Airborne pathogens diffusion: A comparison between tracer gas and pigmented aerosols for indoor environment analysis

The evaluation of airborne pathogens diffusion is a crucial practice in preventing airborne diseases like COVID-19, especially in indoor environments. Through this transmission route, pathogens can be carried by droplets, droplet nuclei and aerosols and be conveyed over long distances. Therefore, understanding their diffusion is vital for prevention and curbing disease transmission. There are different techniques used for this purpose, and one of the most common is the utilization of tracer gas, however, it has limitations such as the difference in size between the gas molecules and the respiratory droplets, as well as its incapability to take into account evaporation. For this reason, a new method for evaluating the diffusion of respiratory droplets has been developed. This approach involves the use of an ultrasonic emitter to release and disperse pigmented aerosols, and a colorimeter for the following quantitative evaluation. A comparison with the tracer gas technique has been carried out, showing for the pigmented aerosols methodology a response that is dependent on different relative humidity conditions, while there is no clear difference in the dispersion of tracer gas at high or low humidity.

Effects of different gasification biochar grain size on greenhouse gases and ammonia emissions in municipal aerated composting processes

This work is aimed at investigating the effects derived from the application of minimum amounts of two different sized biochars, obtained through biomass gasification, on the greenhouse gases and ammonia emissions from a co-composting process of the organic fraction of municipal solid waste. The chosen biochar-to-organic waste share is set to 3% w/w dry, and the results obtained are compared with a conventional composting process without biochar. Nine aerated static pilot-scale bins with a volume of 1.3 m³ were prototyped and run, three per thesis and three for the control. The trial lasted 63 days, following the same approach used in full-scale composting facilities. The testing period was divided into a forced aeration phase followed by a static phase. In terms of global warming potential, the use of fine biochar and coarse biochar resulted in 13 and 11 kg CO₂eq ton-1 emitted respectively. These values are 36% and 45% lower than the 20 kg of CO₂eq ton-1 emitted by the control theses. Specifically, the chosen minimum amounts of biochar produced a reduction of CH₄ and N₂O, while a significant reduction in NH₃ emissions was not detected. Carbon dioxide showed a slight increase in biochar theses. This work has proven that fine and coarse gasification-derived biochars improve the bio-oxidative phenomena and reduce greenhouse gases emissions of the composters, regardless of the biochar particle size and regardless of the modest 3% w/w biochar-to-organic waste share used.

Zero-contrast IVUS-guided complex PCI in a patient with NSTE-ACS and severe renal impairment

A 76-year-old male with severe comorbidities and multiple cardiovascular risk factors including stage IV chronic kidney disease presents with non-ST-elevation myocardial infarction. An ultra-low contrast invasive coronary angiography using the DyeVert system and iso-osmolar contrast agent revealed a multivessel disease with heavy calcifications involving the left main stem and its bifurcation requiring a complex percutaneous coronary intervention. Because of the high risk of contrast-induced acute kidney injury, a zero-contrast intervention was performed using intravascular ultrasound guidance and dedicated stenting techniques with optimal imaging, clinical, and renal outcomes. Zero-contrast policies can be safely implemented even in complex clinical scenarios but at least two orthogonal angiographic projections should always be acquired to rule out distal complications.

Impact of hemoglobin levels at admission on outcomes among elderly patients with acute coronary syndrome treated with low-dose Prasugrel or clopidogrel: A sub-study of the ELDERLY ACS 2 trial

Hemoglobin (Hb) levels have emerged as a useful tool for risk stratification and the prediction of outcome after myocardial infarction. We aimed at evaluating the prognostic impact of this parameter among patients in advanced age, where the larger prevalence of anemia and the higher rate of comorbidities could directly impact on the cardiovascular risk.

METHODS

All the patients in the ELDERLY-2 trial, were included in this analysis and stratified according to the values of hemoglobin at admission. The primary endpoint of this study was cardiovascular mortality within one year. The secondary endpoints were all-cause mortality, MI, Bleeding Academic Research Consortium (BARC) type 2-3 or 5 bleeding, any stroke, re-hospitalization for cardiovascular event or stent thrombosis (probable or definite) within 12 months after index admission.

RESULTS

We included in our analysis 1364 patients, divided in quartiles of Hb values (<12.2; 12.2-13.39; 13.44-14.49; ≥ 4.5 g/dl). At a mean follow- up of 330.4 ± 99.9 days cardiovascular mortality was increased in patients with lower Hb (HR[95%CI] = 0.76 [0.59-0.97], p = 0.03). Results were no more significant after correction for baseline differences (adjusted HR[95%CI] = 1.22 [0.41-3.6], p = 0.16). Similar results were observed for overall mortality. At subgroup analysis, (according to Hb median values) a significant interaction was observed only with the type of antiplatelet therapy, but not with major high-risk subsets of patients.

CONCLUSIONS

Among elderly patients with acute coronary syndrome managed invasively, lower hemoglobin at admission is associated with higher cardiovascular and all-cause mortality and major ischemic events, mainly explained by the higher risk profile.

[Beta-blockers after myocardial infarction with preserved systolic function: useful or redundant?]

Given the lack of adequately sized randomized clinical trials (RCTs) testing the value of maintenance beta-blockers for post-myocardial infarction (MI) patients without reduced left ventricular ejection fraction and treated according to current standards, several observational studies have tried to address this highly relevant issue. However, results from observational studies have yielded opposite conclusions, with some suggesting that beta-blockers are associated with clinical benefit and others suggesting that they have no benefit. Due to the observational nature of these studies, the risk of bias is very high. In particular the existence of a confounding by indication factor is present when the prescription of the therapy is not random and is instead based on patients' clinical characteristics. Some randomness is needed to ensure that individuals with identical characteristics can be observed in both states (with or without beta-blockers). The only chance, therefore, to solve the question of benefits of beta-blockers is the execution of adequately sized RCTs. Currently, four large RCTs are ongoing in Europe, and, among them, the REBOOT-CNIC trial is already beyond three quarters of the expected cohort to be enrolled (6000/8648 revascularized MI patients without left ventricular dysfunction). An Italian cohort (1800 patients) will be included, enrolled by the Italian REBOOT Network. Enrollment is expected to be complete by the end of 2022, and the first results will become available by the end of 2025.

