Comparison of antithrombotic agents during urgent percutaneous coronary intervention following thrombolytic therapy: A retrospective cohort study.

BACKGROUND: The optimal antithrombotic regimen for urgent percutaneous coronary interventions (PCI) following thrombolytic therapy for ST segment myocardial infarction (STEMI) is currently unknown. METHODS: We performed a retrospective analysis of all patients referred to our institution from January 2005 to July 2014 who underwent urgent PCI within 24 hr after receiving thrombolytic therapy. The patients were divided into three cohorts based on the anticoagulation strategy during PCI-bivalirudin, heparin alone or heparin plus Glycoprotein IIb/IIIa inhibitor (GPI). The primary end point of major adverse cardiovascular events (MACE) was defined as a composite of inpatient death, myocardial infarction (MI) and stroke. Net adverse clinical events (NACE) were defined as a combination of MACE plus major bleeding complications. Univariable, multivariable and propensity-weighted modeling were used to compare MACE and NACE between the three treatment groups. RESULTS: A total of 695 patients met the inclusion criteria during the study period. In the univariable analysis, there was no significant difference treatment in MACE between the three groups (Bivalirudin: 1.2% vs. Heparin + GPI: 4.4%; Heparin alone: 2.7%, P = 0.11). In the reduced logistic regression model, compared to bivalirudin, the odds of NACE was significantly higher with heparin alone (OR: 3.58, 95% CI: 1.21, 10.54, P = 0.02) or with heparin plus GPI (OR: 9.0, 95% CI: 2.83, 28.64, P <0.001). CONCLUSION: In STEMI patients undergoing PCI within 24 hr after thrombolytic therapy, bivalirudin was associated with a strong trend toward reduced bleeding complications as compared to heparin alone or heparin plus GPI. The optimal antithrombotic regiment for urgent PCI following thrombolytic therapy is currently unknown. Our study demonstrated that use of bivalirudin during PCI following thrombolytic therapy is associated with a trend toward reduced bleeding complications compared to heparin alone or heparin plus GPI. Large randomized trials of adjunctive anticoagulation during PCI in this complex post-thrombolytic population are warranted. © 2017 Wiley Periodicals, Inc.

The impact of the distance from the interventional cardiologist's home to the hospital during off hours.

OBJECTIVES: The impact of the distance from the interventional cardiologist's home to the hospital and door to balloon time (DTBT) BACKGROUND: The importance of DTBT is highlighted by its inclusion as one of the core quality measures collected by the center for Medicare and Medicaid services and by the Joint commission on Accreditation of Healthcare organizations. We investigated the effect of time of day on the DTBT in patients having primary percutaneous coronary intervention (pPCI) and the impact of distance of the on call interventional cardiologist from the hospital on the DTBT and major adverse cardiac events (MACE) in patients undergoing pPCI during the off hours METHODS: Patients enrolled in the study presented with STEMI either in the field or to the emergency department (ED) and underwent pPCI from October 2007 to July 2009 RESULTS: Significant predictors of DTBT included a history of prior MI (P = 0.001), prior percutaneous coronary intervention (P = 0.021), prior coronary artery bypass grafting (P < 0.001), and history of diabetes mellitus (P = 0.004). The strongest predictor of DTBT was on versus off hours. Mean DTB was 18.5 min greater during off hours (72 min) compared to on-hours (53.5 min). The distance from the cardiologist's home to the hospital was not associated with DTBT on multivariable analysis (P = 0.20) CONCLUSION: When pPCI is performed in a highly organized STEMI center with broad staff support and expertise in cardiac care, the increase in the DTBT during off hours was not associated with increase MACE rates.

High-dose atorvastatin does not negatively influence clinical outcomes among clopidogrel treated acute coronary syndrome patients--a Pravastatin or Atorvastatin Evaluation and Infection Therapy-Thrombolysis in Myocardial Infarction 22 (PROVE IT-TIMI 22) analysis.

