RESUMO
AIM: The use of the Endeavor stent might reduce restenosis and stent thrombosis at 9 months. METHODS: Patients (n =1,197) treated for single coronary artery stenosis were enrolled in a prospective, randomized, double-blind study and randomly assigned to receive the Endeavor zotarolimus-eluting phosphorylcholine polymer-coated stent (n= 598) or the same bare metal stent but without the drug or the polymer coating (n=599). RESULTS: The 2 groups were well matched in baseline characteristics. Diabetes was present in 20.1% of patients; the mean reference vessel diameter was 2.75 mm; and the mean lesion length was 14.2 mm. The primary end point of target vessel failure at 9 months was reduced from 15.1% with the bare metal stent to 7.9% with the Endeavor (P=0.0001), and the rate of major adverse cardiac events was reduced from 14.4% with the bare metal stent to 7.3% with the Endeavor (P=0.0001). Target lesion revascularization was 4.6% with Endeavor compared with 11.8% with the bare metal stent (P=0.0001). The rate of stent thrombosis was 0.5% with the Endeavor, which was not significantly different from 1.2% with the bare metal stent. In 531 patients submitted to angiographic follow-up, late loss was reduced from 1.03+/-0.58 to 0.61+/-0.46 (P<0.001) in stent and from 0.72+/-0.61 to 0.36+/-0.46 (P<0.001) in segment. The rate of in-segment restenosis was reduced from 35% to 13.2% with Endeavor (P<0.0001). There was no excessive edge stenosis, aneurysm formation, or late acquired malposition by intravascular ultrasound imaging. Differences in clinical outcome were maintained at 12 and 24 months (P<0.0001). CONCLUSIONS: Compared with bare metal stents, the Endeavor stent is safe and reduces the rates of clinical and angiographic restenosis at 9, 12, and 24 months.
Assuntos
Fármacos Cardiovasculares/uso terapêutico , Angiografia Coronária , Reestenose Coronária/prevenção & controle , Estenose Coronária/diagnóstico por imagem , Estenose Coronária/terapia , Sirolimo/análogos & derivados , Stents , Idoso , Austrália , Reestenose Coronária/diagnóstico por imagem , Estenose Coronária/tratamento farmacológico , Estenose Coronária/cirurgia , Método Duplo-Cego , Sistemas de Liberação de Medicamentos , Desenho de Equipamento , Europa (Continente) , Feminino , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Nova Zelândia , Ilhas do Pacífico , Fosforilcolina , Estudos Prospectivos , Sirolimo/uso terapêutico , Resultado do TratamentoRESUMO
Reduced CD34(+) cell viability due to cryopreservation has unknown effects on subsequent hematopoietic engraftment in autologous transplantation. Thirty-six consecutive autologous peripheral stem cell collections were analyzed for absolute viable CD34(+) cell numbers at the time of stem cell collection and prior to re-infusion. Viable CD34(+) cells were enumerated using single platform flow cytometry and the molecular exclusion dye 7-amino actinomycin D. The median number of viable CD34(+) cells was 3.6 x 10(6)/kg at the time of harvest and 2.0 x 10(6)/kg after thawing. When viable CD34(+)cells enumerated after thawing were <2.0, 2.0-5.0, or >5.0 x 10(6)/kg, the median time to platelet engraftment was 17, 12 and 10 days, respectively (P < 0.05 for comparison of the group with <2.0 x 10(6)/kg and the other two groups), and the median time to neutrophil engraftment was 13, 14 and 12 days, respectively (P = NS). A minimum of 2.0 x 10(6) CD34(+) cells/kg was harvested in 33 of 36 patients (92%) but only 19 of 36 (52%) patients met this threshold at the time of reinfusion. The reduced numbers of viable CD34(+) cells measured prior to re-infusion is associated with time to platelet engraftment and may be useful in monitoring stem cell loss during processing and identifying patients at risk of graft failure.
