Low plasma vitamin D levels and muscle-related adverse effects in statin users.

BACKGROUND: Treatment with HMG-CoA reductase inhibitors (statins) is often complicated by muscle-related adverse effects (MAEs). Studies of the association between low plasma vitamin D levels and MAEs have yielded conflicting results. OBJECTIVES: To determine if low plasma vitamin D level is a risk factorfor MAEs in statin users. METHODS: Plasma levels of 25(OH) vitamin D were measured as part of the routine evaluation of unselected statin-treated patients attending the coronary and lipid clinics at our hospital during the period 2007-2010. Medical data on muscle complaints and statin use were retrieved from the medical files. Creatine kinase (CK) levels were derived from the hospital laboratory database. RESULTS: The sample included 272 patients (141 men) aged 33-89 years. Mean vitamin D level was 48.04 nmol/L. Levels were higher in men (51.0 +/- 20.5 versus 44.7 +/- 18.9 nmol/L, P = 0.001) and were unaffected by age. MAEs were observed in 106 patients (39%): myalgia in 95 (35%) and CK elevation in 20 (7%); 9 patients (3%) had both. There was no difference in plasma vitamin D levels between patients with and without myalgia (46.3 +/- 17.7 versus 48.9 +/- 21.0 nmol/L, P = 0.31), with and without CK elevation (50.2 +/- 14.6 versus 47.8 +/- 20.3 nmol/L, P = 0.60), or with or without any MAE (50.4 +/- 15.0 versus 47.8 +/- 10.2 nmol/L, P = 0.27). These findings were consistent when analyzed by patient gender and presence/absence of coronary artery disease, and when using a lower vitamin D cutoff (< 25 nmol/L). CONCLUSIONS: There is apparently no relationship between plasma vitamin D level and risk of MAEs in statin users.

Primary PCI: should we stent every single culprit artery?

In four selected patients presenting with ST-segment elevation myocardial infarction (STEMI), aspiration thrombectomy allowed for full filling defect angiographic 'cleaning' of the culprit arteries without need for stent implantation. Obtaining good angiographic results and uneventful early and long-term clinical outcome after thrombus aspiration alone raises the question as to whether stenting the infracted thrombotic artery is mandatory and routinely indicated in every single STEMI patient treated with primary percutaneous coronary intervention.

Incidence, predictors, and outcomes of failed primary percutaneous coronary intervention: a 10-year contemporary experience.

BACKGROUND: Limited contemporary data exist regarding the incidence, predictors, and outcomes of failure of primary percutaneous coronary intervention (PCI) in the treatment of ST-segment elevation myocardial infarction (STEMI). MATERIALS AND METHODS: In this registry-based retrospective cohort study, all consecutive unselected patients (n=1725) who were hospitalized for STEMI and underwent primary PCI from January 2001 to December 2010 were included. PCI failure was defined as a final diameter stenosis greater than 30% or postdilatation Thrombolysis in Myocardial Infarction (TIMI) flow grade of 2 or less. We examined the predictors and survival among patients who failed primary PCI. RESULTS: The overall PCI failure rate was 5.4% (94 of 1725 procedures). After adjusting for prespecified baseline characteristics, independent predictors of PCI failure included age greater than 65 years (P=0.02), procedure date between 2001 and 2005 (P=0.05), night-time PCI (P=0.008), calcific lesion (P=0.008), and lower preprocedural TIMI flow grade (P=0.006). Failed PCI was associated with a 1-year mortality rate of 22% as compared with 4.2% in the successful PCI group (P<0.001). Conservative medical management was preferred in the majority of patients with failed PCI (n=78, 83%). Patients who underwent emergent surgery (n=11), conservative management (n=78), and redo PCI (n=5) experienced 30-day mortality rates of 27, 16, and 0%, respectively. CONCLUSION: Primary PCI failure in the setting of STEMI is not rare. It is associated with high-risk patient-related and angiographic-related characteristics. Primary PCI failure is associated with early and late mortality.

Fractional flow reserve application in everyday practice: adherence to clinical recommendations.

