Complementary evidence on the performance of coronary stents generated by a randomized controlled trial and a worldwide registry

BACKGROUND

Large-scale registries can provide valuable complementary data to randomized controlled trials (RCT) for the postmarketing evaluation of coronary stents, but their scientific relevance remains debated.

METHODS

We sought to compare the evidence on the performance of a single coronary stent platform generated by the RCT for its regulatory approval and a well-conducted international registry. Patients treated with the Ultimaster coronary stent in the CENTURY II (CII-UM) trial (n = 551) were compared to patients in the real-world e-ULTIMASTER (e-UM) registry (n = 35,389). All major events were adjudicated by an independent clinical event committee in both studies. Propensity weighted analysis was used to balance baseline and procedural differences between the 2 populations.

RESULTS

Coronary artery disease was more complex in e-UM compared to CII-UM, including more acute coronary syndromes, multivessel disease, left main, arterial, or venous grafts, and chronic total occlusions (P < .005 for all). At one-year follow-up and after excluding periprocedural myocardial infarction (MI) there was no statistically significant difference between CII-UM and e-UM regarding all-cause death (hazard ratio [HR] 0.55, 95% confidence interval [CI] 0.26-1.20, P = .14), cardiac death (HR 0.71, 95% CI 0.29-1.72, P = .45), target lesion failure (HR 1.18, 95% CI 0.78-1.78, P = .44), and target vessel MI (HR 0.76, 95% CI 0.24-2.38, P = .63). However, target vessel revascularization rate was significantly higher in CII-UM than in e-UM, HR 1.78, 95% CI 1.23-2.56, P = .002.

CONCLUSIONS

A well-conducted large-scale registry can provide valuable complementary evidence to RCTs on the postmarket performance of new coronary stents, across a wider range of uses and various geographic areas.

Musculoskeletal Injury Profile of Circus Artists: A Systematic Review of the Literature

BACKGROUND

The circus arts involve a high degree of acrobatic, athletic, and aesthetic ability with extreme physical demands placed on performers. An understanding of the injury profile is required to guide prevention.

AIM

To provide the first systematic review to enhance understanding of circus-related injuries and to provide a foundation for future preventative intervention.

METHODS

MEDLINE, Scopus, and Web of Science were searched from conception to March 2016 using key search terms relating to circus artists and injury. Studies were limited to English-language human studies and included all levels and ages of circus artists. Risk of bias was assessed using a novel seven-item checklist based on the STROBE statement.

RESULTS

Eight studies of varying design, populations, outcomes, and quality were analysed. Results suggest that the injury rate is relatively low among professional circus artists at 7.37 to 9.27/1,000 artist exposures. The spine and ankle are frequently injured, and most injuries are to soft tissue structures. In the professional setting, injuries appear minor, resulting in few treatments, few missed or altered performances, and a low risk of re-injury.

CONCLUSIONS

The spine and ankle should be targeted for preventative interventions in circus artists due to their high frequency of injury. The heterogeneity of studies included in this review highlights the need for consistency within future research, particularly in terms of injury definition and outcome measurements.

[Use of drug-eluting balloons for coronary interventions: current indications and perspectives]

The paclitaxel-eluting balloon is an emerging percutaneous coronary angioplasty tool which aim is to prevent restenosis by delivering a high intravessel paclitaxel dose during balloon inflation. It has been already approved in the treatment of bare metal stent restenosis and is being investigated in drug-eluting stent restenosis. For the treatment of de novo lesions, it could be used alone or in combination with bare metal stent implantation. Most interesting results were obtained by a drug-eluting balloon alone strategy in small vessels angioplasty. Current and upcoming results of this evolving technology are reviewed.

Time motion and video analysis of classical ballet and contemporary dance performance

Video analysis has become a useful tool in the preparation for sport performance and its use has highlighted the different physiological demands of seemingly similar sports and playing positions. The aim of the current study was to examine the performance differences between classical ballet and contemporary dance. In total 93 dance performances (48 ballet and 45 contemporary) were analysed for exercise intensity, changes in direction and specific discrete skills (e. g., jumps, lifts). Results revealed significant differences between the 2 dance forms for exercise intensity (p<0.001), changes in direction (p<0.001) and discrete skills (p<0.05) with gender differences noted in the latter (p<0.05). Ballet was characterised by longer periods at rest (38 s x min(-1)) and high to very high exercise intensities (9 s x min(-1)), whilst contemporary dance featured more continuous moderate exercise intensities (27 s x min(-1)). These differences have implications on the energy systems utilised during performance with ballet potentially stressing the anaerobic system more than contemporary dance. The observed high rates in the discrete skills in ballet (5 jumps x min(-1); 2 lifts x min(-1)) can cause local muscular damage, particularly in relatively weaker individuals. In conclusion, classical ballet and contemporary dance performances are as significantly different in the underlying physical demands placed on their performers as the artistic aspects of the choreography.