BACKGROUND: Clopidogrel is inactive in vitro and is metabolized by hepatic cytochrome P-450-3A4 to produce active metabolites. Unlike pravastatin, atorvastatin is a statin that is subject to metabolism by cytochrome P-450-3A4, and drug-drug interactions with other potent inhibitors of this cytochrome system have been demonstrated. However, the clinical impact of this interaction has created debate. METHODS: In the PROVE IT-TIMI 22 study, 4162 patients with an acute coronary syndrome within the preceding 10 days were randomly assigned in a 1:1 fashion to pravastatin 40 mg or atorvastatin 80 mg daily. The primary efficacy outcome measure was the time from randomization until the first occurrence of a component of the primary end point: death from any cause, myocardial infarction, documented unstable angina requiring rehospitalization, revascularization with either percutaneous coronary intervention or coronary artery bypass grafting, or stroke. RESULTS: At 30 days, there was a trend for less occurrence of the primary end point in patients randomized to atorvastatin compared with pravastatin, irrespective of whether they were taking clopidogrel. This becomes significant at 2-year follow-up in clopidogrel-treated patients (21.66 % vs 26.18% P = .0091). There was no evidence of interaction in the clopidogrel/no clopidogrel subgroup for the primary end point (interaction P = .65) or the components of the composite. CONCLUSION: In conclusion, the beneficial affects of atorvastatin 80 mg in reducing the primary end point at 2 years is independent of coadministration with clopidogrel.

Friedreich's ataxia as a cause of premature coronary artery disease.

Friedreich's ataxia is the most common hereditary neurodegenerative disorder, and more than half of all patients show echocardiographic evidence of cardiomyopathy. Although angina has been reported in these patients, the role of coronary artery disease has previously been dismissed and is therefore underestimated. Premature obstructive coronary disease has rarely been angiographically demonstrated in patients with Friedreich's ataxia. We present an unusual case of a 35-year-old woman with Friedreich's ataxia who presented with intermittent chest pressure associated with dyspnea and diaphoresis. Cardiac catheterization revealed a chronically occluded left circumflex coronary artery and a high-grade stenosis of the left anterior descending coronary artery. A Cypher stent, placed within the left anterior descending artery, left no residual stenosis. This case illustrates the importance of fully investigating anginal symptoms in patients with Friedreich's ataxia, because coronary artery disease is likely underdiagnosed in this population. Early diagnosis may permit aggressive management and may delay the progression to end-stage cardiomyopathy.

Determinants of 30-day adverse events following saphenous vein graft intervention with and without a distal occlusion embolic protection device.

Distal balloon occlusion was approved as a means of embolic protection during saphenous vein graft intervention based on its ability to decrease major adverse clinical events (MACEs) by 42% in the 801-patient Saphenous Vein Graft Angioplasty Free of Emboli Randomized (SAFER) trial. However, the cost and technical complexity of this device have limited its widespread use and prompted some to avoid its use in cases that appear at "low risk" for complications. If predictors of MACEs and their potential decrease by distal balloon occlusion could be identified, this would have important clinical implications in this challenging population. We therefore used standard demographic and angiographic variables and 2 new angiographic markers (extent of graft degeneration and estimated volume of plaque in the target lesion) to construct multivariable logistic regression models of 30-day of MACEs in the SAFER trial. Independent correlates of increased 30-day MACEs were more extensive vein graft degeneration (p = 0.0001) and bulkier lesions (larger estimated plaque volume, p = 0.0005). Use of a distal balloon occlusion device was independently predictive of lower 30-day rates of MACE (p = 0.01), with uniform benefit across risk strata (no significant interaction between device use and independent angiographic risk factors). Thus, the risk of 30-day MACEs after percutaneous intervention in aortocoronary saphenous vein grafts is increased in more diffusely diseased grafts and in bulkier lesions, but a significant benefit of the GuardWire was seen across all levels of MACE risk rather than just those perceived to be at highest risk.

The heavy LEGACY: Should weight management be part of every atrial fibrillation clinic?

