Efficacy and safety of direct stenting in coronary angioplasty

BACKGROUND

Direct stenting is the deployment of an intracoronary stent without lesion predilation. Potential advantages include shorter procedural time, lower contrast dose and reduced spiral dissections. There is also the potential financial benefit of less balloon and/or stent usage. Concern still exists among some operators, however, regarding failure of stent deployment and local complications.

METHODS

Of 467 consecutive angioplasty cases at the Alfred Hospital between August 1, 1997 and May 22, 1998, direct stenting was attempted in 93 patients (20%). Interventionalist preference determined whether direct stenting was attempted. Vessels with excessive calcification, severe proximal tortuosity or small caliber were typically considered unsuitable for direct stenting.

RESULTS

A total of 102 lesions (38 type A, 60 type B, and 4 type C) were treated with direct stenting. Initial deployment was successful in 98 of 102 lesions, with a further 3 lesions successfully stented following predilation. A stent was unable to be deployed in only 1 case; however, the lesion was treated with balloon angioplasty alone. The majority of lesions required only 1 stent (an average of 1.1 stents were used per lesion). Distal complications occurred in 5 patients. In 3 patients, a small distal dissection was successfully stented, and in 1 case embolization of debris occurred down the distal vessel, resulting in a small procedural myocardial infarction. Only 1 patient out of 93 (1%) developed a large distal dissection requiring the deployment of multiple stents, compared with 22 of the remaining 374 patients (5.9%) who underwent conventional angioplasty. This was a significant difference in favor of direct stenting (Chi-square, p < 0.05). When compared with a cohort of patients matched by lesion grade treated with conventional stenting, direct stenting used significantly less contrast per case (154 +/- 7.6 ml compared with 202 +/- 9.5 ml for conventional stenting; p = 0.0001).

CONCLUSION

Direct stenting is a safe and effective method for treating coronary artery disease. In appropriately selected cases, it has a low rate of procedural failure and results in less contrast usage and fewer distal complications than conventional angioplasty and stenting.

Presynaptic antisympathetic action of amiodarone and its metabolite desethylamiodarone

Amiodarone has a "reserpine-like" sympatholytic action in the heart. The aims of this study were to test whether desethylamiodarone (DEA), the in vivo bioactive metabolite of amiodarone, has this action and whether this action could be demonstrated in a neuronal preparation. Experiments were performed in intact rats, perfused hearts, or brain synaptosomes treated with DEA and amiodarone, and concentrations of norepinephrine (NE) and dihydroxyphenylglycol (DHPG), the intraneuronal metabolite of NE, were assayed in plasma, coronary effluent, and synaptosomes. In perfused hearts, DEA at 1, 3, and 10 microM increased DHPG overflow by threefold, sixfold, and ninefold, respectively (all p < 0.01 vs. control). DEA at 1 microM was more potent than amiodarone in increasing DHPG overflow. DEA at 1 and 3 microM also inhibited NE release evoked by sympathetic nerve stimulation (p < 0.05). In intact rats, intravenous DEA at 15 mg/kg elicited onefold increase in plasma DHPG level, and oral pretreatment with amiodarone did not interfere with the sympatholytic action of intravenous amiodarone. In synaptosomes, 40-min incubation with amiodarone, DEA (both 10 microM), and reserpine reduced synaptosomal NE content by 42, 45, and 60%, respectively. Thus similar to its parent drug, DEA exerts a presynaptic sympatholytic action in rat hearts in vivo and in vitro. This action of amiodarone and DEA also was observed in synaptosomes.

Identification of a novel, inhibitory action of amiodarone on vesicular monoamine transport

The benzofuran antiarrhythmic drug, amiodarone, exhibits a wide range of pharmacological properties. Recent in vivo biochemical studies suggest that amiodarone may exert an antiadrenergic action in the heart, which resembles the effects of reserpine. To investigate the cellular basis for this apparent presynaptic, sympatholytic action we used Chinese hamster ovary (CHO) cells expressing the type 2 vesicular monoamine transporter (VMAT2) as a synaptic vesicular model. Amiodarone inhibited the uptake of [3H]norepinephrine in VMAT2-transfected CHO cells in a concentration-dependent manner, with a -log EC50 of 6.44 +/- 0.32. To further identify the site at which amiodarone suppressed vesicular monoamine transport, we examined the ability of amiodarone to displace [3H]reserpine from its binding site in membrane fractions prepared from CHO cells expressing VMAT2. [3H]Reserpine binding was inhibited in a concentration-dependent manner by amiodarone, with an -log EC50 of 6.76 +/- 0.03, reaching 84 +/- 5% inhibition of reserpine binding at 10 microM. A pH-dependent mechanism for this action of amiodarone was excluded in studies using the pH-sensitive fluorescent indicator 2',7'-bis (carboxyethyl)-5,6-carboxyfluorescein (BCECF). These data indicate that amiodarone inhibits the uptake of monoamine into the axoplasmic storage vesicle by inhibiting VMAT. Furthermore, amiodarone competes specifically with reserpine for binding to VMAT. These findings suggest a novel presynaptic site of action for amiodarone.