[Mycotic coronary aneurysm with Escherichia coli sepsis: a case report]

We report the case of a patient who was admitted for acute coronary syndrom associated with fever originating from urinary tract. Coronary arteriography revealed a huge coronary aneurysm which ruptured a short time after diagnosis. After surgery, it was proven to be mycotic aneurysm related to Escherichia Coli sepsis.

[Acute or sub-acute thrombosis of steel stents]

The use of coronary endoprostheses has greatly contributed to the improvement in the results of coronary angioplasty. Nevertheless, the risk of stent thrombosis remains a major preoccupation. We studied a retrospective series of 2997 patients who had undergone coronary angioplasty between 1999 and 2003. 36 patients (1.2%) had an acute or sub-acute stent thrombosis, occurring in two thirds of cases in the first 4 days with particularly serious clinical consequences: 5 deaths (13.8%) and 27 myocardial infarctions (75%). A comparison between the 2 groups of patients with thrombosis (n = 36) and without thrombosis (n = 2961) using multivariate analysis determined predictive factors for thrombosis: systolic LV dysfunction < 40% (p < 0.0001 OR 3.8 [2-7.3]), angioplasty for lesions on the anterior interventricular artery (p < 0.0001 OR 2.7 [1.4-5]), angioplasty performed in the acute phase of MI (p < 0.05 OR 13.9 [6.7-29.2]), B2-type complex lesions (p < 0.01 OR 2.5 [1.3-5]), residual dissection at the dilated site (p < 0.02 OR 5.1 [1.4-18.2]). More than ever, acute thrombosis remains a topical subject. This study emphasises the incidence of steel stent thrombosis; the clinical consequences and the predictive factors for early occlusion.

[Mortality prognostic factors of cardiogenic shock complicating an acute myocardial infarction and treated by percutaneous coronary intervention]

OBJECTIVE

To determine the in-hospital prognosis and late outcome of cardiogenic shock complicating acute myocardial infarction treated by early (< 24 hours) percutaneous coronary intervention (PCI).

METHODS

Retrospective monocentric study of a consecutive cohort of patients undergoing early PCI (< 24 heures) for cardiogenic shock complicating acute myocardial infarction from 1994 to 2004.

RESULTS

The cohort included 175 patients (mean age = 65 +/- 14 years, 68% male). A successful PCI was obtained in 69% of patients. The in-hospital mortality was 43%. Independent risk factors associated with an increased mortality were: absence of TIMI three flow (P < 0.0001), absence of smoking (P < 0.009) and the need for mechanical ventilation (P < 0.002). Nor stent use or anti GP IIb/IIa infusions were predictors of a better outcome. At hospital discharge, mean left ventricular ejection fraction (LVEF) was 38 +/- 12%. Kaplan-Meier estimate of survival was 63% for in-hospital survivors (maximum follow-up = 9 years). Independent predictors of an impaired long-term outcome were: a LVEF < 0.3 (P < 0.028) and 3-vessel disease on coronary angiography (P < 0.004).

CONCLUSION

In-hospital mortality of patients suffering cardiogenic shock complicating acute myocardial infarction and treated by PCI remains high despite PCI improvement. The long-term survival appears, however, to be better than that of patients with coronary artery disease and low LVEF.

[Efficacy of early reperfusion therapy at the acute stage of myocardial infarction in elderly patients: the USIK database]