Immediate coronary angiography and systematic targeted temperature management are associated with improved outcome in comatose survivors of cardiac arrest

Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC). We evaluated the short- and long-term outcome of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed. All consecutive comatose CA survivors without obvious extra-cardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST elevation on electrocardiogram, and good neurological recovery. We enrolled 107 patients with a median age of 64.9 (57.7-73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty-six (61.7%) patients underwent PCI. In-hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in-hospital survival. Long-term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log-rank: p = 0.002). Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non-shockable) and ST deviation (elevation vs no-elevation), and improved the long-term survival of patients discharged with good neurological recovery. Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST deviation in the post-ROSC electrocardiogram. The benefit was sustained at long-term particularly in those with neurological recovery.

Clinical governance of patients with acute coronary syndromes

AIMS

Using the principles of clinical governance, a patient-centred approach intended to promote holistic quality improvement, we designed a prospective, multicentre study in patients with acute coronary syndrome (ACS). We aimed to verify and quantify consecutive inclusion and describe relative and absolute effects of indicators of quality for diagnosis and therapy.

METHODS AND RESULTS

Administrative codes for invasive coronary angiography and acute myocardial infarction were used to estimate the ACS universe. The ratio between the number of patients included and the estimated ACS universe was the consecutive index. Co-primary quality indicators were timely reperfusion in patients admitted with ST-elevation ACS and optimal medical therapy at discharge. Cox-proportional hazard models for 1-year death with admission and discharge-specific covariates quantified relative risk reductions and adjusted number needed to treat (NNT) absolute risk reductions. Hospital codes tested had a 99.5% sensitivity to identify ACS universe. We estimated that 7344 (95% CI: 6852-7867) ACS patients were admitted and 5107 were enrolled-i.e. a consecutive index of 69.6% (95% CI 64.9-74.5%), which varied from 30.7 to 79.2% across sites. Timely reperfusion was achieved in 22.4% (95% CI: 20.7-24.1%) of patients, was associated with an adjusted hazard ratio (HR) for 1-year death of 0.60 (95% CI: 0.40-0.89) and an adjusted NNT of 65 (95% CI: 44-250). Corresponding values for optimal medical therapy were 70.1% (95% CI: 68.7-71.4%), HR of 0.50 (95% CI: 0.38-0.66), and NNT of 98 (95% CI: 79-145).

CONCLUSION

A comprehensive approach to quality for patients with ACS may promote equitable access of care and inform implementation of health care delivery.

REGISTRATION

ClinicalTrials.Gov ID NCT04255537.

P397 PROGNOSTIC VALUE OF CORONARY CALCIUM IN PATIENTS WITH COVID–19 AND SUSPECTED INTERSTITIAL PNEUMONIA: A CASE–CONTROL STUDY

Background

Short–term prognosis of SARS–CoV2 infection is mainly conditioned by the extent and severity of COVID–19 interstitial pneumonia. Coexistence of cardiac disease is however important and independently associated with an adverse outcome. Coronary calcium (CAC), detected at the time of chest computed tomography, can be a useful prognostic tool, as suggested by some cohort studies.

Material and Methods

We performed a retrospective, multi–centre, case–control (1:2) study in 195 COVID–19 patients admitted from 01–03–2020 to 30–04–2020. Cases were consecutive patients died within 30 days or admitted to the Intensive Care Units for invasive ventilation during the hospitalization (primary outcome measure). Controls were age– and sex–matched patients surviving until 30 days without need for invasive ventilation. For each case, we selected two controls, matched by age and sex dividing cases in age strata of 10 years, assuring within each age stratum twice the number of controls with an identical gender proportion. CAC estimation was performed with a with a semi–quantitative score (0 to 30) based on 10 segments and 4 degrees of severity of the calcification. Estimation of interstitial pneumonia, was similarly performed with a semi–quantitative score (from 0 to 20), based on 5 lobes and 5 degrees of severity of interstitial involvement. CT scans were acquired according to a standard protocol for non–cardio–synchronized chest CT, always on a multi–detector scanner with at least 16 layers.

Results

The mean CAC value in cases was significantly higher (p = 0.001) compared to controls: 5,52±1,38 vs 3,28±0,54 (mean value ± 95% CI). The percentage of cases with moderate–severe CAC was significantly higher (p = 0.013) compared to controls (41.5% vs 22.8%, OR 2.27 95% CI 1.20–4.29; primary end–point of the study). In multivariate analysis, independent predictors of outcome were (in descending order): interstitial pneumonia severity score (Wald 8.143, p = 0.004), CC score (Wald 5.569, p = 0.018), and the LDH value on admission (Wald 3.335, p = 0.034).

Conclusions

In our case–control study, the severity and extent of CAC is the main prognostic factor for the occurrence of adverse clinical outcome, beside the severity of interstitial pneumonia. These data suggest that a semi–quantitative estimation of CAC, feasible on any CT detector without the need of dedicated software, is clinically useful for the prognostic assessment of patients with COVID–19 interstitial pneumonia.

P58 IMMEDIATE CORONARY ANGIOGRAPHY AND SYSTEMATIC TARGETED TEMPERATURE MANAGEMENT ARE ASSOCIATED WITH IMPROVED OUTCOME IN COMATOSE SURVIVORS OF CARDIAC ARREST

Background

Rapid and systematic access to coronary angiography (CAG) and target temperature management (TTM) might improve outcome in comatose patients who survive cardiac arrest (CA). However, there is controversy around indicating immediate CAG in the absence of transmural ischemia on the electrocardiogram after return of spontaneous circulation (ROSC). We evaluated the short– and long–term outcome of our retrospective cohort of patients undergoing systematic CAG and TTM, based on whether culprit lesion percutaneous coronary intervention (PCI) was performed.

Methods

All consecutive comatose CA survivors with no obvious extracardiac causes undergoing TTM were included. Analysis involved the entire population and subgroups, namely patients with initial unshockable rhythm, no ST–elevation on electrocardiogram, and good neurological recovery.

Results

We enrolled 107 patients with a median age of 64.9 (57.7–73.6) years. The initial rhythm was shockable in 83 (77.6%). Sixty–six (61.7%) patients underwent PCI. In–hospital survival was 71%. It was 78.8% and 58.5% in those undergoing or not PCI (p = 0.022), respectively. Age, time from CA to ROSC and culprit lesion PCI were independent predictors of in–hospital survival. Long–term survival was significantly higher in patients who underwent PCI (respectively 61.5% vs 34.1%; Log–rank: p = 0.002). Revascularization was associated with better outcomes regardless of initial rhythm (shockable vs non–shockable) and ST–deviation (elevation vs no–elevation), and improved the long–term survival of patients discharged with good neurological recovery.

