Thirty-days versus standard duration of dual antiplatelet treatment after percutaneous coronary interventions: a systematic review and meta-analysis

Background/Introduction

Abbreviation of duration of dual antiplatelet therapy (DAPT) (one or three months) has been recently proposed, especially for high-bleeding risk patients, after percutaneous coronary intervention (PCI) with drug-eluting stent (DES).

Purpose

The purpose of the specific systematic review and meta-analysis was to compare 30-days versus longer duration (≥3 months) of DAPT in patients undergoing PCI with DES, focusing on ischemic and bleeding events.

Methods

Three databases were screened for eligible randomized-control trials. The primary endpoint was the incidence of net adverse clinical events (NACE), as they were defined in each trial. Secondary endpoints consisted of major adverse cardiovascular events (MACE), all-cause and cardiovascular mortality, myocardial infraction, stroke, stent-thrombosis, repeat revascularization and major bleeding.

Results

We included 4 RCTs with a total of 26,576 patients; 13,282 patients were grouped in 30-days DAPT, while the remaining 13,294 were allocated in longer period of DAPT. One-month of DAPT did not significantly reduce NACE (odds ratio [OR]: 0.87, 95% confidence intervals [Cl]: 0.74–1.03); however major bleedings were significantly reduced by 22% (OR: 0.78, 95% Cl: 0.65–0.94). Mortality or ischemic events (stroke, myocardial infraction, revascularization and stent thrombosis) were not affected.

Conclusions

Thirty-days DAPT did not significantly affect NACEs. However, odds of major bleedings were reduced significantly by 22%. Mortality and ischemic events did not differ between the two arms. Thus, 30-days DAPT could be considered as a safe and feasible after PCI with DES in selected patients, especially those in high-bleeding risk. Forthcoming RCTs could shed light on the optimal duration of DAPT.

Funding Acknowledgement

Type of funding sources: None.

Global left ventricular myocardial work efficiency in left bundle branch pacing versus right ventricular septal pacing: preliminary results of a randomized trial

Background

Recently, the concept of left bundle branch pacing (LBBP) has emerged in clinical practice, in an attempt to prevent the deteriorating effects of right ventricular pacing (Vp).

Purpose

The aim of this study is to compare the effect of Vp on left ventricular (LV) dyssynchrony in patients with atrioventricular block (AVB) and preserved ejection fraction (EF), subjected to either LBBP or right ventricular septal pacing (RVSP).

Methods

Patients with AVB are randomized 1:1 to LBBP or RVSP. The effect of Vp is evaluated by echocardiographic indices of dyssynchrony, such as global myocardial work efficiency (GWE) and peak systolic dispersion (PSD). GWE represents the ratio of constructive work divided by the sum of constructive and wasted work [1]. Successful LBBP is defined by the presence of right bundle branch block paced QRS morphology in lead V1 and stim to LV activation time <75 msec [2]. No back-up right Vp lead was used in LBBP group.

Results

We conducted a preliminary analysis of the first 20 patients. Enrollment is still ongoing and total follow-up period is one year. We sought to investigate the acute effect of Vp on LV dyssynchrony 24 hours post procedure. Patients' baseline characteristics were similar in both groups and are presented in Table 1.

One crossover was noted from LBBP to RVSP group, due to high ventricular capture threshold during implant. Implantation time was increased in LBBP arm (130±17.4 min in LBBP versus 47.7±4.5 min in RVSP group, p=0.004). Left bundle branch potential was recorded in 3 out of 10 LBBP patients. No statistically significant difference was demonstrated in GWE between the two groups (91.3% in LBBP versus 87.4% in RVSP group, p=0.052). PSD was numerically shorter in LBBP (53.3 msec) versus in RVSP (63.6 msec), p=0.114. There were no complications during both the acute perioperative phase and the running period of the follow-up. Moreover, no acute ventricular threshold capture rise, or lead dislodgement has been observed in neither group.

The increased implantation time may be attributed to the more demanding technique, or the learning curve period required in the arm of LBBP. In the present analysis, a remarkable difference regarding GWE in favor of the LBBP group was demonstrated, although statistically not significant. However, even in this initial phase of the study, there is a trend of better LV synchrony and less wasted myocardial work in the LBBP group. The final difference of these indices will be assessed at the end of the one-year follow-up, when comparative results will be available.

