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Orban M, Trenk D, Geisler T, Rieber J, Hadamitzky M, Gross L, Orban M, Kupka D, Baylacher M, Müller S, Huber K, Koltowski L, Huczek Z, Heyn J, Jacobshagen C, Aradi D, Massberg S, Sibbing D, Hein R. Smoking and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients: a substudy from the randomized TROPICAL-ACS trial. European Heart Journal - Cardiovascular Pharmacotherapy 2019; 6:372-381. [DOI: 10.1093/ehjcvp/pvz084] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 11/24/2019] [Accepted: 12/13/2019] [Indexed: 11/13/2022]
Abstract
Abstract
Aims
Prior analyses disclosed variations in antiplatelet drug response and clinical outcomes between smokers and non-smokers, thus the safety and efficacy of any dual antiplatelet therapy (DAPT) de-escalation strategy may differ in relation to smoking status. Hence, we assessed the impact of smoking on clinical outcomes and adenosine diphosphate-induced platelet aggregation following guided de-escalation of DAPT in invasively managed acute coronary syndrome (ACS) patients.
Methods and results
The multicentre TROPICAL-ACS trial randomized 2610 biomarker-positive ACS patients 1:1 to standard treatment with prasugrel for 12 months (control group) or a platelet function testing guided de-escalation of DAPT. Current smokers (n = 1182) showed comparable event rates between study groups [6.6% vs. 6.6%; hazard ratio (HR) 1.0, 95% confidence interval (CI) 0.64–1.56, P > 0.99]. In non-smokers (n = 1428), a guided DAPT de-escalation was associated with a lower 1-year incidence of the primary endpoint [cardiovascular death, myocardial infarction, stroke, or bleeding ≥ Grade 2 according to Bleeding Academic Research Consortium (BARC) criteria] compared with control group patients (7.9% vs. 11.0%; HR 0.71, 95% CI 0.50–0.99, P = 0.048). This reduction was mainly driven by a lower rate of BARC ≥ Grade 2 bleedings (5.2% vs. 7.7%; HR 0.68, 95% CI 0.45–1.03, P = 0.066). There was no significant interaction of smoking status with treatment effects of guided DAPT de-escalation (Pint = 0.23). Adenosine diphosphate-induced platelet aggregation values were higher in current smokers [median 28 U, interquartile range (IQR: 20–40)] vs. non-smoker [median 24 U (16–25), P < 0.0001] in the control group and in current smokers [median 42 U, IQR (27–68)] vs. non-smoker [median 37 U, IQR (25–55), P < 0.001] in the monitoring group.
Conclusion
Guided DAPT de-escalation appears to be equally safe and effective in smokers and non-smokers. Regardless of smoking status and especially for those patients deemed unsuitable for 1 year of potent platelet inhibition this DAPT strategy might be used as an alternative antiplatelet treatment regimen.
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Affiliation(s)
- Martin Orban
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, Südring 15, 79189 Bad Krozingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, Otfried-Müller-Straße 10, 72076 Tübingen, Germany
| | - Johannes Rieber
- Department of Cardiology and Intensive Care Medicine, Heart Centre Bogenhausen, Englschalkinger Straße 77, 81925 München, Germany
| | - Martin Hadamitzky
- Department of Radiology, German Heart Center of Munich, Lazarettstraße 36, 80636 München, Germany
| | - Lisa Gross
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Mathias Orban
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Danny Kupka
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Monika Baylacher
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Susan Müller
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Kurt Huber
- 3 Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, and Sigmund Freud Private University, Medical School, Montleartstrasse 35-37, 1160 Vienna, Austria
| | - Lukasz Koltowski
- 1 Department of Cardiology, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warszawa, Poland
| | - Zenon Huczek
- 1 Department of Cardiology, Medical University of Warsaw, Żwirki i Wigury 61, 02-091 Warszawa, Poland
| | - Jens Heyn
- Department of Anesthesiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
| | - Claudius Jacobshagen
- Department of Cardiology and Pneumology, Heart Centre/Georg-August-University Göttingen, 37073 Göttingen, Germany
| | - Dániel Aradi
- Department of Cardiology, Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University, Gyógy tér 2 8230 Balatonfüred, Budapest, Hungary
| | - Steffen Massberg
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Dirk Sibbing
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
| | - Ralph Hein
- Department of Cardiology, Ludwig-Maximilians University, Marchioninistraße 15, 81377 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Biedersteiner Straße 29, 80802 München, Germany
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Sibbing D, Gross L, Trenk D, Jacobshagen C, Geisler T, Hadamitzky M, Merkely B, Kiss RG, Komócsi A, Parma R, Felix SB, Neumann FJ, Hausleiter J, Baylacher M, Koltowski L, Mehilli J, Huber K, Huczek Z, Aradi D, Massberg S. Age and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients undergoing percutaneous coronary intervention: results from the randomized TROPICAL-ACS trial. Eur Heart J 2019; 39:2749-2758. [PMID: 29912422 DOI: 10.1093/eurheartj/ehy332] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [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] [Received: 12/20/2017] [Accepted: 05/23/2018] [Indexed: 11/13/2022] Open