The role of early reperfusion therapy at the acute stage of myocardial infarctus in elderly patients is debated. The aim of this study was to analyze the prognostic role of reperfusion with i.v. thrombolysis or primary PTCA in the nationwide USIK database, which prospectively included all pts admitted to a CCU for an AMI < 48 hours in France in November 1998. For the purpose of the present study, only patients admitted within 24 hours of AMI and with one-year follow-up available were included. Of the 1838 patients included, 785 were > 70 years-old, of whom 225 (29%) had early reperfusion therapy with thrombolysis (N = 173) or primary PTCA (N = 52). Patients treated with early reperfusion had a baseline profile that differed substantially from that of patients treated conventionally: women (31% vs 50%, p < 0.001), admission within six hours of symptom onset (84% vs 55%, p < 0.001), history of systemic hypertension (48% vs 60%, p < 0.002), stroke (5% vs 11%, p < 0.01), peripheral arterial disease (8% vs 18%, p < 0.001); congestive heart failure (5% vs 20%, p < 0.001) or previous MI (12% vs 25%, p < 0.001), more anterior location of current MI (40% vs 28%, p < 0.002). Overall one-year Kaplan-Meier survival was 78% for patients with versus 64% for those without reperfusion therapy (p < 0.01). In patients with Q wave myocardial infarction, Cox multivariate analysis showed that reperfusion therapy was an independent predictor of survival (RR 0.66; 95% Confidence Interval: 0.45-0.96), along with age, anterior location and history of congestive heart failure. Therefore, data from this large "real life" registry indicate that reperfusion therapy with either thrombolysis or primary PTCA is associated with improved one-year survival in patients over 70 years of age.

Comparison of effects of ioxaglate versus iomeprol on histamine and tryptase release in patients with ischemic cardiomyopathy

We observed a release of histamine, but not of tryptase, in arterial blood from 64 patients with ischemic heart disease and 24 patients without coronary disease, which was provoked by ioxaglate, a ionic compound, but was not provoked by iomeprol, a non-ionic radiocontrast compound. The release of histamine in arterial blood after ionic contrast medium injection was higher in patients with ischemic heart disease compared with patients without coronary disease, suggesting that an increased release from heart mast cells previously observed exists also for systemic blood basophils.

Homocysteine, vitamins B6, B12, folate, and risk of coronary artery disease in patients undergoing diagnostic coronary angiography

Homocysteine and vitamins B were correlated with coronary artery disease in patients undergoing diagnostic coronary angiography. 160 patients having > or =1 stenosis (G1), 55 patients having normal coronary arteries (G2) and 171 healthy volunteers (G3) were prospectively recruited. Homocysteine levels were significantly higher in patients, particularly in those with normal coronary angiograms, than in healthy subjects (13.8 +/-6.3 micromol/L in G1 (p < 0.0001) and 15.2 +/- 8.8 micromol/L in G2 (p < 0.0001) versus 10.1 +/- 3.1 micromol/L in G3). Homocysteine levels were not related to the extent of coronary artery disease. In patients with normal angiogram, vitamin B12 and folate levels were significantly higher compared with the other groups (p < 0.05 and p < 0.001, respectively) showing that vitamin B deficiency was not involved in the hyperhomocysteinemia. In conclusion, homocysteine and vitamins B levels do not contribute to discriminate for the presence of coronary artery disease in patients undergoing diagnostic coronary angiography. Homocysteine levels, however, were higher in patients referred for coronary angiography than in healthy controls.

Dipyridamole and exercise SPET provide different estimates of myocardial ischaemic areas: role of the severity of coronary stenoses and of the increase in heart rate during exercise

In patients unable to perform a maximal exercise test, dipyridamole single-photon emission tomography (SPET) has a higher capacity than exercise SPET to detect coronary artery disease (CAD). However, in patients with myocardial ischaemia who are able to perform a maximal exercise test, it is not known whether these two tests may be equally used to assess the areas of myocardial ischaemia. This study was aimed at comparing the results provided by dipyridamole and exercise SPET in CAD patients with documented exercise myocardial ischaemia. Forty CAD patients who had undergone exercise thallium-201 SPET and who had myocardial ischaemia documented by an unequivocally positive exercise test underwent an additional 201Tl SPET study after dipyridamole infusion and low-level (40 W) exercise. The extent of defects was compared between the two tests and predictors of discrepant results were sought among data from exercise testing and coronary angiography. The extent of SPET defects was equivalent between the two tests in only 11 patients (28%), larger defects being observed with exercise in 18 [average difference: 12%+/-5% of left ventricle (LV)] and with dipyridamole in 11 (average difference: 15%+/-11% of LV). The best independent predictors of discrepancies between the two tests were: (1) increase in heart rate at exercise SPET, with defects being smaller at exercise than after dipyridamole in none of the patients with an increase >60 bpm (0/14), but in 42% of the others (11/26; P=0.004); and (2) an ischaemic territory related to a <70% coronary stenosis, for which SPET defects were always induced at exercise (10/10) but in only 30% (3/10) with dipyridamole (P=0.0004). Exercise and dipyridamole SPET provide different estimates of myocardial ischaemic areas. Dipyridamole allows the unmasking of perfusion abnormalities in patients who have low increases in heart rate at exercise SPET. However, dipyridamole is also much less efficient at inducing perfusion abnormalities in the ischaemic areas supplied by coronary stenoses of intermediate severity at rest angiography.

