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Lanzer P, Widimský P. Ischaemic stroke and ST-segment elevation myocardial infarction: fast-track single-stop approach. Eur Heart J 2015; 36:2348-55. [DOI: 10.1093/eurheartj/ehv217] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Accepted: 05/04/2015] [Indexed: 11/14/2022] Open
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Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_26] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Unger E, Porter T, Lindner J, Grayburn P. Cardiovascular drug delivery with ultrasound and microbubbles. Adv Drug Deliv Rev 2014; 72:110-26. [PMID: 24524934 DOI: 10.1016/j.addr.2014.01.012] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2013] [Revised: 01/23/2014] [Accepted: 01/29/2014] [Indexed: 01/14/2023]
Abstract
Microbubbles lower the threshold for cavitation of ultrasound and have multiple potential therapeutic applications in the cardiovascular system. One of the first therapeutic applications to enter into clinical trials has been microbubble-enhanced sonothrombolysis. Trials were conducted in acute ischemic stroke and clinical trials are currently underway for sonothrombolysis in treatment of acute myocardial infarction. Microbubbles can be targeted to epitopes expressed on endothelial cells and thrombi by incorporating targeting ligands onto the surface of the microbubbles. Targeted microbubbles have applications as molecular imaging contrast agents and also for drug and gene delivery. A number of groups have shown that ultrasound with microbubbles can be used for gene delivery yielding robust gene expression in the target tissue. Work has progressed to primate studies showing delivery of therapeutic genes to generate islet cells in the pancreas to potentially cure diabetes. Microbubbles also hold potential as oxygen therapeutics and have shown promising results as a neuroprotectant in an ischemic stroke model. Regulatory considerations impact the successful clinical development of therapeutic applications of microbubbles with ultrasound. This paper briefly reviews the field and suggests avenues for further development.
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De Luca G, Dirksen MT, Spaulding C, Kelbæk H, Schalij M, Thuesen L, van der Hoeven B, Vink MA, Kaiser C, Musto C, Chechi T, Spaziani G, de la Llera LSD, Pasceri V, Di Lorenzo E, Violini R, Suryapranata H, Stone GW. Drug-eluting stents in patients with anterior STEMI undergoing primary angioplasty: a substudy of the DESERT cooperation. Clin Res Cardiol 2014; 103:685-99. [PMID: 24687617 DOI: 10.1007/s00392-014-0702-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 03/11/2014] [Indexed: 01/28/2023]
Abstract
BACKGROUND Several concerns have emerged on the higher risk of in-stent thrombosis after drug-eluting stent (DES) implantation, especially in the setting of STEMI patients. Few data have even been reported in high-risk patients, such as those with anterior MI. Therefore this represents the aim of the current study. METHODS The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of DES for STEMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, stenting, DES, sirolimus-eluting stent (SES), Cypher, paclitaxel-eluting stent (PES), Taxus. No language restrictions were enforced. RESULTS Individual patient's data were obtained from 11 out of 13 trials, including a total of 2,782 patients with anterior MI [1,739 or 62.5% randomized to DES and 1,043 or 37.5% randomized to bare-metal stent (BMS)]. At long-term follow-up, no significant benefit was observed with DES as compared to BMS in terms of mortality [9.8 vs 10.9%, HR (95% CI) = 0.81 (0.61, 1.07), p = 0.13, p heterogeneity = 0.18], reinfarction [8.8 vs 6.4%, respectively; HR (95% CI) = 1.14 (0.80, 1.61), p = 0.47, p heterogeneity = 0.82], and stent thrombosis [5.6 vs 5%, OR (95% CI) = 0.88 (0.59, 1.30), p = 0.51, p heterogeneity = 0.65], whereas DES was associated with a significant reduction in terms of target-vessel revascularization (TVR) [13.7 vs 23.4%; OR (95% CI) = 0.56 (0.46, 0.69), p < 0.0001, p het = 0.81] that was observed at both early (within 1 year) [7 vs 14.7%, HR (95% CI) = 0.56 (0.46, 0.69), p < 0.0001, p het = 0.81] and late (>1 year) follow-up [7.2 vs 9%, HR (95% CI) = 0.67 (0.47, 0.96), p = 0.03, p het = 0.96]. CONCLUSIONS This study showed that among patients with anterior STEMI undergoing primary angioplasty, SES and PES, as compared to BMS, are associated with a significant reduction in TVR at long-term follow-up. No concerns were found with the use of first-generation DES in terms of mortality.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Ospedale "Maggiore della Carità", Eastern Piedmont University, C.so Mazzini, 18, 24100, Novara, Italy,
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Prodanov P, Widimsky P. Acute Revascularization in ST-Segment-Elevation Myocardial Infarction. Curr Atheroscler Rep 2014; 16:412. [DOI: 10.1007/s11883-014-0412-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Brodie BR, Pokharel Y, Garg A, Kissling G, Hansen C, Milks S, Cooper M, McAlhany C, Stuckey TD. Very late hazard with stenting versus balloon angioplasty for ST-elevation myocardial infarction: a 16-year single-center experience. J Interv Cardiol 2013; 27:21-8. [PMID: 24372979 DOI: 10.1111/joic.12082] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES This study compares very late outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction (STEMI) with stenting versus balloon angioplasty (BA). BACKGROUND Stenting compared with BA for STEMI improves outcomes at 6-12 months, but comparisons beyond 6-12 months have not been studied. Recent studies have shown that stent thrombosis (ST) continues to increase beyond 3-5 years and may be higher with drug-eluting stents (DES) than bare metal stents (BMS). We hypothesized that there may be a very late hazard with stenting versus BA due to very late ST. METHODS From 1994 to 2010 consecutive patients with STEMI treated with BA (n = 601) or stenting (n = 1,594) were prospectively enrolled in our registry and followed for 1-16 years. RESULTS Patients treated with BA were older, were more often female, had more three-vessel disease, and had smaller vessels. Stented patients had trends for less stent/lesion thrombosis (ST/LT) and target vessel (TV) reinfarction at 1 year. In landmark analyses >1 year, stented patients had more very late ST/LT (6.1% vs. 2.9%, P = 0.002) and more TV reinfarction (7.9% vs. 3.1%, P < 0.001) which remained significant after adjusting for baseline risk. The greatest differences in very late outcomes were between DES and BA, but there were also significant differences between BMS and BA. CONCLUSIONS There appears to be a very late hazard with stenting versus BA for STEMI. These data should encourage new strategies for prevention of very late ST with both BMS and DES including the development of bio-absorbable polymers and stent platforms.
