The long-term cardiac events after coronary bifurcation stenting with second-generation drug-eluting stents in elderly patients are comparable to those of younger patients

Background

Elderly patients undergoing percutaneous coronary intervention (PCI) generally have a high risk of adverse clinical outcomes. We investigated the long-term clinical impact of PCI on coronary bifurcation disease in elderly patients in Korea and Italy.

Methods

From the BIFURCAT (comBined Insights from the Unified RAIN and COBIS bifurcAtion regisTries) data, we evaluated 5,537 patients who underwent PCI for coronary bifurcation disease. The primary outcome was major adverse cardiac events (MACEs), defined as the composite of target vessel myocardial infarction, target lesion revascularisation, and stent thrombosis. Kaplan–Meier estimates and Cox proportional hazard models were used to compare elderly patients (aged ≥75 years) and younger patients (aged <75 years).

Results

A total of 1,415 patients (26%) were aged ≥75 years. Elderly patients were more frequently female, had higher rates of hypertension and chronic kidney disease (CKD), and presented more frequently with left main (LM) disease. After a median follow-up of 2.1 years, MACEs were comparable between elderly and younger patients. In multivariable analysis, old age was not an independent predictor of MACEs (p=0.977). In elderly patients, CKD and LM disease were independent predictors of MACEs, whereas in younger patients, hypertension, diabetes, CKD, reduced left ventricular ejection fraction, LM disease, and two-stent strategy usage were independent predictors.

Conclusions

Elderly patients who underwent coronary bifurcation PCI with second-generation drug-eluting stents demonstrated similar clinical outcomes to those of younger patients. Both CKD and LM disease were independent predictors of MACEs, regardless of age after coronary bifurcation PCI.

Funding Acknowledgement

Type of funding sources: None.

Effect of an early invasive strategy based on time of symptom onset in patients with non-ST elevation myocardial infarction

Background

A limitation of the current guidelines of the timing of invasive coronary angiography (ICA) for patients with non-ST-segment elevation (NSTE) acute coronary syndrome is based on randomization time. So far, no study has reported the clinical outcomes of invasive strategy timing based on the time of symptom onset. Herein, we aimed to investigate the effect of invasive strategy timing from the time of symptom onset on the 3-year clinical outcomes of patients with NSTE myocardial infarction (MI).

Methods and results

Among 13,104 patients from the Korea Acute Myocardial Infarction Registry-National Institutes of Health, we evaluated 5,856 patients with NSTEMI. The patients were categorized according to symptom-to-catheter (StC) time (<48 h and ≥48 h). The primary outcome was 3-year all-cause mortality, and the secondary outcome was a 3-year composite of all-cause mortality, recurrent MI, and hospitalization for heart failure. Overall, 3,919 (66.9%) patients were classified into the StC time <48 h group. This group had lower all-cause mortality than the StC time ≥48 h group (7.3% vs. 13.4%, p<0.001). The continuous association of StC time and risk of primary and secondary endpoints showed shorter StC time (reference: 48 h), and lower adjusted hazard ratio reduction was observed. In multivariable analysis, independent predictors of delayed ICA were older age, non-specific symptoms, no use of emergency medical services, no ST-segment deviation, chronic kidney disease, and Global Registry of Acute Coronary Events score >140.

Conclusion

Early invasive strategy based on the StC time improves all-cause mortality in patients with NSTEMI.

Funding Acknowledgement

Type of funding sources: None.

Clinical impact of intravascular ultrasound guidance in patients of ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention with drug eluting stent

Background

There is little data about clinical role of intravascular ultrasound (IVUS)-guided Percutaneous (PCI) in the setting of ST-segment elevation myocardial infarction (STEMI).

Methods

From 2005 to 2018, a total of 8,129 patients who underwent PCI with STEMI were investigated from the Korea Acute Myocardial Infarction Registry-National Institute of Health database. Patients with Non-ST segment elevation myocardial infarction, cardiogenic shock, bare metal stent implantation, thrombolytic treatment, and coronary artery bypass graft surgery were excluded. We categorized patients into two groups based on the treatment strategy: IVUS-guided PCI group (n=1,544), and coronary angiography guidance (CAG)-guided PCI group (n=6,585). The primary endpoint was composite of major adverse cardiovascular (MACE), including, cardiac death, myocardial infarction (MI), repeat target vessel revascularization (TVR) and stent thrombosis (ST).