Fractional flow reserve (FFR) is considered the gold standard for invasive assessment of functional, significant coronary stenosis. Nevertheless, its application and outcome in daily practice is rarely reported. We investigated whether decisions in clinical practice adhered to FFR-generated recommendations and whether FFR influenced cardiovascular outcomes. This retrospective, observational, cohort study included 189 patients that underwent FFR measurements during coronary angiography at our institution The median follow up was 27 months (range, 7-112 months). Clinical outcomes (up to 2 years) included all-cause mortality, cardiac-mortality, and major adverse cardiac events (MACE) which comprised cardiac mortality, non-fatal MI, target vessel revascularization, and coronary artery bypass graft (CABG). Patients most frequently presented with unstable angina (74.6%). Only 55 patients (29.1%) exhibited significant functional stenosis (FFR ≤0.8). Nevertheless, 68 patients (36%) underwent immediate coronary interventions; 64% were deferred from revascularization procedures and managed conservatively with optimal medical treatment. Thirty-five patients (18.5%) were treated in discordance with FFR results, but the overall MACE rate was similar to that of patients treated in concordance with FFR results (8.3% vs. 8.6%, P=0.41). In conclusion, in our everyday practice, the operator's decision was in discordance to the FFR measurements and indications in nearly 20% of cases. In these selected cases, the operator's subjective judgment may continue to play an important role.

Retroperitoneal bleeding after cardiac catheterization: a 7-year descriptive single-center experience.

BACKGROUND: Retroperitoneal bleeding (RPB) is an unusual but potentially fatal vascular complication occurring after cardiac catheterization (CC). Contemporary data of RPB in the era of dual antiplatelet therapy and vascular closure devices are lacking. METHODS: We retrospectively examined all RPB cases that occurred after CC in the Rabin Medical Center between the years 2005 and 2011. RESULTS: Of 26,487 patients who underwent CC, a total of 48 patients (mean age 60.9 ± 13.8 years, 52.1% female) with RPB were identified (0.18%). The indication for CC was acute coronary syndrome (43.7%), myocardial infarction (35.4%), stable angina pectoris (8.3%), hemodynamic studies for valvular heart disease (10.4%) and others (2.1%). Coronary intervention was performed in 34 patients (70.9%) and a vascular closure device (VCD) was used in 16 patients (33.3%). Seventy-seven percent of patients were treated with clopidogrel, 20.8% with glycoprotein IIb-IIIa inhibitors and 85.4% with anticoagulation during CC. Median time to diagnosis of bleeding was 9.0 h, while the median time to bleeding differed between patients with and without a VCD (12 vs. 5 h, respectively). The clinical presentation of RPB was hemorrhagic shock in 39.6% of patients and 50.0% required at least one blood transfusion. Patients were managed either with conservative treatment (79.2%), angiography stenting (14.6%) or vascular surgery (6.2%). A total of 3 patients died during hospitalization, of which RPB was the etiology in 2 (4.2%). CONCLUSIONS: RPB which is a rare complication of CC is associated with younger age and female gender, as compared to patients without RPB. Onset of bleeding can be delayed in patients with VCDs. With careful and early diagnosis, most patients with RPB after CC can be managed conservatively.

Intracoronary monocyte chemoattractant protein 1 and vascular endothelial growth factor levels are associated with necrotic core, calcium and fibrous tissue atherosclerotic plaque components: an intracoronary ultrasound radiofrequency study.

AIMS: To investigate the relationship between various serum biomarkers and coronary atherosclerotic plaque composition obtained by intravascular ultrasound virtual histology (IVUS-VH). METHODS: Using ELISA, we measured the serum levels of CD40 ligand, C-reactive protein, monocyte chemoattractant protein 1 (MCP-1), metalloproteinase 9, P-selectin and vascular endothelial growth factor (VEGF) in 40 patients with manifested coronary artery disease. RESULTS: Correlation analysis between biomarkers levels, IVUS grayscale parameters and VH-defined necrotic core (NC), calcium, fibrous and fibrofatty components was performed. MCP-1 and VEGF levels correlated with the severity of area stenosis (r = 0.35, p = 0.03 and r = 0.38, p = 0.017, respectively) and inversely correlated with the remodeling index (r = -0.35, p = 0.03 and r = 0.35, p = 0.02, respectively). Higher levels of MCP-1 were associated with increased calcium (r = 0.47, p = 0.004), NC (r = 0.38, p = 0.02) and less fibrous tissue components (r = -0.34, p = 0.03), whereas VEGF had an inverse correlation with both calcium components (r = -0.37, p = 0.02) and NC (r = -0.34, p = 0.036) but was strongly associated with increased fibrous components (r = 0.47, p = 0.003). No significant correlation was noted for any of the other biomarkers. CONCLUSIONS: MCP-1 and VEGF serum levels in patients with ischemic heart disease are correlated with coronary artery plaque burden and composition.