Abstract
Aims Guided de-escalation of P2Y12-inhibitor treatment was recently identified as an effective alternative treatment strategy in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention. Safety and efficacy of this strategy may differ in relation to patient's age. This pre-specified analysis of the TROPICAL-ACS trial aimed to assess the impact of age on clinical outcomes following guided de-escalation of antiplatelet treatment in ACS patients. Methods and results Patients were randomly assigned in a 1:1 fashion to either standard treatment with prasugrel for 12 months (control group) or to a guided de-escalation regimen (1 week prasugrel followed by 1 week clopidogrel and platelet function testing guided maintenance therapy with clopidogrel or prasugrel from day 14 after hospital discharge; guided de-escalation group). We used Cox regression models to assess the associations of age on clinical endpoints and interactions. In younger patients (age ≤70, n = 2240), the 1 year incidence of the primary endpoint (cardiovascular death, myocardial infarction, stroke, or bleeding ≥ grade 2 according to Bleeding Academic Research Consortium criteria) was significantly lower in guided de-escalation vs. control group [5.9% vs. 8.3%; hazard ratio (HR) 0.70, 95% confidence interval (CI) 0.51-0.96; P = 0.03, number needed to treat = 42]. In elderly patients (age >70, n = 370), the absolute risk of events was higher without significant differences between guided de-escalation vs. control group (15.5% vs. 13.6%; HR 1.17, 95% CI 0.69-2.01; P = 0.56). When the impact of age, as a continuous variable, was analysed on outcomes after guided de-escalation vs. control treatment, an increasing relative risk reduction was observed in the primary endpoint by decreasing age (Pint = 0.02), due to significant reductions in bleeding. Conclusion Treatment effects of guided de-escalation for P2Y12 inhibitors depend on patient's age with younger patients deriving a significant net clinical benefit. Although the safety and efficacy of guided de-escalation in the elderly was similar to uniform prasugrel therapy, this should be further investigated due to the limited sample size of this group.
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Affiliation(s)
- Dirk Sibbing
- Department of Cardiology, LMU München, Marchioninistraße 15, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Lisa Gross
- Department of Cardiology, LMU München, Marchioninistraße 15, Munich, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Claudius Jacobshagen
- Department of Cardiology und Pneumology, Heart Centre/Georg-August-University Göttingen, Göttingen, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, Tübingen, Germany
| | - Martin Hadamitzky
- Department of Radiology, Deutsches Herzzentrum München, Munich, Germany
| | - Béla Merkely
- Heart and Vascular Centre, University of Semmelweis, Budapest, Hungary
| | | | - András Komócsi
- Department of Interventional Cardiology, Heart Institute, University of Pécs, Pécs, Hungary
| | - Radoslaw Parma
- 3rd Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | - Stephan B Felix
- Department of Internal Medicine B, University Medicine Greifswald, Greifswald, Germany.,DZHK, partner site Greifswald, Greifswald, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, Bad Krozingen, Germany
| | - Jörg Hausleiter
- Department of Cardiology, LMU München, Marchioninistraße 15, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Monika Baylacher
- Department of Cardiology, LMU München, Marchioninistraße 15, Munich, Germany
| | - Lukasz Koltowski
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Julinda Mehilli
- Department of Cardiology, LMU München, Marchioninistraße 15, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Kurt Huber
- 3rd Medical Department, Cardiology and Intensive Care Medicine, Sigmund Freud Private University, Medical School, Wien, Austria
| | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Dániel Aradi
- Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Steffen Massberg
- Department of Cardiology, LMU München, Marchioninistraße 15, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
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Rizas KD, Gross L, Trenk D, Komocsi A, Baylacher M, Orban M, Loew A, Massberg S, Aradi D, Sibbing D. 252Guided de-escalation of antiplatelet treatment in patients with acute coronary syndrome and multivessel coronary artery disease: a post-hoc analysis of the TROPICAL-ACS trial. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0068] [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
The TROPICAL-ACS trial showed that platelet function testing (PFT) guided de-escalation of P2Y12-inhibitor is a safe alternative treatment strategy in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). No specific data are available on the efficacy of this strategy in patients with multivessel coronary artery disease (CAD).
Purpose
To investigate the safety and efficacy of guided de-escalation of P2Y12-inhibitor treatment in patients with multivessel CAD.