Results

IVUS-guided PCI was performed in 19% patients (1544/8129). After propensity score matching, there were no statistically difference in the rate of cardiac death (0% in IVUS vs. 0.26% in CAG, p=0.947), MI (2.01% vs. 2.01%, p=0.408), TVR (1.23% vs. 0.91%, p=0.131), ST (0.32% vs. 0.45%, p=0.828) and composite of MACE at 1 year between two groups (2.01% vs. 2.40%, p=0.843). Independent risk factors for MACE were diabetes mellitus and multi-vessel disease, but not IVUS-guided PCI (HR 1.167, 95% CI, 0.896–1.520, p=0.251).

Conclusion

This study suggests that routine usage of IVUS in the setting of STEMI may not be necessary. Large-scaled random study will be needed for further evaluation.

Funding Acknowledgement

Type of funding sources: None.

P3127Optimal revascularization strategy in non-ST-segment elevation myocardial infarction with multivessel coronary artery disease: staged vs. one-time vs. culprit-only revascularization

Background/Introduction

Although optimal revascularization strategy in patients with ST-segment elevation myocardial infarction with multivessel coronary artery disease (MVD) was well established, there are few studies which investigated optimal revascularization strategy in non-ST-segment elevation myocardial infarction (NSTEM) with MVD.

Purpose

We investigated 2-year clinical outcomes according to strategy of revascularization in patients with NSTEMI and MVD.

Methods

Between November 2011 and October 2015, a total of 2474 patients with NSTEMI and MVD who underwent successful percutaneous coronary intervention were analyzed from the Korea Acute Myocardial Infarction Registry-National Institute of Health (staged 308, one-time 1043 and culprit-only 1123 patients). We did not include patients with left main disease and cardiogenic shock. Primary endpoint was major adverse cardiac events (MACE: the composite of cardiac death, myocardial infarction [MI] or target-vessel revascularization [TVR]) during 2-year follow-up (median 737 days [interquartile range 705–764]). We also analyzed the of all-cause mortality, stroke and non-TVR.

Results

Baseline characteristics such as age, gender, and prevalence of atherosclerotic risk factors between multivessel revascularization (MVR; staged or one-time revascularization) and CVR were similar. There was also no difference in symptom to balloon time in 2 groups. MACE occurred in 305 patients (12.3%) during 2-year follow-up. MVR could reduce incidence of MACE (10.2% vs. 14.9%; adjusted hazard ratio [HR] 1.50 for CVR, 95% confidence interval [CI] 1.20–1.88, p<0.001), all-cause death (8.4% vs. 12.1%; adjusted HR 1.45 for CVR, 95% CI 1.13–1.87, p=0.003) and non-TVR (1,9% vs. 7.0%; adjusted HR 3.99 for CVR, 95% CI 2.55–6.27, p<0.001). There was no difference in incidence of stroke between MVR and CVR. We also analyzed same analysis between staged and one-time revascularization. Complete revascularization was more achieved in one-time revascularization group compared to staged revascularization group (62.0% vs. 76.1%, p<0.001). In multivariate Cox-regression analysis, staged revascularization was not associated with improved clinical outcomes in terms of MACE (HR 0.74, 95% CI 0.50–1.09, p=0.126), all-cause death (HR 1.07, 95% CI 0.69–1.68, p=0.759), stroke (HR 1.75, 95% CI 0.68–4.52, p=0.245) and non-TVR (HR 2.56, 95% CI 0.75–8.68, p=0.132). Analysis by propensity score matching and inverse probability of treatment weighting did not significantly affect the results.

Conclusions

MVR reduced 2-year adverse cardiac events in patients with NSTEMI and MVD compared to CVR. However, staged revascularization was not superior to one-time revascularization for reducing MACE among NSTEMI patients with MVD who received MVR.