Outcome of patients presenting with ST elevation myocardial infarct and cardiogenic shock: a contemporary single center's experience.

OBJECTIVES: Acute ST elevation myocardial infarction (STEMI) presenting with cardiogenic shock (CS) is associated with dismal prognosis. In the last years, significant advances have been made in reperfusion techniques and pharmacological treatment. Therefore, we aimed to assess the outcome of these patients during the past decade and identify major factors that impact their prognosis. METHODS: We identified 170 patients who presented with STEMI, CS, and underwent primary percutaneous coronary intervention (PCI) between 2001 and 2011. Patients were allocated into two groups based on period of presentation: 2001-2005 (n = 70) and 2006-2011 (n = 100). Clinical outcomes up to 6 months were evaluated. RESULTS: Patients in the latter period were younger, and had lower rates of renal failure and higher rates of stent use. Despite these differences, mortality did not differ and remained high in both periods (52-59% at 6 months). Time frames from onset of symptoms to arrival to the emergency department and to performance of coronary intervention were similar in both periods. Intra-aortic balloon pump use was similar in both periods. In multivariate analysis, factors associated with 1-month mortality were: diabetes (OR = 3.6, 1.4-9.4, p = 0.007), LVEF <40% (OR = 1.8, 1.3-2.6, p = 0.001), GFR <60 ml/min/m(2) (OR = 1.8, 1.3-2.4, p < 0.009) and glycoprotein IIb/IIIa inhibitor use (OR = 0.5, 0.2-1.1, p = 0.08). The combination of diabetes and renal failure was associated with particularly high mortality. CONCLUSIONS: Prognosis of patients presenting with STEMI, CS, and treated with primary PCI during the past decade, remains poor. Better risk-stratification may help improve their grave outcome.

The impact of intracoronary thrombus aspiration on STEMI outcomes.

BACKGROUND: Manual coronary thrombus aspiration was associated with improved outcomes of ST-elevation myocardial infarction (STEMI) patients. We aimed to evaluate the outcome of aspiration in a "real-world" setting of primary percutaneous coronary intervention (PPCI). METHODS AND MATERIALS: We analyzed the outcome of STEMI patients who underwent PPCI (initial Thrombolysis in Myocardial Infarction flow grade 0/1), comparing patients who underwent aspiration (ASP) to those who had standard (STD) therapy. Various subgroups outcomes were further analyzed. Clinical end points included mortality and major adverse cardiovascular events (MACE) at 30 days and at 1 year. RESULTS: One thousand thirty-five consecutive patients were included: 189 (18.26%) with ASP and 846 (81.74%) with STD. ASP patients were younger (58±12 vs. 61±13, P<.05) and had higher incidence of direct stenting compared to STD patients (34% vs. 16.7%, P<.05). No significant differences were noted in the outcome of ASP vs. STD at 30 days (mortality rate 4.2% vs. 4.5%, P=.9; MACE 6.9% vs. 9.8%, P=.2) and at 1 year (mortality rate 8.0% vs. 8.3%, P=.9; MACE 20.0% vs. 22.3%, P=.5). A significant advantage in favor of ASP was evident in patients with proximal culprit lesions, anterior infarcts, and right ventricular involvement. CONCLUSIONS: Although this was largely a negative study, when STEMI involved a large jeopardized myocardium, aspiration was associated with sustained improved clinical outcomes.