Conclusion

Systematic CAG and revascularization, when indicated, were associated with higher survival in comatose patients undergoing TTM, regardless of initial rhythm and ST–deviation in the post–ROSC electrocardiogram. The benefit was sustained at long–term particularly in those with neurological recovery.

Impacts of gasification biochar and its particle size on the thermal behavior of organic waste co-composting process

This work investigates the effects of gasification biochar on the thermal behavior of organic municipal waste composting. Two different biochar granulometries were mixed in a 3% w/w share with the organic fraction of municipal waste and tested in nine (three per thesis and three as control) reactors of 1 m³ of volume, designed to simulate full-scale aerated static piles. The temperatures of each composter were monitored for 31 days of the active composting phase and used as key parameters for air flow tuning. After the active phase was completed, the air was turned off and the temperatures were monitored for an additional 31 days during compost maturation. Results show that biochar-aided composters run 4 °C hotter and are more stable in temperature compared to the control thesis. Experimental data were used as a basis for thermal energy modeling: the addition of fine biochar to composting material increased the thermal energy production by 0.5 MJ kg^-1 compared to the control thesis; coarse biochar increased the thermal energy production by 0.4 MJ kg^-1. The standard composting process, without biochar, produced 2.5 MJ kg^-1. Results might serve as a starting point for further considerations in terms of composting time reduction, improvement of the final product and reduction of process related issues, such as undesired anaerobic decomposition, leachate production and temperature instability.

Rationale and design of the pragmatic clinical trial tREatment with Beta-blockers after myOcardial infarction withOut reduced ejection fracTion (REBOOT)

BACKGROUND

There is a lack of evidence regarding the benefits of β-blocker treatment after invasively managed acute myocardial infarction (MI) without reduced left ventricular ejection fraction (LVEF).

METHODS AND RESULTS

TREatment with Beta-blockers after myOcardial infarction withOut reduced ejection fraction (REBOOT) trial is a pragmatic, controlled, prospective, randomized, open-label blinded endpoint (PROBE design) clinical trial testing the benefits of β-blocker maintenance therapy in patients discharged after MI with or without ST-segment elevation. Patients eligible for participation are those managed invasively during index hospitalization (coronary angiography), with LVEF >40%, and no history of heart failure (HF). At discharge, patients will be randomized 1:1 to β-blocker therapy (agent and dose according to treating physician) or no β-blocker therapy. The primary endpoint is a composite of all-cause death, nonfatal reinfarction, or HF hospitalization over a median follow-up period of 2.75 years (minimum 2 years, maximum 3 years). Key secondary endpoints include the incidence of the individual components of the primary composite endpoint, the incidence of cardiac death, and incidence of malignant ventricular arrhythmias or resuscitated cardiac arrest. The primary endpoint will be analyzed according to the intention-to-treat principle.

CONCLUSION

The REBOOT trial will provide robust evidence to guide the prescription of β-blockers to patients discharged after MI without reduced LVEF.

Clinical governance programme in patients with acute coronary syndrome: design and methodology of a quality improvement initiative

INTRODUCTION

Despite the availability of diverse evidence-based diagnostic and treatment options, many patients with acute coronary syndrome (ACS) still fail to receive effective, safe and timely diagnoses and therapies. The Association of Acute CardioVascular Care of the European Society of Cardiology has proposed and retrospectively validated a set of ACS-specific quality indicators. Combining these indicators with the principles of clinical governance-a holistic, patient-centred approach intended to promote continuous quality improvement-we designed the clinical governance programme in patients with ACS.

METHODS AND ANALYSIS

This is a multicentre quality improvement initiative exploring multiple dimensions of care, including diagnosis, therapy, patient satisfaction, centre organisation and efficiency in all comers patients with ACS.The study will enrol ≈ 5000 patients prospectively (ie, at the time of the first objective qualifying ACS criterion) with a 1-year follow-up. Consecutive inclusion will be promoted by a simplified informed consent process and quantified by the concordance with corresponding hospital administrative records using diagnosis-related group codes of ACS.Coprimary outcome measures are (1) timely reperfusion in patients with ST-elevation ACS and (2) optimal medical therapy at discharge in patients with confirmed acute myocardial infarction. Secondary outcomes broadly include multiple indicators of the process of care. Clinical endpoints (ie, death, myocardial infarction, stroke and bleeding) will be adjudicated by a clinical event committee according to predefined criteria.

ETHICS AND DISSEMINATION

The study has been approved by local ethics committee of all study sites. As a quality improvement initiative and to promote consecutive inclusion of the population of interest, a written informed consent will be requested only to patients who are discharged alive. Dissemination will be actively promoted by (1) the registration site (ClinicalTrials.Gov ID NCT04255537), (2) collaborations with investigators through open data access and sharing.

[A practical approach to the diagnosis of cardiomyopathy: a roadmap from the phenotype]

Cardiomyopathies are a heterogeneous group of cardiac diseases for which diagnosis and treatment are not always simple. The diagnosis of cardiomyopathy, in particular the etiology, comes from an integration between symptoms and results collected by several instrumental exams. The brain storming for the diagnosis includes also the identification of the "red flags", i.e. the pathognomonic features for each etiology that can drive the choice of appropriate diagnostic tests and therapy. In this review, we provide a step by step approach in order to help cardiologists, not specifically dedicated to cardiomyopathies, to draw the diagnosis, therapy and follow-up. This approach will be accompanied by the consultation of other specialists to discuss together the results of the exams performed and to deepen extracardiac signs and symptoms.

Rapid rule-out of suspected acute coronary syndrome in the Emergency Department by high-sensitivity cardiac troponin T levels at presentation

The reliability of initial high-sensitivity cardiac troponin T (hs-cTnT) under limit-of-detection in ruling-out short- and long-term acute coronary events in subjects for suspected non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is not definitely settled. In a retrospective chart review analysis, 1001 subjects with hs-cTnT ≤ 14 ng/L out of 4053 subjects with hs-cTnT measured at Emergency Department (ED) presentation were recruited. The main outcome measure is fatal or non-fatal myocardial infarction (MI) within 30 days; secondary outcomes are MI or major acute coronary events (MACE) as a combination of MI or re-hospitalization for unstable angina within 1 year. In subjects with hs-cTnT < 5 ng/L [32.6% of cases, mean age 63 years (interquartile range 23)], no cases (0%, NPV 100%) had MI within 30 days, 2 cases (0.6%, NPV 99.4%) MI at 1-year, and 11 cases (3.4%, NPV 96.6%) MACE at 1-year. Patients with hs-cTnT < 5 ng/L would have benefited from a shortened decision (9.30 h and 53% overnight ED stay saved). Hs-cTnT < 5 ng/L is confirmed as safe for patients and comfortable for physicians in ruling out MI or MACE both at short and long term, suggesting that a sizable number of patients can be rapidly discharged without unnecessary diagnostic tests and ED observation.

