Clinical characteristics, angiographic findings, and one-year outcome of 101 consecutive stent thrombosis cases in British Columbia.

BACKGROUND: Stent thrombosis (ST) is rare, but is associated with significant morbidity and mortality. METHODS: We analyzed data from the British Columbia (BC) Registry from April 2011-January 2012. RESULTS: 101 ST cases were reported and verified. Based on timing, ST was considered early (≤30days) in 35.6%, late (>30days-1year) in 17.8% and very late (>1year) in 46.5%. The majority (68.5%) presented with STEMI, and the remaining with non-STEMI (31.5%). Most vessels were functionally occluded (TIM1 flow grade ≤1 in 67.1%). Thrombus burden was high (TIMI thrombus grade ≥4 in 77.2%). Aspiration thrombectomy was performed in 41% of cases. New stents were implanted in 62.4% cases. Intra-coronary imaging was low (11%). At the original stent implantation, STEMI was the clinical presentation in 39.6%, the lesion was complex in 62.1%, and thrombus was visualized in 23.0%. Prognosis after ST was unfavorable with high mortality (11.9% at 30days and 16.8% at one year), and further revascularization (5.0% repeat PCI and 6.9% coronary artery bypass graft surgery). Early ST was associated with worse clinical outcome compared to late/very late ST: 30-day mortality at 22.2% versus 6.2% (p=0.02), and 1-year mortality at 27.8% versus 10.8% (p=0.05). CONCLUSIONS: In this prospective registry from BC, all ST presented with myocardial infarction, and the majority was treated with emergency PCI. Additional stents were commonly implanted with infrequent use of intracoronary imaging. Mortality rate was higher for early ST in comparison with late/very late ST. A comprehensive approach should be developed to treat this difficult complication.

Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology/Canadian Society of Cardiac Surgery position statement on revascularization--multivessel coronary artery disease.

This position statement addresses issues in revascularization for multivessel coronary artery disease (CAD) from the perspective of both cardiologists and cardiac surgeons. Recommendations are made based on evidence from clinical trials and observational studies, with an emphasis on the increasing number of individuals with significant comorbid disease burden and functional debilitation who are being referred for definitive management of their multivessel CAD in the context of routine clinical practice. These types of individuals have traditionally not been included in the many clinical trials that have been the basis for guidelines and recommendations, and the objective of the proposed medical intervention or revascularization (or both) would not necessarily be to improve prognosis but to improve quality of life. One purpose of this document is to propose practical multidisciplinary approaches to the management of these patients. Recommendations are made for revascularization in acute coronary syndromes and stable CAD, with specific considerations for individuals with left ventricular dysfunction and heart failure, chronic renal failure, and chronic obstructive pulmonary disease. We also consider the use of various risk scores, including the Society of Thoracic Surgeons score, the EuroSCORE, and the SYNTAX II score. The importance of a heart team approach is also emphasized. The complementary role of coronary bypass surgery and percutaneous coronary intervention is highlighted, along with the importance of optimal medical therapy.

Visual outcomes after wavefront-guided photorefractive keratectomy and wavefront-guided laser in situ keratomileusis: Prospective comparison.

PURPOSE: To compare visual outcomes between wavefront-guided photorefractive keratectomy (PRK) and wavefront-guided laser in situ keratomileusis (LASIK). SETTING: Academic center, Salt Lake City, Utah, USA. METHODS: In this randomized prospective study, myopic eyes were treated with wavefront-guided PRK and or wavefront-guided LASIK using a Visx Star S4 CustomVue platform with iris registration. Primary outcome measures were uncorrected (UDVA) and corrected (CDVA) distance visual acuities and manifest refraction. Secondary outcome measures were higher-order aberrations (HOAs) and contrast sensitivity. RESULTS: The PRK group comprised 101 eyes and the LASIK group, 102 eyes. At 6 months, the mean UDVA was -0.03 logMAR +/- 0.10 [SD] (20/19) and 0.07 +/- 0.09 logMAR (20/24), respectively (P = .544). In both groups, 75% eyes achieved a UDVA of 20/20 or better (P = .923); 77% of eyes in the PRK group and 88% in the LASIK group were within +/-0.50 diopter of emmetropia (P = .760). There was no statistically significant difference between groups in contrast sensitivity at 3, 6, 12, or 18 cycles per degree. The mean postoperative HOA root mean square was 0.45 +/- 0.13 mum in the PRK group and 0.59 +/- 0.22 mum in the LASIK group (P = .012), representing an increase factor of 1.22 and 1.74, respectively. CONCLUSIONS: Wavefront-guided PRK and wavefront-guided LASIK had similar efficacy, predictability, safety, and contrast sensitivity; however, wavefront-guided PRK induced statistically fewer HOAs than wavefront-guided LASIK at 6 months. FINANCIAL DISCLOSURE: No author has a financial or proprietary interest in any material or method mentioned.

Effects of enalaprilat on venoconstriction to norepinephrine: role of prostaglandins.

OBJECTIVE: Most patients with cardiovascular disease continue to receive both aspirin and an angiotensin-converting enzyme (ACE) inhibitor. This is despite the fact that ACE inhibition also inhibits the enzyme kininase II and leads to accumulation of bradykinin which increases prostaglandins. We hypothesized that in normal veins, vasodilator prostaglandins contribute significantly to ACE inhibitor dilation of norepinephrine-induced venoconstriction, and this would be blocked by cyclooxygenase inhibition. METHODS: The study was performed using the in vivo dorsal hand vein technique for measuring vascular responses directly. Venoconstriction to norepinephrine infusions (0.5-1024 ng/min) was assessed in eight normal subjects (46+/-5 years, mean+/-S.E.M.) during coinfusion of saline in one hand (control) and enalaprilat (1000 microg/min) in the contralateral hand. On a second morning (7+/-1 days apart, mean+/-S.E.M., random order), the same procedure was repeated with indomethacin (3 microg/min) coinfusion in both hands. RESULTS: Enalaprilat shifted the norepinephrine dose-response curve to the right (P=0.024) and increased the norepinephrine log ED(50) (dose required to cause 50% venoconstriction) from 1.70+/-0.08 to 2.31+/-0.11 log ng/min (P=0.001). Indomethacin shifted the norepinephrine dose-response curve to the left (P=0.018) and decreased the norepinephrine log ED(50) from 1.70+/-0.08 to 1.09+/-0.18 log ng/min (P=0.002). In the presence of indomethacin, enalaprilat caused only a small but significant increase in the norepinephrine log ED(50), from 1.09+/-0.18 to 1.29+/-0.18 log ng/min (P=0.041). CONCLUSIONS: The results suggest that vasodilator prostaglandins contribute significantly to the attenuation of sympathetic venoconstriction by enalaprilat. This may have clinical relevance in patients receiving aspirin and ACE inhibitors in the setting of increased sympathetic activity.