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Affiliation(s)
- Bruce R Brodie
- The LeBauer Cardiovascular Research Foundation, Greensboro, North Carolina
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Kurisu S, Iwasaki T, Ishibashi K, Mitsuba N, Dohi Y, Kihara Y. Comparison of treatment and outcome of acute myocardial infarction between cancer patients and non-cancer patients. Int J Cardiol 2013. [DOI: 10.1016/j.ijcard.2012.11.009] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Predicting 30-day major adverse cardiovascular events after primary percutaneous coronary intervention. The RISK-PCI score. Int J Cardiol 2013; 162:220-7. [DOI: 10.1016/j.ijcard.2011.05.071] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 02/23/2011] [Accepted: 05/13/2011] [Indexed: 11/21/2022]
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Lee JH, Yun JK, Kim DW, Kang SD. Clinical and angiographic outcomes of wingspan stent placement for treatment of symptomatic intracranial stenosis: single center experience with 19 cases. J Cerebrovasc Endovasc Neurosurg 2012; 14:157-63. [PMID: 23210041 PMCID: PMC3491208 DOI: 10.7461/jcen.2012.14.3.157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2012] [Revised: 08/17/2012] [Accepted: 08/22/2012] [Indexed: 11/24/2022] Open
Abstract
Objective The limitations of medical management of symptomatic intracranial arterial stenosis (ICS) have prompted development of new strategies, including endovascular treatment. However, stenting of symptomatic ICS remains investigational. Here, we have reported and analyzed a series of 19 endovascular procedures involving placement of a Wingspan stent. Methods We conducted a retrospective review of a series of ICS in which patients were treated with percutaneous transarterial balloon angioplasty and stent placement (PTAS). Patients included in the study were diagnosed as symptomatic ICS between May 2010 and September 2011. Results Nineteen patients (median age, 65 years; 12 males, seven women) were treated with the Wingspan stent system for symptomatic ICS ranging from 50% to 99%. The technical success rate was 100%. The location of ICS included the internal carotid (n = 5; 1 petrous, 3 cavernous, and 1 clinoid segments), vertebral (n = 1; V4 segment), basilar (n = 1), and middle cerebral (n = 12; 9 M1, 3 M2) arteries. There was no occurrence of procedure-related mortality. Periprocedural morbidity occurred in two cases (10.5%), including carotid-cavernous fistula (n = 1) and subarachnoid hemorrhage (n = 1). No ipsilateral stroke was recorded beyond 30 days during a mean follow-up period of 13.2 months (range 9-19 months). Restenosis (> 50%) was observed in one patient (6.3%), who was asymptomatic, on follow-up imaging. Conclusion Wingspan stent for symptomatic ICS can be performed with a high rate of technical success and acceptable periprocedural morbidity rates. Our initial experience indicates that this procedure represents a viable treatment option for this patient population.
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Affiliation(s)
- Jun Hyoung Lee
- Department of Neurosurgery, Institute of Wonkwang Medical Science, School of Medicine, Wonkwang University, Iksan, Korea
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Ishihara M, Sato H. Thirty years trend in acute myocardial infarction undergoing coronary angiography at a tertiary emergency center in Japan. J Cardiol 2012; 59:243-8. [DOI: 10.1016/j.jjcc.2011.10.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Revised: 10/04/2011] [Accepted: 10/27/2011] [Indexed: 10/28/2022]
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Celik T, Iyisoy A. Primary stenting in the patients with acute myocardial infarction: the preferred strategy. Int J Cardiol 2010; 143:446-7. [PMID: 19108917 DOI: 10.1016/j.ijcard.2008.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Accepted: 12/04/2008] [Indexed: 11/18/2022]
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Rodriguez AE, Rodriguez-Granillo A. Stent selection in patients with acute coronary syndromes and unstable coronary lesions. Interv Cardiol 2010. [DOI: 10.2217/ica.10.42] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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De Luca G, Małek LA, Maciejewski P, Wąsek W, Niewada M, Kamiński B, wiecki JD, Kośmider M, Kubica J, Rużyłło W, Peruga JZ, Dudek D, Opolski G, Dobrzycki S, Gil RJ, Witkowski A. Impact of diabetes on survival in patients with ST-segment elevation myocardial infarction treated by primary angioplasty: Insights from the POLISH STEMI registry. Atherosclerosis 2010; 210:516-20. [DOI: 10.1016/j.atherosclerosis.2009.12.012] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 12/01/2009] [Accepted: 12/08/2009] [Indexed: 01/08/2023]
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Gender-related differences in outcome after ST-segment elevation myocardial infarction treated by primary angioplasty and glycoprotein IIb–IIIa inhibitors: insights from the EGYPT cooperation. J Thromb Thrombolysis 2010; 30:342-6. [DOI: 10.1007/s11239-010-0451-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Brueck M, Bandorski D, Kramer W, Wieczorek M, Höltgen R, Tillmanns H. A Randomized Comparison of Transradial Versus Transfemoral Approach for Coronary Angiography and Angioplasty. JACC Cardiovasc Interv 2009; 2:1047-54. [DOI: 10.1016/j.jcin.2009.07.016] [Citation(s) in RCA: 288] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2009] [Accepted: 07/25/2009] [Indexed: 11/26/2022]
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De Luca G, Gibson CM, Bellandi F, Noc M, Dudek D, Zeymer U, Arntz HR, Cutlip D, Maioli M, Zorman S, Mesquita Gabriel H, Emre A, Rakowski T, Gyongyosi M, Huber K, van’t Hof AW. Diabetes mellitus is associated with distal embolization, impaired myocardial perfusion, and higher mortality in patients with ST-segment elevation myocardial infarction treated with primary angioplasty and glycoprotein IIb-IIIa inhibitors. Atherosclerosis 2009; 207:181-5. [DOI: 10.1016/j.atherosclerosis.2009.03.042] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Revised: 02/21/2009] [Accepted: 03/30/2009] [Indexed: 01/08/2023]
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Three-year prognosis of Japanese patients with ST-elevation myocardial infarction treated with sirolimus-eluting stents. Coron Artery Dis 2009; 20:422-7. [DOI: 10.1097/mca.0b013e32832fa92c] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Iijima R, Byrne RA, Dibra A, Ndrepepa G, Spaulding C, Laarman GJ, Menichelli M, Valgimigli M, Di Lorenzo E, Kaiser C, Tierala I, Mehilli J, Suttorp MJ, Violini R, Schömig A, Kastrati A. Drug-eluting stents versus bare-metal stents in diabetic patients with ST-segment elevation acute myocardial infarction: a pooled analysis of individual patient data from seven randomized trials. Rev Esp Cardiol 2009; 62:354-64. [PMID: 19401120 DOI: 10.1016/s1885-5857(09)71662-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES The performance of drug-eluting stents (DESs) in high-risk patients with diabetes and acute ST-elevation myocardial infarction (STEMI) who have undergone primary angioplasty has not been previously studied. The objective was to evaluate the efficacy and safety of DESs in diabetic patients with STEMI. METHODS We performed a pooled analysis of individual patient data from seven randomized trials that compared DESs (i.e., sirolimus- or paclitaxel-eluting stents) with bare-metal stents (BMSs) in patients with STEMI. The analysis involved 389 patients with diabetes mellitus from a total of 2476 patients. The outcomes of interest were target-lesion revascularization, stent thrombosis, death and the composite endpoint of death or recurrent myocardial infarction during a follow-up of 12-24 months. RESULTS Overall, 206 diabetic patients received a DES and 183, a BMS. The risk of target-lesion revascularization was significantly lower in patients treated with a DES compared to those treated with a BMS (hazard ratio [HR] 0.44, 95% confidence interval [CI] 0.23-0.88; P=.02). There was no significant difference in the risk of stent thrombosis between those treated with a DES or a BMS (HR 0.33, 95% CI 0.09-1.13; P=.08). Similarly, the risk of the combined endpoint of death or myocardial infarction was not significantly different between patients treated with a DES or a BMS (HR 0.64, 95% CI 0.36-1.13; P=.12). CONCLUSIONS Compared with BMSs, DES use improved clinical outcomes in diabetic patients undergoing primary angioplasty for STEMI: the need for reintervention was reduced, with no increase in mortality or myocardial infarction.