Assuntos
Antígenos CD34/análise , Sobrevivência de Enxerto , Transplante de Células-Tronco Hematopoéticas/normas , Adolescente , Adulto , Idoso , Contagem de Células , Sobrevivência Celular , Criopreservação/normas , Transplante de Células-Tronco Hematopoéticas/métodos , Células-Tronco Hematopoéticas/citologia , Células-Tronco Hematopoéticas/imunologia , Humanos , Cinética , Pessoa de Meia-Idade , Neoplasias/terapia , Transplante de Células-Tronco de Sangue Periférico/métodos , Transplante de Células-Tronco de Sangue Periférico/normas , Prognóstico , Estudos Prospectivos , Manejo de Espécimes , Transplante Autólogo/métodos , Transplante Autólogo/normasRESUMO
Current stent delivery systems make primary stenting (stent placement without predilatation) possible, but few controlled trials have been performed to evaluate the success, safety, cost saving, and potential benefit of this approach in reducing late restenosis. The Comparison of PRE-Dilatation Versus Direct Stenting In Coronary Treatment using the Medtronic AVE S670 Coronary Stent System trial was a 399-patient study comparing results with the Medtronic-AVE S670 stent to objective performance criteria based on prior approved stents, with subrandomization to direct stenting versus stenting after balloon predilatation. Overall, results with the S670 stent showed excellent success and safety, with delivery success of 99%, a 14-day adverse event rate of 6.8% (including 6.5% non-Q-wave myocardial infarction), and favorable angiographic (20%) and clinical (12%) restenosis rates. Direct stenting was successful in 92% of cases, with a 99.5% secondary success rate including additional pretreatment of initially unsuccessful direct-stenting attempts, and no increase in complications. There were modest ( approximately 10%) savings in fluoroscopy time, contrast use, and a decrease in angioplasty balloon use (0.6 vs 1.3 balloons/case), but no reduction in clinical or angiographic restenosis. Patients treated later in the study, with a device that had less balloon extension beyond the edges of the stent, had slightly lower angiographic restenosis rates (19% vs 23%). In conclusion, the S670 stent showed excellent overall performance. Although direct stenting was safe and highly successful, it offered only modest cost savings, and no reduction in late restenosis compared with stenting after predilatation.
Assuntos
Cateterismo , Reestenose Coronária/prevenção & controle , Stents , Angiografia Coronária , Humanos , Pessoa de Meia-Idade , Estudos Prospectivos , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
OBJECTIVES: The study compared the safety and efficacy of coronary artery stenting in aged and nonaged patients and identified predictors of adverse clinical outcomes. BACKGROUND: Limited data are available on the outcomes of stenting in the aged (> or = 80 years) compared to nonaged patients. METHODS: The study was a pooled analysis of 6,186 patients who underwent coronary artery stenting in six recent multicenter trials. A clinical events committee adjudicated clinical end points, and quantitative angiography was performed by an independent core laboratory. RESULTS: There were 301 (4.9%) aged patients (> or = 80 years). Compared to nonaged patients, aged patients had a higher prevalence of multivessel disease (16.5% vs. 9.6%, p = 0.001), unstable angina (50.8% vs. 42.1%, p = 0.003), moderate to severe target lesion calcification (30.4% vs. 15.3%, p = 0.001) and smaller reference vessel diameter (2.90 mm vs. 2.98 mm, p = 0.004). Procedural success rate (97.4% vs. 98.5%, p = 0.14) was similar in the two groups. In-hospital mortality (1.33% vs. 0.10%, p = 0.001), bleeding complications (4.98% vs. 1.00%, p < 0.001) and one-year mortality (5.65% vs. 1.41%, p < 0.001) were significantly higher for the aged patients. Clinical restenosis was similar for the two groups (11.19% vs. 11.93%, p = 0.78). Advanced age, diabetes, prior myocardial infarction and presence of three-vessel disease were independent predictors of long-term mortality. CONCLUSIONS: Coronary artery stenting can be performed safely in patients > or = 80 years of age, with excellent acute results and a low rate of clinical restenosis, albeit with higher incidences of in-hospital and long-term mortality, and vascular and bleeding complications compared to nonaged patients.