Methods
Two-thousand six-hundred-two biomarker-positive ACS patients were 1:1 randomized to either conventional treatment with prasugrel for 12 months (control group) or to a PFT guided de-escalation treatment strategy (guided de-escalation group). The primary endpoint (net clinical benefit) was defined as the composite of cardiovascular mortality (CVM), myocardial infarction (MI), stroke, and clinically overt bleeding (bleeding ≥ grade 2 according to the BARC criteria). The ischemic endpoint was defined as the composite of CVM, MI or stroke. We used log-rank statistics and Cox regression analysis with interaction testing to assess the effect of multivessel CAD on the primary and ischemic endpoints.
Results
Patients with multivessel (n=709) versus single-vessel CAD (n=1,901) exhibited a higher risk for the primary endpoint (10.2% vs. 7.6%; HR 1.36; 95% CI 1.02–1.81; p=0.034). Guided de-escalation was non-inferior to conventional treatment for the primary endpoint in both patients with single-vessel CAD (6.7% vs. 8.5%; pnon-inferiority = 0.001; Figure 1A) and multivessel CAD (9,5% vs. 10.9%; pnon-inferiority=0.041; Figure 1B). Moreover, there was no significant interaction in the prognostic value of guided de-escalation between single-vessel and multivessel CAD for both the primary (HR 0.78 [0.56–1.08]; p=0.137 in patients with single-vessel CAD vs. 0.86 [0.54–1.37; p=0.524 in patients with multivessel CAD; pinteraction=0.732) and combined ischemic endpoints (HR 0.80 [0.44–1.45]; p=0.456 in patients with single-vessel CAD vs. 0.71 [0.35–1. 46]; p=0.356 in patients with multivessel CAD; pinteraction=0.823).
Kaplan-Meier curves
Conclusion
A guided de-escalation of P2Y12-inhibitor appears to be safe and effective in ACS patients with both single-vessel and multivessel CAD.
Acknowledgement/Funding
Klinikum der Universität München, Roche Diagnostics, Eli Lilly, and Daiichi Sankyo.
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Affiliation(s)
- K D Rizas
- Ludwig-Maximilians University, Medizinische Klinik und Poliklinik I, Munich, Germany
| | - L Gross
- Ludwig-Maximilians University, Medizinische Klinik und Poliklinik I, Munich, Germany
| | - D Trenk
- University Heart Centre Freiburg, Bad Krozingen, Department of Cardiology and Angiology II, Freiburg, Germany
| | - A Komocsi
- University of Pecs, Department of Interventional Cardiology, Heart Institute, Pecs, Hungary
| | - M Baylacher
- Ludwig-Maximilians University, Medizinische Klinik und Poliklinik I, Munich, Germany
| | - M Orban
- Ludwig-Maximilians University, Medizinische Klinik und Poliklinik I, Munich, Germany
| | - A Loew
- Ludwig-Maximilians University, Medizinische Klinik und Poliklinik I, Munich, Germany
| | - S Massberg
- Ludwig-Maximilians University, Medizinische Klinik und Poliklinik I, Munich, Germany
| | - D Aradi
- Semmelweis University, Heart Centre Balatonfüred and Heart and Vascular Centre, Budapest, Hungary
| | - D Sibbing
- Ludwig-Maximilians University, Medizinische Klinik und Poliklinik I, Munich, Germany
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Hein R, Gross L, Aradi D, Rieber J, Hadamitzky M, Merkely B, Huczek Z, Ince H, Hummel A, Baylacher M, Massberg S, Trenk D, Sibbing D. Diabetes and outcomes following guided de-escalation of antiplatelet treatment in acute coronary syndrome patients undergoing percutaneous coronary intervention: a pre-specified analysis from the randomised TROPICAL-ACS trial. EUROINTERVENTION 2019; 15:e513-e521. [PMID: 31012853 DOI: 10.4244/eij-d-18-01077] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 11/23/2022]
Abstract
AIMS A guided de-escalation of P2Y12 inhibitor treatment is considered an alternative treatment strategy in ACS patients undergoing PCI. However, the safety and efficacy of this strategy may differ in diabetic vs non-diabetic patients. The aim of this study was to compare the outcomes of platelet function testing (PFT)-guided de-escalation of dual antiplatelet therapy (DAPT) in ACS patients with and without diabetes mellitus. METHODS AND RESULTS The TROPICAL-ACS trial randomised 2,610 biomarker-positive ACS patients 1:1 to either standard treatment with prasugrel for 12 months (control group) or PFT-guided DAPT de-escalation. The association and interaction of diabetes on clinical endpoints across treatment groups and on platelet reactivity was investigated. In diabetic patients (n=527, 20.2%), the overall event rates were high and the one-year incidence of the primary endpoint (cardiovascular death, myocardial infarction, stroke or bleeding ≥grade 2) did not differ between guided de-escalation and control group patients (12.5% vs 10.8%; HR 1.17, 95% CI: 0.71-1.93, p=0.55). In non-diabetic patients (n=2,083, 79.8%), the one-year incidence of the primary endpoint was lower in the guided de-escalation vs control group (6.1% vs 8.5%; HR 0.71, 95% CI: 0.52-0.99, p=0.04, pint=0.10). Diabetic patients showed higher platelet reactivity levels in both control (=on prasugrel, p=0.01) and guided de-escalation group (=on clopidogrel, p=0.005) patients. CONCLUSIONS Although diabetic status did not significantly interfere with the treatment effects of guided DAPT de-escalation, our results suggest that this approach might be safe and effective in non-diabetic patients. Further investigation is definitely warranted in diabetic patients.
