Clinical outcome of patients with ST-elevation myocardial infarction and angiographic evidence of coronary artery ectasia

OBJECTIVES

The aim of this study was to describe the prevalence of coronary artery ectasia (CAE) in patients with ST-elevation myocardial infarction (STEMI) and to compare the long-term outcome of subjects with and without CAE undergoing emergent coronary angiography.

BACKGROUND

The prognostic impact of CAE in STEMI patients has been poorly investigated.

METHODS

This retrospective, single-center, study included consecutive patients with STEMI undergoing emergent coronary angiography from January 2012 to December 2017. The primary endpoint was the assessment of recurrent myocardial infarction (MI) in patients with versus those without CAE at the longest available follow-up. The propensity score weighting technique was employed to account for potential selection bias between groups.

RESULTS

From 1,674 patients with STEMI, 154 (9.2%) had an angiographic evidence of CAE; 380 patients were included in the no CAE group. CAE patients were more often males and smokers, and showed a lower prevalence of diabetes than no CAE patients. After percutaneous coronary intervention, the corrected thrombolysis in MI frame count (p < .001) and the myocardial blush grade (p < .001) were significantly lower in CAE than in no CAE patients. The mean follow-up was 1,218.3 ± 574.8 days. The adjusted risk for the primary outcome resulted significantly higher in patients with CAE compared to those without (adjusted HR: 1.84; p = .017). No differences in terms of all-cause and cardiac death were found between groups.

CONCLUSIONS

In this study, STEMI patients with CAE had a distinct clinical and angiographic profile, and showed a significantly higher risk of recurrent MI than those without CAE.

One-year clinical outcome of biodegradable polymer sirolimus-eluting stent in diabetic patients: Insight from the ULISSE registry (ULtimaster Italian multicenter all comerS Stent rEgistry)

BACKGROUND

The ULISSE registry evaluated the real-world performance of the Ultimaster® biodegradable polymer sirolimus-eluting stent (BP-SES) in a multicenter-independent cohort of patients undergoing percutaneous coronary intervention, including a large proportion of diabetes mellitus (DM) patients.

METHODS

In this subgroup analysis, 1,660 consecutive patients, 2,422 lesions, treated with BP-SES enrolled in the ULISSE registry were divided in two groups: DM (485 patients, 728 lesions) and non-DM (1,175 patients, 1,694 lesions). Primary endpoint was target lesion failure (TLF), a composite endpoint of cardiac-death, target-vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (TLR) at 1-year. Secondary endpoint was TLR at 1-year.

RESULTS

At 1-year follow-up TLF occurred in 5% overall patients and was significantly higher in DM patients (8 vs. 3.7%; p = .001), due to more cardiac deaths (3.4 vs. 1.1%; p = .002). TLR occurred in 3.2% overall patients, and it was not significantly higher in DM compared to non-DM patients (4.4 vs. 2.8%; p = .114). The incidence of stent thrombosis was low and similar between groups (0.4 vs. 0.9%; p = .526). Insulin-treated DM (ITDM) patients showed higher rate of TLF as compared to non-ITDM patients (13 vs. 6.5%; p = .041), but similar rate of TLR (6 vs. 4%; p = .405). After adjustment for relevant comorbidities, DM was not significantly associated with TLF or cardiac death in patients undergoing BP-SES implantation.

CONCLUSIONS

This study is the first all-comers evaluation of BP-SES in DM patients. Our findings show that DM patients, mostly those with ITDM, still represent a vulnerable population and experience significantly higher rate of TLF. Overall BP-SES efficacy is considerable, although not statistically significant higher rate of TLR is still present in DM compared to non-DM patients.

Outcomes of the amphilimus-eluting polymer-free stent for chronic total occlusion treatment: a multicentre experience

AIMS

Late stent thrombosis and delayed vessel wall healing remain an important issue in coronary vessels treated with drug-eluting stents (DES), especially when long-vessel segments need to be covered, like in chronic total occlusions (CTO). Avoiding polymer use to avoid chronic inflammatory responses is a potential solution to reduce target vessel failure (TVF). We aimed to validate the clinical safety and efficacy at 1 year of the polymer-free Cre8 DES vs. nonpolymer-free DES for the percutaneous treatment of CTO.

METHODS

Between September 2011 and August 2016, patients were prospectively enrolled in three CTO centres. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), including cardiac death, any myocardial infarction, stent thrombosis, TVF and target vessel revascularization.

RESULTS

A total of 102 Cre8 and 133 non-Cre8 patients were enrolled. At 1 year, a low cumulative MACCE was observed in the Cre8 group (6.9%, respectively). Moreover, a numerical trend towards better MACCE was observed in the Cre8 group vs. the non-Cre8 group (6.9 vs. 14.3%; P = 0.065). The clinically driven TVF rate was not statistically different between Cre8 and non-Cre8 patients (6.9 vs. 9.8%; P = 0.373). A borderline significant difference regarding mortality was observed in favour of Cre8 patients (0 vs. 3.8%; P = 0.049).

