Percutaneous coronary intervention with ridaforolimus eluting-stents in small vessel coronary artery disease.

INTRODUCTION: The ridaforolimus-eluting stent (RES) system uses a novel cobalt alloy-based coronary stent with a durable elastomeric polymer eluting ridaforolimus. AIM OF STUDY: To assess the safety and efficacy of small diameter (2.25 mm) RES (EluNIR) in small coronary artery disease. METHODS: A prospective, multicenter, single-arm, open-label clinical trial. Clinical follow-up was performed at 30 days, 6 months, and 1 year after the procedure. Target lesions were located in native coronary arteries or bypass graft conduits, with visually estimated diameter of ≥2.25 mm to ≤2.5 mm. The primary endpoint was combined device success, defined as final in-stent residual diameter stenosis <30%, without 30-day major adverse cardiovascular events (MACE). RESULTS: A total of 81 patients were enrolled in the study. Twenty-three patients (28%) had acute coronary syndrome (ACS) at presentation and 37 (46%) had prior myocardial infarction (MI). Most of the target lesions were located in the circumflex coronary artery (44%) and were classified as B2/C grade according to the American Heart Association/American College of Cardiology classification. The final mean minimal lumen diameter, mean reference vessel diameter, and mean residual percent diameter stenosis were 2.0 ± 0.2 mm, 2.3 ± 0.1 mm, and 14 + 6.6%, respectively. The primary endpoint of device success without 30-day MACE was achieved in 98.8% of the patients. Target lesion failure (TLF) at 6 months was 1.2%. Thirty-day and 1-year MACE rates were 1.2% and 2.5%, respectively. CONCLUSION: The EluNIR 2.25 mm stent shows excellent results in small coronary artery disease and adds another tool in the treatment of this complex lesion type.

The impact of Heart Team discussion on decision making for coronary revascularization in patients with complex coronary artery disease.

BACKGROUND AND AIM: Revascularization guidelines support routine Heart Team (HT) discussion of appropriate patients. The effect of HT on decision making and clinical outcomes has not been explored. The aim of our study is to investigate the impact of the HT on the mode and delay to revascularization. METHODS: We compared data from a prospective cohort of consecutive patients with multivessel coronary artery disease (CAD) referred for HT discussion between 2016 and 2017 (HT group) with a historic control group of patients matched according to clinical and angiographic characteristics treated between 2005 and 2015 (No HT group). RESULTS: There were 93 patients in each group. The HT group and the No HT groups had a similar rate of ACS as well as cardiovascular risk factors and significant left ventricular (LV) dysfunction. No difference was observed in the mean Society of Thoracic Surgery score (2.5 ± 3 vs 3 ± 3; P = .32) and the mean SYNTAX score was low and similar in both groups (21 ± 6 vs 19 ± 6; P = .59). The treatment recommendations changed greatly, with 63% of patients being referred for coronary artery bypass grafting (CABG) after HT discussion but only 23% in the No HT group (P < .01). HT discussion led to a significant delay to PCI (8 ± 5 vs 1.8 ± 4 days; P = .02), while surgical revascularization times were not affected. CONCLUSION: HT discussion in patients with multivessel CAD was associated with an increased referral to CABG but led to a significant delay in revascularization by angioplasty. The impact of these findings on patient satisfaction and outcome should be further investigated.

Length of left anterior descending coronary artery determines prognosis in acute anterior wall myocardial infarction.

BACKGROUND: The left anterior descending artery (LAD) supplies blood to a large part of the myocardium. However, the amount of myocardium supplied varies depending on the length of the LAD and as a result, occlusion of its proximal portion may influence outcome. We investigated the prognosis of patients with anterior wall myocardial infarction as the initial presentation of coronary disease who underwent primary percutaneous coronary intervention (PPCI) in our institution due to isolated proximal LAD occlusion. METHODS: We retrospectively analyzed all patients that underwent PPCI in our institution from 2002 to June 2012. The individuals who fulfilled the above criteria constituted the study group. We recorded demographic, clinical, and angiographic data as well as mortality during the study period. RESULTS: Of 2,532 patients undergoing PPCI, 196 had isolated proximal LAD occlusion. In 112 of them (57%), the LAD wrapped around the apex (group A) and in the remaining 84 (43%), the LAD terminated at or before the apex (group B). At univariate analysis, patients in group A were found to be older (P = 0.04). Over the study period, 28% of patients in group A died in comparison to 2.4% in group B (P < 0.01). When differentiating between cardiac and non-cardiac death, both were also significantly higher in group A (P < 0.01). At multivariate analysis, the strongest predictor of death was long LAD versus shorter LAD (HR 9.1, 95% CI 1.1-76, P = 0.04). CONCLUSION: Wrap-around LAD is a strong predictor of prognosis in patients with anterior wall MI undergoing PPCI to isolated proximal LAD occlusion. In addition, those with a shorter LAD have an excellent prognosis.

