Effect of sevoflurane on serum CK-MB levels after percutaneous coronary stent placement: A prospective randomized clinical trial.

OBJECTIVES: Markers of myocardial injury, such as creatine kinase-myocardial band (CK-MB) mass, are elevated in up to 30% of patients undergoing percutaneous coronary intervention (PCI) with stent deployment. This elevation represents myocardial injury that can impact the patient in the long term, including the risk of death. Sevoflurane, an inhaled anesthetic, may have cardioprotective properties that benefit patients undergoing PCI. The primary objective was to compare serum CK-MB mass raise in patients who received sevoflurane to those who received a placebo prior to PCI. METHODS: We enrolled patients with coronary artery disease who were eligible for PCI in a randomized (1:1), double-blind, placebo-controlled trial; patients having experienced acute myocardial infarction within 72 hours and those with saphenous vein graft stenting were excluded. Patients (n = 1254) were randomized to receive sevoflurane (2% inspired fraction) or placebo (oxygen alone) for 30 minutes prior to PCI. Additionally, we compared substantial elevations in CK-MB mass (defined as >5x the upper limit of normal), length of stay in the intensive care unit and in-hospital, and 1-year mortality. RESULTS: Sevoflurane was unable to promote cardioprotection, as determined by CK-MB mass levels (sevoflurane group: 2.52 ± 9.64; control group: 1.84 ± 8.58; P=.32). No effect was noticed on the reduction among patients who (AQ: with?) increase (AQ: increased?) marker levels (prevalence of increase in CK-MB mass greater than the upper limit of normality was 30.8% in the sevoflurane group and 28.9% in the control group; P=.33; 4.6% vs 3.1%, respectively, for increases 5x above the upper limit of normality [P=.21]). CONCLUSIONS: Sevoflurane failed to reduce myocardial injury after PCI. Therefore, its usage should not be routinely recommended.

Efficacy of Patient Selection for Diagnostic Coronary Angiography in Suspected Coronary Artery Disease.

BACKGROUND: Guidelines recommend that in suspected stable coronary artery disease (CAD), a clinical (non-invasive) evaluation should be performed before coronary angiography. OBJECTIVE: We assessed the efficacy of patient selection for coronary angiography in suspected stable CAD. METHODS: We prospectively selected consecutive patients without known CAD, referred to a high-volume tertiary center. Demographic characteristics, risk factors, symptoms and non-invasive test results were correlated to the presence of obstructive CAD. We estimated the CAD probability based on available clinical data and the incremental diagnostic value of previous non-invasive tests. RESULTS: A total of 830 patients were included; median age was 61 years, 49.3% were males, 81% had hypertension and 35.5% were diabetics. Non-invasive tests were performed in 64.8% of the patients. At coronary angiography, 23.8% of the patients had obstructive CAD. The independent predictors for obstructive CAD were: male gender (odds ratio [OR], 3.95; confidence interval [CI] 95%, 2.70 - 5.77), age (OR for 5 years increment, 1.15; CI 95%, 1.06 - 1.26), diabetes (OR, 2.01; CI 95%, 1.40 - 2.90), dyslipidemia (OR, 2.02; CI 95%, 1.32 - 3.07), typical angina (OR, 2.92; CI 95%, 1.77 - 4.83) and previous non-invasive test (OR 1.54; CI 95% 1.05 - 2.27). CONCLUSIONS: In this study, less than a quarter of the patients referred for coronary angiography with suspected CAD had the diagnosis confirmed. A better clinical and non-invasive assessment is necessary, to improve the efficacy of patient selection for coronary angiography.

Efficacy of Patient Selection for Diagnostic Coronary Angiography in Suspected Coronary Artery Disease / Eficácia da Seleção de Pacientes para Cateterismo Coronário por Suspeita de Doença Arterial Coronariana

AbstractBackground:Guidelines recommend that in suspected stable coronary artery disease (CAD), a clinical (non-invasive) evaluation should be performed before coronary angiography.Objective:We assessed the efficacy of patient selection for coronary angiography in suspected stable CAD.Methods:We prospectively selected consecutive patients without known CAD, referred to a high-volume tertiary center. Demographic characteristics, risk factors, symptoms and non-invasive test results were correlated to the presence of obstructive CAD. We estimated the CAD probability based on available clinical data and the incremental diagnostic value of previous non-invasive tests.Results:A total of 830 patients were included; median age was 61 years, 49.3% were males, 81% had hypertension and 35.5% were diabetics. Non-invasive tests were performed in 64.8% of the patients. At coronary angiography, 23.8% of the patients had obstructive CAD. The independent predictors for obstructive CAD were: male gender (odds ratio [OR], 3.95; confidence interval [CI] 95%, 2.70 - 5.77), age (OR for 5 years increment, 1.15; CI 95%, 1.06 - 1.26), diabetes (OR, 2.01; CI 95%, 1.40 - 2.90), dyslipidemia (OR, 2.02; CI 95%, 1.32 - 3.07), typical angina (OR, 2.92; CI 95%, 1.77 - 4.83) and previous non-invasive test (OR 1.54; CI 95% 1.05 - 2.27).Conclusions:In this study, less than a quarter of the patients referred for coronary angiography with suspected CAD had the diagnosis confirmed. A better clinical and non-invasive assessment is necessary, to improve the efficacy of patient selection for coronary angiography.