Comparison of late (3-year) registry data outcomes using bare metal versus drug-eluting stents for treating ST-segment elevation acute myocardial infarctions.

Clinical trial data have supported the safety and efficacy of drug-eluting stents (DES) in the treatment of patients with ST-segment elevation myocardial infarctions (STEMIs), but contemporary "real-world" registry data regarding the late safety profiles of DES are limited. This prospective registry-based study included 1,569 consecutive unselected patients with STEMIs who underwent emergency primary percutaneous coronary intervention from January 2001 to December 2009. Of the study cohort, 200 patients (12.7%) received DES, while 1,369 patients (87.3%) underwent bare-metal stent (BMS) placement. The primary end points of the study were all-cause mortality and target vessel revascularization at 1, 2, and 3 years. Survival status was assessed by municipal civil registries. Repeat revascularization procedures were prospectively collected in the hospital database. All-cause mortality was significantly lower in the DES group at 3 years (4.2% vs 13.5%, p = 0.007) compared to BMS-treated patients, but DES use was not an independent predictor of all-cause mortality (adjusted odds ratio 0.5, 95% confidence interval 0.2 to 1.2, p = 0.10). Target vessel revascularization was significantly lower in the DES group compared to the BMS group at 3 years (10.5% vs 21%, p = 0.001). DES use was an independent predictor of reduced target vessel revascularization (adjusted odds ratio 0.44, 95% confidence interval 0.25 to 0.77, p = 0.004). Late definite stent thrombosis occurring after 1 year occurred in 4 (2.5%) patients in the DES group compared to 6 (0.7%) in the BMS group (p = 0.05). DES use was an independent predictor of late stent thrombosis (adjusted odds ratio 8.6, 95% confidence interval 1.9 to 38, p = 0.004). In conclusion, this contemporary registry-based study of patients who underwent primary percutaneous coronary intervention for STEMI demonstrated improved revascularization rates without increased 3-year hazard of adverse clinical outcomes in DES-treated patients.

Drug eluting stenting in bifurcation coronary lesions long-term results applying a systematic treatment strategy.

OBJECTIVES: To explore the long-term results following implantation of drug-eluting stents (DES) in bifurcation lesions according to contemporary "real world" practice. BACKGROUND: Limited information is available on the long-term outcomes of patients with bifurcation lesions who are treated using DES. A systematic approach for bifurcation lesion management was applied, using either a "provisional" single stent technique or a dedicated two stents strategy according to the side-branch diameter and severity of its ostial stenosis. METHODS: Four hundred one consecutive patients underwent bifurcation percutaneous coronary intervention (PCI) using DES and were included in our prospective registry. All adverse events were recorded up to 2 years and distinguished according to the planned PCI strategy (e.g., one versus two stents technique). RESULTS: A planned two stents strategy was used in 141 patients (35% of patients). In 260 patients (65%), the planned treatment involved stenting of the main branch only with "provisional" stenting of the side-branch according to procedural course. Thus, 24 patients (9.2%) needed additional stenting at the side-branch to complete the PCI. Cumulative major adverse cardiac event rate at 1 and 2 years was similar for both groups (11.4% vs. 14.8% at 1 year and 19.4% vs. 25.7% at 2 years for the single vs. two stents groups, accordingly, P = NS for both). Likewise, there was no difference in mortality, cardiac mortality, myocardial infarction, need for target lesions or target vessel revascularization, or definite stent thrombosis rate between the two groups at 6, 12, and 2 years follow-up. The rate of angiographically confirmed (i.e., definite) stent thrombosis did not differ between the two groups during follow-up. CONCLUSIONS: Our study revealed favorable long-term clinical results following DES implantation using a systematic, rather simplified approach towards bifurcation stenting and using either a single or double stenting technique.

Necrotic core and thin cap fibrous atheroma distribution in native coronary artery lesion-containing segments: a virtual histology intravascular ultrasound study.