As the global burden of atrial fibrillation (AF) and its attendant economic impact on the healthcare system surges, there is increasing interest in the secondary prevention of AF with various therapies. Of the several identified risk factors for AF, obesity is an important contributor that may be managed with intensive lifestyle modification. Prior studies have demonstrated the short-term and long-term benefits of weight loss in reduction of AF symptoms. In the LEGACY study [Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort: A Long-Term Follow-Up Study], the investigators evaluated the long-term effects of a weight management program on AF symptoms. Of the 355 patients included in this cohort, outcomes such as AF symptom burden, arrhythmia-free survival, inflammatory markers and structural cardiac changes all appear to have improved in the intense weight loss group as compared to the 2 other groups. Further, the benefits of weight loss appear to be lost when > 5% weight fluctuation (WF) occurred over the 5-year follow-up period. In this review, we discuss the design of the weight management clinic and its impact on the management of AF in the LEGACY study. Given that weight management appears to be an effective intervention that will not have the marketing and financial push that pharmaceutical and device based therapies enjoy, it behooves administrators of AF clinics to develop innovative funding strategies to incorporate weight management programs in order to improve patient-centered outcomes.

Plasma ProBNP Is Not a Specific Marker for Transient Myocardial Ischemia.

BACKGROUND: Plasma proBNP levels are increased in patients with acute myocardial infarction. Previous studies have shown conflicting data on the effect of transient myocardial ischemia on plasma BNP levels. We designed the current study to examine plasma proBNP levels in patients with transient myocardial ischemia during a percutaneous coronary intervention (PCI). This study was to study plasma proBNP as a marker of transient myocardial ischemia. METHODS: We enrolled 49 consecutive patients with a history of angina or abnormal stress test who presented for cardiac catheterization. We obtained plasma proBNP levels in all patients at 1) arterial access (proBNP-1), 2) the end of the procedure (proBNP-2) and 3) 4 hours after procedure (proBNP-3). Hotelling's T-squared test was used to evaluate the equality of means. Log transforms of proBNP were used to impart data normality. RESULTS: Twenty-two patients underwent diagnostic catheterization (DCA group) and 27 underwent PCI (PCI group). Both groups had normal left ventricular function and a baseline creatinine < 2 mg/dL. Baseline log (proBNP) was 4.7 + 0.99 (units) and rose significantly at 4 hours in both groups (P < 0.02), with no difference in rate of change. CONCLUSIONS: Plasma proBNP was increased in both DCA and PCI groups which limits its utility to identify transient myocardial ischemia. The etiology of increase in proBNP in both groups is speculative and may be related to injection of radiographic contrast media into the coronary artery which leads to microcirculatory impairment resulting in myocardial tissue hypoxia and transient increase in left ventricular pressure; however, further evaluation is required.

Meta-analysis of corticosteroid treatment in acute myocardial infarction.

Acute and chronic inflammation play a central role in the pathophysiology of atherosclerosis. Corticosteroids are the gold standard anti-inflammatory agent and may have a role in treating acute myocardial infarction. However, concern exists regarding the potential for impaired wound healing and wall thinning. The MEDLINE and PreMEDLINE databases were searched for articles from 1966 through May 2002. A total of 186 articles and 16 English-language publications were identified. A meta-analysis of mortality in controlled trials was performed. Sensitivity analyses and 2 tests for publication bias were used to test the robustness of the results. Sixteen studies involving 3,793 patients were reviewed. Most studies were small (<100 patients) and revealed conflicting efficacy using surrogate outcome measures, such as infarct size. No clear association with myocardial rupture was observed. Meta-analysis of 11 controlled trials (2,646 patients) revealed a 26% decrease in mortality with corticosteroids (odds ratio 0.74, 95% confidence interval [CI] 0.59 to 0.94; p = 0.015). Sensitivity analyses limited to large studies and randomized controlled trials revealed odds ratios of 0.76 (95% CI 0.53 to 1.09) and 0.95 (95% CI 0.72 to 1.26), respectively. Two tests revealed no evidence for publication bias. Thus, the review of available clinical studies demonstrated no harm and a possible mortality benefit of corticosteroids in acute myocardial infarction.