Assuntos
Doença das Coronárias/terapia , Stents , Fatores Etários , Idoso , Ensaios Clínicos como Assunto , Angiografia Coronária , Doença das Coronárias/diagnóstico por imagem , Humanos , Análise Multivariada , Estudos Prospectivos , Resultado do TratamentoRESUMO
Percutaneous coronary intervention can be safely performed in patients with acute coronary syndromes (ACS), including those with non-ST-segment elevation myocardial infarction (MI), and unstable angina. Although there remains debate about whether an aggressive strategy involving early coronary arteriography and revascularization should be routinely performed in patients who present with non-ST-segment elevation MI and unstable angina, recent clinical trials suggest that an aggressive approach should be taken in both intermediate- and high-risk patients with ACS. There have been 4 clinical trials that have compared the outcomes of patients presenting with non-ST-segment elevation MI or unstable angina who were assigned to invasive or conservative strategies. The Thrombolysis in Myocardial Infarction (TIMI) IIIB trial and the Veterans Affairs Non-Q-Wave Infarction Strategies in Hospital (VANQWISH) trial failed to demonstrate a reduction in death or MI in patients assigned to an invasive approach, but it did demonstrate an important reduction in the frequency of rehospitalization. However, these studies were performed before the availability of coronary stents or the use of glycoprotein IIb/IIIa inhibitors. In contrast, the Fragmin and Fast Revascularisation During Instability in Coronary Artery Disease (FRISC) II and the Treat Angina with Aggrastat and Determine Cost of Therapy with an Invasive or Conservative Strategy (TACTICS) trials demonstrated significant improvements in the rates of death or MI in patients with non-ST-segment elevation MI or unstable angina assigned to an invasive strategy. Event reductions were greatest in patients with non-ST-segment elevation MI or unstable angina at intermediate or high risk for an adverse outcome. Understanding that these subgroups comprise approximately 75% of patients presenting with non-ST-segment elevation MI or unstable angina, we believe that an invasive approach is indicated in most patients who develop non-ST-segment elevation MI or unstable angina. Regardless of the strategy used in ACS patients, lipid-lowering therapy is necessary to reduce recurrent ischemia events at the site of plaque instability and in atherosclerotic disease remote to the target lesion.
Assuntos
Angina Instável/terapia , Infarto do Miocárdio/cirurgia , Revascularização Miocárdica , Tirosina/análogos & derivados , Angina Instável/tratamento farmacológico , Angina Instável/cirurgia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Síndrome , Terapia Trombolítica , Tirofibana , Tirosina/uso terapêuticoRESUMO
Perioperative graft failure after coronary artery bypass graft (CABG) can result in acute myocardial infarction with dire clinical consequences. We report a case of rescue percutaneous coronary intervention immediately after unsuccessful CABG. This approach salvaged the patient from cardiogenic shock and should be recognized as a viable alternative to immediate reoperation for certain patients.