Long-term outcome in patients treated by intracoronary stenting with ticlopidine and aspirin, and deleterious prognostic role of unstable angina pectoris

Compared with stable clinical conditions, unstable angina carries an increased risk of immediate and delayed cardiac adverse events after balloon coronary angioplasty. The influence of stent use in reducing these differences remains unknown. We analyzed the early (30 days) and late outcome of a cohort of 459 consecutive patients who underwent stent placement with ticlopidine and aspirin as antithrombotic regimen according to the presence (group 1, n = 151) or absence (group 2, n = 308) of unstable angina at rest (Braunwald classes II and III). Group 1 patients were older and more likely to be current or former smokers. In group 2, prior myocardial infarction was more frequent. Procedural, in-hospital results, and early outcome were similar in the 2 groups. However, over the long term, the incidence of myocardial infarction (11% vs 6%, p <0.04), target lesion revascularization (19% vs 13%, p <0.04), or any revascularization (30% vs 20%, p <0.01) was significantly higher in group 1. Kaplan-Meier probabilities of survival without myocardial infarction (85% vs 91%, p <0.05), survival without revascularization of the target lesion (73% vs 83%, p <0.01), survival without any revascularization (65% vs 77%, p <0.006), and survival without any events (61% vs 73%, p <0.009) were significantly worse in group 1. In addition, Cox multivariate analysis showed that unstable angina at rest was an independent predictor of target lesion revascularization, of survival without any revascularization, and without any events. Thus, unstable angina at rest remains an adverse prognostic indicator in patients treated with intracoronary stents, particularly with regard to subsequent requirement of revascularization procedures and event-free survival.

[Long-term follow up of 115 patients with ischemic heart disease and ventricular flutter induced by programmed ventricular stimulation in the absence of ventricular arrhythmia]

The clinical significance of rapid monomorphic ventricular tachycardia (VT) (> 270 beats/min), also called ventricular flutter, remains controversial in patients without documented spontaneous sustained VT. The aim of this study was to evaluate the outcome of 115 patients with ischaemic heart disease, aged 58 +/- 10 years, without spontaneous ventricular arrhythmias, but who had inducible ventricular flutter during programmed ventricular stimulation. The patients underwent stimulation to evaluate the prognosis after myocardial infarction or to investigate a malaise with or without loss of consciousness. Sustained ventricular flutter was the only inducible arrhythmia in all patients. The mean left ventricular ejection fraction (LVEF) was 42 +/- 14%. During an average follow-up period of 66 +/- 43 months, 31 deaths, including 27 of cardiac causes, were observed. The 1, 5, and 11 year survival of the whole population was 94, 79 and 64% respectively. In univariate analysis, anterior wall myocardial infarction, a low LVEF, the presence of non-sustained ventricular tachycardia (NSVT) on 24 hour Holter monitoring and Class III antiarrhythmic treatment, were poor prognostic factors (p 0.05). In multivariate analysis, the only independent predictive factors of mortality were low LVEF (p = 0.006), the presence of NSVT on Holter monitoring (p = 0.003) and the absence of betablocker therapy (p = 0.015). Medical therapy with betablockers or the implantation of an automatic defibrillator may be indicated in these patients at higher risk.

[Betablocker therapy in acute myocardial infarction]

A review of the results of randomised trials of the use of betablockers in acute myocardial infarction shows by techniques of meta-analysis that their prescription in the early hours of the acute event leads to a reduction in short-term mortality: the reduction of risk is 12% as compared with groups which are not given betablockers. In addition to its impact on mortality, early betablocker therapy is associated with a reduction in the risk of recurrence of myocardial infarction and a proven antalgic effect. However, in patients receiving thrombolysis, the beneficial effect on mortality and recurrence of infarction of intravenous betablockers seems less evident. In daily clinical practice, the prescription of betablockers in the first days of infarction has significantly increased over the last ten years. In the USIK trial carried out in France in November 1995, nearly two thirds of patients received betablocker therapy. In the same study, the prescription of betablockers is associated with a reduction in mortality independent of the classical risk factors and the prescription of angiotensin converting enzyme inhibitors. These results confirm the value of this therapeutic class in the acute phase of myocardial infarction.

[Prevention of venous thromboembolism. Survey of in-hospital medical practice]

OBJECTIVES

In an effort to improve the prevention of venous thromboembolism, the Nancy University Hospitals conducted a survey of medical practice concerning indications for preventive therapy and surveillance of platelet counts and anti Xa activity.