Does knowledge of the cost of cardiovascular tests influence physician ordering patterns?

INTRODUCTION: The United States spends a higher percentage of its gross domestic product on health care than any other country. Previous efforts to curtail health care spending have had minimal impact. We hypothesized that informing physicians of the cost of expensive cardiovascular diagnostic tests would change their ordering behavior. MATERIALS AND METHODS: Hospitalist physicians (n = 38) were randomly assigned to either seeing or not seeing the cost of diagnostic tests, via a computer pop-up screen, at the time of order entry. Patients were inpatients on a general medical service. Cost-aware physicians were shown the cost of the test they ordered as well as the cost of similar tests with different costs. There was a 4-month baseline period prior to randomization followed by a 4-month intervention period. The primary outcome measure was a change in the proportion of imaging stress tests in the study period. RESULTS: Of the total number of stress tests ordered (imaging and nonimaging), cost-aware physicians ordered 89% of their tests with imaging during both the baseline and study periods. Cost-unaware physicians ordered 91% imaging tests during the baseline period and 87% during the study period. There were no significant differences between the groups regarding change in ordering from baseline to study period. Both groups showed a slight increase (P < 0.03) in ordering the more expensive regadenoson nuclear stress tests (cost-aware: 30% baseline, 44% study period; cost-unaware: 36% baseline, 41% study period). DISCUSSION: Informing physicians of the cost of certain diagnostic tests is not a sufficient intervention to influence their ordering behavior.

ST segment elevation myocardial infarction as a presenting feature of thrombotic thrombocytopenic purpura.

Myocardial infarction with ST segment elevation (STE) on electrocardiography (ECG) is a common presentation in emergency rooms across the world. Myocardial injury and necrosis are infrequently the initial presentation in patients with thrombotic thrombocytopenic purpura (TTP). A 48-year-old woman presented with STE myocardial infarction from outside hospital for primary percutaneous coronary intervention. However, her clinical picture was not consistent. Rapid evaluation revealed symptoms associated with microangiopathic hemolytic anemia, thrombocytopenia, acute kidney injury with waxing and waning mental status. A diagnosis of TTP was made with low ADAMST-13 activity. Plasmapheresis was initiated along with intravenous steroid therapy. The patient had a full recovery and went home after full recovery of left ventricular ejection fraction and normal myocardial perfusion studies. Rapid evaluation is needed to identify infrequent causes of STE myocardial infarction. As swift protocols are activated in the emergency room and catheterization laboratories to ensure quality control, it is equally important to integrate all aspects of the patient's clinical and objective data to detect unusual disease entities.

A prospective multicenter registry of laser therapy for degenerated saphenous vein graft stenosis: the COronary graft Results following Atherectomy with Laser (CORAL) trial.

PURPOSE: The primary aim of this study was to prospectively evaluate the safety and efficacy of Excimer laser atherectomy as a primary treatment strategy in consecutively eligible patients presenting for percutaneous coronary intervention (PCI) of degenerated saphenous vein graft (SVG) lesions using a multicenter registry. Prior single-center experience suggested that laser atherectomy may decrease acute procedural complications during treatment of degenerated SVGs, including lesions not amenable to distal protection devices (DPDs). METHODS AND MATERIALS: The COronary graft Results following Atherectomy with Laser investigators enrolled 98 patients at 18 centers between June 23, 2003, and October 4, 2004, with greater than 50% stenosis of an SVG who presented for PCI due to angina pectoris or objective evidence of myocardial ischemia in a concordant myocardial distribution. Laser atherectomy was planned. Patients were excluded if the operator planned to utilize a DPD. Inclusion and exclusion criteria were aligned to those in the Saphenous vein graft Angioplasty Free of Emboli Randomized (SAFER) trial. RESULTS: The primary end point [30-day major adverse cardiac events (MACE)] occurred in 18/98 (18.4%) patients driven primarily by non-q-wave myocardial infarction. Major procedural complications included no reflow (n=5) and major dissection (n=1). No perforations occurred. Univariate predictors of 30-day MACE included lesion length, vessel angulation, plaque burden, SVG degeneracy score, number of laser pulses used, and larger-sized laser catheters. CONCLUSIONS: This study demonstrated that Excimer laser atherectomy of diseased SVGs is feasible with results comparable to the 30-day MACE in the control population from the SAFER trial. Whether the addition of laser to embolic protection devices is of any clinical utility remains to be tested in future studies.