Cardiac Arrest in a 31-Year-Old Man With Noonan Syndrome

A 31-year-old man with Noonan syndrome who suffered an out-of-hospital cardiac arrest presented at our institution with severe postanoxic coma (Glasgow coma scale 3), but normalized electrocardiogram and stable hemodynamics. Coronary angiography documented a giant right coronary artery supplying collateral flow to the left coronary artery, which presented a left main functional occlusion.

[Rescue thrombolytic therapy for the treatment of ST-elevation myocardial infarction after unsuccessful primary percutaneous coronary intervention in a patient with coronary artery aneurysm]

The recommended treatment for ST-segment elevation myocardial infarction (STEMI) is primary percutaneous coronary intervention (pPCI). However, in a non-negligible proportion of patients, pPCI is ineffective and the cardiologist must face the decision of how to achieve optimal myocardial reperfusion. Although the possibility of a rescue fibrinolytic strategy has not been evaluated yet in this clinical setting, it is a viable alternative to emergency cardiac surgery. We here report the case of a 60-year-old STEMI patient presenting with a coronary anatomy unsuitable for percutaneous mechanical revascularization, characterized by marked dilation and tortuosity of the proximal and middle epicardial segments. After pPCI failure, the administration of recombinant tissue-type plasminogen activator allowed us to obtain reperfusion as shown by clinical outcome, ST-segment resolution and subsequent angiographic study. No indication was given to further percutaneous or surgical revascularization. The long-term pharmacological management of these patients represents a challenge for the clinician, also considering the available data on the use of new antiplatelet and anticoagulant molecules and their possible associations.

Conjunctive Administration of Intravenous Heparin Attenuates Cross-linked Fibrin Degradation in Patients Treated with Streptokinase

Increases in thrombin activity occur in patients treated with streptokinase, but conjunctive therapy with intravenous heparin does not appear to improve either the rate of early infarct artery patency or survival in patients with acute myocardial infarction. In a recent study we found that concentrations of fibrinopeptide A, a marker of thrombin-mediated fibrin formation, were lower in the first 3 h in patients treated with intravenous heparin (5000 U bolus followed by a fixed-dose 1000 U/h infusion, n = 14) compared with subcutaneous (12,500 U every 12 h, started 4 h after streptokinase, n = 14) administration, but were increased in both groups of patients, consistent with persistent thrombin activity. To determine whether the differential effects of the intensity of heparinization on thrombin formation were reflected in differences in fibrin degradation, we measured cross-linked fibrin degradation products (XL-FDP) before and 1,2,3,8,12, and 24 h after streptokinase in the same cohort of patients, with a new ELISA with a D-dimer-specific capture antibody (MAb 3B6) and a fibrin-specific tag antibody (MAb 1D2, Agen, Brisbane, Australia). The incidence of early coronary recanalization assessed by creatine-kinase MM isoforms (increase in activity ≥0.18%/min), was similar in both groups (79 vs 86%). Concentrations of XL-FDP were similar in patients with and without recanalization, but were lower in patients treated with intravenous compared with subcutaneous heparin at 8 h, but the results did not reach statistical significance (627 ±151 ng/ml versus 1007 ± 157 ng/ ml, p = 0.06), and were significantly lower at 12 h (327 ± 72 versus 781 ± 162 ng/ml, p = 0.03 at 12 h) (mean ± SEM). Concentrations of cross-linked fibrin degradation products were also lower in patients in whom the activated partial thromboplastin time was greater than two times the control, compared with those with inadequate anticoagulation (498 ± 105 versus 1084 ± 179 ng/ml; p = 0.02) (mean ± SEM). Thus, more effective inhibition of thrombin with conjunctive intravenous heparin therapy results in less cross-linked fibrin turnover in the first 12 h after thrombolysis with streptokinase. This probably reflects decreased fibrin formation with therapeutic anticoagulation.

Comparison of Reduced-Dose Prasugrel and Standard-Dose Clopidogrel in Elderly Patients With Acute Coronary Syndromes Undergoing Early Percutaneous Revascularization

Background:

Elderly patients are at elevated risk of both ischemic and bleeding complications after an acute coronary syndrome and display higher on-clopidogrel platelet reactivity compared with younger patients. Prasugrel 5 mg provides more predictable platelet inhibition compared with clopidogrel in the elderly, suggesting the possibility of reducing ischemic events without increasing bleeding.

Methods:

In a multicenter, randomized, open-label, blinded end point trial, we compared a once-daily maintenance dose of prasugrel 5 mg with the standard clopidogrel 75 mg in patients >74 years of age with acute coronary syndrome undergoing percutaneous coronary intervention. The primary end point was the composite of mortality, myocardial infarction, disabling stroke, and rehospitalization for cardiovascular causes or bleeding within 1 year. The study was designed to demonstrate superiority of prasugrel 5 mg over clopidogrel 75 mg.

Results:

Enrollment was interrupted, according to prespecified criteria, after a planned interim analysis, when 1443 patients (40% women; mean age, 80 years) had been enrolled with a median follow-up of 12 months, because of futility for efficacy. The primary end point occurred in 121 patients (17%) with prasugrel and 121 (16.6%) with clopidogrel (hazard ratio, 1.007; 95% confidence interval, 0.78–1.30; P =0.955). Definite/probable stent thrombosis rates were 0.7% with prasugrel versus 1.9% with clopidogrel (odds ratio, 0.36; 95% confidence interval, 0.13–1.00; P =0.06). Bleeding Academic Research Consortium types 2 and greater rates were 4.1% with prasugrel versus 2.7% with clopidogrel (odds ratio, 1.52; 95% confidence interval, 0.85–3.16; P =0.18).

Conclusions:

The present study in elderly patients with acute coronary syndromes showed no difference in the primary end point between reduced-dose prasugrel and standard-dose clopidogrel. However, the study should be interpreted in light of the premature termination of the trial.