OBJECTIVES: The aim of this study was to assess the longitudinal topographical relationships between minimal luminal area (MLA) sites and plaques with the most vulnerable characteristics using radiofrequency-based virtual histology intravascular ultrasound analysis. METHODS: We analyzed 69 native coronary artery segments with de-novo lesions (>50% stenosis) obtained from 50 patients with ischemic coronary artery disease. Maximal necrotic core (maxNC) was defined as a virtual histology intravascular ultrasound frame with the maxNC area and virtual histology-characterized thin cap fibrous atheroma was defined as a cross-section, which contained a plaque burden of more than 40%, relative necrotic core area of 10% or more, and a narrow band encircling the lumen containing relative necrotic core area of more than 10%, in three consecutive frames. RESULTS: MaxNC was present at the MLA site in only 17.4% of the segments, proximal in 52.2% (by 5.0 ± 5.4 mm), and distal to MLA in 30.4% (by 4.0 ± 5.1 mm). Non-MLA sites with maxNC (n=57) compared with MLA sites had reduced plaque burden (64.5 ± 11.2% vs. 76.0 ± 10.5%, P<0.001), increased remodeling index (1.04 ± 0.17 vs. 0.89 ± 0.15, P<0.001), less fibrotic tissue (47.7 ± 13.4% vs. 54.8 ± 13.8%, P<0.001), and higher dense calcium deposition (15.3 ± 10.8% vs. 11.9 ± 10.3%, P<0.001). Plaques containing maxNC and virtual histology-characterized thin cap fibrous atheroma were found in 23 of the non-MLA sites compared with two of the MLA sites (P<0.0001). CONCLUSIONS: In coronary artery segments with intermediate-to-severe stenosis, plaques containing maxNC are mostly located away from the MLA site and more often comprise virtual histology-characterized thin cap fibrous atheroma. Such data may carry practical implications for coronary revascularization procedures.

Characterization and clinical outcomes of drug-eluting in-stent restenosis.

BACKGROUND: The best therapeutic alternative for patients suffering from in-stent restenosis after drug-eluting stent implantation remains to be elucidated. OBJECTIVE: To characterize the pattern, treatment and outcomes of DES-related in-stent restenosis in patients treated at our institution. METHODS: We determined the incidence and major adverse clinical events in 71 consecutive patients with DES failure among 2473 patients who were treated with 2548 drug-eluting stents between 2004 and 2007. We analyzed the clinical data, procedural parameters and clinical outcomes. RESULTS: The type and number of stents implanted were as follows: Cypher (n = 1808), Endeavor (421) and Taxus (319); of these, 53 (2.9%), 10 (2.4%), and 8 (2.5%) patients respectively presented with restenosis. The mean time to restenosis was 11.3 +/- 9.9 months. Patients' mean age was 65 +/- 11 years; 75% were male, and 68% had diabetes mellitus. Unstable angina was the clinical presentation in 52 (73%). At 6 months, 3 patients had developed myocardial infarction (4.2%), repeat restenosis at follow-up was diagnosed in 8 patients (11.3%), the overall major adverse clinical events rate was 18.3% (13 patients), and 2 patients died (2.8%). CONCLUSIONS: Drug-eluting stent-related restenosis is relatively infrequent but remains a clinical challenge. It occurs more frequently in complex lesion subsets, but the overall intermediate-term prognosis is tolerable.

A comparative analysis of major clinical outcomes using drug-eluting stents versus bare-metal stents in a large consecutive patient cohort.

OBJECTIVES: To ascertain the long-term safety, efficacy, and pattern of use of drug-eluting stents (DES) in routine clinical practice. METHODS: We analyzed a registry of 6,583 consecutive patients undergoing percutaneous coronary intervention (PCI), of whom 2,633 were treated using DES (DES group) and 3,950 were treated using bare-metal stents (BMS group). Propensity score was used for stratified analysis of outcomes and for matching. Outcomes were total mortality, myocardial infarction (MI), repeat target vessel revascularization (TVR) rates, and risk-adjusted event-free survival. RESULTS: Follow-up time was 6 months to 5.18 years (mean: 3 years). Patients in the DES group were more likely to be diabetic and had use of longer or more stents, treatment of more lesions and of more proximal main vessels. After propensity score matching, the cumulative mortality was 12.85% in the DES group versus 14.14% in the BMS group (P = 0.001). Use of DES reduced the occurrence of MI (5.17% vs.5.83%, P = 0.046), of clinically driven TVR (9.76% vs. 12.28%, P < 0.001) and of the composite endpoint of death/MI/TVR (23.38% vs. 26.07%; P < 0.001). CONCLUSIONS: Our risk-adjusted event-free survival analysis indicates a prognostic benefit for DES utilization that sustains up to 5 years following PCI.

