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Vogel RF, Delewi R, Wilschut JM, Lemmert ME, Diletti R, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Van Mieghem NM, Smits PC, Vlachojannis GJ. Direct stenting versus stenting after predilatation in STEMI patients with high thrombus burden: a subanalysis from the randomized COMPARE CRUSH trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background/Introduction
Direct stenting has been proposed to reduce vessel wall damage and distal embolization in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). However, studies comparing direct stenting with stenting after predilatation have shown mixed results so far. Patients presenting with high thrombus burden in the culprit lesion represent a subgroup of STEMI patients that may particularly benefit from direct stenting, as high thrombus burden is associated with suboptimal reperfusion and poor clinical outcomes.
Purpose
We sought to determine the efficacy of direct stenting compared with stenting after predilatation in STEMI patients presenting with high thrombus burden.
Methods
The randomized COMPARE CRUSH trial assessed the efficacy of pre-hospital administration of crushed versus integral prasugrel tablets in patients presenting with STEMI planned for primary PCI. We assessed Thrombolysis In Myocardial Infarction (TIMI) flow, corrected TIMI frame count (cTFC) and myocardial blush grade at the end of primary PCI, as well as the occurrence of complete (≥70%) ST-segment resolution 1 hour post-PCI in STEMI patients presenting with high thrombus burden in the culprit lesion (defined as a TIMI thrombus grade ≥3).
Results
A total of 417 STEMI patients were included in the current analysis of which 336 (81%) presented with high thrombus burden on initial angiography with 144 patients (43%) being treated with direct stenting. Patients undergoing direct stenting exhibited significantly lower cTFC post-PCI compared with stenting after predilatation (16 [12–24] vs. 20 [13–29], p=0.02). Moreover, direct stenting patients more frequently exhibited complete ST-segment resolution 1 hour post-PCI compared with stenting after predilatation (72% vs. 59%, OR 1.82 [95% CI, 1.11–2.99], p=0.02). In contrast, we found no differences in the occurrence of TIMI 3 flow (DS 92% vs. 92%, OR 1.02 [0.47–2.22], p=0.97) or myocardial blush grade 3 (DS 63% vs. 54%, OR 1.45 [95% CI, 0.83–2.52], p=0.19) post-PCI between groups.
Conclusion
STEMI patients presenting with high thrombus burden treated with direct stenting showed improved markers of early myocardial reperfusion compared with patients treated with stenting after predilatation, indicating that a direct stenting strategy may benefit the subgroup of STEMI patients that present with high thrombus burden. Randomized trials are warranted to further investigate whether the potential benefits of direct stenting outweigh potential hazards over the long-term.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Daiichi-Sankyo and Shanghai MicroPort Medical
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Affiliation(s)
- R F Vogel
- Amsterdam University Medical Centre , Amsterdam , The Netherlands
| | - R Delewi
- Amsterdam University Medical Centre , Amsterdam , The Netherlands
| | - J M Wilschut
- Erasmus University Medical Centre, Cardiology , Rotterdam , The Netherlands
| | - M E Lemmert
- Isala Hospital, Cardiology , Zwolle , The Netherlands
| | - R Diletti
- Erasmus University Medical Centre, Cardiology , Rotterdam , The Netherlands
| | - R J Nuis
- Erasmus University Medical Centre, Cardiology , Rotterdam , The Netherlands
| | - V Paradies
- Maasstad Hospital, Cardiology , Rotterdam , The Netherlands
| | - D Alexopoulos
- National & Kapodistrian University of Athens Medical School, Cardiology , Athens , Greece
| | - F Zijlstra
- Erasmus University Medical Centre, Cardiology , Rotterdam , The Netherlands
| | - G Montalescot
- Pitie Salpetriere APHP University Hospital, Cardiology , Paris , France
| | - D J Angiolillo
- University of Florida College of Medicine, Cardiology , Jacksonville , United States of America
| | - M W Krucoff
- Duke University Medical Center, Cardiology , Durham , United States of America
| | - N M Van Mieghem
- Erasmus University Medical Centre, Cardiology , Rotterdam , The Netherlands
| | - P C Smits
- Maasstad Hospital, Cardiology , Rotterdam , The Netherlands
| | - G J Vlachojannis
- University Medical Center Utrecht, Cardiology , Utrecht , The Netherlands
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Vriesendorp PA, Wilschut JM, Diletti R, Daemen J, Kardys I, Zijlstra F, Van Mieghem NM, Bennett J, Esposito G, Sabate M, den Dekker WK. Immediate versus staged revascularisation of non-culprit arteries in patients with acute coronary syndrome: a systematic review and meta-analysis. Neth Heart J 2022; 30:449-456. [PMID: 35536483 PMCID: PMC9474746 DOI: 10.1007/s12471-022-01687-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 12/02/2022] Open
Abstract
Although there is robust evidence that revascularisation of non-culprit vessels should be pursued in patients presenting with an acute coronary syndrome (ACS) and multivessel coronary artery disease (MVD), the optimal timing of complete revascularisation remains disputed. In this systematic review and meta-analysis our results suggest that outcomes are comparable for immediate and staged complete revascularisation in patients with ACS and MVD. However, evidence from randomised controlled trials remains scarce and cautious interpretation of these results is recommended. More non-biased evidence is necessary to aid future decision making on the optimal timing of complete revascularisation.