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Affiliation(s)
- Raisuke Iijima
- Deutsches Herzzentrum, Technische Universität, Lazarettstr 36, Múnich 80636, Alemania.
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Juwana YB, Suryapranata H, Ottervanger JP, De Luca G, van't Hof AWJ, Dambrink JHE, de Boer MJ, Gosselink ATM, Hoorntje JCA. Comparison of rapamycin- and paclitaxel-eluting stents in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction. Am J Cardiol 2009; 104:205-9. [PMID: 19576348 DOI: 10.1016/j.amjcard.2009.03.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 03/12/2009] [Accepted: 03/12/2009] [Indexed: 01/18/2023]
Abstract
Compared with bare metal stents, sirolimus- and paclitaxel-eluting stents (SESs and PESs, respectively) have been shown to improve angiographic and clinical outcomes after percutaneous coronary intervention (PCI) in elective patients and those with ST-elevation myocardial infarction (STEMI). The aim of the present study was to compare SESs with PESs in patients with STEMI undergoing primary PCI. Patients with STEMI were randomized 1:1 to receive SESs (n = 196) or PESs (n = 201). The primary end point was late lumen loss at 9-month follow-up by quantitative coronary angiography. Secondary end points were major adverse cardiac clinical events (death, reinfarction, target vessel revascularization) at 1 month and 9 and 12 months. Three hundred ninety-seven patients with STEMI were randomized. The 2 groups had comparable baseline clinical and angiographic characteristics. Mortality was low, 1.5% after 30 days, 2.3% after 9 months, and 3.1% after 1 year. There was no difference in any clinical outcome at any follow-up period between the 2 treatment groups. Follow-up angiography was completed in 272 of 397 patients (69%). Mean +/- SD in-stent late loss was 0.01 +/- 0.42 mm in the SES group versus 0.21 +/- 0.50 mm in the PES group (difference -0.20 mm, p = 0.001). In conclusion, in patients with STEMI, primary PCI with SESs results in less late loss compared with PESs. However, these benefits did not translate into a significant decrease in major adverse cardiac events at 1-year follow-up.
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Affiliation(s)
- Yahya B Juwana
- Cardiovascular Center, Hospital Cinere, Jakarta, Indonesia
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Fuchs AT, Kuehnl A, Pelisek J, Rolland PH, Mekkaoui C, Netz H, Nikol S. Meta-Analysis Shows Similar Risk of Thrombosis After Drug-Eluting Stent, Bare-Metal Stent, or Angioplasty. ACTA ACUST UNITED AC 2009; 15:93-100. [DOI: 10.1080/10623320802092534] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Bartorelli AL, Koh TH, Di Pede F, Reimers B, Thuesen L, Amann FW, Fabbiocchi F, Suryapranata H. Distal embolic protection during percutaneous coronary intervention in patients with acute coronary syndromes: The RUBY study. ACTA ACUST UNITED AC 2009; 8:148-54. [PMID: 17012129 DOI: 10.1080/17482940600931966] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess the safety and feasibility of the GuardWire system as an embolic protection device during percutaneous coronary intervention (PCI) in acute coronary syndromes (ACS). BACKGROUND Distal embolization occurs in approximately 15% of patients after primary angioplasty and is associated with reduced myocardial reperfusion, more extensive myocardial damage and a poor prognosis. Distal embolic protection could reduce the rate of embolic complications and improve outcome. METHODS 329 patients (mean age 60+/-12 years) were included: 278 (84.5%) with ST-elevation myocardial infarction (STEMI), 50 (15.2%) with unstable angina/non-STEMI and 1 (0.3%) with post-infarction angina. Primary endpoint was the incidence of major adverse cardiac events (MACE) at 30 days. Secondary endpoints were the magnitude of ST-segment resolution at 90 and 180 min post-procedure, myocardial blush grade, and angiographically visible distal emboli. RESULTS The GuardWire system was successfully positioned in 99% of patients. Complete ST-elevation resolution (>70%) was observed in 28.5% immediately post-procedure, and in 35.4% and 41.6% at 90 and 180 min post-procedure. TIMI-3 flow grade was achieved by 89.8% of patients after intervention and mean corrected TIMI frame count was 20.2+/-13.2. Grade-3 myocardial blush was seen in 47.7% of patients and distal emboli were angiographically visible in 7.4%. Incidence of MACE at 30 days was 3.3% (death 1.2%; Q-wave MI 0.3%; non-Q-wave MI 0.3%; coronary artery bypass graft 0.6%; repeat PCI 0.9%). CONCLUSION The GuardWire system was successfully positioned in nearly all patients without complications. The use of this embolic protection device in ACS patients undergoing PCI was associated with low rates of distal embolization and 30-day MACE.
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Affiliation(s)
- Antonio L Bartorelli
- Institute of Cardiology, University of Milan, Centro Cardiologico Monzino, Milan, Italy.
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Hong YJ, Jeong MH, Ahn Y, Sim DS, Chung JW, Cho JS, Yoon NS, Yoon HJ, Moon JY, Kim KH, Park HW, Kim JH, Cho JG, Park JC, Kang JC. Plaque prolapse after stent implantation in patients with acute myocardial infarction: an intravascular ultrasound analysis. JACC Cardiovasc Imaging 2009; 1:489-97. [PMID: 19356472 DOI: 10.1016/j.jcmg.2008.04.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2008] [Revised: 03/11/2008] [Accepted: 04/09/2008] [Indexed: 12/13/2022]
Abstract
OBJECTIVES The aim of this study was to assess the incidence, predictors, and outcome of plaque prolapse (PP) after stent implantation in acute myocardial infarction. BACKGROUND The imaging characteristics of PP in patients with acute myocardial infarction are not well known. METHODS Intravascular ultrasound (IVUS) imaging was performed in 310 patients immediately following stenting for their first acute myocardial infarction. Multiple clinical, angiographic and IVUS derived variables were compared among patients with and without intrastent PP. RESULTS The PP was detected in 27% of the 310 lesions examined. Stent length was longer (31 +/- 13 mm vs. 21 +/- 8 mm, p < 0.001), and positive remodeling (48% vs. 32%, p = 0.008), plaque rupture (51% vs. 31%, p = 0.001), and thrombus (40% vs. 21%, p = 0.001) were significantly more common in PP lesions compared with non-PP lesions. The creatine kinase-myocardial band (CK-MB) was significantly greater after stenting in PP lesions compared with non-PP lesions (Delta = +12.3 +/- 32.0 U/l vs. -4.9 +/- 46.1 U/l, p = 0.002). During a 1-month follow-up, the incidence of stent thrombosis was not significantly different between PP and non-PP lesions [2/85 (2.4%) vs. 2/225 (0.9%), p = 0.308]. Multivariate analysis showed that PP (odds ratio [OR]: 7.34, p < 0.001), plaque rupture (OR: 1.95, p = 0.023), and thrombus (OR: 1.84, p = 0.026) were independently associated with post-stenting CK-MB elevation, and stent length (OR: 2.39, p = 0.003), plaque rupture (OR: 1.96, p = 0.015), and positive remodeling (OR: 1.72, p = 0.044) were independently associated with the development of PP. CONCLUSIONS PP occurs in one-fourth of infarct-related arteries after stent implantation. Lesion characteristics such as plaque rupture and positive remodeling, together with longer stent predict PP. Although long-term follow-up is pending, PP is associated with more myonecrosis after stenting in patients with acute myocardial infarction.
