[Efficacité du tirofiban intracoronaire avant pose d'un stent suivi d'une perfusion dans une charge de thrombus importante prouvée par angiographie : une étude randomisée]

BACKGROUND

The presence of angiographic thrombus is associated with poor outcomes in contemporary cardiology practice. Percutaneous coronary intervention (PCI) in such lesions is associated with slow flow and no-reflow phenomenon which translate into poor clinical outcomes.

METHODS

This was a single-centre, prospective, open-label, randomized controlled study with 50 patients each in intervention group and control group. Patients with angiographically proven large thrombus burden were recruited. In the intervention group, patients were given loading dose of intracoronary tirofiban (25 mcg/kg infused over 5 minutes) followed by prolonged infusion of tirofiban (0.15 mcg/kg/min for 12-18 hours) followed by PCI after 48-72 hours interval. In control group patients were taken up directly for PCI during the index procedure. Outcomes were assessed angiographically and in terms of clinical endpoints.

RESULTS

The primary composite-endpoint of recurrent angina, myocardial infarction, cardiovascular death, target lesion revascularization and unscheduled CABG was significantly lower in the intervention arm compared to control arm (4% vs 16%, p = 0.04). Amongst the secondary endpoints, a statistically significant 30-day increase in ejection fraction from baseline was observed in the intervention group compared to the control group (1.6 ± 1.3 vs 0.2 ± 0.4, p = 0.0001). Overall mortality was similar in the two groups (4% vs 8%, p = 0.39). The primary safety endpoint of major bleeding was also similar in the 2 groups (2% vs 0%, p = 0.31).

CONCLUSIONS

Tirofiban use prior to PCI in high thrombus burden was associated with improved clinical and angiographic endpoints with similar adverse events compared to controls.

[Imaging and radial approach]

Radial approach allows in a large majority of cases to perform endovascular imaging. If we can assess anatomical variations with angiography, echography approach begins a mandatory tool to do the puncture safely, but also allows to identify anatomical variations and complications.

[Personalized Therapeutic Concepts in Chronic Coronary Syndromes]

Personalized Therapeutic Concepts in Chronic Coronary Syndromes Abstract. Chronic coronary syndromes (CCS) are related to substantial morbidity and mortality. Myocardial ischemia in CCS is caused by either obstructive or non-obstructive alterations of the coronary arteries, including both morphological and functional changes of epicardial vessels and the coronary microvasculature. Diagnostic algorithms of patients with suspected CCS include non-invasive and invasive imaging and functional testing. Therapeutic management comprises lifestyle changes, optimal medical therapy, and coronary revascularization when indicated. This review summarizes the contemporary management of patients with CCS, focusing on the role of invasive assessment and treatment.

[The Role of Percutaneous Coronary Revascularization in Chronic Coronary Syndromes]

The Role of Percutaneous Coronary Revascularization in Chronic Coronary Syndromes Abstract. Coronary heart disease represents the leading cause of morbidity and mortality worldwide. Optimal management of these patients is therefore crucial and includes lifestyle changes, optimal medical therapy, and coronary revascularization. This review summarizes diagnostic and therapeutic strategies of patients with chronic coronary syndromes, focusing on the 2019 European Society of Cardiology (ESC) guidelines for the diagnosis and management of chronic coronary syndromes. In particular, the role of invasive assessment and coronary revascularization in chronic coronary syndromes is discussed.

Weighing Coronary Revascularization Options in Patients With Type 2 Diabetes Mellitus

Patients with diabetes mellitus (DM) are at increased risk for developing coronary artery disease. Choosing the optimal revascularization strategy, such as coronary artery bypass grafting or percutaneous coronary intervention (PCI), may be difficult in this population. A large body of evidence suggests that, for patients with DM and stable multivessel ischemic heart disease, coronary artery bypass grafting is usually superior to PCI, leading to lower rates of all-cause mortality, myocardial infarction and repeat revascularization in the long term. In patients with less complex coronary anatomy (2- or single-vessel disease, especially without involvement of the proximal left anterior descendent artery), PCI may be a viable option. Because these anatomic patterns are less frequent in patients with DM, there is less evidence to guide revascularization in these cases. Patients with DM and left main disease and those in the acute coronary syndrome setting are also underrepresented in randomized trials, and the best revascularization strategy for these patients is not clear. Once the revascularization procedure is performed, patients should be kept engaged in controlling the risk factors for progression of cardiovascular disease. Avoidance of smoking, control of cholesterol, blood pressure and glycemic levels; regular practice of physical activity of at least moderate intensity; and a balanced diet are of key importance in the post-revascularization period. In this study, we review the current literature in the management of patients with DM and coronary artery disease undergoing a revascularization procedure.