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Affiliation(s)
- P A Vriesendorp
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
- The Heart Centre, The Alfred Hospital, Melbourne, Australia
| | - J M Wilschut
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - R Diletti
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J Daemen
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - I Kardys
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - F Zijlstra
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - N M Van Mieghem
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - J Bennett
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - G Esposito
- Division of Cardiology, Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - M Sabate
- Cardiovascular Institute, Hospital Clinic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - W K den Dekker
- Department of Cardiology, Thoraxcenter, Erasmus University Medical Centre, Rotterdam, The Netherlands.
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Vogel RF, Vlachojannis GJ, Wilschut JM, Lemmert ME, Diletti R, Nuis RJ, Paradies V, Alexopoulos D, Zijlstra F, Montalescot G, Angiolillo DJ, Krucoff MW, Van Mieghem NM, Smits PC, Delewi R. Platelet reactivity and bleeding outcomes in female patients presenting with ST-segment elevation myocardial infarction: a COMPARE CRUSH substudy. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.1225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background/Introduction
Females presenting with ST-segment elevation myocardial infarction (STEMI) are characterized by an increased risk of bleeding after primary percutaneous coronary intervention (pPCI) compared with males. The reason for increased bleeding rates is multifactorial, including age, comorbidities, vessel anatomy and possible differences in platelet biology. Data about platelet reactivity levels in females versus males presenting with STEMI is scarce.
Purpose
Investigation of gender-driven variances in platelet reactivity and bleeding outcomes in STEMI patients planned to undergo pPCI.
Methods
The COMPARE CRUSH trial was a randomized multicenter ambulance trial assessing the effect of prehospital administration of P2Y12 inhibitor loading dose with crushed versus integral prasugrel tablets in STEMI patients. We assessed the occurrence of high platelet reactivity (HPR), predictors of HPR at baseline and bleeding outcomes between females and males. Blood samples were analyzed at four prespecified time points using VerifyNow.
Results
The COMPARE CRUSH trial included 633 STEMI patients in the period between November 2017 and March 2020. Females more frequently exhibited HPR at baseline than males (76% vs. 41%, odds ratio (OR), 4.58 [95% CI, 2.52 to 8.32], p<0.01). Moreover, female sex was a strong, independent predictor for HPR at baseline (OR, 4.93 [95% CI, 2.30 to 10.57], p<0.01). HPR rates at other time points were not significantly different between females and males. The risk of bleeding within the first 48 hours was significantly increased in females (OR, 6.02 [95% CI, 2.58 to 14.08], p<0.01), but after adjustment for baseline characteristics this increased risk was no longer statistically significant (OR, 2.61 [95% CI, 0.73 to 9.32], p=0.14).
Conclusion
Female sex is an independent predictor for occurrence of HPR at baseline in STEMI patients. However, females exhibit a stronger platelet inhibition effect by oral P2Y12 inhibitors than males, which may contribute to an increased bleeding risk. A more tailored antiplatelet therapy approach should be considered for female STEMI patients to reduce bleeding risk.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): Unrestricted grants from Daiichi-Sankyo and Shanghai MicroPort Medical.
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Affiliation(s)
- R F Vogel
- University Medical Center Utrecht, Cardiology, Utrecht, Netherlands (The)
| | - G J Vlachojannis
- University Medical Center Utrecht, Cardiology, Utrecht, Netherlands (The)
| | - J M Wilschut
- Erasmus University Medical Centre, Cardiology, Rotterdam, Netherlands (The)
| | - M E Lemmert
- Isala Hospital, Cardiology, Zwolle, Netherlands (The)
| | - R Diletti
- Erasmus University Medical Centre, Cardiology, Rotterdam, Netherlands (The)
| | - R J Nuis
- Erasmus University Medical Centre, Cardiology, Rotterdam, Netherlands (The)
| | - V Paradies
- Maasstad Hospital, Cardiology, Rotterdam, Netherlands (The)
| | - D Alexopoulos
- National & Kapodistrian University of Athens Medical School, Cardiology, Athens, Greece
| | - F Zijlstra
- Erasmus University Medical Centre, Cardiology, Rotterdam, Netherlands (The)
| | | | - D J Angiolillo
- University of Florida College of Medicine, Cardiology, Jacksonville, United States of America
| | - M W Krucoff
- Duke University Medical Center, Cardiology, Durham, United States of America
| | - N M Van Mieghem
- Erasmus University Medical Centre, Cardiology, Rotterdam, Netherlands (The)
| | - P C Smits
- Maasstad Hospital, Cardiology, Rotterdam, Netherlands (The)
| | - R Delewi
- Amsterdam UMC - Location Academic Medical Center, Cardiology, Amsterdam, Netherlands (The)
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