METHODS

The survey involved 163 medical files. Questionnaires were filled out in 6 units (3 medical wards and 3 intensive care units).

RESULTS

Indications for preventive therapy were found to be quite variable with the exception of very low risk of thromboembolism where the treat/do not treat ratio was 0.1/1, indicating a clear tendency for abstention. This ratio was 0.77/1 and 0.38/1 respectively for low and moderate risk and 2/1 for high risk. There was undoubtedly a ward effect. The attitudes in practice tended toward non-prevention in patients without limited mobility. For platelet counts, an initial count was performed in 95% of the cases and during treatment in 38% although the specific rates were not the same for different types of units. Anti-Xa activity, which according to prevention recommendations need not to be determined, was not monitored in 88% of the cases. In accordance with prevention recommendations, anti-Xa activity was not determined in 88% of the cases.

CONCLUSION

Further progress is needed in the prevention of venous thromboembolism and should be based on wider use of existing methods.

[Coronary angiography: 1st or 2nd-line test?]

Coronary angiography, although now performed extremely frequently, remains an invasive and expensive examination, whose place, as first-line diagnostic method, must be discussed; Its main advantage is to provide a definitive diagnosis of coronary atherosclerosis as well as simple prognostic indicators (single vessel, two-vessel or three-vessel disease; concomitant evaluation of left ventricular function by associated radiological ventriculography). However, it is unable to precisely assess the degree of coronary wall disease and, more importantly, cannot evaluate the functional repercussions of stenosis. Under these conditions, only cases in which myocardial revascularization is expected to provide a definite clinical benefit (presence of frank angina symptoms) probably justify first-line coronary angiography. In all other cases, coronary angiography is a useful examination to provide reference "mapping" of the coronary lesions, but an obvious clinical benefit for the patient cannot be expected from systematic use of this technique. In particular, in such situations, coronary angiography should not be the only element on which the decision to perform myocardial revascularization should be based: the "oculostenotic reflex" must always be avoided.

[Effect of late revascularization of the responsible artery after infarction on left ventricular function and remodeling]

The effects of late angioplasty of the culprit artery after myocardial infarction on the decisive prognostic factors of left ventricular function and remodeling are not well known. When the culprit artery is narrowed but patent, angioplasty leads to improvement in segmental contractility and global left ventricular function: it does not seem to influence left ventricular end-diastolic volume. When the artery remains occluded, global and regional left ventricular function is also improved when the recanalised artery remains patent. Moreover, restoration of satisfactory artery patency prevents ventricular remodeling whereas in failed angioplasty or reocclusion, there is a progressive increase in left ventricular volume. However, these results observed in unselected patients could be improved: it would seem that the different beneficial effects only occur when there is residual myocardial viability; in the absence of signs of myocardial viability, the ventricular effects of limitations of angioplasty (incidence of restenosis or reocclusion in this specific context, lower primary success rate in complete arterial occlusion) explain the negativity of rare randomised studies comparing the outcome of left ventricular function depending on whether a conventional attitude or systematic revascularisation of the culprit artery is adopted.

[Does recanalisation of chronic right coronary occlusion improve long-term quality of life and the return to work?]

Between 1985 and 1990, right coronary artery recanalisation was attempted in 60 consecutive patients. In order to evaluate the long-term benefits, 2 groups were compared: group A (27 patients: 26 men, 1 woman) with an initial success; 1 patient was lost to follow-up (3.7%); group B (33 patients, 31 men, 2 women) with an initial failure; no patients were lost to follow-up and 1 patient died after secondary coronary artery surgery. After a follow-up of at least 1 year, the patients assessed their health and compared it with their pre-angioplasty state with the aid of a questionnaire. Age, initial left ventricular ejection fraction, the percentage of multiple vessel disease and the number of patients at work before angioplasty were the same in the two groups. After a mean follow-up period of two and a half years, 7.6% of patients had undergone coronary bypass surgery in group A compared with 18.2% in group B (NS); 69% of patients in group A claimed to be improved compared with only 24% in group B (p = 0.07); a bi or triple anti-anginal therapy was used in 58% of patients in group B and 42% of patients in group A (NS); however, 59% of patients returned to work in group B compared with 44% in group A (NS). Initial successful recanalisation of chronic right coronary occlusion improves the quality of life at long-term but does not increase the chances of returning to work.(ABSTRACT TRUNCATED AT 250 WORDS)