Clinical Trial Registration:

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01777503.

Reperfusion in STEMI patients: still a role for cardioprotection?

Ischemic heart disease remains a leading cause of death worldwide, responsible for an estimated 17.5 million deaths in 2012. Mortality from ST-elevation myocardial infarction STEMI have decreased over the last 3 decades. However, despite the success of reperfusion therapy by primary percutaneous coronary intervention (PPCI) or thrombolysis, STEMI is still of significant concern. A recent patient-level meta-analysis emphasized the pivotal importance of infarct size within 1 month after PPCI as a determinant of all-cause mortality and hospitalization for heart failure at 1 year. Although timely and complete reperfusion is the most effective way of limiting infarct size (IS) and subsequent ventricular remodeling, reperfusion per se adds an additional component of irreversible injury to the myocardium (known as ischemia/reperfusion injury, IRI), and the coronary circulation and it contributes to final infarct size. The prevention and treatment of lethal IRI and coronary microvascular dysfunction pose a continued and formidable barrier to successful myocardial perfusion as opposed to establishing patency of the epicardial infarct-related artery (IRA), and in this context the need for additional cardioprotective strategies to reduce IS and coronary microvascular dysfunction remains the 'last frontier' of reperfusion therapy.

Switching from clopidogrel to prasugrel to protect early invasive treatment in acute coronary syndromes: Results of the switch over trial

BACKGROUND

Clopidogrel is used to pretreat patients with non-ST elevation acute coronary syndromes (NSTE-ACS), but prasugrel provides better platelet inhibition with improved outcome. However, switching from clopidogrel at the time of percutaneous coronary intervention (PCI) remains incompletely defined. Our aim was to compare the pharmacodynamic (PD) effects of 3 prasugrel loading doses (LDs; G1:10mg, G2: 30mg, and G3: 60mg) before PCI. A fourth group, continuing clopidogrel, served as control (G4).

METHODS

100 clopidogrel-pretreated patients were enrolled and blood collected before PCI, 30min, 1, 2, 4, 6, 24 and 48h thereafter. Platelet inhibition was measured by vasodilator-stimulated phosphoprotein phosphorylation (VASP) and Verify-Now assays. The end-points (EP) was the difference of PD effect at 4h between G3 and G4 (primary EP) with hierarchic evaluation between G2 and G1 versus G4 (secondary EP). A mixed-design ANOVA statistic was used to compare the four group scores over time.

RESULTS

Baseline characteristics were balanced across the groups. Only patients receiving 60 and 30mg prasugrel LDs showed a rapid (<1h) and significant (p<0.001) platelet inhibition up to 48h after PCI·The primary EP was met by G3 (p<0.0001), but also G2 scored different (p<0-001) from G4 at 4h after PCI. Similar findings were observed with Verify-Now. No differences in 30-day clinical outcomes were observed across groups.

CONCLUSIONS

Switching NSTE-ACS patients before PCI to prasugrel 60 or 30mg LDs determined a better and faster platelet inhibition than continuing clopidogrel, while PCI it is still underway.

Data on administration of cyclosporine, nicorandil, metoprolol on reperfusion related outcomes in ST-segment Elevation Myocardial Infarction treated with percutaneous coronary intervention

Mortality and morbidity in patients with ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI) are still high [1]. A huge amount of the myocardial damage is related to the mitochondrial events happening during reperfusion [2]. Several drugs directly and indirectly targeting mitochondria have been administered at the time of the PCI and their effect on fatal (all-cause mortality, cardiovascular (CV) death) and non fatal (hospital readmission for heart failure (HF)) outcomes have been tested showing conflicting results [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. Data from 15 trials have been pooled with the aim to analyze the effect of drug administration versus placebo on outcome [17]. Subgroup analysis are here analyzed: considering only randomized clinical trial (RCT) on cyclosporine or nicorandil [3], [4], [5], [9], [10], [11], excluding a trial on metoprolol [12] and comparing trial with follow-up length <12 months versus those with longer follow-up [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16]. This article describes data related article titled “Clinical Benefit of Drugs Targeting Mitochondrial Function as an Adjunct to Reperfusion in ST-segment Elevation Myocardial Infarction: a Meta-Analysis of Randomized Clinical Trials” [17].

Cyclosporine A in Reperfused Myocardial Infarction: The Multicenter, Controlled, Open-Label CYCLE Trial

BACKGROUND

Whether cyclosporine A (CsA) has beneficial effects in reperfused myocardial infarction (MI) is debated.

OBJECTIVES

This study investigated whether CsA improved ST-segment resolution in a randomized, multicenter phase II study.

METHODS

The authors randomly assigned 410 patients from 31 cardiac care units, age 63 ± 12 years, with large ST-segment elevation MI within 6 h of symptom onset, Thrombolysis In Myocardial Infarction (TIMI) flow grade 0 to 1 in the infarct-related artery, and committed to primary percutaneous coronary intervention, to 2.5 mg/kg intravenous CsA (n = 207) or control (n = 203) groups. The primary endpoint was incidence of ≥70% ST-segment resolution 60 min after TIMI flow grade 3. Secondary endpoints included high-sensitivity cardiac troponin T (hs-cTnT) on day 4, left ventricular (LV) remodeling, and clinical events at 6-month follow-up.

RESULTS

Time from symptom onset to first antegrade flow was 180 ± 67 min; a median of 5 electrocardiography leads showed ST-segment deviation (quartile [Q]1 to Q3: 4 to 6); 49.8% of MIs were anterior. ST-segment resolution ≥70% was found in 52.0% of CsA patients and 49.0% of controls (p = 0.55). Median hs-cTnT on day 4 was 2,160 (Q1 to Q3: 1,087 to 3,274) ng/l in CsA and 2,068 (1,117 to 3,690) ng/l in controls (p = 0.85). The 2 groups did not differ in LV ejection fraction on day 4 and at 6 months. Infarct site did not influence CsA efficacy. There were no acute allergic reactions or nonsignificant excesses of 6-month mortality (5.7% CsA vs. 3.2% controls, p = 0.17) or cardiogenic shock (2.4% CsA vs. 1.5% controls, p = 0.33).

CONCLUSIONS

In the CYCLE (CYCLosporinE A in Reperfused Acute Myocardial Infarction) trial, a single intravenous CsA bolus just before primary percutaneous coronary intervention had no effect on ST-segment resolution or hs-cTnT, and did not improve clinical outcomes or LV remodeling up to 6 months. (CYCLosporinE A in Reperfused Acute Myocardial Infarction [CYCLE]; NCT01650662; EudraCT number 2011-002876-18).