Conclusion

LBBP is a novel, safe pacing method. Despite the longer procedural time and the risk of crossover, LBBP seems to offer better – without however statistical significance – LV synchrony even in the acute postoperative phase compared to RVSP. Longer follow-up studies are required to test whether LBBP compared to RVSP confers substantial clinical benefit.

Funding Acknowledgement

Type of funding sources: None.

Shockwave intravascular lithotripsy facilitated percutaneous coronary intervention in patients with calcified coronary artery disease: a systematic review and meta-analysis of observational studies

Background

Percutaneous coronary intervention (PCI) outcomes for patients with significant coronary artery calcification (CAC) have been consistently inferior compared to patients without significant CAC. Shockwave Intravascular Lithotripsy (S-IVL) system offers a novel option for lesion modification of severely calcified plaques but supporting evidence on safety and efficacy of this technology is narrow. The aim of this study is to assess S-IVL safety and efficacy in patients with severe CAC undergoing PCI.

Methods

We systematically searched MEDLINE, ClinicalTrials.gov and the Cochrane Library to identify studies assessing the efficacy and safety of S-IVL in adult patients with calcified coronary artery disease undergoing PCI. We excluded those studies assessing the effect of S-IVL in patients with under-expanded coronary stents and/or in-stent restenosis.

Results

The largest meta-analysis to date was performed. All studies were observational since no relevant randomized controlled trials have been published so far. Nine studies were included in our qualitative synthesis, while 7 of them, in a total of 794 enrolled patients, were used in the quantitative synthesis. Frequency of peri-procedural outcomes of interest was low: a) coronary dissection: 2.52%, b) coronary perforation: 3.0%, c) MI: 3.51%. Relative frequency of 1-month MACE was 5.59% and cardiovascular death 1.01%. S-IVL resulted in a significant increase in the in-stent post-IVL minimum lumen diameter by 1.67 mm, a significant decrease in the in-stent post-IVL vessel diameter stenosis by 53.60%, and a significant increase in the in-stent post-IVL acute gain by 1.68 mm. OCT analysis confirmed a significant decrease in area stenosis post-IVL by 19.71% and calcium angle by 22.14o and a significant increase in lumen area by 1.62 mm2, without however affecting maximum calcium thickness. When we compared post-stent post-IVL vs. pre-stent post-IVL OCT results, we demonstrated a further significant decrease in area stenosis by 35.89% and in calcium angle by 20.33o, a significant increase in lumen area by 2.74 mm2 and a neutral effect on maximum calcium thickness.

Conclusion

Shockwave Intravascular lithotripsy offers a significant improvement in coronary lumen to facilitate stent delivery and deployment in severely calcified coronary arteries. Although S-IVL appears to be associated with a low incidence of complications and MACE based on our present findings, further evidence from RCTs and longer-term follow-up is required to advocate its routine use in patients with severe CAC.

Funding Acknowledgement

Type of funding sources: None.

P3716Increased two-year cerebrovascular event rate in patients with bilateral high carotid tempratures

Introduction

The association of carotid plaque inflammation with cerebrovascular events is a matter of rigorous research. Microwave Radiometry (MWR) allows in vivo noninvasive measurement of the internal temperatures of tissues, reflecting inflammation.

Purpose

To investigate whether increased carotid temperatures in patients with documented coronary artery disease (CAD) are associated with cerebrovascular events.

Methods

Consecutive patients with significant CAD from three tertiary centers were included in the study. Maximum carotid plaque thickness was assessed in all carotids by ultrasound. ΔT by MWR was assigned as the temperature difference (maximal minus minimum) along the carotid artery. ΔT ≥0.90°C was assigned as high ΔT. All patients were followed-up clinically for two years and all strokes were adjudicated by an independent committee. Transient ischemic attacks were excluded.

Results

In total 300 patients were included in the study. High ΔT temperatures bilaterally were measured in 47 patients (15.7%). Three patients (1.0%) suffered a stroke, including one fatal. Stoke rate was 4.3% in the group with bilateral high ΔT and 0.4% in non-high ΔT group (p=0.02). In Kaplan-Meier plot patients with bilateral high ΔT showed higher stroke rate (log-rank p=0.004, figure)

Conclusions

Bilateral high carotid temperatures are associated with increased two-year stroke rate. The potential value of the present finding in risk stratification of intermediate carotid stenosis mandates further investigation.