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Affiliation(s)
- Young Joon Hong
- Heart Center of Chonnam National University Hospital, Cardiovascular Research Institute, Chonnam National University, Gwangju, Korea
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Percutaneous coronary intervention for ST-elevation myocardial infarction: drug-eluting stents or bare metal stents? Am J Ther 2009; 17:516-22. [PMID: 19451810 DOI: 10.1097/mjt.0b013e318199d6c7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The treatment paradigm for patients with an ST-elevation myocardial infarction (STEMI) has shifted greatly in the last 20 years. The use of fibrinolytic agents vastly altered the landscape in treating this entity and was further advanced by the introduction of percutaneous catheter-based methods of therapy. Percutaneous coronary intervention (PCI) has become the preferred method of treatment for patients with this condition when compared with thrombolytic agents as evidenced by a number of positive clinical trials. However, PCI in itself has had several adaptations over the last decade, namely in the shift from a balloon-only approach to the widespread usage of balloon-expandable metallic stents. The use of bare metal stents has proven to be more efficacious in regard to rates of repeat procedures when compared with the balloon-only approach and has become a standard in PCI for STEMI. The composition of the stents themselves had also undergone transformation as evidenced by the introduction of drug-eluting stents (DES). Although there have been encouraging data to support the use of DES in the elective setting, the use of these devices in primary PCI has been controversial. The pathologic milieu that is present in the STEMI setting is distinctly different than that seen in the elective, stable atherosclerotic setting and the use of DES has raised concerns over safety issues with their implementation. There have been a host of recent studies dedicated to elucidating the risk of using DES versus bare metal stents in the setting of STEMI and although the results have been generally favorable for the use of DES, this subject remains one that is under significant scrutiny.
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Yoshida S, Nakamura S, Sugiura T, Tsuka Y, Maeba H, Yuasa F, Senoo T, Takehana K, Baden M, Iwasaka T. Factors associated with myocardial salvage immediately after emergent percutaneous coronary intervention in patients with ST-elevation acute myocardial infarction. Ann Nucl Med 2009; 23:383-90. [DOI: 10.1007/s12149-009-0253-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Accepted: 02/05/2009] [Indexed: 11/28/2022]
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Rasoul S, Ottervanger JP, de Boer MJ, Dambrink JHE, Hoorntje JC, Gosselink AM, Zijlstra F, Suryapranata H, van 't Hof AW. Primary percutaneous coronary intervention for ST-elevation myocardial infarction: From clinical trial to clinical practice. Int J Cardiol 2009; 134:104-9. [DOI: 10.1016/j.ijcard.2008.01.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2007] [Revised: 01/07/2008] [Accepted: 01/20/2008] [Indexed: 11/30/2022]
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Celik T, Iyisoy A, Kardesoglu E, Isik E. Stenting versus plain old angioplasty in patients with ST segment elevation myocardial infarction: understanding of the randomized trials. Int J Cardiol 2009; 133:394-6; author reply 396. [PMID: 18077019 DOI: 10.1016/j.ijcard.2007.08.090] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Accepted: 08/10/2007] [Indexed: 11/27/2022]
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Iijima R, Byrne RA, Dibra A, Ndrepepa G, Spaulding C, Laarman GJ, Menichelli M, Valgimigli M, Di Lorenzo E, Kaiser C, Tierala I, Mehilli J, Suttorp MJ, Violini R, Schömig A, Kastrati A. Stents liberadores de fármacos frente a stents convencionales en pacientes diabéticos con infarto agudo de miocardio con elevación del segmento ST: un análisis combinado de los datos de pacientes individuales de 7 ensayos aleatorizados. Rev Esp Cardiol 2009. [DOI: 10.1016/s0300-8932(09)70892-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hong YJ, Jeong MH, Choi YH, Ko JS, Lee MG, Kang WY, Lee SE, Kim SH, Park KH, Sim DS, Yoon NS, Youn HJ, Kim KH, Park HW, Kim JH, Ahn Y, Cho JG, Park JC, Kang JC. Impact of plaque components on no-reflow phenomenon after stent deployment in patients with acute coronary syndrome: a virtual histology-intravascular ultrasound analysis. Eur Heart J 2009; 32:2059-66. [PMID: 19228713 PMCID: PMC3155758 DOI: 10.1093/eurheartj/ehp034] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Aims We used virtual histology-intravascular ultrasound (VH-IVUS) to evaluate the relation between coronary plaque characteristics and no-reflow in acute coronary syndrome (ACS) patients. Methods and results A total of 190 consecutive ACS patients were imaged using VH-IVUS and analysed retrospectively. Angiographic no-reflow was defined as TIMI flow grade 0, 1, and 2 after stenting. Virtual histology-intravascular ultrasound classified the colour-coded tissue into four major components: fibrotic, fibro-fatty, dense calcium, and necrotic core (NC). Thin-cap fibroatheroma (TCFA) was defined as focal, NC-rich (≥10% of the cross-sectional area) plaques being in contact with the lumen in a plaque burden ≥40%. Of the 190 patients studied at pre-stenting, no-reflow was observed in 24 patients (12.6%) at post-stenting. The absolute and %NC areas at the minimum lumen sites (1.6 ± 1.2 vs. 0.9 ± 0.8 mm2, P < 0.001, and 24.5 ± 14.3 vs. 16.1 ± 10.6%, P = 0.001, respectively) and the absolute and %NC volumes (30 ± 24 vs. 16 ± 17 mm3, P = 0.001, and 22 ± 11 vs. 14 ± 8%, P < 0.001, respectively) were significantly greater, and the presence of at least one TCFA and multiple TCFAs within culprit lesions (71 vs. 36%, P = 0.001, and 38 vs. 15%, P = 0.005, respectively) was significantly more common in the no-reflow group compared with the normal-reflow group. In the multivariable analysis, %NC volume was the only independent predictor of no-reflow (odds ratio = 1.126; 95% CI 1.045–1.214, P = 0.002). Conclusion In ACS patients, post-stenting no-reflow is associated with plaque components defined by VH-IVUS analysis with larger NC and more TCFAs.