ResumoFundamento:Diretrizes recomendam que na suspeita de doença arterial coronariana (DAC) estável, uma avaliação clínica (não-invasiva) deve ser realizada antes da realização da coronariografia.Objetivo:Avaliar a eficácia da seleção de pacientes à coronariografia invasiva na suspeita de DAC estável.Métodos:Prospectivamente, selecionamos pacientes sem diagnóstico prévio de DAC referenciados a um centro terciário de grande volume. Características demográficas, fatores de risco, sintomatologia e resultados de exames não-invasivos foram correlacionados com a presença de DAC obstrutiva. Estimamos a probabilidade de DAC com base nos dados clínicos disponíveis e no valor incremental diagnóstico dos exames não-invasivos.Resultados:Um total de 830 pacientes foi incluído, mediana de idade de 61 anos, 49,3% homens, 81% hipertensos e 35,5% de diabéticos. Exames não-invasivos foram realizados em 64,8% dos pacientes. Na coronariografia, 23,8% dos pacientes tinham DAC obstrutiva. Os preditores independentes para DAC obstrutiva foram: sexo masculino (odds ratio [OR], 3,95; intervalo de confiança [IC] de 95%, 2,70 – 5,77), idade (OR por incremento de 5 anos, 1,15; IC 95%, 1,06 – 1,26), diabetes (OR, 2,01; IC 95%, 1,40 – 2,90), dislipidemia (OR, 2,02; IC 95%, 1,32 – 3,07), angina típica (OR, 2,92; IC 95%, 1,77 – 4,83) e teste não-invasivo prévio (OR 1,54; IC 95% 1,05 – 2,27).Conclusão:Nesse estudo, menos de um quarto dos pacientes referenciados a um centro terciário para a realização de coronariografia por suspeita de DAC estável teve o diagnóstico confirmado. Uma melhor avaliação clínica e maior acesso a exames não-invasivos são necessários para aumentar a eficácia da seleção de pacientes para coronariografia invasiva.

Late outcome of sirolimus-eluting stents: comparison of multidetector computed tomography with quantitative coronary angiography and intravascular ultrasound

Objective: To assess the performance of multidetector computed tomography in determining late clinical outcomes of patients undergoing sirolimus-eluting stent implantation.Methods: Thirty patients, successfully submitted to sirolimus-eluting stent implantation for more than six months, were

selected to participate in the study. All underwent invasive angiography and intravascular ultrasound following CT angiography

using iodinated contrast medium at a dose of 1.5 ml/kg.Results: Mean proximal reference diameter was 3.01 ± 0.31 mm by tomography and 3.14 ± 0.31 mm by angiography (p

= 0.04). When the left circumflex artery was excluded from the analysis, the difference between both examinations was

no longer significant (tomography = 3.01 ± 0.32 mm; angiography = 3.10 ± 0.30 mm, p = 0.65). Mean distal reference

diameter was 2.86 ± 0.30 mm by tomography and 2.92 ± 0.32 by angiography (p = 0.25). Mean in-stent minimal lumen

diameter was 2.85 ± 0.25 mm by tomography and 2.85 ± 0.29 mm by angiography (p = 0.27). Mean minimal in-stent crosssectional

area was 7.19 ± 1.47 mm2 by tomography and 6.90 ± 1.52 mm2 by intravascular ultrasound (p = 0.36), but there

was only a weak correlation between these measurements (r = 0.33).Conclusion: Computed tomography allows the qualitative assessment of sirolimus-eluting stents, accurate estimate of proximal

and distal reference diameters of the target vessel, and in-stent minimal lumen diameter. Its correlation with measurements

performed using intravascular ultrasound, however, is less strong.

Nonrandomized registries for de novo lesions (FIM) and in-stent restenosis

Takind advantage of the knowledge accumulated over decades of unsuccessful attempts to prevent restenosis, novel devices for local drug-eluting stents, have been developed in the recent years. Sirolimus eluting Bx Velocity stents is certainly one of these novel technologies that may finnally represent the "magic bullet" we have been searching for in our war against the restenosis. The first clinical evaluation of this new technology was initiated in December 1999. This endeavor was conducted at Institute Dante Pazzanese of Cardiology in São Paulo, Braziland at Thoraxcenter, Rotterdam, The Netherlands. The unparalleled 1-year out-come of this first series of patients treated with sirulimus-eluting stents (SES) paved the way to launch a more challenging pilot study involving only patients with in-stent restenosis, which was started in 2000...