Diagnostics And Control Of High-Density Etching Plasmas

Advanced diagnostics of high-density inductively coupled plasmas (ICPs) are presented supporting the following three proposals of innovative etching modes: First, pulsed plasma etching mode can suppress charge-up on high-aspect-ratio micro-patterns. In order to understand the mechanism, time-resolved measurements of electrons, chlorine atoms and negative ions in a pulsed chlorine ICP are performed. As a result of electron cooling and negative ion yield in afterglow, electrons are found to be accelerated toward a rf-biased electrode, thus neutralizing positive surface charges on that. Second, downstream etching mode using C4F8 gas enables high etch selectivity of SiO2 to Si. The reason for this is qualitatively discussed using comprehensive measurements of spatial distributions of CF3, CF2, CF and F densities in CF4 and C4F8 plasmas. Third, hot wall etching mode also enables high selectibity etching in fluorocarbon plasmas. Radical diagnostics reveal that wall heating dramatically modifies the radical composition of both CF4 and C4F8 plasmas, and it improves the etch selectivity and reproducibility.

Comparison of inflammatory markers and angiographic outcomes after implantation of sirolimus and paclitaxel-eluting stents

OBJECTIVE

We compared the degree of systemic inflammation and its relation to the angiographic outcomes after drug-eluting stent (DES) implantations.

METHODS

We implanted a single DES in 79 stable angina patients (50 men; 60.4 (9.5) years of age; sirolimus-eluting stent (SES), n = 38; paclitaxel-eluting stent (PES), n = 41). The high-sensitivity C-reactive protein (hs-CRP) and interleukin 6 (IL-6) levels were determined before and at 24 hours, 72 hours, and 4 weeks after the percutaneous coronary intervention (PCI). An angiography and intravascular ultrasound (IVUS) were performed.

RESULTS

The hs-CRP and IL-6 levels at baseline did not differ between the two groups. The hs-CRP increased significantly from baseline at 24 hours and 72 hours after the PCI in both groups and there was a significant increase in the IL-6 level at 24 hours after the PCI in both groups. However, there was no significant difference between the two groups in any of the hs-CRP or IL-6 measurements. At follow-up, the late lumen loss was significantly higher in the PES group than in the SES group (0.57 (0.56) mm vs 0.28 (0.58) mm, respectively, p = 0.020). The neointimal hyperplasia (NIH) volume in the PES group was significantly higher than that in the SES group (23.1 (22.7) vs 3.8 (7.1) mm(3), respectively, p = 0.000). The percentage luminal volume reduction was higher in the PES group than in the SES group (18.9 vs 3.9%, p = 0.002). The absolute values or change in the inflammatory markers did not correlate with the NIH or stent volume reduction.

CONCLUSIONS

Our study showed that the benefits obtained from the SES, which reduce neointimal proliferation, are not probably mediated by the attenuation of the systemic inflammatory markers hs-CRP or IL-6.

Effects of tert-butyl acetate on maternal toxicity and embryo-fetal development in Sprague-Dawley rats

This study investigated the potential adverse effects of tert-butyl acetate (TBAc) on maternal toxicity and embryo-fetal development after maternal exposure of pregnant rats from gestational days 6 through 19. TBAc was administered to pregnant rats by gavage at 0, 400, 800, and 1,600 mg/kg/day. All dams were subjected to a Caesarean section on day 20 of gestation, and their fetuses were examined for any morphological abnormalities. At 1,600 mg/kg, maternal toxicity manifested as increases in the incidence of clinical signs and death, lower body weight gain and food intake, increases in the weights of adrenal glands and liver, and a decrease in thymus weight. Developmental toxicity included a decrease in fetal weight, an increase in the incidence of skeletal variation, and a delay in fetal ossification. At 800 mg/kg, only a minimal developmental toxicity, including an increase in the incidence of skeletal variation and a delay in fetal ossification, were observed. In contrast, no adverse maternal or developmental effects were observed at 400 mg/kg. These results show that a 14-day repeated oral dose of TBAc is embryotoxic at a maternally toxic dose (i.e., 1,600 mg/kg/day) and is minimally embryotoxic at a nonmaternally toxic dose (i.e., 800 mg/kg/day) in rats. However, no evidence for the teratogenicity of TBAc was noted in rats. It is concluded that the developmental findings observed in the present study are secondary effects to maternal toxicity. Under these experimental conditions, the no-observed-adverse-effect level of TBAc is considered to be 800 mg/kg/day for dams and 400 mg/kg/day for embryo-fetal development.