Acute renal artery occlusion: making the case for renal artery revascularization.

Atherosclerotic renal artery disease is a common disease entity that may be identified in patients with difficult-to-control hypertension and/or chronic kidney disease but is probably underdiagnosed. Current evidence from both observational and randomized studies offers mixed results regarding the support for renal artery revascularization. There is lack of equipoise with regard to the efficacy of renal artery revascularization among the interventional and renal communities, as well as disagreements on the appropriate endpoints to measure in clinical trials, which have led to selection bias confounding the scant available data. We report a patient who does not fit any clinical trial inclusion criteria with acute on chronic kidney injury and new-onset heart failure whose symptoms and renal function improved significantly after renal artery intervention.

Postoperative atrial fibrillation is not associated with an increase risk of stroke or the type and number of grafts: a single-center retrospective analysis.

BACKGROUND: Atrial fibrillation (AF) and atrial flutter are the 2 most common types of dysrhythmia in patients undergoing coronary artery bypass graft (CABG) surgery and are associated with increased morbidity and mortality. We sought to explore the association between the type and quantity of bypass grafts and cardiovascular outcomes in patients with postoperative AF (POAF). HYPOTHESIS: The type and quantity of bypass grafts is associated with POAF. METHODS: We queried the Society of Thoracic Surgery National Database for CABG operations, both with and without valve procedures, performed at Baystate Medical Center between January 2002 and July 2007. We used multivariable logistic regression modeling to identify predictors of POAF and to explore the impact of AF on major adverse cardiac outcomes in this post-CABG population. RESULTS: A total of 3068 patients received CABG surgery, 187 (6.1%) of whom received concurrent valve replacement or repair. The incidence of POAF was 38.3%. POAF was significantly associated with readmission within 30 days (P < 0.009), increased length of stay (P << 0.0001), and a strong trend toward increased 30 day mortality (P = 0.058). There was no association between POAF and postoperative stroke (P = 0.92), graft type (P = nonsignificant) or number of grafts (P = nonsignificant). CONCLUSIONS: Patients with POAF experienced increased morbidity and mortality as demonstrated by previous studies. Neither the number of grafts nor type of grafts was associated with POAF. Furthermore, the rate of stroke was not associated with POAF.

Influence of low-dose aspirin (81 mg) on the incidence of definite stent thrombosis in patients receiving bare-metal and drug-eluting stents.