[Controversies on the role of mitochondria in coronary reperfusion damage as potential therapeutic target]

Reperfusion of an occluded coronary artery is the most effective intervention in reducing cardiac injury which occurs as a consequence of an acute myocardial infarction. However, reperfusion per se may exacerbate the extent of myocardial injury which started at the onset of ischemia, thus leading to the so-called "reperfusion injury". The published studies in the last few years provide new hopes on the mitochondrion and its role in ischemia/reperfusion injury, through the modulation of the mitochondrial permeability pore. After very encouraging experimental data, two clinical trials are presented, CIRCUS and CYCLE, which should help addressing the still outstanding question: may an intervention targeted to decrease the permeability of the mitochondrial pore during reperfusion reduce infarct size and improve clinical outcomes of patients with myocardial infarction undergoing primary percutaneous coronary intervention?

[The heart of Italians. A population survey on the perception and evaluation of the National Health Service by citizens with heart disease and without heart disease (with special reference to cardiology)]

BACKGROUND

The purpose of this study was to collect information to understand how citizens perceive the National Health System (NHS), and what is the degree of confidence they have in the NHS.

METHODS

We carried out an opinion poll with the Demos & Pi group on the perception of the NHS by Italian citizens, with particular reference to the activities related to cardiology, by interviewing 2311 people with a set of 33 questions, about the perception of their health status, lifestyles, the propensity to use public or private services, consideration of the level of the NHS, and the trust in the medical profession. The subjects included were also preliminarily stratified according to the presence or absence of heart disease.

RESULTS

Overall, Italian citizens express a high level of satisfaction for the NHS (on average, 65% of approval rating), including the whole professional staff, hoping that the NHS will be kept appropriately funded. The result is even better in the subset of interviewed citizens, who suffered from cardiovascular disease. People also consider the NHS an essential requirement to ensure equity in access to medical treatment and to keep costs competitive, even compared to private healthcare. The NHS major weakness remains the waiting lists, which are considered too long for diagnostic procedures and ordinary interventions.

CONCLUSIONS

There is a widespread positive feeling among Italian citizens concerning the role and functioning of the NHS. Such opinion, shared by the whole country, should be taken into account when the time will come to define strategies for health policy of the Italian society in the near future.

Off-hour primary percutaneous coronary angioplasty does not affect outcome of patients with ST-Segment elevation acute myocardial infarction treated within a regional network for reperfusion: The REAL (Registro Regionale Angioplastiche dell'Emilia-Romagna) registry

OBJECTIVES

This study aims to evaluate whether results of "off-hours" and "regular-hours" primary angioplasty (primary percutaneous coronary intervention [pPCI]) are comparable in an unselected population of patients with ST-segment elevation acute myocardial infarction treated within a regional network organization.

BACKGROUND

Conflicting results exist on the outcome of off-hours pPCI.

METHODS

We analyzed in-hospital and 1-year cardiac mortality among 3,072 consecutive ST-segment elevation myocardial infarction (STEMI) patients treated with pPCI between January 1, 2004, and June 30, 2006, during regular-hours (weekdays 8:00 AM to 8:00 PM) and off-hours (weekdays 8:01 PM to 7:59 AM, weekends, and holidays) within the STEMI Network of the Italian Region Emilia-Romagna (28 hospitals: 19 spoke and 9 hub interventional centers).

RESULTS

Fifty-three percent of patients were treated off-hours. Baseline findings were comparable, although regular-hours patients were older and had more incidences of multivessel disease. Median pain-to-balloon (195 min, interquartile range [IQR]: 140 to 285 vs. 186 min, IQR: 130 to 280 min; p = 0.03) and door-to-balloon time (88 min, IQR: 60 to 122 vs. 77 min, IQR: 48 to 116 min; p < 0.0001) were longer for off-hours pPCI. However, unadjusted in-hospital (5.8% off-hours vs. 7.2% regular-hours, p = 0.11) and 1-year cardiac mortality (8.4% off-hours vs. 10.3% regular-hours, p = 0.08) were comparable. At multivariate analysis, off-hours pPCI did not predict an adverse outcome either for the overall population (odds ratio [OR]: 0.70, 95% confidence interval [CI]: 0.49 to 1.01) or for patients directly admitted to the interventional center (OR: 0.79, 95% CI: 0.52 to 1.20).

CONCLUSIONS

When pPCI is performed within an efficient STEMI network focused on reperfusion, the clinical effectiveness of either off-hours or regular-hours pPCI is comparable.

Comparison by meta-analysis of eptifibatide and tirofiban to abciximab in patients with ST-elevation myocardial infarction treated with primary percutaneous coronary intervention

Adjunctive therapy with abciximab during primary percutaneous coronary intervention (PPCI) in patients with ST-elevation myocardial infarction (STEMI) determines a better short-term outcome compared to placebo. Tirofiban and eptifibatide represent a valid option with lower cost, but these have been less studied. The aim of the present study was to combine all randomized trials and registries to demonstrate the noninferiority of tirofiban and eptifibatide compared to abciximab in patients with STEMI treated with PPCI. We identified 6 randomized trials and 4 registries. Overall, 4,653 received small molecules and 2,696 abciximab, and the rate of combined death and nonfatal reinfarction did not differ (4.6% vs 4.5%, odds ratio 0.99, 95% confidence interval [CI] 0.78 to 1.27, p = 0.95) up to 30 days of follow-up, with an absolute difference of 0.1% (95% CI -1.06 to 0.8). Because the noninferiority limit was set at +1.5%, and because the upper point estimate (0.8%) of the 95% CI did not cross the prespecified limit, the noninferiority of the small molecules was documented. In-hospital major bleeding was also similar (8.8% vs 6.1%, odds ratio 0.92, 95% CI 0.75 to 1.13, p = 0.43). Sensitivity analysis comparing randomized trials to registries and tirofiban or eptifibatide to abciximab did not show any significant differences. In conclusion, our results documented noninferiority of "small molecules" compared to abciximab and, therefore, support their alternative use as adjunctive therapy during PPCI for patients with STEMI.