Multiple predictors of coronary restenosis after drug-eluting stent implantation in patients with diabetes

OBJECTIVES

To identify parameters influencing the likelihood of restenosis after implantation of drug-eluting stents (DES) in patients with diabetes.

METHODS

Stented patients (n = 840) with DES were retrospectively reviewed for inclusion in the study from the Multicenter PCI Database Registry. From this database, 211 (25.1%) of 840 patients with six-month angiographic follow up had diabetes. Predictors of coronary restenosis were identified with univariate and multivariate logistic regression analyses.

RESULTS

Restenosis occurred in 92 of 629 (14.6%) patients without diabetes and in 44 (20.9%) of 211 patients with diabetes (p < 0.001). Multivariate parameters for predicting restenosis in the diabetic group were current smoking (odds ratio (OR) 1.923, 95% confidence interval (CI) 1.055 to 4.725, p = 0.036), higher C reactive protein concentration (OR 1.031, 95% CI 1.011 to 1.075, p = 0.043), use of the paclitaxel-eluting stent (OR 2.638, 95% CI 1.338 to 5.200, p = 0.005), longer stent length (OR 1.065, 95% CI 1.021 to 1.119, p = 0.033), smaller reference diameter before DES implantation (OR 0.501, 95% CI 0.110 to 0.965, p = 0.040), smaller reference diameter (OR 0.455, 95% CI 0.120 to 0.814, p = 0.026) and minimum lumen diameter (OR 0.447, 95% CI 0.068 to 0.876, p = 0.039) after DES implantation.

CONCLUSION

Even with the introduction of DES, diabetes remains a significant predictor of coronary restenosis, especially in cases of a small baseline vessel size, small vessel size after percutaneous coronary intervention, longer stent length, use of the paclitaxel-eluting stent, current smoking and high C reactive protein concentration.

Effect of hormone replacement therapy on nitric oxide bioactivity and monocyte chemoattractant protein-1 levels

BACKGROUND

Vascular inflammation plays an important role in the pathogenesis of atherosclerosis. We investigated the effect of hormone replacement therapy (HRT) on vasomotor function and monocyte chemoattractant protein (MCP)-1 levels, an important serological marker of inflammation.

METHODS

We administered micronized progesterone (MP) 200 mg for 10 days with conjugated equine estrogen (CEE) 0.625 mg for 25 days and remaining 5 days off cyclically during 2 months to 20 healthy postmenopausal women (PMW). We measured NO bioactivity and plasma levels of MCP-1 before and after HRT in 20 PMW. And we measured plasma levels of MCP-1 in each 20 subjects of premenopausal women, men <50, and men >50 years, respectively.

RESULTS

MP combined with CEE significantly improved the percent flow-mediated dilator response to hyperemia relative to baseline measurements (P<0.001). PMW receiving HRT had lower levels of MCP-1 than those not receiving HRT (121+/-38 versus 146+/-44 pg/ml, P<0.001). In all comparisons, subjects with high estrogen status had significantly lower MCP-1 levels than subjects with low estrogen status (P<0.001 by ANOVA). Premenopausal women had lower levels of MCP-1 than men of a similar age (106+/-14 versus 164+/-40 pg/ml, P<0.001). PMW not receiving HRT had similar levels of MCP-1 compared with men of a similar age (146+/-44 versus 143+/-29 pg/ml, P=0.816). Premenopausal women had markedly lower levels of MCP-1 than PMW not receiving HRT (106+/-14 versus 146+/-44 pg/ml, P=0.001). PMW receiving HRT had similar levels of MCP-1 compared with premenopausal women (121+/-38 versus 106+/-14 pg/ml, P=0.323).

CONCLUSION

These findings might provide at least a partial explanation for the protection against cardiovascular disease experienced by premenopausal women, and the loss of that protection following menopause.