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Affiliation(s)
- Ralph Hein
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
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Gross L, Kupka D, Trenk D, Geisler T, Hadamitzky M, Löw A, Orban M, Huber K, Kiss RG, Merkely B, Huczek Z, Beuthner BE, Hein-Rothweiler R, Baylacher M, Rizas K, Massberg S, Aradi D, Sibbing D, Jacobshagen C. Gender and Outcomes following Guided De-Escalation of Antiplatelet Treatment in Acute Coronary Syndrome Patients: The TROPICAL-ACS Gender Substudy. Thromb Haemost 2019; 119:1527-1538. [PMID: 31226717 DOI: 10.1055/s-0039-1692441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES This prespecified analysis of the TROPICAL-ACS trial aimed to assess the impact of gender on clinical outcomes and platelet reactivity (PR) following guided de-escalation of dual antiplatelet treatment (DAPT) in acute coronary syndrome (ACS) patients. BACKGROUND Guided de-escalation of DAPT was recently identified as an effective alternative treatment strategy in ACS. METHODS We used Cox proportional hazards models and linear regression analysis to assess the interaction of gender with clinical endpoints and PR. RESULTS In both male (n = 2,052) and female (n = 558) patients, the 1-year incidence of the primary endpoint did not differ in guided de-escalation versus control group patients (male: 7.0% vs. 9.0%; hazard ratio [HR], 0.78, 95% confidence interval [CI], 0.57-1.06, p = 0.11; female: 8.4% vs. 9.2%; HR, 0.92, 95% CI, 0.53-1.62, p = 0.76, p int = 0.60). The 1-year incidence of combined ischemic events (male: 2.5% vs. 3.3%; HR, 0.76, 95% CI, 0.46-1.26, p = 0.29; female: 2.2% vs. 2.8%; HR, 0.78,95% CI, 0.27-2.25, p = 0.65, p int = 0.96) as well as Bleeding Academic Research Consortium ≥ 2 bleeding (male: 4.6% vs. 6.0%; HR, 0.77, 95% CI, 0.52-1.12, p = 0.17; female: 6.2% vs. 6.4%; HR, 0.99, 95% CI, 0.51-1.92, p = 0.97, p int = 0.51) was similar in the guided de-escalation versus control group for both male and female patients. Interaction testing revealed no significant impact of gender on PR levels (prasugrel or clopidogrel) across treatment groups (p int = 0.72). CONCLUSION Guided de-escalation of DAPT appears to be equally safe and effective in women and men. Especially in patients with increased bleeding risk and independent from gender, a guided DAPT de-escalation strategy may be used as an alternative treatment strategy. CLINICAL TRIAL REGISTRATION URL: https//www.clinicaltrials.gov. Unique Identifier: NCT: 01959451.
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Affiliation(s)
- Lisa Gross
- Department of Cardiology, LMU München, Munich, Germany
| | - Danny Kupka
- Department of Cardiology, LMU München, Munich, Germany
| | - Dietmar Trenk
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Tobias Geisler
- Department of Cardiology, University Hospital of Tuebingen, Tübingen, Germany
| | - Martin Hadamitzky
- Department of Radiology, German Heart Center of Munich, Munich, Germany
| | - Anja Löw
- Department of Cardiology, LMU München, Munich, Germany
| | - Martin Orban
- Department of Cardiology, LMU München, Munich, Germany
| | - Kurt Huber
- Wilhelminen Hospital, 3rd Medical Department for Cardiology and Emergency Medicine, and Sigmund Freud University, Medical School, Vienna, Austria
| | | | - Bela Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Zenon Huczek
- 1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Bo Eric Beuthner
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
| | | | | | | | - Steffen Massberg
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Daniel Aradi
- Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Dirk Sibbing
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Claudius Jacobshagen
- Department of Cardiology and Pneumology, University Medical Center Göttingen (UMG), Göttingen, Germany