Contemporary antiplatelet treatment in acute coronary syndrome patients undergoing percutaneous coronary intervention: 1-year outcomes from the GReek AntiPlatElet (GRAPE) Registry

Essentials The comparative efficacy and safety of antiplatelet agents in 'real life' is not clear. We recruited acute coronary syndrome patients receiving percutaneous coronary intervention. At 1-year follow-up, prasugrel offers better anti-ischemic protection than clopidogrel. Prasugrel and ticagrelor are accompanied by more frequent bleeding events.

SUMMARY

Background The comparative efficacy and safety of antiplatelet treatment outside randomized trials is not clear. Objectives To investigate long-term efficacy and safety in 'real-life' acute coronary syndrome (ACS) patients treated by percutaneous coronary intervention (PCI) with contemporary use of clopidogrel, prasugrel and ticagrelor. Methods In a prospective, observational, multicenter cohort study, 2047 patients were recruited into the GReek AntiPlatElet (GRAPE) Registry and were followed-up for 1 year for major adverse cardiovascular events (MACE, a composite of death, non-fatal myocardial infarction, urgent revascularization and stroke) and bleeding events (Bleeding Academic Research Consortium [BARC] classification). Results Exposure to clopidogrel, prasugrel and ticagrelor by PCI occurred in 959, 363 and 717 patients, respectively. After adjustment, the rate of MACE (primary outcome endpoint) was lower in prasugrel-treated patients (4.4%) than in clopidogrel-treated patients (10.1%) (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.30-0.91), although not significantly different between ticagrelor (6.8%) and clopidogrel groups (HR, 0.78; 95% CI, 0.54-1.12). Any type of BARC-classified bleeding (secondary outcome endpoint) was more frequent in prasugrel-treated patients (51.2%) than in clopidogrel-treated patients (37.6%) (HR, 1.61; 95% CI, 1.33-1.95) and more frequent in ticagrelor-treated patients (56.9%) than in clopidogrel-treated patients (HR, 1.81; 95% CI, 1.55-2.10). An adjusted comparison between prasugrel and ticagrelor-treated groups did not reveal differences in any outcome measure. After adjustment, the death rate was more reduced by novel agents in comparison with clopidogrel (2.9% vs. 6.2%). Conclusions In ACS/PCI patients, prasugrel offered better anti-ischemic protection than clopidogrel, whereas use of both novel agents is accompanied by more frequent bleeding events.

Antiplatelet effects of prasugrel vs. double clopidogrel in patients on hemodialysis and with high on-treatment platelet reactivity

BACKGROUND

High on-treatment platelet reactivity (HTPR) is frequent in patients on hemodialysis (HD) receiving clopidrogel.

OBJECTIVES

The primary aim of this study was to determine the antiplatelet effects of prasugrel vs. high-dose clopidogrel in patients on HD with HTPR.

PATIENTS/METHODS

We performed a prospective, single-center, single-blind, investigator-initiated, randomized, crossover study to compare platelet inhibition by prasugrel 10 mg day(-1) with that by high-dose 150 mg day(-1) clopidogrel in 21 patients on chronic HD with HTPR. Platelet function was assessed with the VerifyNow assay, and genotyping was performed for CYP2C19*2 carriage.

RESULTS

The primary endpoint of platelet reactivity (PR, measured in P2Y12 reaction units [PRU]) was lower in patients receiving prasugrel (least squares [LS] estimate 156.6, 95% confidence interval [CI] 132.2-181.1) than in those receiving high-dose clopidogrel (LS 279.9, 95% CI 255.4-304.3), P < 0.001). The LS mean differences between the two treatments were - 113.4 PRU (95% CI - 152.9 to - 73.8, P < 0.001) and - 163.8 PRU (95% CI - 218.1 to - 109.2, P < 0.001) in non-carriers and carriers of at least one CYP2C19*2 allele, respectively. HTPR rates were lower for prasugrel than clopidogrel, in all patients (19% vs. 85.7%, P < 0.001) and in non-carriers (25.7% vs. 80%, P = 0.003). All carriers continued to show HTPR while receiving high-dose clopidogrel, but none showed it while receiving prasugrel.