Assuntos
Angioplastia Coronária com Balão , Ponte de Artéria Coronária , Oclusão de Enxerto Vascular/terapia , Choque Cardiogênico/terapia , Stents , Idoso , Angiografia Coronária , Eletrocardiografia , Feminino , Oclusão de Enxerto Vascular/diagnóstico por imagem , Humanos , Choque Cardiogênico/diagnóstico por imagemRESUMO
BACKGROUND: We have previously reported a virtual absence of neointimal hyperplasia 4 months after implantation of sirolimus-eluting stents. The aim of the present investigation was to determine whether these results are sustained over a period of 1 year. METHODS AND RESULTS: Forty-five patients with de novo coronary disease were successfully treated with the implantation of a single sirolimus-eluting Bx VELOCITY stent in São Paulo, Brazil (n=30, 15 fast release [group I, GI] and 15 slow release [GII]) and Rotterdam, The Netherlands (15 slow release, GIII). Angiographic and volumetric intravascular ultrasound (IVUS) follow-up was obtained at 4 and 12 months (GI and GII) and 6 months (GIII). In-stent minimal lumen diameter and percent diameter stenosis remained essentially unchanged in all groups (at 12 months, GI and GII; at 6 months, GIII). Follow-up in-lesion minimal lumen diameter was 2.28 mm (GIII), 2.32 mm (GI), and 2.48 mm (GII). No patient approached the >/=50% diameter stenosis at 1 year by angiography or IVUS assessment, and no edge restenosis was observed. Neointimal hyperplasia, as detected by IVUS, was virtually absent at 6 months (2+/-5% obstruction volume, GIII) and at 12 months (GI=2+/-5% and GII=2+/-3%). CONCLUSIONS: This study demonstrates a sustained suppression of neointimal proliferation by sirolimus-eluting Bx VELOCITY stents 1 year after implantation.
Assuntos
Implante de Prótese Vascular/instrumentação , Doença das Coronárias/cirurgia , Oclusão de Enxerto Vascular/prevenção & controle , Sirolimo/administração & dosagem , Stents , Implante de Prótese Vascular/efeitos adversos , Implante de Prótese Vascular/métodos , Brasil , Estudos de Coortes , Angiografia Coronária , Doença das Coronárias/diagnóstico , Doença das Coronárias/tratamento farmacológico , Preparações de Ação Retardada/administração & dosagem , Implantes de Medicamento/administração & dosagem , Endossonografia , Feminino , Seguimentos , Oclusão de Enxerto Vascular/etiologia , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Sirolimo/efeitos adversos , Stents/efeitos adversos , Taxa de Sobrevida , Resultado do Tratamento , Túnica Íntima/efeitos dos fármacos , Grau de Desobstrução Vascular/efeitos dos fármacosRESUMO
Vascular closure devices offer advantages over traditional means of obtaining hemostasis after percutaneous coronary intervention (PCI) in terms of patient comfort and time to ambulation. We investigate whether such devices also reduce the risk of vascular complications in selected patient populations. We conducted a retrospective analysis of all patients who underwent PCI at our institution between January 1998 and December 1999. Of 3,151 consecutive patients, 3,027 were eligible to receive vascular closure devices. Of these, 1,485 received a closure device and 1,409 received glycoprotein IIb-IIIa antagonists. The overall vascular complication rate, as defined by the need for surgical repair or transfusion, or the development of arteriovenous fistula, pseudoaneurysm, or large hematoma, was 4.20%. By univariate analysis, the use of closure devices was associated with a lower vascular complication rate (3.03% vs 5.52%; p = 0.002) and a shorter length of hospital stay (2.77 vs 3.97 days, p <0.001). Multivariate analysis showed a significant reduction in vascular complications with closure devices (odds ratio 0.59, p = 0.007). For the subgroup of patients receiving glycoprotein IIb-IIIa antagonists, the use of closure devices was associated with an even more pronounced reduction in the risk of vascular complications (odds ratio 0.45, p <0.008). Thus, the use of closure devices in selected patients undergoing PCI is associated with a low rate of vascular complications and decreased length of stay. This benefit was most marked for patients receiving glycoprotein IIb-IIIa antagonists.
Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/instrumentação , Anticorpos Monoclonais/administração & dosagem , Doença das Coronárias/etiologia , Hematoma/etiologia , Infarto do Miocárdio/terapia , Distribuição por Idade , Idoso , Análise de Variância , Falso Aneurisma/etiologia , Anticorpos Monoclonais Humanizados , Fístula Arteriovenosa/etiologia , Distribuição de Qui-Quadrado , Doença das Coronárias/cirurgia , Anomalias dos Vasos Coronários/etiologia , Vasos Coronários/lesões , Segurança de Equipamentos , Feminino , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/mortalidade , Probabilidade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Distribuição por SexoRESUMO
BACKGROUND: Recent studies have suggested that smokers may require less frequent repeated revascularization after percutaneous coronary intervention (PCI) compared with nonsmokers. However, the mechanism of this phenomenon is unknown. METHODS AND RESULTS: We examined the association between smoking and restenosis using pooled data from 8671 patients treated with PCI in 9 multicenter clinical trials. Clinical restenosis was examined in the cohort of 5682 patients who were assigned to clinical follow-up only. Angiographic restenosis was evaluated in the subset of 2989 patients who were assigned to mandatory angiographic restudy. Among those patients assigned to clinical follow-up only, target lesion revascularization (TLR) occurred in 6.6% of smokers and 10.1% of nonsmokers (P<0.001). After adjustment for baseline clinical and angiographic differences, the rate of TLR remained significantly lower in smokers with an adjusted relative risk of 0.69 (95% CI, 0.54 to 0.88). Among the angiographic cohort, there were no differences in the rates of angiographic restenosis or follow-up diameter stenosis in either univariate or multivariate analyses. This dissociation between clinical and angiographic restenosis was explained in part by reduced sensitivity to restenosis on the part of smokers and by the greater reluctance of smokers to seek medical attention despite recurrent angina. CONCLUSIONS: In patients undergoing contemporary PCI, cigarette smoking is associated with a lower rate of subsequent TLR without affecting angiographic restenosis. These findings have important implications for the follow-up of smokers after PCI and suggest that cross-study comparisons of rates of clinical restenosis must account for the potential confounding effect of smoking.
Assuntos
Angioplastia Coronária com Balão , Oclusão de Enxerto Vascular/epidemiologia , Fumar/epidemiologia , Idoso , Angioplastia Coronária com Balão/estatística & dados numéricos , Viés , Ensaios Clínicos como Assunto , Estudos de Coortes , Comorbidade , Fatores de Confusão Epidemiológicos , Angiografia Coronária , Doença das Coronárias/terapia , Feminino , Seguimentos , Oclusão de Enxerto Vascular/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Multicêntricos como Assunto , Razão de Chances , Risco , Stents/estatística & dados numéricos , Estados Unidos/epidemiologiaRESUMO
Intimal hyperplasia within the body of the stent is the primary mechanism for in-stent restenosis; however, stent edge restenosis has been described after brachytherapy. Our current understanding about the magnitude of in vivo intimal hyperplasia and edge restenosis is limited to data obtained primarily from select, symptomatic patients requiring repeat angiography. The purpose of this study was to determine the extent and distribution of intimal hyperplasia both within the stent and along the stent edge in relatively nonselect, asymptomatic patients scheduled for 6-month intravascular ultrasound (IVUS) as part of a multicenter trial: Heparin Infusion Prior to Stenting. Planar IVUS measurements 1 mm apart were obtained throughout the stent and over a length of 10 mm proximal and distal to the stent at index and follow-up. Of the 179 patients enrolled, 140 returned for repeat angiography and IVUS at 6.4 +/- 1.9 months and had IVUS images adequate for analysis. Patients had 1.2 +/- 0.6 Palmaz-Schatz stents per vessel. There was a wide individual variation of intimal hyperplasia distribution within the stent and no mean predilection for any location. At 6 months, intimal hyperplasia occupied 29.3 +/- 16.2% of the stent volume on average. Lumen loss within 2 mm of the stent edge was due primarily to intimal proliferation. Beyond 2 mm, negative remodeling contributed more to lumen loss. Gender, age, vessel location, index plaque burden, hypercholesterolemia, diabetes, and tobacco did not predict luminal narrowing at the stent edges, but diabetes, unstable angina at presentation, and lesion length were predictive of in-stent intimal hyperplasia. In a non-radiation stent population, 29% of the stent volume is filled with intimal hyperplasia at 6 months. Lumen loss at the stent edge is due primarily to intimal proliferation.