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Hamm W, von Stülpnagel L, Klemm M, Baylacher M, Rizas KD, Bauer A, Brunner S. Deceleration Capacity of Heart Rate After Acute Altitude Exposure. High Alt Med Biol 2018; 19:299-302. [DOI: 10.1089/ham.2018.0041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Wolfgang Hamm
- Medical Department I, Cardiology, Ludwig-Maximilian University Munich, Munich, Germany
- German Cardiovascular Research Center (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Lukas von Stülpnagel
- Medical Department I, Cardiology, Ludwig-Maximilian University Munich, Munich, Germany
- German Cardiovascular Research Center (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Mathias Klemm
- Medical Department I, Cardiology, Ludwig-Maximilian University Munich, Munich, Germany
- German Cardiovascular Research Center (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Monika Baylacher
- Medical Department I, Cardiology, Ludwig-Maximilian University Munich, Munich, Germany
| | - Konstantinos D. Rizas
- Medical Department I, Cardiology, Ludwig-Maximilian University Munich, Munich, Germany
- German Cardiovascular Research Center (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Axel Bauer
- Medical Department I, Cardiology, Ludwig-Maximilian University Munich, Munich, Germany
- German Cardiovascular Research Center (DZHK), Partner Site: Munich Heart Alliance, Munich, Germany
| | - Stefan Brunner
- Medical Department I, Cardiology, Ludwig-Maximilian University Munich, Munich, Germany
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Gross L, Trenk D, Jacobshagen C, Krieg A, Gawaz M, Massberg S, Baylacher M, Aradi D, Stimpfle F, Hromek J, Vogelgesang A, Hadamitzky M, Sibbing D, Geisler T. Genotype-Phenotype Association and Impact on Outcomes following Guided De-Escalation of Anti-Platelet Treatment in Acute Coronary Syndrome Patients: The TROPICAL-ACS Genotyping Substudy. Thromb Haemost 2018; 118:1656-1667. [PMID: 30103241 DOI: 10.1055/s-0038-1667337] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Phenotype-guided de-escalation (PGDE) of P2Y12-inhibitor treatment with an early switch from prasugrel to clopidogrel was identified as an effective alternative treatment strategy in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). The Testing Responsiveness to Platelet Inhibition on Chronic Antiplatelet Treatment for Acute Coronary Syndromes (TROPICAL-ACS) Genotyping Substudy aimed to investigate whether CYP2C19 genotypes correlate with on-treatment platelet reactivity (PR) in ACS patients treated with clopidogrel or prasugrel and thus might be useful for guidance of early de-escalation of anti-platelet treatment. METHODS AND RESULTS A total of 603 ACS consecutive patients were enrolled in four centres (23.1% of the overall TROPICAL-ACS population). Rapid genotyping (Spartan RX) for CYP2C19*2, *3 and *17 alleles was performed. Associations between PR and the primary and secondary endpoints of the TROPICAL-ACS trial and CYP2C19*2 and CYP2C19*17 carrier status were evaluated.For the PGDE group, the on-clopidogrel PR significantly differed across CYP2C19*2 (p < 0.001) and CYP2C19*17 genotypes (p = 0.05). Control group patients were not related (p = 0.90, p = 0.74) to on-prasugrel PR. For high PR versus non-high PR patients within the PGDE group, significant differences were observed for the rate of CYP2C19*2 allele carriers (43% vs. 28%, p = 0.007). CONCLUSION CYP2C19*2 and CYP2C19*17 carrier status correlates with PR in ACS patients treated with clopidogrel and thus might be useful for pre-selecting patients who will and who may not be suitable for PGDE of anti-platelet treatment. Regarding phenotype-guided treatment, we did not observe added benefit of genotyping to predict ischaemic and bleeding risk in patients who underwent a PGDE approach. CLINICAL TRIAL REGISTRATION URL: https//www.clinicaltrials.gov. Unique Identifier: NCT: 01959451.