Vascular effects of estrogen in type II diabetic postmenopausal women

OBJECTIVES

We assessed the effects of estrogen on vascular dilatory and other homeostatic functions potentially affected by nitric oxide (NO)-potentiating properties in type II diabetic postmenopausal women.

BACKGROUND

There is a higher cardiovascular risk in diabetic women than in nondiabetic women. This would suggest that women with diabetes do not have the cardioprotection associated with estrogen.

METHODS

We administered placebo or conjugated equine estrogen, 0.625 mg/day for 8 weeks, to 20 type II diabetic postmenopausal women in a randomized, double-blinded, placebo-controlled, cross-over design.

RESULTS

Compared with placebo, estrogen tended to lower low-density lipoprotein (LDL) cholesterol levels by 15 +/- 23% (p = 0.007) and increase high-density lipoprotein (HDL) cholesterol levels by 8 +/- 16% (p = 0.034). Thus, the ratio of LDL to HDL cholesterol levels significantly decreased with estrogen, by 20 +/- 24%, as compared with placebo (p = 0.001). Compared with placebo, estrogen tended to increase triglyceride levels by 16 +/- 48% and lower glycosylated hemoglobin levels by 3 +/- 13% (p = 0.295 and p = 0.199, respectively). However, estrogen did not significantly improve the percent flow-mediated dilatory response to hyperemia (17 +/- 75% vs. placebo; p = 0.501). The statistical power to accept our observation was 81.5%. Compared with placebo, estrogen did not significantly change E-selectin, intercellular adhesion molecule-1, vascular cell adhesion molecule-1, monocyte chemoattractant protein-1 or matrix metalloproteinase-9 levels. Compared with placebo, estrogen tended to decrease tissue factor antigen and increase tissue factor activity levels by 7 +/- 46% and 5 +/- 34%, respectively (p = 0.321 and p = 0.117, respectively) and lower plasminogen activator inhibitor-1 levels by 16 +/- 31% (p = 0.043).

CONCLUSIONS

The effects of estrogen on endothelial, vascular dilatory and other homeostatic functions were less apparent in type II diabetic postmenopausal women, despite the beneficial effects of estrogen on lipoprotein levels.

Efficacy of heparin-coated stent in early setting of acute myocardial infarction

Primary stenting has been reported to be superior to balloon percutaneous transluminal coronary angioplasty (PTCA) in acute myocardial infarction (AMI) for recurrent ischemia, target lesion revascularization, and restenosis. However, concerns about early reocclusion or thrombosis after stenting in the very thrombotic environment of acute myocardial infarction still remain. Therefore, postprocedural short-term heparin or GpII(b)/III(a) receptor blockades has been used. The aim of our study was to evaluate the safety, feasibility, and long-term efficacy of heparin-coated stent in the early setting of AMI without postprocedural heparin or GpII(b)/III(a) receptor blockade infusion. We studied 102 consecutive patients presenting to cardiac catheterization laboratory < or = 6 hr from the onset of chest pain. No patients who were implanted with heparin-coated stents received heparin or GpII(b)/III(a) receptor blockade infusion after the procedures, not even patients who showed an angiographically large thrombus burden before stenting. Patients were evaluated for clinical endpoints at 30 days and 6 months. Coronary angiography was required for all patients at 2 weeks and 6 months after the procedure. Angiographic and procedural successes were 100% and 98%, respectively. Two patients (2%) died of heart failure without evidence of reocclusion of stented vessel during the hospitalization and 4 (4%) additional patients died of refractory heart failure within the first 6 months. Major bleeding complication occurred in one patient (1%). Recurrent myocardial infarction developed in one patient at 4 months. Early angiographic follow up at 2 weeks was performed in 88% of all patients, none of whom showed thrombotic stent occlusion. Six-month angiographic follow-up was completed in 71%(64/91) of eligible patients and binary restenosis was present in 17.2% of stented vessels. Eight(8%) patients underwent repeat PTCA. Cardiac event-free survival rate at 6 months was 86.3%. This study demonstrates that heparin-coated stents are safe in the early setting of acute myocardial infarction and no additional heparin infusion after stenting is necessary, which may reduce bleeding complications. Angiographic restenosis rate compares favorably to the binary restenosis rate from other studies with uncoated stents.