Assuntos
Doença das Coronárias/patologia , Stents , Túnica Íntima/patologia , Doença das Coronárias/terapia , Feminino , Seguimentos , Humanos , Hiperplasia/etiologia , Hiperplasia/patologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Prospectivos , Recidiva , Stents/efeitos adversosRESUMO
To compare the efficacy of self-expanding (SE) and balloon-expandable (BE) stents in native coronary arteries, we randomly assigned 1,096 patients with new and restenotic lesions to receive either device. Baseline demographics and coronary angiographic characteristics were similar in the 2 groups. The incidence of major adverse cardiac events including death, myocardial infarction, bypass surgery, and repeat intervention was similar for both groups at 1 month (2.9% vs 3.1% for SE vs BE, respectively) and at 9 months (19.3% vs 20.1%, SE vs BE respectively). In a subgroup of patients who underwent follow-up angiography (n = 250), the binary restenosis rates (24.2% vs 18.7%, p = 0.30), late loss (0.98 vs 94 mm, p = 0.60), and loss index (0.55 vs 55, p = 0.95) were not significantly different for both groups. In 62 patients who underwent intravascular ultrasound examination (IVUS), there was a trend toward a lower incidence of edge tears in the SE group (6% vs 23%, p = 0.06). Follow-up IVUS analysis showed that the minimum stent area of the SE stent increased by 33% at 6 months, whereas no change occurred in the BE stents; this was accompanied by a greater degree of intimal proliferation in the SE stents compared with BE stents (3.1 +/- 2.0 vs 1.7 +/- 1.7 mm(2)). Thus, the SE stents had similar clinical and angiographic outcomes in patients with lesions in native coronary arteries.
Assuntos
Angioplastia Coronária com Balão , Doença das Coronárias/terapia , Stents , Doença das Coronárias/diagnóstico por imagem , Estudos Cross-Over , Desenho de Equipamento , Feminino , Seguimentos , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Pressão , Estudos Prospectivos , UltrassonografiaRESUMO
A Jostent stent-graft was placed in a renal artery with a focal stenosis and an associated aneurysm in a young patient with fibromuscular dysplasia. Arteriographic follow-up at 16 months showed that the stent-graft remained patent and the aneurysm was excluded.
Assuntos
Aneurisma/complicações , Aneurisma/terapia , Displasia Fibromuscular/complicações , Displasia Fibromuscular/terapia , Artéria Renal/transplante , Stents , Adolescente , Feminino , Humanos , Grau de Desobstrução VascularAssuntos
Cateterismo Cardíaco , Laboratórios/normas , Adulto , Anestesia , Cateterismo Cardíaco/normas , Criança , Angiografia Coronária , Ética Médica , Humanos , Processamento de Imagem Assistida por Computador , Laboratórios/economia , Pessoal de Laboratório Médico , Infarto do Miocárdio/terapia , Revascularização Miocárdica , Pré-Medicação , Garantia da Qualidade dos Cuidados de Saúde , Estados Unidos , Recursos HumanosAssuntos
Angioplastia Coronária com Balão , Angina Instável/terapia , Angioplastia Coronária com Balão/normas , Cateterismo Cardíaco , Ponte de Artéria Coronária , Doença das Coronárias/terapia , Angiopatias Diabéticas/terapia , Humanos , Infarto do Miocárdio/terapia , Inibidores da Agregação Plaquetária/uso terapêutico , Garantia da Qualidade dos Cuidados de Saúde , Medição de Risco , Terapia TrombolíticaAssuntos
Angioplastia Coronária com Balão/normas , Doença da Artéria Coronariana/terapia , Fatores Etários , Angina Pectoris/terapia , Angioplastia Coronária com Balão/efeitos adversos , Angioplastia Coronária com Balão/tendências , Serviço Hospitalar de Cardiologia/normas , Comorbidade , Contraindicações , Ponte de Artéria Coronária/normas , Doença da Artéria Coronariana/classificação , Doença da Artéria Coronariana/complicações , Complicações do Diabetes , Oclusão de Enxerto Vascular/prevenção & controle , Hemodinâmica , Complicações Intraoperatórias/etiologia , Infarto do Miocárdio/terapia , Inibidores da Agregação Plaquetária/uso terapêutico , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Complicações Pós-Operatórias/etiologia , Competência Profissional/normas , Garantia da Qualidade dos Cuidados de Saúde/normas , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco , Fatores de Risco , Fatores Sexuais , Taxa de Sobrevida , Terapia Trombolítica , Resultado do TratamentoRESUMO