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Affiliation(s)
- Young Joon Hong
- Heart Center of Chonnam National University Hospital, Chonnam National University Research Institute of Medical Sciences, 671 Jaebongro, Dong-gu, Gwangju 501-757, Republic of Korea
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De Luca G, Suryapranata H, van't Hof AWJ, Ottervanger JP, Hoorntje JCA, Dambrink JH, Gosselink ATM, de Boer MJ. Routine stenting vs. balloon angioplasty in ST-segment elevation myocardial infarction due to proximal left anterior descending coronary artery occlusion. J Cardiovasc Med (Hagerstown) 2009; 10:22-6. [PMID: 19145115 DOI: 10.2459/jcm.0b013e32830a48d2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Primary angioplasty has been shown to improve the outcome in selected patients with ST-segment elevation myocardial infarction. However, no data have been reported of patients with proximal left anterior descending artery occlusion. In the Zwolle-6 randomized trial, a total of 1683 consecutive patients with ST-segment elevation myocardial infarction were randomized to stenting or balloon angioplasty without any exclusion criteria. The aim of this substudy was to investigate the benefits of coronary stenting as compared to balloon angioplasty in patients with proximal left anterior descending artery occlusion. METHODS From April 1997 to October 2001, among a total of 1683 consecutive patients with ST-segment elevation myocardial infarction randomized to stenting or balloon angioplasty before the initial angiography, a total of 218 patients underwent primary angioplasty of proximal left anterior descending artery occlusion. One-year follow-up data were available from all patients. RESULTS A total of 107 patients were randomized to stent and 111 patients to balloon angioplasty. The cross-over rates from balloon to stent and stent to balloon were 35.1 and 13.1%, respectively (P<0.0001). The groups were comparable in terms of postprocedural thrombolysis in myocardial infarction flow, myocardial blush grade, distal embolization, and ST-segment resolution. Stenting was associated with benefits in terms of restenosis (27.6 vs. 53.8%, P=0.03) and target vessel revascularization (15.0 vs. 24.3%, P=0.081), whereas no difference was observed in mortality (11.2 vs. 13.5%, P>0.1) and reinfarction (11.2 vs. 8.1%, P>0.1) as compared with balloon angioplasty. CONCLUSION As compared with balloon angioplasty, routine stenting does reduce angiographic restenosis, without significant benefits in terms of death and reinfarction among patients undergoing primary angioplasty for ST-segment elevation myocardial infarction due to proximal left anterior descending artery occlusion.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology and Centro di Biotecnologie per la Ricerca Medica Applicata (BRMA), Eastern Piedmont University, Novara, Italy.
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Ino Y, Kubo T, Tomobuchi Y, Oshika H, Kitabata H, Obana M, Tanimoto T, Takarada S, Tanaka A, Imanishi T, Okamura Y, Akasaka T. Branch Segment Occlusion With Acute Myocardial Infarction is a Risk for Left Ventricular Free Wall Rupture. Circ J 2009; 73:1473-8. [DOI: 10.1253/circj.cj-08-1112] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yasushi Ino
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takashi Kubo
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Hiroyuki Oshika
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Masahiro Obana
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Takashi Tanimoto
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Shigeho Takarada
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Atsushi Tanaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Toshio Imanishi
- Department of Cardiovascular Medicine, Wakayama Medical University
| | | | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
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De Luca G, Suryapranata H, Stone GW, Antoniucci D, Biondi-Zoccai G, Kastrati A, Chiariello M, Marino P. Coronary stenting versus balloon angioplasty for acute myocardial infarction: A meta-regression analysis of randomized trials. Int J Cardiol 2008; 126:37-44. [PMID: 17544528 DOI: 10.1016/j.ijcard.2007.03.112] [Citation(s) in RCA: 93] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Revised: 02/21/2007] [Accepted: 03/28/2007] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Although stenting has been shown to reduce the need for target vessel revascularization (TVR) in acute myocardial infarction (AMI), the benefits in terms of mortality and reinfarction are still unclear. Previous meta-analyses have failed to include all currently available randomized trials. The aim of the current study was to perform an updated meta-analysis to evaluate the benefits of coronary stenting for AMI in terms of mortality, reinfarction, and TVR, and whether these benefits correlated with the patient's risk profile. METHODS The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL) from January 1990 to September 2006. We examined all completed, published, randomized trials of coronary stenting for AMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, rescue angioplasty, stenting, and balloon angioplasty. Information on study design, type of stent, inclusion and exclusion criteria, primary endpoint, number of patients, angiographic and clinical outcome, were extracted by two investigators. Disagreements were resolved by consensus. RESULTS A total of 13 randomized trials were identified and analyzed involving 6922 patients (3460 or 50% randomized to stent and 3462 or 50% to balloon). Stenting was not associated with a significant reduction in 30-day (2.9% versus 3.0%, p=0.81) and 1-year mortality (5.1% versus 5.2%, p=0.81), as compared to balloon angioplasty. However, a significant relationship was observed between patient's risk profile and mortality benefits from coronary stenting at 30-day (beta -0.63 [-25.4; -2.45], p=0.022) and 1-year follow-up (beta -0.61 [-15.9; -0.76], p=0.034). Stenting was associated with benefits in terms of TVR at both 30-day (3.1% versus 5.1%, p<0.0001) and 6 to 12 months (11.3% versus 18.4%, p<0.0001) follow-up, without any difference in terms of reinfarction. CONCLUSIONS Among AMI patients undergoing primary angioplasty, coronary stent implantation, when anatomically and technically feasible, may be considered, in addition to benefits in terms of TVR, to reduce mortality in high-risk patients, who may be identified by the use of validated risk scores.
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Affiliation(s)
- Giuseppe De Luca
- Division of Cardiology, Maggiore della Carità Hospital, Eastern Piedmont University, C.So Mazzini, 18, 24100 Novara, Italy.
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Efficacy and safety of drug-eluting stents in ST-segment elevation myocardial infarction: a meta-analysis of randomized trials. Int J Cardiol 2008; 133:213-22. [PMID: 18394731 DOI: 10.1016/j.ijcard.2007.12.040] [Citation(s) in RCA: 75] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Revised: 12/11/2007] [Accepted: 12/14/2007] [Indexed: 11/20/2022]
Abstract
BACKGROUND Recent concerns have emerged on the potential higher risk of stent thrombosis after DES implantation, that might be even more pronounced among STEMI patients. Thus, the aim of the current study was to perform a meta-analysis to evaluate the benefits and safety of DES as compared to BMS in patients undergoing primary angioplasty for STEMI. METHODS The literature was scanned by formal searches of electronic databases (MEDLINE and CENTRAL). We examined all completed randomized trials of DES for STEMI. The following key words were used for study selection: randomized trial, myocardial infarction, reperfusion, primary angioplasty, stenting, DES, sirolimus-eluting stent (SES), Cypher, paclitaxel-eluting stent (PES), Taxus. Information on study design, type of stent, inclusion and exclusion criteria, primary endpoint, number of patients, angiographic and clinical outcome, were extracted by two investigators. Disagreements were resolved by consensus. RESULTS A total of 11 trials were included in the meta-analysis, involving 3605 patients (1888 or 52.3% randomized to DES and 1719 or 47.7% randomized to BMS). At 12 months follow-up, no significant difference was observed in mortality (4.1% vs 4.4%, OR [95% CI]=0.91 [0.66-1.27], p=0.59, reinfarction (3.1% vs 3.4%, OR [95% CI]=0.85 [0.58, 1.23], p=0.38 or stent thrombosis (1.6% vs 2.2%, OR [95% CI]=0.76 [0.47, 1.23], p=0.22), whereas DES were associated with a significant reduction in TVR (5.0% vs 12.6%, OR [95% CI]=0.36 [0.28, 0.47], p<0.0001). Safety and efficacy of DES were confirmed at 18 to 24 months follow-up (data available from 4 trials including 1178 patients). CONCLUSIONS This meta-analysis shows that among selected STEMI patients undergoing primary angioplasty, SES and PES, as compared to BMS, are safe and associated with a significant reduction in TVR at 1 and 2 years follow-up.