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Affiliation(s)
- Lisa Gross
- Department of Cardiology, LMU München, Munich, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, University of Freiburg, Bad Krozingen, Germany
| | - Claudius Jacobshagen
- Department of Cardiology and Pneumology, Heart Centre, Georg-August-University Göttingen, Göttingen, Germany
| | - Anne Krieg
- Department of Cardiology, LMU München, Munich, Germany
| | - Meinrad Gawaz
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Steffen Massberg
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | | | - Daniel Aradi
- Heart Centre Balatonfüred and Heart and Vascular Centre, Semmelweis University, Budapest, Hungary
| | - Fabian Stimpfle
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
| | - Julia Hromek
- Department of Cardiology and Angiology II, University Heart Centre Freiburg, University of Freiburg, Bad Krozingen, Germany
| | - Anja Vogelgesang
- Department of Cardiology and Pneumology, Heart Centre, Georg-August-University Göttingen, Göttingen, Germany
| | - Martin Hadamitzky
- Department of Radiology, Deutsches Herzzentrum München, Technical University of Munich, München, Germany
| | - Dirk Sibbing
- Department of Cardiology, LMU München, Munich, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Disease, University Hospital Tübingen, University of Tübingen, Tübingen, Germany
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Gross L, Trenk D, Jacobshagen C, Krieg A, Gawaz M, Massberg S, Baylacher M, Aradi D, Stimpfle F, Hromek J, Vogelgesang A, Hadamitzky M, Sibbing D, Geisler T. P5731CYP2C19 genotyping as complementary tool for guidance of early de-escalation of antiplatelet treatment in acute coronary syndrome patients. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- L Gross
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - D Trenk
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - C Jacobshagen
- University Medical Center Gottingen (UMG), Department of Cardiology and Pneumology, Gottingen, Germany
| | - A Krieg
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - M Gawaz
- University Hospital of Tubingen, Department of Cardiology, Tubingen, Germany
| | - S Massberg
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - M Baylacher
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - D Aradi
- Semmelweis University, Heart Centre Balatonfüred and Heart and Vascular Centre, Budapest, Hungary
| | - F Stimpfle
- University Hospital of Tubingen, Department of Cardiology, Tubingen, Germany
| | - J Hromek
- University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - A Vogelgesang
- University Medical Center Gottingen (UMG), Department of Cardiology and Pneumology, Gottingen, Germany
| | - M Hadamitzky
- German Heart Center of Munich, Department of Radiology, Munich, Germany
| | - D Sibbing
- Ludwig-Maximilians University, Department of Cardiology, Munich, Germany
| | - T Geisler
- University Hospital of Tubingen, Department of Cardiology, Tubingen, Germany
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9
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Sibbing D, Gross L, Trenk D, Jacobshagen C, Geisler T, Hadamitzky M, Merkely B, Kiss R, Komócsi A, Parma R, Gori T, Felix S, Schwinger R, Neumann FJ, Hausleiter J, Baylacher M, Koltowski L, Mehilli J, Huber K, Huczek Z, Aradi D, Massberg S. AGE AND OUTCOMES FOLLOWING GUIDED DE-ESCALATION OF ANTIPLATELET TREATMENT IN ACUTE CORONARY SYNDROME PATIENTS UNDERGOING PERCUTANEOUS CORONARY INTERVENTION: RESULTS OF A RANDOMIZED MULTICENTRE TRIAL. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)31744-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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10
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Jacobshagen C, Gross L, Trenk D, Geisler T, Orban M, Gori T, Hadamitzky M, Merkely B, Kiss R, Komócsi A, Dézsi CA, Thalmeier A, Löw A, Holdt L, Teupser D, Ince H, Felix SB, Parma R, Malek L, Horstkotte J, Baylacher M, Schwinger R, Rieber J, Mudra H, Hausleiter J, Huber K, Neumann FJ, Koltowski L, Huczek Z, Mehilli J, Massberg S, Sibbing D, Aradi D. A randomised trial on platelet function-guided de-escalation of antiplatelet treatment in ACS patients undergoing PCI. Thromb Haemost 2017; 117:188-195. [DOI: 10.1160/th16-07-0557] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 09/09/2016] [Indexed: 12/21/2022]
Abstract
SummaryOutcomes of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) have been significantly improved with the use of potent P2Y12 receptor inhibitors like prasugrel. While most of the ischaemic risk reduction for prasugrel versus clopidogrel was demonstrated in the early treatment period, the risk of bleeding became particularly prominent during the chronic course of therapy. It may therefore be a valid approach to substitute prasugrel for clopidogrel in the early phase of chronic antiplatelet treatment after PCI. In the Testing Responsiveness To Platelet Inhibition On Chronic Antiplatelet Treatment For Acute Coronary Syndromes (TROPICAL-ACS) trial, we aim to compare standard prasugrel therapy with a de-escalating antiplatelet treatment approach guided by platelet function testing (PFT). The study is an investigator-initiated European multicentre, randomised clinical trial in biomarker-positive ACS patients after successful PCI. Two thousand six hundred patients will be randomised prior to hospital discharge in a 1:1 fashion to either receive standard prasugrel therapy (control group) or de-escalating therapy (one-week prasugrel followed by one-week clopidogrel and PFT-guided maintenance therapy from day 14 after hospital discharge, monitoring group). Patients of the monitoring group with high on-clopidogrel platelet reactivity (HPR) based on Multiplate analyzer testing (HPR: ≥ 46U per consensus definition) will be switched back to prasugrel, whereas those without HPR (<46 U) will continue clopidogrel treatment. The overall study treatment duration will be one year in both groups. The primary endpoint of the study is net clinical benefit (combined incidence of cardiovascular death, myocardial infarction, stroke and bleeding ≥ grade 2 according to BARC criteria) one-year after randomisation. TROPICAL-ACS is the first large-scale, randomised controlled trial assessing the clinical value of a PFT-guided de-escalation of antiplatelet treatment in biomarker positive ACS patients undergoing PCI.ClinicalTrials.gov Identifier: NCT01959451