Impact of myocardial blush on left ventricular remodeling after first anterior myocardial infarction treated successfully with primary coronary intervention.

BACKGROUND: Myocardial blush grade is a useful marker of microvascular reperfusion that may influence left ventricular dilation. OBJECTIVES: To assess the impact of MB grade on LV remodeling in patients undergoing successful primary PCI for first anterior ST elevation myocardial infarction. METHODS: In 26 consecutive patients MB grade was evaluated immediately after primary PCI. Each patient underwent transthoracic echocardiography at 24 hours and 6 months after PCI for evaluation of LV volumes. LV remodeling was defined as an increase in end-diastolic volume by > or = 20%. RESULTS: The presence of myocardial reperfusion (MB 2-3) after primary PCI was associated with a significantly lower rate of remodeling than the absence of myocardial reperfusion (MB 0-1) (17.6% vs. 66.6%, P = 0.012). Accordingly, at 6 months, patients with MB 2-3 had significantly smaller LV end-diastolic volume (94 +/- 21.5 vs. 115.2 +/- 26 ml) compared with patients with MB 0-1. In univariate analysis, only MB (0-1 versus 2-3) was associated with increased risk of LV remodeling (odds ratio 9.3, 95% confidence interval 1.45-60.21, P = 0.019). CONCLUSIONS: Impaired microvascular reperfusion, as assessed by MB 0-1, may be associated with LV remodeling in patients with STEMI treated successfully with primary PCI.

Treatment of aspirin-resistant patients with omega-3 fatty acids versus aspirin dose escalation.

OBJECTIVES: The aim of this study was to evaluate whether addition of omega-3 fatty acids or increase in aspirin dose improves response to low-dose aspirin among patients who are aspirin resistant. BACKGROUND: Low response to aspirin has been associated with adverse cardiovascular events. However, there is no established therapeutic approach to overcome aspirin resistance. Omega-3 fatty acids decrease the availability of platelet arachidonic acid (AA) and indirectly thromboxane A2 formation. METHODS: Patients (n = 485) with stable coronary artery disease taking low-dose aspirin (75 to 162 mg) for at least 1 week were screened for aspirin response with the VerifyNow Aspirin assay (Accumetrics, San Diego, California). Further testing was performed by platelet aggregation. Aspirin resistance was defined by > or =2 of 3 criteria: VerifyNow score > or =550, 0.5-mg/ml AA-induced aggregation > or =20%, and 10-micromol/l adenosine diphosphate (ADP)-induced aggregation > or =70%. Thirty patients (6.2%) were found to be aspirin resistant and randomized to receive either low-dose aspirin + omega-3 fatty acids (4 capsules daily) or aspirin 325 mg daily. After 30 days of treatment patients were re-tested. RESULTS: Both groups (n = 15 each) had similar clinical characteristics. After treatment significant reductions in AA- and ADP-induced aggregation and the VerifyNow score were observed in both groups. Plasma levels of thromboxane B2 were also reduced in both groups (56.8% reduction in the omega-3 fatty acids group, and 39.6% decrease in the aspirin group). Twelve patients (80%) who received omega-3 fatty acids and 11 patients (73%) who received aspirin 325 mg were no longer aspirin resistant after treatment. CONCLUSIONS: Treatment of aspirin-resistant patients by adding omega-3 fatty acids or increasing the aspirin dose seems to improve response to aspirin and effectively reduces platelet reactivity.

Pulse wave analysis during instructed breathing as an indicator of significant coronary artery disease.