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Sianos G, Papafaklis MI, Daemen J, Vaina S, van Mieghem CA, van Domburg RT, Michalis LK, Serruys PW. Reply. J Am Coll Cardiol 2008. [DOI: 10.1016/j.jacc.2007.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Reperfusion Strategies in Acute ST-Elevation Myocardial Infarction: An Overview of Current Status. Prog Cardiovasc Dis 2008; 50:352-82. [DOI: 10.1016/j.pcad.2007.11.004] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Svilaas T, van der Horst ICC, Zijlstra F. A quantitative estimate of bare-metal stenting compared with balloon angioplasty in patients with acute myocardial infarction: angiographic measures in relation to clinical outcome. Heart 2007; 93:792-800. [PMID: 17569804 PMCID: PMC1994459 DOI: 10.1136/hrt.2006.093740] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We performed a systematic review of all randomised controlled trials (RCTs) from the pre-drug-eluting-stent era comparing bare-metal stenting (BMS) with balloon angioplasty in patients with acute myocardial infarction (MI) to examine coronary angiographic parameters of infarct-related vessel patency and to relate the angiographic measures to clinical outcome. The search was restricted to published RCTs in humans. 10 RCTs, (6192 patients) were analysed. Compared with balloon angioplasty, BMS was associated with reduced rates of reocclusion (6.7% vs 10.1%, OR 0.62, 95% CI 0.40 to 0.96, p = 0.03) and restenosis (23.9% vs 39.3%, OR 0.45, 95% CI 0.34 to 0.59, p<0.001), but not with reduced rates of subacute thrombosis (1.7% in both groups). BMS showed a reduction in target vessel revascularisation (TVR; 12.2% vs 19.2%, OR 0.50, 95% CI 0.37 to 0.69, p<0.001), but not in mortality (5.3% vs 5.1%) or reinfarction (3.9% vs 4%). The findings of this study support BMS placement in acute MI. The discrepancy between angiographic and clinical parameters has important implications for future studies investigating further technical improvements in mechanical reperfusion therapy.
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Affiliation(s)
- Tone Svilaas
- Thoraxcenter, Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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De Luca G, Suryapranata H, Ottervanger JP, van 't Hof AWJ, Hoorntje JCA, Dambrink JH, Gosselink ATM, de Boer MJ. Comparison between stenting and balloon in elderly patients undergoing primary angioplasty for ST-segment elevation myocardial infarction. Int J Cardiol 2007; 119:306-9. [PMID: 17276529 DOI: 10.1016/j.ijcard.2006.07.143] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2006] [Revised: 07/18/2006] [Accepted: 07/29/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Coronary stenting has been shown to improve clinical outcome in comparison with balloon angioplasty in patients with ST-segment elevation myocardial infarction (STEMI). However, few data have been reported so far in the elderly. Thus, the aim of the current study was to evaluate the benefits from routine stenting in this high-risk subset of patients. METHODS In the Zwolle-6 randomized trial a total of 1683 consecutive patients with STEMI was randomized to stenting or balloon angioplasty without any exclusion criteria. One year follow-up data were available from all patients. RESULTS Among a total of 143 patients older than 75 years, 73 were randomized to stent and 67 to balloon angioplasty. No difference was observed in 1-year mortality (17.1% vs 11.9%, p=NS), reinfarction (9.2% vs 11.9%, p=NS), target vessel revascularization (15.8% vs 14.9%, p=NS) or major adverse cardiac events (28.9% vs 26.9%, p=NS) between the groups at 1-year follow-up. CONCLUSION In conclusion, our study showed that as compared to balloon angioplasty, the clinical benefits of routine coronary stenting in the setting of acute myocardial infarction may not be necessarily applicable to elderly patients.
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Affiliation(s)
- Giuseppe De Luca
- Divison of Cadiology, Ospedale Maggiore della Carità, Università del Piemonte Orientale A. Avogadro, Novara, Italy
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Barbagelata A, Perna ER, Clemmensen P, Uretsky BF, Canella JPC, Califf RM, Granger CB, Adams GL, Merla R, Birnbaum Y. Time to reperfusion in acute myocardial infarction. It is time to reduce it! J Electrocardiol 2007; 40:257-64. [PMID: 17478179 DOI: 10.1016/j.jelectrocard.2007.01.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2006] [Revised: 01/26/2007] [Accepted: 01/30/2007] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVES Mortality from ST-segment elevation myocardial infarction remains high, with most deaths occurring before hospital admission. Despite effective pre- and in-hospital reperfusion strategies becoming standard over the past 2 decades, time-to-admission and time-to-treatment remain prolonged. We reviewed temporal trends in these times in published clinical trials. METHODS All major randomized clinical trials reporting on reperfusion strategies for acute myocardial infarction published between 1993 and 2003 were evaluated. Strategies included pre- and in-hospital thrombolysis, primary percutaneous coronary intervention (pPCI) with or without transfer, and "facilitated" PCI. We generated overall estimates of time-to-admission, time-to-treatment, door-to-balloon (DTB), and door-to-needle (DTN) times and evaluated temporal trends in the length of time-to-admission and time-to-treatment. RESULTS In studies that evaluated only in-hospital thrombolysis, the time-to-admission was 149 +/- 45 minutes; the mean time-to-treatment was 181 +/- 29 minutes. In studies that considered only in-hospital pPCI (without transfer), the mean time-to-admission was 153 +/- 41 minutes; the mean time-to-treatment was 234 +/- 43 minutes. In studies that compared in-hospital pPCI with in-hospital thrombolytic therapy, the mean time-to-admission was 155 +/- 47 and 150 +/- 48 minutes, respectively. The DTN time was 65 +/- 10 minutes, whereas DTB time was 81 +/- 39 minutes. In other trials evaluating in-hospital thrombolysis and pPCI with transfer to a referral center, the time-to-admission in subjects treated with thrombolysis (n = 1345) was 127 +/- 32 minutes vs 131 +/- 36 minutes for pPCI (n = 1528). For in-hospital thrombolysis, time-to-treatment was 151 +/- 23 minutes vs 203 +/- 15 minutes for pPCI patients with transfer. The DTN time in the thrombolysis group was 44 +/- 28 minutes as compared with DTB time of 78 +/- 38 minutes in the pPCI group. Throughout the last decade, time-to-admission decreased significantly (P = .02) but time-to-treatment remained unchanged (P = .38) for patients undergoing thrombolysis. In the pPCI arm, time-to-admission remained unchanged (P = .11) but a insignificant trend toward reduction was demonstrated in time-to-treatment (P = .11). CONCLUSION Time-to-admission and time-to-treatment for ST-segment elevation myocardial infarction are still prolonged. Resources should be directed to early recognition of the acute myocardial infarction, improved utilization of emergency services for transportation, and prehospital diagnosis and triaging. Ambulances equipped with wireless capability to transmit electrocardiograms to the on-call cardiologist seem to be promising tools to achieve earlier diagnosis and triaging with high diagnostic sensitivity and specificity.