CONCLUSION

Low rates of MACCE and TVF up to 1 year were observed in the Cre8 group, supportive of the use of polymer-free DES for lesions with high complexity.

β2-Adrenergic receptor stimulation improves endothelial progenitor cell-mediated ischemic neoangiogenesis

RATIONALE

Endothelial progenitor cells (EPCs) are present in the systemic circulation and home to sites of ischemic injury where they promote neoangiogenesis. β2-Adrenergic receptor (β2AR) plays a critical role in vascular tone regulation and neoangiogenesis.

OBJECTIVE

We aimed to evaluate the role of β2AR on EPCs' function.

METHODS AND RESULTS

We firstly performed in vitro analysis showing the expression of β2AR on EPCs. Stimulation of wild-type EPCs with β-agonist isoproterenol induced a significant increase of Flk-1 expression on EPCs as assessed by fluorescence-activated cell sorter. Moreover, β2AR stimulation induced a significant increase of cell proliferation, improved the EPCs migratory activity, and enhanced the EPCs' ability to promote endothelial cell network formation in vitro. Then, we performed in vivo studies in animals model of hindlimb ischemia. Consistent with our in vitro results, in vivo EPCs' treatment resulted in an improvement of impaired angiogenic phenotype in β2AR KO mice after induction of ischemia, whereas no significant amelioration was observed when β2AR knock out (KO) EPCs were injected. Indeed, wild-type-derived EPCs' injection resulted in a significantly higher blood flow restoration in ischemic hindlimb and higher capillaries density at histological analysis as compared with not treated or β2AR KO EPC-treated mice.

CONCLUSIONS

The present study provides the first evidence that EPCs express a functional β2AR. Moreover, β2AR stimulation results in EPCs proliferation, migration, and differentiation, enhancing their angiogenic ability, both in vitro and in vivo, leading to an improved response to ischemic injury in animal models of hindlimb ischemia.

Abciximab in elderly with acute coronary syndrome invasively treated: effect on outcome

Older age is an independent predictor of mortality after percutaneous coronary intervention (PCI) in patients with Non-ST elevation Acute Coronary Syndrome (ACS). GPIIb/IIIa inhibitors are proved to improve outcome in high risk patients, but conflicting data are available about the effects of these inhibitors in elderly. Accordingly, we studied a consecutive population of elderly patients undergoing PCI for Non-ST elevation ACS. A total of 500 patients were divided in: GPI group (247 pts; mean age 77+/-1.9 years) treated by stenting plus abciximab and, no GPI group (253 pts; mean age 77+/-2.4 years) treated by stenting alone. Propensity analysis was used to account for the nonrandomized use of GPIIb/IIIa inhibitors. During hospitalization, incidence of death was similar among groups (3.2% vs 4.6%) without difference regarding incidence of major (1.6% vs 1.1%) and minor bleedings (4% vs 3%). At long-term follow-up the rate of death was significantly lower in GPI group (4.5% vs 12.3%; p=0.002) as well as the rate of acute myocardial infarction (2.8% vs 11.1%; p=0.0001), and pre-PCI (5.7% vs 13.4%; p=0.003). Cox regression analysis identified abciximab use as an independent predictor of lower long-term major adverse cardiac event (MACE) after adjustment for propensity score (Exp (B) 0.620, 95%CI 0.394-0.976, p=0.039). Our results suggest that addition of abciximab to stenting improves outcome in elderly patients with Non-ST elevation ACS, leading to an absolute benefit for reduction of death and MACE, with an acceptable rate of major and minor bleedings.

Hemodynamic alterations during massive incisional hernioplasty

BACKGROUND

The operative treatment of a large abdominal incisional hernia increases intra-abdominal pressure (IAP). This study was done to verify if this IAP elevation acts on the cardiocirculatory function.

STUDY DESIGN

Hemodynamic measurements were performed in five patients who underwent massive incisional hernioplasty before and after abdominal wall closure.

RESULTS

Reduction of a large abdominal hernia increases (+226 percent) IAP, which can produce serious hemodynamic alterations, manifested in two patients by a fall of cardiac output (-30 percent), without significant variations of heart rate and arterial pressure. Cardiac output is decreased secondary to decreased venous return, despite the increase in measured central venous pressure (CVP) and pulmonary capillary wedge pressure (PCWP).

CONCLUSIONS

During massive incisional hernioplasty, CVP cannot be used as an indicator of venous return to the heart as it reflects a composite of venous filling pressure, pleural pressure, and transmitted IAP. Transmural CVP and PCWP, and not directly measured CVP and PCWP, should be used as clinical indicators of venous return to the heart in this situation.