Athlete's heart in Israel: fact or fiction.

BACKGROUND: The effects of exercise training on cardiac structure and function have been thoroughly investigated in athletes from sport-developed nations; few data are available on sportsmen from sport-developing countries. OBJECTIVES: To assess the incidence and magnitude of the "athlete heart" phenomenon in an elite group of Israeli cyclists. METHODS: An echocardiography study was performed in 56 cyclists (49 males, mean age 38 +/- 10 years, weekly average training 13.1 +/- 5.9 hours); 96 sedentary subjects served as a control group. RESULTS: There were significant differences in left ventricular end-diastolic diameter (LVEDD) between cyclists and the control group (48 +/- 4.7 mm versus 45 +/- 4.1 mm respectively, P < 0.001), as well as in inter-ventricular septum (IVS) thickness (9.9 +/- 1.2 versus 8.9 +/- 1.2 mm, P < 0.001) and LV mass index (LVMI) (79 +/- 16 versus 68 +/- 13 g/m(2), P < 0.001). In 5% of the cyclists LVEDD exceeded the upper normal limit of 56 mm. In 7% of the cyclists IVS thickness exceeded the upper normal limit of 11 mm. LV hypertrophy defined as LVMI > or = 134 g/m(2) was absent in the entire cyclist group. CONCLUSIONS: Endurance sport activity in well-trained Israeli sportsmen results in a modest increment in LV dimensions and LV mass. LV dilatation and wall thickness above values compatible with primary cardiac disease are rare. These results highlight that in Israeli athletes any abnormal echocardiographic value must be thoroughly investigated and not simply assumed to be a consequence of sport activities.

Coronary thrombus in ST elevation myocardial infarction and atrial fibrillation.

Coronary embolization is a rare cause of acute myocardial infarction (AMI) and few descriptions are found in the literature. Since atrial fibrillation is a known cause of systemic embolization our aim was to investigate the incidence of globular filling defects suggesting embolization in patients presenting with atrial fibrillation (AF) and ST elevation AMI with single vessel disease. We retrospectively analyzed all patients from our data base between 2002 and 2011 (2,067 patients) presenting with AF, AMI and single vessel disease and compared them to a randomly chosen control group with AMI, single vessel disease and in sinus rhythm. Of the 14 patients meeting the above criteria, 12 had a globular filling defect at the occlusion site (86%), in comparison to only 8 of 30 in the control group (27%) (p < 0.01). The study group patients were older, more frequently female, diabetic, dyslipidemic and hypertensive and had more valvular heart disease, while patients in the control group were more often smokers. Almost all the patients in the study group were either not receiving anticoagulation or inadequately anticoagulated. Atrial fibrillation was found to be the only factor independently associated with a globular filling defect on multivariable analysis (OR 34, 95% CI: 2-72). In conclusion, a globular filling defect is a common finding in patients with AF and single vessel disease presenting with AMI, probably as a result of embolization.

Renal safety and angiotensin II blockade medications in patients undergoing non-emergent coronary angiography: a randomized controlled study.