CONCLUSIONS

In HD patients exhibiting HTPR following standard clopidogrel treatment, prasugrel 10 mg day(-1) is significantly more efficient than doubling the clopidogrel dosage in achieving adequate platelet inhibition. Neither effect seems to be influenced by carriage of the loss-of-function CYP2C19*2 allele.

Diagnostic superiority of continuous-loop electrocardiographic recording over other testing in a patient with recurrent syncope and underlying coronary artery disease with severe left ventricular dysfunction

Dysrhythmic causes of syncope may elude diagnosis in postinfarction patients despite elaborate testing, including electrophysiologic study. For a correct diagnosis, capture of cardiac rhythm during patient's typical symptoms is crucial. This report describes a patient with coronary artery disease and decreased left ventricular ejection fraction who experienced recurrent syncopal episodes without obvious precipitating factors. The 12-lead electrocardiogram showed left bundle-branch block indicating a possible conduction abnormality as the underlying cause of syncope. Twenty-four-h Holter monitoring exhibited no sinus rhythm or conduction disturbances but revealed a nonsustained run of ventricular tachycardia. Findings at electrophysiologic testing led to a presumptive diagnosis of tachyarrhythmic cause of syncope; however, the correct diagnosis was only made with use of a loop monitor which documented a 15-s sinus pause during a syncopal episode.

Prednisolone and azathioprine in membranous nephropathy: a 10-year follow-up study

BACKGROUND

Idiopathic membranous nephropathy (IMN) is the most common cause of nephrotic syndrome in adults. Although its clinical course is usually benign, some patients develop chronic renal failure. Combination of corticosteroids with cytotoxic drugs and cyclosporin have been used in the treatment of the disease. Conflicting results are reported with the use ofprednisolone and azathioprine. In this study, the effect of treatment with prednisolone and azathioprine and the parameters related to a poor outcome over a follow-up period of 10 years is estimated.

METHODS

50 patients were included in this study; 33 were treated with prednisolone (initially 60 mg/day) and azathioprine (initially 2 mg/kg body weight/day) in gradually reduced doses for 26 +/- 9 months, whereas 17 patients received no immunosuppressive drugs. The clinical course was estimated using the end-points of doubling of baseline serum creatinine and/or end-stage renal failure (ESRF). The contribution of clinical and histological parameters in the clinical outcome was examined by univariate and multivariate analyses.

RESULTS

Doubling of baseline serum creatinine was observed in 20 of 50 patients (40%), 14 from treated and 6 from the untreated group (42% vs. 35%, p=NS). ESRF developed in 10 of 50 patients (20%), 7 from treated and 3 from the untreated group (21% vs. 18%, p=NS). Most patients from both groups who reached the end-points had impaired renal function at presentation and persistent nephrotic syndrome during the follow-up period. Both parameters were identified as independent risk factors related to an unfavorable clinical outcome. No difference in the remission rate of nephrotic syndrome was observed between treated and untreated patients (51% vs. 58%, p=NS).

CONCLUSION

Treatment with prednisolone and azathioprine seems to be of no long-term benefit in ameliorating the clinical course of nephrotic patients with membranous nephropathy. Thus, other therapeutic regimens including cyclophosphamide, chlorambucil or cyclosporin should be used in nephrotic IMN patients with poor prognostic features.

In-vivo testing of digital cellular telephones in patients with implantable cardioverter-defibrillators

AIMS

To investigate the susceptibility of implantable cardioverter defibrillators to electromagnetic interference generated by digital cellular telephones, functioning in both international transmission technologies: the Global System for Mobile Communication (GSM) and the Digital Cellular System (DCS 1800).

METHODS AND RESULTS

In 36 patients with transvenous implantable cardioverter defibrillators from two manufacturers (Medtronic and Guidant/CPI), cellular telephones with different levels of minimal and maximal power output were tested in the transmitting and receiving mode. Evaluation was performed in activated implantable defibrillators during spontaneous cardiac activity and continuous VVI or DDD pacing to assess possible electromagnetic interference. In two patients, appropriateness of ventricular fibrillation detection and therapy was judged during telephone testing. There was no damage, reprogramming, inappropriate shock therapy or pacing inhibition during the tests. In seven pre-pectoral Medtronic implantable defibrillators, transient electromagnetic interference caused 19 erroneous sensing events, when the operating phone was held in close vicinity to the programmer head. These 'pseudo-oversensing' events, which did not result in logging of arrhythmia episodes in the device counter, were interpreted as an adverse interaction between the telephone and the programming device.