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11
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Rieber J, Rittger H, Henrichs S, Ostermeier M, Baylacher M, Schmidt M, Hoffmann E. Clinical evaluation of dynamic layer separation for coronary DSA and enhancement in fluoroscopic sequences. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht307.p265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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12
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Moschovitis A, Simon R, Seidenstücker A, Klauss V, Baylacher M, Lüscher T, Moccetti T, Windecker S, Meier B, Hess O. Randomised comparison of titanium-nitride-oxide coated stents with bare metal stents: five year follow-up of the TiNOX trial. EUROINTERVENTION 2010. [DOI: 10.4244/eijv6i1a10] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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13
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Moschovitis A, Simon R, Seidenstücker A, Klauss V, Baylacher M, Lüscher TF, Moccetti T, Windecker S, Meier B, Hess OM. Randomised comparison of titanium-nitride-oxide coated stents with bare metal stents: five year follow-up of the TiNOX trial. EUROINTERVENTION 2010; 6:63-68. [PMID: 20542799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
AIMS Revascularisation with Titanium-Nitride-Oxide (TiNOX) coated stents is safe and effective in patients with de novo native coronary artery lesions. In the TiNOX trial there was a reduction in restenosis and major adverse cardiac events as compared with stainless steel stents of otherwise identical design. The purpose of the present study was to evaluate the long-term outcome of these patients over five years. METHODS AND RESULTS In 2003, 92 patients with de novo lesions were randomly assigned to treatment with TiNOX coated stents (n=45) or stainless steel stents (n=47; control). Baseline characteristics were similar in both groups. Follow-up at six months and five years was obtained in 87 patients. Five patients were lost to follow-up due to emigration or change in home address. At six months and five years, significantly less major adverse cardiac events (MACE) occurred in the TiNOX group (7% vs. 27%, [p=0.02] respectively and 16% vs. 39%, [p=0.03]), largely driven by a reduced need for target-lesion revascularisation. No stent thrombosis occurred in the TiNOX group vs. one in the control group. Patients in the TiNOX-group had lower all-cause mortality and less myocardial infarction, but the difference was not statistically significant. CONCLUSIONS Five-year follow-up after implantation of titanium-nitride-oxide coated stents is favourable with a low rate of MACE and no stent thrombosis compared to bare metal stents of identical design. The need for revascularisation at five years was 9% in the TiNOX and 25% in the control group with little progression of native coronary disease.
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Affiliation(s)
- Aris Moschovitis
- Department of Cardiology, Swiss Cardiovascular Center, University Hospital Bern, Switzerland
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14
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Erhard I, Rieber J, Jung P, Hacker M, Schiele T, Stempfle HU, König A, Baylacher M, Theisen K, Siebert U, Klauss V. The validation of fractional flow reserve in patients with coronary multivessel disease: a comparison with SPECT and contrast-enhanced dobutamine stress echocardiography. ACTA ACUST UNITED AC 2005; 94:321-7. [PMID: 15868360 DOI: 10.1007/s00392-005-0213-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2004] [Accepted: 12/06/2004] [Indexed: 10/25/2022]
Abstract
UNLABELLED Fractional flow reserve (FFR) is a new but well established parameter for the hemodynamic evaluation of coronary stenoses. A FFR below 0.75 was validated as functionally significant in coronary one or two vessel disease. This study was designed to prospectively define the best FFR cut off value (BCV) in patients with multivessel disease using two noninvasive tests, myocardial perfusion scintigraphy (SPECT) and contrast-enhanced dobutamine stress echocardiography (DSE) as reference methods. METHODS 47 symptomatic patients (29 male, mean age 64+/-10 yrs) with angiographically intermediate coronary lesions (50-75% diameter stenosis) entered the study. DSE (5-40 microg/min/kg dobutamine) was performed after intravenous injection of a second generation transpulmonary contrast agent. SPECT (Tc-99m-MIBI) was done at peak stress. All tests (DSE, SPECT and FFR) were performed within 4 weeks. RESULTS SPECT yielded positive results in 15 and DSE in 16 patients, respectively. Mean FFR measured in the target lesion (RCA n=10; LAD n=22, RCX n=15) was 0.80+/-0.13. FFR was <0.75 in 15 patients. By performing a ROC analysis the BCV (highest sum of sensitivity and specificity) was found at 0.75. At this cut off value using both non-invasive tests as reference method, sensitivity and specificity were 83 and 77%. CONCLUSION In patients with multivessel disease, a FFR <0.75 identifies a hemodynamically relevant lesion as compared to DSE and SPECT. This study underlines that FFR criteria are also applicable in patients with complex coronary artery disease.
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Affiliation(s)
- I Erhard
- Dept. of Cardiology, Medizinische Poliklinik-Innenstadt, University of Munich, Ziemssenstr. 1, 80336 Munich, Germany.