BACKGROUND: Contrast-induced nephropathy (CIN) is one of the major causes of new-onset renal failure in hospitalized patients. Although renin-angiotensin-aldosterone system (RAAS) blocking agents are widely used among patients requiring contrast studies, data on the effect of these agents on the development of CIN are sparse and inconsistent. OBJECTIVES: To evaluate in a randomized controlled trial whether uninterrupted administration of angiotensin II (AnglI) blockade medications influence estimated glomerular filtration rate (eGFR) in patients undergoing non-emergent coronary angiography. METHODS: Patients receiving treatment with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB) were recruited consecutively. The enrolled subjects were randomized into three groups at a 1:1:1 ratio: group A (ACE/ARB stopped 24 hours prior to the procedure and restarted immediately after the procedure), group B (ACE/ARB stopped 24 hours prior to the procedure and restarted 24 hours after the procedure), and group C (ACE/ARB continued throughout the study period). Plasma creatinine was measured and eGFR was calculated according to the Cockroft-Gault equation before and 48 hours after the coronary angiography. The primary endpoint was a change in eGFR at 48 hours. RESULTS: Groups A, B and C comprised 30, 31 and 33 patients respectively. The mean age of the study population was 65 +/- 12 years and 67% were males. Fifty percent of the subjects had diabetes mellitus. The primary endpoint analysis showed that at 48 hours after the procedure there was no difference in delta eGFR between groups A and C (4.25 +/- 12.19 vs. 4.65 +/- 11.76, P = 0.90) and groups B and C (3.72 +/- 17.42 vs. 4.65 +/- 11.76, P = 0.82). In post-hoc analysis the patients were clustered according to the following groups: medical alternation (group A and B) versus control (group C), and to baseline eGFR > or = 60 ml/min vs. eGFR (< 60 ml/min. In patients with baseline eGFR < 60 ml/min the delta eGFR (baseline eGFR-eGFR 48 hours post-angiography) was significantly different between the intervention vs. control group (median 5.61 vs. median -2.19, P= 0.03 respectively). While in patients with baseline eGFR > or = 60 ml/min there was no significant difference in delta eGFR between the intervention and control groups. CONCLUSIONS: ACE-I and ARB can safely be used before and after coronary angiography in patients with eGFR > or = 60 ml/min.

Nonobstructive coronary atherosclerosis is associated with adverse prognosis among patients diagnosed with myocardial infarction without obstructive coronary arteries.

BACKGROUND AND AIMS: The prognostic impact of nonobstructive coronary artery disease (CAD), as opposed to normal coronary arteries, on long-term outcomes of patients with myocardial infarction with no obstructive coronary arteries (MINOCA) is unclear. We aimed to address the association between nonobstructive-CAD and major adverse events (MAE) following MINOCA. METHODS: We conducted a retrospective cohort study of consecutive MINOCA patients admitted to a large referral medical center between 2005 and 2018. Patients were classified according to coronary angiography as having either normal-coronaries or nonobstructive-CAD. The primary outcome was MAE, defined as the composite of all-cause mortality and recurrent acute coronary syndrome (ACS). RESULTS: Of the 1544 MINOCA patients, 651 (42%) had normal coronaries, and 893 (58%) had CAD. The mean age was 61.2 ± 12.6 years, and 710 (46%) were females. Nonobstructive-CAD patients were older and less likely to be females, with higher rates of diabetes, hypertension, dyslipidemia, atrial fibrillation, and chronic renal-failure (p < 0.05). At a median follow-up of 7 years, MAE occurred in 203 (23%) patients and 67 (10%) patients in the nonobstructive-CAD and normal-coronaries groups, respectively (p < 0.01). In multivariable models, nonobstructive -CAD was significantly associated with long-term MAE [adjusted-hazard-ratio (aHR):1.67, 95% confidence-interval (95%CI):1.25-2.23; p < 0.001]. Other factors associated with a higher MAE-risk were older-age (aHR:1.05,95%CI:1.03-1.06; p < 0.001) and left ventricular ejection-fraction<40% (aHR:3.04,95%CI:2.03-4.57; p < 0.001), while female-sex (aHR:0.72, 95%CI: 0.56-0.94; p=0.014) and sinus rhythm at presentation (aHR:0.66, 95%CI: 0.44-0.98; p=0.041) were associated with lower MAE-risk. CONCLUSIONS: In MINOCA, nonobstructive-CAD is independently associated with a higher MAE-risk than normal-coronaries. This finding may promote risk-stratification of patients with nonobstructive-CAD-MINOCA who require tighter medical follow-up and treatment optimization.

Predictors of Adverse Outcome in High-Risk Percutaneous Coronary Interventions Patients.