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Srinivas VS, Skeif B, Negassa A, Bang JY, Shaqra H, Monrad ES. Effectiveness of glycoprotein IIb/IIIa inhibitor use during primary coronary angioplasty: results of propensity analysis using the New York State Percutaneous Coronary Intervention Reporting System. Am J Cardiol 2007; 99:482-5. [PMID: 17293189 DOI: 10.1016/j.amjcard.2006.08.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 08/24/2006] [Accepted: 08/24/2006] [Indexed: 11/19/2022]
Abstract
Patients undergoing primary angioplasty in clinical practice experience a higher risk for adverse events than those enrolled in clinical trials. Whether glycoprotein (GP) IIb/IIIa inhibitor use during primary angioplasty is both safe and effective in real life is unknown. Therefore, we examined the pattern of GP IIb/IIIa use and its effectiveness in a large population-based cohort of 7,321 patients who underwent primary angioplasty in New York State. Propensity analysis was used to account for the nonrandomized use of GP IIb/IIIa inhibitors. Overall, 78.5% of patients who underwent primary angioplasty received GP IIb/IIIa inhibitors. In-hospital mortality was significantly lower with GP IIb/IIIa use (3% vs 6.2%, p <0.0001) after adjustment for both propensity score (odds ratio 0.57, 95% confidence interval 0.44 to 0.74, p <0.0001) and the combination of propensity score and clinical characteristics (odds ratio 0.63, 95% confidence interval 0.45 to 0.88, p = 0.006). Patients with older age and higher Mayo Clinic Risk Score (MCRS) received GP IIb/IIIa inhibitors less often. However, stratified analysis of patients with low to moderate risk (MCRS <12) versus high risk (>or=12) demonstrated that GP IIb/IIIa use lowered risk of mortality both in low- to moderate-risk (1.39% vs 3.23%, p <0.0001) and high-risk patients (16.15% vs 22.41%, p = 0.03). In conclusion, adjunct GP IIb/IIIa inhibitor use during primary angioplasty is effective and associated with improved in-hospital survival rates.
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Muramatsu T, Kozuma K, Tsukahara R, Ito Y, Fujita N, Suwa S, Koyama S, Saitoh M, Kamiya H, Nakamura M. Comparison of myocardial perfusion by distal protection before and after primary stenting for acute myocardial infarction: Angiographic and clinical results of a randomized controlled trial. Catheter Cardiovasc Interv 2007; 70:677-82. [PMID: 17621653 DOI: 10.1002/ccd.21190] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES To assess the myocardium-reperfusing effect of a distal protection device, GuardWire Plus (GuardWire Plus), in patients with acute myocardial infarction (AMI). BACKGROUND Distal embolization may result in reduced myocardial perfusion, increasing the risk of non-Q-wave myocardial infarction and death. Distal protection devices may protect the microcirculation from embolic debris, improving short- and long-term clinical outcomes. METHODS From February 2002 to July 2003, a total of 341 AMI patients at 22 institutions in Japan were enrolled in the present, multicenter, prospective, randomized trial. Patients experiencing AMI within 12 hr of symptom onset, who were considered treatable by stenting and who met the inclusion criteria, were eligible for randomization. Stenting with and without GuardWire Plus was conducted to examine whether the device provides faster and more complete ST-segment resolution, smaller infarct size, and improved myocardial blush score. RESULTS The rates of slow flow and no-reflow immediately after PCI were 5.3 and 11.4% in the GuardWire Plus and control groups, respectively (P = 0.05). Blush score 3 acquisition rates immediately after PCI were 25.2 and 20.3% in the GuardWire Plus and control groups, respectively (P = 0.26), and the rates at 30 days after PCI were 42.9 and 30.4%, respectively (P = 0.035). CONCLUSIONS A significant difference was found between the GuardWire Plus and control groups with respect to the total incidence of distal embolization, indicating that GuardWire Plus angiographically improved myocardial perfusion without demonstrating the preventive effect of myocardial damage.
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Wilson JM, Ferguson JJ, Hall RJ. Coronary Artery Bypass Surgery and Percutaneous Coronary Revascularization: Impact on Morbidity and Mortality in Patients with Coronary Artery Disease. CARDIOVASCULAR MEDICINE 2007. [DOI: 10.1007/978-1-84628-715-2_50] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Rasoul S, Ottervanger JP, Dambrink JHE, Boer MJD, Hoorntje JCA, Gosselink ATM, Zijlstra F, Suryapranata H, van 't Hof AWJ. External validity of ST elevation myocardial infarction trials: The Zwolle studies. Catheter Cardiovasc Interv 2007; 69:632-6. [PMID: 17253599 DOI: 10.1002/ccd.21013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Guidelines are mainly based upon results of randomised controlled clinical trials. However, due to low external validity of these trials, their results can not reasonably be applied to all patients in routine practice. In our hospital, all patients with ST-elevation myocardial infarction (STEMI) are eligible for inclusion in one of our ongoing trials or registries. To asses differences between patients enrolled versus not-enrolled in a trial or registry, we evaluated all patients with a discharge diagnose of STEMI during the study period. METHODS Retrospectively, individual patient data from all patients with a discharge diagnosis of STEMI between Jan 2001 and Dec 2001 were evaluated. Follow-up data were obtained until Dec 2004. RESULTS A total of 583 patients were discharged with a diagnosis of STEMI. About 455 (78%) patients were enrolled in one of the ongoing clinical trials or registry and 128 were not. Not-enrolled patients were significantly older; more often had a history of previous MI and had higher risk profiles. Multivariate analysis revealed that higher age was the only independent predictor for non enrollment. Not-enrolled patients were more often treated conservatively and had a higher mortality rate (36% vs. 6%, P << 0.001). After multivariate analysis, non-enrollment (OR: 95% CI) 4.02 (1.98-8.16), age 1.07 (1.04-1.12), and diabetes 2.39 (1.17-4.89) were the only independent predictors of long term mortality. CONCLUSIONS This study shows important differences in baseline characteristics, treatment, and prognosis between patients with STEMI who were enrolled or not in a trial. To better reflect daily clinical practice, guidelines should also consider results of observational studies of unselected patients.