Improving the management of non-ST elevation acute coronary syndromes: systematic evaluation of a quality improvement programme European QUality Improvement Programme for Acute Coronary Syndrome: the EQUIP-ACS project protocol and design

BACKGROUND

Acute coronary syndromes, including myocardial infarction and unstable angina, are important causes of premature mortality, morbidity and hospital admissions. Acute coronary syndromes consume large amounts of health care resources, and have a major negative economic and social impact through days lost at work, support for disability, and coping with the psychological consequences of illness. Several registries have shown that evidence based treatments are under-utilised in this patient population, particularly in high-risk patients. There is evidence that systematic educational programmes can lead to improvement in the management of these patients. Since application of the results of important clinical trials and expert clinical guidelines into clinical practice leads to improved patient care and outcomes, we propose to test a quality improvement programme in a general group of hospitals in Europe.

METHODS/DESIGN

This will be a multi-centre cluster-randomised study in 5 European countries: France, Spain, Poland, Italy and the UK. Thirty eight hospitals will be randomised to receive a quality improvement programme or no quality improvement programme. Centres will enter data for all eligible non-ST segment elevation acute coronary syndrome patients admitted to their hospital for a period of approximately 10 months onto the study database and the sample size is estimated at 2,000-4,000 patients. The primary outcome is a composite of eight measures to assess aggregate potential for improvement in the management and treatment of this patient population (risk stratification, early coronary angiography, anticoagulation, beta-blockers, statins, ACE-inhibitors, clopidogrel as a loading dose and at discharge). After the quality improvement programme, each of the eight measures will be compared between the two groups, correcting for cluster effect.

DISCUSSION

If we can demonstrate important improvements in the quality of patient care as a result of a quality improvement programme, this could lead to a greater acceptance that such programmes should be incorporated into routine health training for health professionals and hospital managers.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00716430.

[Acute profound thrombocytopenia associated with tirofiban: clinical approach to diagnosis and therapeutic management]

Acute profound thrombocytopenia is a serious complication of glycoprotein IIb/IIIa inhibitor therapy characterized by a precipitous decline in platelet count to <20 x 10(9)/l within few hours of therapy initiation. This potentially devastating event is extremely uncommon in patients receiving small molecule inhibitors such as eptifibatide and tirofiban. The authors present a case of a patient with acute coronary syndrome scheduled for urgent percutaneous coronary intervention who developed acute profound thrombocytopenia during treatment with intravenous tirofiban. The platelet count decreased to a nadir of 3 x 10(9)/l 2 h after initiation of inhibitor administration. All other possible etiologies of thrombocytopenia were unlikely and the low platelet count had to be attributed to tirofiban. Tirofiban was discontinued and the patient was treated with steroids, immunoglobulin and platelet transfusion. No bleeding events occurred and the patient was discharged on day 18. Interestingly, the patient underwent a percutaneous coronary intervention 1 month before and received the same dosage regimen of tirofiban without complications. Implications for the incidence, diagnosis and treatment of thrombocytopenia disorders are discussed.

[Coronary care units: who to admit and how long]

Coronary care units (CCUs) should ensure the best intensive therapy for all critical cardiologic patients and not only for patients with acute coronary heart disease. Such structures apply the Hub & Spoke model, which consists of an integrated network of services allowing a health organization in which different realities interact and collaborate; this organization is composed of referral core centers (Hubs) and smaller structures (Spokes) referring to Hubs that are engaged in selection, channeling of patients in the acute phase, and for follow-up care of patients in the post-acute phase. The CCUs, based on the organizational reality in which they operate, must hospitalize and dismiss complex patients in a brief lapse of time. Criteria for CCU admission and length of stay are still ill-defined. Therefore, the following paper, summarizing the contents of the recent CCU convention at the ANMCO congress, attempts to define the priorities for hospitalization in the CCU, based on three different levels of evidence: level A indication (immediate mandatory admission); level B indication (immediate admission, the availability of beds allowing); level C indication (admission not indicated, but possible in the absence of other alternatives, e.g. limited bed availability in other intensive care units). Concerning the duration of stay within the CCU, clear-cut indications are difficult, but the concept is emphasized that the length of stay should be minimized, given the limited bed availability, in order to ensure the availability of intensive monitoring to all critical patients.

Low-Molecular-Weight Heparins in Conjunction with Thrombolysis for ST-Elevation Acute Myocardial Infarction

BACKGROUND

Intravenous unfractionated heparin (UFH) is recommended in ST-elevation acute myocardial infarction (STEMI), following thrombolysis with fibrin-specific agents. Subcutaneous low-molecular-weight heparins (LMWH), previously proven effective in non-ST-elevation acute coronary syndromes, have been recently investigated in the setting of STEMI. We aimed at evaluating the current level of evidence supporting the use of LMWH in STEMI.

METHODS

A Medline search of the English language literature between January 1995 and December 2005 was performed and randomized clinical trials comparing LMWH to either placebo or UFH in conjunction with thrombolysis were selected.

RESULTS

About 26,800 patients treated with various thrombolytic regimens were included in 12 randomized clinical trials. Dalteparin was superior to placebo on left ventricular thrombosis/arterial thromboembolism, with no significant effect on the early patency rate of the infarct-related artery (IRA). Compared to UFH, dalteparin had no significant effect on clinical events and on the IRA late patency, although less thrombus was present. Enoxaparin was superior to placebo on the medium-term death/reinfarction/angina rate and late IRA patency, and superior also to UFH on in-hospital and medium-term occurrence of death/reinfarction/angina. The effect of enoxaparin on IRA patency rate was not univocal. Compared to placebo, reviparin significantly reduced early and medium-term mortality and reinfarction rates, without a substantial increase in overall stroke rate. As regards safety, bleedings were more frequent than placebo and comparable to UFH in LMWH groups, with the exception of the pre-hospital ASSENT-3 PLUS trial, where in elderly patients, enoxaparin had an incidence of intracranial hemorrhage twice higher than UFH.

CONCLUSIONS

In-hospital subcutaneous administration of dalteparin, enoxaparin or reviparin, as an adjunct to various thrombolytics in STEMI, appears feasible and at least as effective and safe as intravenous UFH. Before LMWH might be recommended, however, some yet unresolved issues (i.e. use in elderly patients, in severe renal insufficiency, in association with glycoprotein IIb/IIIa inhibitors and during interventional procedures), need to be addressed.

Epidemiology of non-ST elevation acute coronary syndromes in the Italian cardiology network: the BLITZ-2 study

AIMS

Acute coronary syndromes without ST-segment elevation (NSTEACS) represent an increasingly frequent cause of hospital admission. The BLITZ-2 study was planned to survey the epidemiology and management strategies of NSTEACS in the Italian cardiological network.