AIMS: Previous studies indicated that fluctuations in photoplethysmograph (PPG) amplitude may predict coronary artery disease (CAD). The respiratory modulation response (RMR) is derived from spectral analysis of the PPG signal during instructed breathing. We sought to evaluate the RMR obtained from the fingertip as a predictor of significant CAD. METHODS AND RESULTS: RMR was calculated as the relative change in the respiratory modulation of the PPG, in response to breathing at 0.1Hz. RMR results of 97 consecutive patients (age 62+/-12 years, 77% male) were compared with their angiograms. Coronary lesions with diameter stenosis >50% that required revascularisation were classified significant. RMR was analysed after 20 sec. of spontaneous breathing, followed by 70 sec. of breathing at 0.1Hz. The test was repeated post procedure in 76 patients. RMR was lower in patients with significant CAD compared to those with non-significant (16.3+/-20.1; n=66 vs. 40.6+/-16.9; n=31, P<0.001). It improved after successful angioplasty (from 15.0+/-19.0 to 40.0+/-18.9; P<0.001) and did not change after diagnostic catheterisation. Using receiver operating characteristic analysis, we identified RMR<30% (sensitivity 79%, specificity 87%; positive predictive value 93%; negative predictive value 66%) to be the optimal cutoff for predicting significant CAD. CONCLUSIONS: The RMR is a novel, non-invasive parameter for the assessment of significant CAD.

Hematocrit level as a marker of outcome in ST-segment elevation myocardial infarction.

Anemia is a well-known predictor of a poor outcome in patients with ST-segment elevation myocardial infarction (STEMI). In contrast, data relating erythrocytosis to clinical outcomes in patients with STEMI are limited. Because erythrocytosis predisposes to a prothrombotic state, we hypothesized it would be associated with an increased risk of thrombotic complications in patients with STEMI undergoing primary percutaneous coronary intervention. We studied 1,042 consecutive patients with STEMI who underwent primary percutaneous coronary intervention and were a part of our primary percutaneous coronary intervention registry from 2001 to 2007. Patients with cardiogenic shock and late arrival were excluded. Patients were allocated into 3 groups according to their baseline hematocrit: anemia (<36% for women and <39% for men), normal, erythrocytosis (>46% for women and >47% for men). The clinical outcomes were assessed at 1, 6, and 12 months. The patients with anemia had the greatest clinical risk profile. Patients with erythrocytosis had a lower risk profile than the other 2 groups, except for greater rates of smoking. The mortality rates were greatest among the patients with anemia, followed by the patients with erythrocytosis, who in turn had greater short-term mortality than patients with normal hematocrit. Multivariate analysis, which included patients with erythrocytosis and those with normal hematocrit (excluding the patients with anemia), revealed that erythrocytosis was associated with an odds ratio of 4.3 (95% confidence interval 1.4 to 13, p = 0.01) for 1-month mortality. In conclusion, although not as strong a predictor of mortality as anemia, erythrocytosis might be associated with increased short-term mortality compared to a normal hematocrit. The measurement of hematocrit can be used as a useful prognostic marker in patients with STEMI.

The risk of cardiac complications following noncardiac surgery in patients with drug eluting stents implanted at least six months before surgery.

AIMS: Given the anecdotal reports and case series suggesting that drug-eluting coronary stents [DES] may be still vulnerable to coronary thrombosis after six months, we sought to assess this risk in patients undergoing non-cardiac surgery six months after stenting. METHODS AND RESULTS: Linking the Rabin Medical Centre interventional cardiology database with its non-cardiac surgical database, we identified 78 patients who underwent DES placement and subsequently [after six months] had noncardiac surgery [15-vascular, 37- abdominal and genitourinary and 26-others, excluding ophthalmic surgery]. Outcome measures included 30-day rate of postoperative myocardial infarction (MI), DES-related thrombosis, and cardiac mortality. Major adverse cardiac events [death and non-fatal MI] occurred in 6 (7.7%) patients including 2 cardiac deaths (2.6%), 4 (5.1%) non-fatal myocardial infarctions (MIs). Two patients (2.6%) sustained stent thrombosis [one patient had 'definite' and one 'probable' stent thrombosis]. All MIs [including stent thrombosis] occurred in the vascular and abdominal surgery group. Two of the MIs events occurred while the patients were on dual antiplatelet agents. IN CONCLUSIONS: Perioperative cardiac events during non cardiac surgery after six months of DES deployment still occur. These cardiac complications [not entirely prevented by continued dual antiplatelet agents] remain a matter of diagnostic and therapeutic challenge and concern.