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Affiliation(s)
- Saman Rasoul
- Isala Klinieken, Department of Cardiology, Zwolle, The Netherlands
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De Luca G, Suryapranata H, van 't Hof AWJ, Ottervanger JP, Hoorntje JCA, Dambrink JH, Gosselink ATM, de Boer MJ. Comparison between stenting and balloon angioplasty in patients undergoing primary angioplasty of small coronary vessels. Am Heart J 2006; 152:915-20. [PMID: 17070158 DOI: 10.1016/j.ahj.2006.05.023] [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] [Received: 11/03/2005] [Accepted: 05/15/2006] [Indexed: 01/18/2023]
Abstract
BACKGROUND Primary angioplasty has been shown to improve outcomes in selected patients with ST-segment elevation myocardial infarction. However, no information has been reported so far in small vessels. In the Zwolle-6 randomized trial, consecutive patients with ST-segment elevation myocardial infarction were randomized to stenting or to balloon angioplasty without any exclusion criterion. In this study, we present data on patients with small vessels (< 3.0 mm). METHODS From April 1997 to October 2001, 798 patients randomized to balloon angioplasty or to stenting before their initial angiogram underwent primary angioplasty of small vessels, defined according to a postprocedural reference diameter < or = 3 mm. One-year follow-up data were available from all patients. RESULTS Three hundred eighty-seven patients were randomized to stent, whereas 411 were to balloon. The crossover rates from balloon to stent and from stent to balloon were 28% and 13.9%, respectively (P < .001). The groups were comparable in terms of postprocedural TIMI flow, myocardial blush grade, distal embolization, and ST-segment resolution. No difference was observed in 1-year mortality (7.2% vs 5.8%, P = not significant [NS]), target vessel revascularization (17.8% vs 22.1%, P = NS), and major adverse cardiac events (24.8% vs 29.0%, P = NS) between the groups. CONCLUSIONS As compared with balloon angioplasty, routine stenting does not seem to improve clinical outcomes in patients undergoing primary angioplasty of small vessels. Future trials are certainly needed to evaluate the safety and benefits of drug-eluting stents in this high-risk subset of patients.
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Affiliation(s)
- Giuseppe De Luca
- Department of Cardiology, ISALA Klinieken, Hospital De Weezenlanden, Zwolle, The Netherlands
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De Luca G, Ernst N, van 't Hof AWJ, Ottervanger JP, Hoorntje JCA, Gosselink ATM, Dambrink JHE, de Boer MJ, Suryapranata H. Predictors and clinical implications of early reinfarction after primary angioplasty for ST-segment elevation myocardial infarction. Am Heart J 2006; 151:1256-9. [PMID: 16781232 DOI: 10.1016/j.ahj.2005.06.047] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2005] [Accepted: 06/28/2005] [Indexed: 11/23/2022]
Abstract
BACKGROUND Recurrent infarction after fibrinolytic therapy has been shown to be associated with increased mortality. The aim of this study was to analyze predictors and outcome of reinfarction in a consecutive series of patients undergoing primary angioplasty. METHODS Our population is represented by a total of 1955 patients with ST-segment elevation myocardial infarction treated by primary angioplasty between 1997 to 2002. All clinical, angiographic, and follow-up data were prospectively collected. Early reinfarction was defined when two clinical criteria were satisfied within 30 days after the procedure: (1) recurrent ischemic symptoms for >15 minutes after resolution of symptoms from initial MI; (2) new ST-T-wave changes or new Q waves; (3) reelevation in creatine kinase (CK) or CK-MB to higher levels than normal (or by another 20% if already higher than normal). RESULTS Early reinfarction was observed in 75 (3.8%) patients. At multivariate analysis, advanced Killip class (P = .002), poor preprocedural TIMI flow (P = .014), administration of IIb-IIIa inhibitors (P = .02), and diabetes (P = .038) were independent predictors of 30-day reinfarction. A total of 107 (5.6%) patients had died. Early reinfarction was associated with a significantly higher mortality (22.7% vs 4.9%, P < .001), even after adjustment for confounding factors (blood pressure, diabetes, Killip class, preprocedural TIMI flow, coronary stenting, multivessel disease, anterior infarct location, preprocedural stenosis, and administration of IIb-IIIa inhibitors) (HR 3.32, 95% CI 1.88-5.84, P < .0001). CONCLUSIONS This study showed that, among patients undergoing primary angioplasty for ST-segment elevation myocardial infarction, advanced Killip class at presentation, poor preprocedural TIMI flow, the use of IIb-IIIa inhibitors, and diabetes are independently associated with 30-day reinfarction. Early reinfarction is an independent predictor of 1-year mortality.
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Affiliation(s)
- Giuseppe De Luca
- Department of Cardiology, ISALA Klinieken, Hospital De Weezenlanden, Zwolle, The Netherlands
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De Luca G, Suryapranata H, van 't Hof AWJ, Ottervanger JP, Hoorntje JCA, Dambrink JH, Gosselink ATM, de Boer MJ. Impact of routine stenting on myocardial perfusion and the extent of myocardial necrosis in patients undergoing primary angioplasty for ST-segment elevation myocardial infarction. Am Heart J 2006; 151:1296.e1-6. [PMID: 16781239 DOI: 10.1016/j.ahj.2005.12.026] [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] [Received: 08/31/2005] [Accepted: 12/14/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary stenting for ST-segment elevation myocardial infarction (STEMI) has been shown to improve the outcome because of the benefits in terms of restenosis. However, still controversial are the benefits in terms of reperfusion. In the Zwolle-6 randomized trial, a consecutive cohort of patients with STEMI was randomized to balloon angioplasty or stenting, without exclusion criteria. In this study, we analyzed data on myocardial perfusion and the extent of myocardial necrosis. METHODS From April 1997 to October 2001, a total of 1683 consecutive patients with STEMI were randomized to stenting or balloon angioplasty. No exclusion criteria were applied. Myocardial perfusion was evaluated by myocardial blush grade and ST-segment resolution. The extent of myocardial necrosis was evaluated by enzymatic infarct size and predischarge ejection fraction. All data were prospectively collected. RESULTS A total of 785 patients (92.5%) in the stent group and 763 patients (91.5%) in balloon group underwent primary angioplasty. The 2 groups showed similar baseline characteristics. No difference was observed between stent and balloon in myocardial blush grade, complete ST-segment resolution, distal embolization, enzymatic infarct size, and predischarge ejection fraction at both intention-to-treat and actual treatment analysis, even when restricted to patients with anterior infarction. Time delay to treatment (earlier or later than 6 hours) did not affect the results. No difference was observed in 1-year mortality (6.0% vs 5.9%, P = NS). CONCLUSIONS As compared with balloon angioplasty, routine stenting does not improve myocardial perfusion, the rate of distal embolization, and the extent of myocardial necrosis in a large cohort of unselected patients with STEMI.
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Affiliation(s)
- Giuseppe De Luca
- Department of Cardiology, ISALA Klinieken, Hospital De Weezenlanden, Zwolle, The Netherlands
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