The objectives of this analysis were to develop and validate simplified risk score models for predicting the risk of major in-hospital complications after percutaneous coronary intervention (PCI) in the era of widespread stenting and use of glycoprotein IIb/IIIa antagonists. We then sought to compare the performance of these simplified models with those of full logistic regression and neural network models. From January 1, 1997 to December 31, 1999, data were collected on 4,264 consecutive interventional procedures at a single center. Risk score models were derived from multiple logistic regression models using the first 2,804 cases and then validated on the final 1,460 cases. The area under the receiver operating characteristic (ROC) curve for the risk score model that predicted death was 0.86 compared with 0.85 for the multiple logistic model and 0.83 for the neural network model (validation set). For the combined end points of death, myocardial infarction, or bypass surgery, the corresponding areas under the ROC curves were 0.74, 0.78, and 0.81, respectively. Previously identified risk factors were confirmed in this analysis. The use of stents was associated with a decreased risk of in-hospital complications. Thus, risk score models can accurately predict the risk of major in-hospital complications after PCI. Their discriminatory power is comparable to those of logistic models and neural network models. Accurate bedside risk stratification may be achieved with these simple models.
Assuntos
Angioplastia Coronária com Balão/efeitos adversos , Doença das Coronárias/mortalidade , Mortalidade Hospitalar , Complicações Pós-Operatórias/mortalidade , Medição de Risco/métodos , Ponte Cardiopulmonar , Doença das Coronárias/terapia , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Redes Neurais de Computação , Complicações Pós-Operatórias/epidemiologia , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos , Curva ROC , Fatores de RiscoRESUMO
BACKGROUND: The optimal level of platelet inhibition with a glycoprotein (GP) IIb/IIIa antagonist necessary to minimize thrombotic complications in patients undergoing a percutaneous coronary intervention (PCI) is currently unknown. METHODS AND RESULTS: Five hundred patients undergoing a PCI with the planned use of a GP IIb/IIIa inhibitor had platelet inhibition measured at 10 minutes, 1 hour, 8 hours, and 24 hours after the initiation of therapy with the Ultegra Rapid Platelet Function Assay (Accumetrics). Major adverse cardiac events (MACES: composite of death, myocardial infarction, and urgent target vessel revascularization) were prospectively monitored, and the incidence correlated with the measured level of platelet function inhibition at all time points. One quarter of all patients did not achieve >/=95% inhibition 10 minutes after the bolus and experienced a significantly higher incidence of MACEs (14.4% versus 6.4%, P=0.006). Patients whose platelet function was <70% inhibited at 8 hours after the start of therapy had a MACE rate of 25% versus 8.1% for those >/=70% inhibited (P=0.009). By multivariate analysis, platelet function inhibition >/=95% at 10 minutes after the start of therapy was associated with a significant decrease in the incidence of a MACE (odds ratio 0.46, 95% CI 0.22 to 0.96, P=0.04). CONCLUSIONS: Substantial variability in the level of platelet function inhibition is achieved with GP IIb/IIIa antagonist therapy among patients undergoing PCI. The level of platelet function inhibition as measured by a point-of-care assay is an independent predictor for the risk of MACEs after PCI.