Clinical results of unprotected left main coronary stenting.

BACKGROUND: Although unprotected left main coronary artery disease is considered by contemporary guidelines to be an indication for surgery, percutaneous coronary intervention may be necessary in patients at high surgical risk. OBJECTIVES: To assess the outcome of angioplasty in the treatment of unprotected LMCA disease. METHODS: Angiographic and clinical data were collected prospectively for all patients who underwent emergent or nonemergent (planned) therapeutic PCI for unprotected LMCA disease at our center from 2003 to 2007. Baseline values were compared with findings at 1, 6 and 12 months after the procedure. RESULTS: The study group comprised 71 consecutive patients with a mean age of 74 +/- 12 years; 63% were men, and 31% had diabetes. Forty-three patients had a planned procedure and 28 an emergent procedure. Mean EuroScore was 7.3 +/- 3.6 (range 5-12). Forty-nine percent of the procedures were performed with bare metal stents and 51% with drug-eluting stents. Procedural success was achieved in 100% of cases. The overall mortality rate was 11.3% at 1 month, 18.3% at 6 months and 19.7% at 12 months. Elective PCI was associated with significantly lower mortality (2.3% vs. 25% at 1 month, 4.6% vs. 39% at 6 months and 6.9% vs. 39% at 12 months), and the use of drug-eluting stents was associated with lower rates of target vessel revascularization and major adverse cardiac events than use of bare metal stents (2.8% vs. 14% at 1 month, 8.3% vs. 43% at 6 and 12 months). Variables that correlated with increased mortality or MACE at 6 and 12 months were cardiogenic shock, emergent PCI, ejection fraction < 35%, renal failure, distal left main stenosis location, and reference diameter < 3 mm. CONCLUSIONS: PCI is a feasible and relatively safe therapeutic option for unprotected LMCA. The less favorable outcome of emergent compared to planned PCI is probably attributable to the overwhelming acute myocardial ischemic injury in emergent cases. The use of drug-eluting stents may improve the intermediate-term restenosis rate.

Major bleeding complicating contemporary primary percutaneous coronary interventions-incidence, predictors, and prognostic implications.

BACKGROUND: Major bleeding is one of the most frequent procedural-related complications of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infraction (STEMI). We investigated the incidence, predictors, and prognostic impact of peri-procedural bleeding in a cohort of unselected patients undergoing contemporary primary PCI. METHODS: A total of 831 consecutive patients who underwent primary PCI between 1/2001 and 6/2005 were studied. Major bleeding was defined as hemorrhagic stroke, hemoglobin (Hb) drop of >5 g%, or 3-5 g% with a need for blood transfusion. Clinical outcomes were evaluated at 30 days and 6 months. RESULTS: Major bleeding occurred in 27 patients (3.5%). Those who experienced major bleeding were older (66+/-15 vs. 61+/-13, P=.02), more frequently female gender (48% vs. 27%, P=.0001), presented more often with cardiogenic shock (37% vs. 8%, P=.0001), and had higher CADILLAC score (7.8+/-4.5 vs. 5.1+/-4.0, P=.002) and activated clotting time (ACT) levels (284+/-63 vs. 248+/-57 s, P=.007). In multivariate analysis, significant predictors of major bleeding were female gender (OR 5.1, 95% CI 1.7-15.2, P=.004), ACT levels >250 s (OR 3.6, 95% CI 1.1-12.1, P=.04), and use of intra-aortic balloon pump (IABP) (OR 3.5, 95% CI 1.0-12.1, P=.047). Major bleeding was associated with increased 6-month mortality rates (37% vs. 10%, P=.0001), which remained significant after adjustment for baseline CADILLAC score (37% vs. 19.4%, P=.05). CONCLUSIONS: Major bleeding complicating primary PCI is associated with increased 6-month mortality. Women and those who need IABP support are at particularly high risk. Tight monitoring of anticoagulation may reduce the risk of bleeding.