METHODS AND RESULTS

The study included 1888 patients with NSTEACS in 275 hospitals in 3 weeks. At admission, almost 20% of patients showed clinical signs of heart failure, half showed ST-segment depression, and half showed any positive biochemical myocardial necrosis marker. Patients admitted to hospitals without CathLab (n=973) were older (P=0.0005) and with higher Killip class on admission (P<0.0001) when compared with those admitted to hospitals with CathLab (n=915). During index hospitalization, 76% of the patients initially admitted to hospitals with invasive capability underwent coronary angiography and 39% percutaneous coronary intervention when compared with 39 and 17.2% of those admitted to hospitals without CathLab (P<0.001). Overall, 30-day mortality was 2.4% (2.0% in patients with invasive capability vs. 2.9% in hospitals without CathLab, P=0.2). Cardiac ischaemic events at 30 days (recurrent MI, recurrent angina, and re-hospitalization for ACS) were significantly higher in the group of patients admitted to hospitals without CathLab (OR 1.71, 95% CI 1.24-2.35). However, after multivariable adjustment, only advanced age (OR 1.043, 95% CI 1.021-1.065, P<0.0001) and Killip class >1 (OR 1.633, 95% CI 1.020-2.614, P=0.04) resulted in independent predictors of death, in-hospital MI, and re-admission for ACS, whereas the absence of an on-site CathLab did not predict an adverse outcome (OR 1.104, 95% CI 0.734-1.660).

CONCLUSION

According to this, the nationwide registry outcome is only marginally influenced by invasive procedures. Contemporary management of patients with NSTEACS in Italy is primarily driven by resource availability.

[Acute coronary syndromes without persistent ST-segment elevation: is risk stratification correctly applied?]

Risk stratification of patients with acute coronary syndromes is of paramount importance in achieving maximal benefit from current therapeutic modalities and for correct resource allocation. Since risk prediction based on the integration of key prognostic variables is relatively inaccurate, the clinical guidelines of the European Society of Cardiology (which have been endorsed by the Italian Federation of Cardiology) suggest an univariate approach favoring the sensitivity of the detection of high-risk patients compromising specificity. Such an approach is likely to identify a large population of high-risk patients possibly causing a mismatch between the number of patients in need of invasive evaluation and treatment, and the availability of interventional resources. Most of the risk of adverse cardiac events can be captured by the observation of three prognostic indicators: the presence of heart failure, the finding of ST-segment shifts (both elevation or depression) in the presenting electrocardiogram, and the elevation of markers of myocardial damage. The risk can be even higher in subjects who concurrently display additional risk features such as diabetes, renal insufficiency, advanced age, or previous revascularization procedures. Such patients are likely to be less treated both medically and invasively, than patients without such characteristics. The results of Italian regional registries show a favorable temporal trend toward a more a aggressive approach in such neglected high-risk subgroups.

Therapeutic strategies, immediate and mid-term outcomes in non-ST-segment elevation acute coronary syndromes with respect to age: a single-center registry of 488 consecutive patients

BACKGROUND

Elderly patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) may receive benefit from an early invasive strategy. However, aged patients often suffer from comorbidities that may contraindicate an invasive approach and affect prognosis adversely. The impact of comorbidities on an invasive approach to NSTE-ACS in the elderly has not been fully investigated.

HYPOTHESIS

This study sought to examine the outcome of an unselected population of patients with NSTE-ACS stratified according to age and treatment approach.

METHODS

The feasibility and efficacy of an invasive strategy for NSTE-ACS and the 6-month outcome were assessed in 253 unselected consecutive patients > or = 70 years (elderly) and compared with those of 235 unselected consecutive patients < 70 years.

RESULTS

Angiography was not performed in 69 patients (86% > or = 70 years) because of contraindications. In the whole population, the 6-month event rate was significantly higher in elderly compared with younger patients (22 vs. 14%; odds ratio 1.8, 95% confidence interval 1.1-2.9; p < 0.02). This difference was driven by the high event rate observed in the elderly with contraindications to angiography (47 vs. 16% in the elderly treated invasively; p < 0.002). On the other hand, no significant difference was observed in the 6-month event rate between elderly and younger patients undergoing an invasive approach (16 vs. 13%; p = 0.36). Contraindications to angiography-namely, creatinine > or = 1.5 mg/dl and elevated troponin I at admission--were the only independent predictors of 6-month outcome.

CONCLUSIONS

The invasive approach was feasible in 77% of patients > or = 70 years. Those with contraindications to angiography showed a poor mid-term prognosis. The early invasive strategy was associated with more favorable outcomes regardless of age.

Frequency and determinants of direct stenting in routine percutaneous coronary interventions: data on 835 consecutive procedures in a single center

BACKGROUND

Recent studies evaluated the technique of direct coronary stenting as compared to stenting-after-predilation in selected anatomic and clinical settings. However, the impact of direct stenting in routine interventional practice remains poorly elucidated.

METHODS

From April 1999 to March 2001, all percutaneous coronary interventions performed at our Center were prospectively analyzed to determine the frequency of direct stenting, the success rate and the variables associated with its utilization.

RESULTS

1151 lesions were treated in 835 procedures. Stenting was attempted in 835/1151 lesions (72.5%), 309 (37%) with direct stenting and 526 (63%) with stenting-after-predilation. Direct stenting was successful in 300/309 (97%) and stenting-after-predilation in 515/526 (98%). The success rate of direct stenting was significantly lower in small vessels (< or = 2.75 mm) (89.2 vs 98.5%, p = 0.005). Patients treated with direct stenting were younger (63 +/- 11 vs 65 +/- 11 years, p = 0.024). Direct stenting was preferentially used in saphenous vein grafts and at the ostium of the left anterior descending coronary artery, while it was avoided in bifurcation lesions and with increasing calcium burden. Operators with a caseload > 140 interventions per year were significantly more likely to perform direct stenting than less experienced operators (p = 0.017). In direct stenting, the total contrast medium and the fluoroscopy and procedural times were all significantly (p < 0.0001) lower than those observed in case of stenting-after-predilation.

CONCLUSIONS

Direct coronary stenting is currently performed in about one third of the overall caseload. Variables pertaining to the operator's experience, lesion morphology and length, vessel size, and the clinical presentation are all important factors determining the selection of candidates suitable for direct stenting.