BACKGROUND: Dual antiplatelet therapy with aspirin plus clopidogrel is the mainstay of therapy in patients undergoing percutaneous coronary intervention (PCI). However, the optimal dose of aspirin following PCI has not been established. HYPOTHESIS: There is no difference for definite stent thrombosis in patients taking low dose versus standard aspirin. METHODS: Low-dose (81 mg) aspirin was used as part of a standard dual antiplatelet therapy in patients receiving bare-metal stents (BMS) or drug-eluting stents (DES) at a large tertiary medical center. We retrospectively analyzed 5368 consecutive cases treated with stent placement and dual antiplatelet therapy. The incidence of definite stent thrombosis (DST) at our institution was compared to DST as reported in a large, published cohort of 24 trials and 12973 patients. We stratified DST events into early (<30 days) and late (>30 days) timing and also stratified by stent type. The effect of aspirin dosing was evaluated using χ(2) , Cochran-Mantel-Haenszel, and homogeneity testing. RESULTS: A total of 5187 patients underwent 7604 stent implantations during the study period. The cumulative incidence of DST was 0.60% (95% confidence interval [CI], 0.42%-0.84%) at 30 days and 0.76% (95% CI, 0.56%-1.03%) at 1 year. The overall incidence of DST during the study period was not different based on type of stent (0.53% for DES and 0.75% for BMS, P = 0.36). Compared to the historic, standard-dose aspirin (162-325 mg) cohort, DST in our low-dose aspirin (81 mg) cohort was not significantly different at either 30 days (0.72% vs 0.60%, P = 0.39) or at 1 year (1.08% vs 0.76%, P = 0.07). There was no appreciable interaction of aspirin dose on the incidence of DST, controlling for stent type, or timing of the event. CONCLUSIONS: Low-dose aspirin therapy in combination with clopidogrel following implantation of either BMS or DES in our cohort does not appear to increase the risk of DST compared to a higher-dose aspirin regimen.

Spontaneous left anterior descending coronary artery dissection in a patient with neurofibromatosis.

Neurofibromatosis (NF) is a genetic disorder inherited in an autosomal dominant pattern. Subtypes I and II are the most well recognized, and among these, Type I has associated vasculopathy. Less than 3% of patients have vascular involvement, with the renal artery as the most commonly involved vessel. Dissection and rupture of aneurysms in larger arteries such as the subclavian and the aorta have been previously reported. This is the first reported case of a spontaneous coronary artery dissection in a patient with NF-I. Imperative in the percutaneous treatment of coronary artery dissections is early recognition and proactive decision making. Recognition of a possible association between NF and coronary dissections will further facilitate successful and prompt management of this otherwise rare entity.

Bivalirudin use during PCI for stent thrombosis in a patient with subacute intracranial hemorrhage.

Caring for patients at high risk is inherent to the practice of interventional cardiology. Recognizing high-risk situations, minimizing risk and employing preventive techniques proactively to avoid complications cannot be over-emphasized within this dynamic field. This case demonstrates real-world concerns and decision-making regarding severe bleeding risk, rescue angioplasty, stent thrombosis, appropriate usage of intravascular ultrasound and differences in stent design. Three take-home messages are identified to reduce complications in similar situations.

Takayasu arteritis in a young woman: a 4-year case history.

Takayasu arteritis is a chronic, progressive, autoimmune, idiopathic, large-vessel vasculitis that usually affects young adults. The disease has been reported to occur in all races and ethnicities. The diffuse nature of this vasculitis can affect multiple-organ systems to varying degrees. Herein, we report the case of a young woman whose exertional angina and claudication were the initial presentation of active Takayasu arteritis. During more than 4 years of ongoing treatment, therapy, and follow-up, she has displayed differing disease symptoms of varying intensity. We discuss the challenges of managing Takayasu arteritis in our patient and describe different treatments for this rare vasculitic disorder.

Recombinant nematode anticoagulant protein c2 in non-ST segment elevation acute coronary syndrome and beyond.

Patients with acute coronary syndromes (ACS) have high recurrent ischemic event rates despite management with current guideline-based therapies. Recombinant nematode anticoagulant protein (rNAP)c2 provides factor Xa-dependent inhibition of the tissue factor/factor VIIa complex acting proximally on the clotting cascade. It may be administered either intravenously or subcutaneously and has an elimination half-life of approximately 50-60 h. rNAPc2 reduces thrombin formation in patients undergoing elective percutaneous coronary interventions (PCI) and in patients with non-ST segment elevation ACS managed with an early invasive strategy, while bleeding rates are comparable with currently used anticoagulants. Patients receiving rNAPc2 undergoing emergent coronary artery bypass surgery within 96 h of dosing have increased rates of major bleeding. Some heparin coadministration may be necessary to avoid PCI-related thrombotic complications. Large-scale trials are needed to confirm these findings and to evaluate the impact of rNAPc2 on clinical events.