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Klauss V, Erdin P, Rieber J, Leibig M, Stempfle HU, König A, Baylacher M, Theisen K, Haufe MC, Sroczynski G, Schiele T, Siebert U. Fractional flow reserve for the prediction of cardiac events after coronary stent implantation: results of a multivariate analysis. Heart 2005; 91:203-6. [PMID: 15657233 PMCID: PMC1768692 DOI: 10.1136/hrt.2003.027797] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To determine the prognostic value of fractional flow reserve (FFR) measurements after coronary stent implantation including multiple clinical and angiographic parameters collected in one centre. METHODS 119 consecutive patients were enrolled who had a stent implanted with the use of a pressure wire as a guidewire. Patients were followed up for at least six months. Any death, myocardial infarction, and target vessel revascularisation were considered major adverse cardiac events (MACE). Multivariate logistic regression was used to determine adjusted odds ratios (OR) and 95% confidence intervals (CI) for FFR and covariates. RESULTS Complete follow up data were available for all 119 patients. Pre-interventional FFR increased from 0.65 (0.15) to 0.94 (0.06) (p < 0.0001) after stent implantation. Eighteen MACE (15%) occurred during follow up including 15 (12.6%) target vessel revascularisations. Final FFR was significantly higher in patients without than in patients with an event (0.95 (0.05) v 0.88 (0.08), p = 0.001). In the multivariate logistic regression analysis, only final FFR < 0.95 (OR 6.22, 95% CI 1.79 to 21.62, p = 0.004) and reduced left ventricular function (OR 0.95, 95% CI 092 to 0.99, p = 0.021) remained as significant independent predictors for MACE. CONCLUSION These results including multiple parameters underline that FFR after coronary stenting is a strong and independent predictor for subsequent cardiac events after six months' follow up.
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Affiliation(s)
- V Klauss
- Department of Cardiology, Medizinische Poliklinik-Innenstadt, University of Munich, Ziemssenstrasse 1, D-80336 Munich, Germany.
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16
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Rieber J, Schiele TM, Erdin P, Stempfle HU, König A, Erhard I, Segmiller T, Baylacher M, Theisen K, Haufe MC, Siebert U, Klauss V. Fractional flow reserve predicts major adverse cardiac events after coronary stent implantation. Z Kardiol 2003; 91 Suppl 3:132-6. [PMID: 12641028 DOI: 10.1007/s00392-002-1324-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Determination of fractional flow reserve (FFR) allows the functional assessment of coronary stenoses before and after an intervention. Preliminary data suggest that a FFR > or = 0.94 is associated with an excellent clinical outcome after stent implantation. However, these results were limited both by the number of patients included and the use of non-contemporary stent designs. We sought to determine the prognostic value of FFR measurements in a large patient cohort undergoing coronary stent implantation. METHODS Eighty-nine consecutive patients were enrolled in whom a stent implantation was performed and a pressure wire was used as a guide wire. Patients were followed for at least 6 months. Death, myocardial infarction (MI) and target vessel revascularization (TVR) were considered cardiac events. A FFR > or = 0.94 was regarded as an optimal functional result. RESULTS A complete follow-up was available in all patents. Pre-interventional FFR increased from 0.66 +/- 0.16 to 0.95 +/- 0.05 (p < 0.0001) after stent implantation. Sixteen (18%) events occurred during follow-up including 10 (11.2%) TVR. Final FFR was significantly higher in patients without compared to patients with an event (0.92 +/- 0.06 vs. 0.96 +/- 0.05, p < 0.003). By univariate analysis, the presence of diabetes mellitus, left ventricular function, residual diameter stenosis and final FFR were associated with a worse clinical outcome. In the multivariate analysis, only the final FFR and left ventricular function remained as significant predictors for cardiac events (relative risk, 3.50; 95% CI: 1.29-9.52, P < 0.014, and 0.97; 95% CI: 0.93-1.00, p = 0.047). CONCLUSION These results demonstrate in a nonselected patient cohort a strong correlation between FFR values after coronary stenting and subsequent cardiac events. Further studies have to investigate whether outcome after stenting might be improved by guiding the procedure with a pressure guide wire.
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Affiliation(s)
- Johannes Rieber
- Dept. of Cardiology, Medizinische Klinik-Innenstadt, University of Munich, Ziemssenstr. 1 80336 Munich, Germany
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17
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Schiele TM, König A, Zimmermann A, Rieber J, Krötz F, Sohn HY, Baylacher M, Pöllinger B, Kantlehner R, Dühmke E, Theisen K, Klauss V. Angiographic and intravascular ultrasound analysis of overlapped beta-radiation fields on vessel geometry after manual stepping brachytherapy. J Am Coll Cardiol 2002. [DOI: 10.1016/s0735-1097(02)80152-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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