CONCLUSION

Digital cellular telephones do not represent a risk to Medtronic and Guidant/CPI recipients of the specific implantable defibrillator models herein tested.

Intravenous magnesium sulfate versus diltiazem in paroxysmal atrial fibrillation

BACKGROUND

Drugs currently available for the acute treatment of paroxysmal atrial fibrillation have significant limitations. We assessed the safety and effectiveness of intravenous magnesium sulfate versus diltiazem therapy in patients with prolonged episodes of paroxysmal atrial fibrillation.

METHODS

In a prospective randomized trial, 46 symptomatic patients presenting with paroxysmal atrial fibrillation were given intravenous magnesium sulfate (n=23) or diltiazem (n=23) therapy. Primary outcome measures were effects on ventricular rate control and proportion of patients restored to sinus rhythm at 6 h after initiation of treatment.

RESULTS

There were no differences in baseline characteristics between the two groups. Both forms of treatment were well tolerated, with no adverse clinical events. Both drugs had similar efficacy in reducing the ventricular rate at the first hour of treatment (P<0.05) with a tendency toward a further decrease during infusion times of 2 (P<0.01), 3, 4, 5 and 6 h, respectively (P<0.001). However, at the end of the 6-h treatment period, restoration of sinus rhythm was observed in a significantly higher proportion of patients in the magnesium group compared with the diltiazem group [13 of 23 patients, (57%), versus five of 23 patients, (22%), P=0.03].

CONCLUSIONS

Magnesium sulfate favorably affects rate control and seems to promote the conversion of long lasting episodes of paroxysmal atrial fibrillation to sinus rhythm, representing a safe, reliable and cost-effective alternative treatment strategy to diltiazem.

Significance of R-on-T phenomenon in early ventricular tachyarrhythmia susceptibility after acute myocardial infarction in the thrombolytic era

We investigated the clinical significance and mechanism of the R-on-T phenomenon in the current thrombolytic era as potential precipitant of R-on-T-induced early ventricular tachyarrhythmias in patients with a thrombolysed acute myocardial infarction. We also examined the role of QT dispersion on ventricular vulnerability and its association with R-on-T-initiated ventricular tachyarrhythmias. A total of 93 patients underwent 24-hour Holter monitoring starting at hospital admission before thrombolysis. Patients were classified into 2 groups: those with (n = 76) and those without (n = 17) reperfusion according to electrocardiographic criteria. All R-on-T ventricular premature complexes (VPCs) and R-on-T-initiated arrhythmic events (ventricular tachycardia [VT], ventricular fibrillation) were counted to estimate arrhythmia density and severity in 2 time periods during and after completion of thrombolysis. Measurements of QT and QTc intervals and dispersion parameters were obtained on the 12-lead electrocardiogram before thrombolysis and at 24 hours in patients with and without R-on-T VTs. Overall, R-on-T VPCs were rarely observed (1.8% of total VPCs over 24 hours), occurring more frequently during than after thrombolysis (at a rate of 8 vs 0.6 VPCs/hour, p = NS) and at a higher rate during thrombolysis in nonreperfused than in perfused patients (15 vs 8/hour, p = NS). Three VF episodes were observed in 1 reperfused patient, and all were R-on-T initiated. Episodes of nonsustained R-on-T VTs (3.3% of total VTs over 24 hours) appeared more frequent during than after thrombolysis (at a rate of 0.8 vs 0.05 VPCs/ hour, p = NS), and compared with non-R-on-T VTs they were significantly faster (374 +/- 56 ms vs 411 +/- 69 ms; p < 0.05), with a trend toward longer duration. Our findings indicate that R-on-T VPCs and R-on-T VTs are early rare features in acute myocardial infarction, and do not serve as triggers of severe ventricular tachyarrhythmia. The study of ventricular repolarization did not elicit an identifiable risk factor of R-on-T VT susceptibility.