BACKGROUND: Identifying high-risk percutaneous coronary intervention (PCI) patients is challenging. We aimed to evaluate which high-risk patients are prone to adverse events. METHODS: We performed a retrospective study including consecutive high-risk PCIs from 2005 to 2018 in a large tertiary medical centre. Patients with unprotected left main (LM) disease, last patent coronary vessel, or 3-vessel coronary artery disease with left ventricular ejection fraction < 35% were included. A predictive 30-day major adverse cardiac events (MACE) score consisting of any myocardial infarction, all-cause death, or target-vessel revascularisation was constructed. RESULTS: From 2005 to 2018, a total of 1890 patients who underwent PCI met the predefined high-risk PCI criteria. Mortality rate was 8.8% at 30 days and 20.7% at 1 year, and 30-day MACE rate was 14.2% and 33.5% at 1 year. Predictors of short-term MACE were New York Heart Association functional class (NYHA) 4 (hazard ratio [HR] 6.65; P < 0.001), systolic blood pressure (SBP) < 90 mm Hg (HR 4.93; P < 0.001), creatinine > 1.3 mg/dL (HR 3.57; P < 0.001), hemoglobin < 11.0 g/dL (HR 3.07; P < 0.001), pulmonary artery systolic pressure > 50 mm Hg (HR 2.06; P < 0.001), atrial fibrillation (HR 1.74; P < 0.001), and LM disease (HR 2.04; P < 0.001) or last patent vessel (HR 1.70; P = 0.002). A score constructed from these parameters reached a sensitivity of 90% and a specificity of 81% with areas under the receiver operating characteristic curve of 0.92 for MACE and 0.94 with 89% sensitivity and 87% specificity for all-cause mortality. CONCLUSIONS: Specific features such as LM lesion or last patent conduit, pulmonary hypertension, atrial fibrillation, anemia, and renal failure, along with low SBP and NYHA 4, aid risk stratification and consideration of further treatment measures.

Performance of a novel artificial intelligence software developed to derive coronary fractional flow reserve values from diagnostic angiograms.

BACKGROUND: Although invasive measurement of fractional flow reserve (FFR) is recommended to guide revascularization, its routine use is underutilized. Recently, a novel non-invasive software that can instantaneously produce FFR values from the diagnostic angiograms, derived completely from artificial intelligence (AI) algorithms has been developed. We aim to assess the accuracy and diagnostic performance of AI-FFR in a real-world retrospective study. METHODS: Retrospective, three-center study comparing AI-FFR values with invasive pressure wire-derived FFR obtained in patients undergoing routine diagnostic angiography. The accuracy, sensitivity, and specificity of AI-FFR were analyzed. RESULTS: A total of 304 vessels from 297 patients were included. Mean invasive FFR was 0.86 vs. 0.85 AI-FFR (mean difference: -0.005, P  = 0.159). The diagnostic performance of AI-FFR demonstrated sensitivity of 91%, specificity 95%, positive predictive value 83% and negative predictive value 97%. Overall accuracy was 94% and the area under curve was 0.93 (95% CI 0.88-0.97). 105 lesions fell around the cutoff value (FFR = 0.75-0.85); in this sub-group, AI-FFR demonstrated sensitivity of 95%, and specificity 94%, with an AUC of 0.94 (95% CI 88.2-98.0). AI-FFR calculation time was 37.5 ±â€…7.4 s for each angiographic video. In 89% of cases, the software located the target lesion and in 11%, the operator manually marked the target lesion. CONCLUSION: AI-FFR calculated by an AI-based, angio-derived method, demonstrated excellent diagnostic performance against invasive FFR. AI-FFR calculation was fast with high reproducibility.

Comparison of Transcatheter Aortic Valve Implantation Devices in Aortic Stenosis: A Network Meta-Analysis of 42,105 Patients.

Background: In recent years, trans-catheter aortic valve implantation (TAVI) has emerged as an excellent alternative to surgical aortic valve replacement (SAVR). Currently, there are several approved devices on the market, yet comparisons among them are scarce. We aimed to compare the various devices via a network meta-analysis. Methods: We performed a network meta-analysis including randomized controlled trials (RCTs) and propensity-matched studies that provide comparisons of either a single TAVI with SAVR or two different TAVI devices and report clinical outcomes. Results: We included 12 RCT and 13 propensity-matched studies comprising 42,105 patients, among whom 27,134 underwent TAVI using various valve systems (Sapien & Sapien XT, Sapien 3, Corvalve, Evolut & Evolut Pro, Acurate Neo, Portico). The mean follow-up time was 23.4 months. Sapien 3 was superior over SAVR in the reduction of all-cause mortality (OR = 0.53; 95%CrI 0.31-0.91), while no significant difference existed between other devices and SAVR. Aortic regurgitation was more frequent among TAVI devices compared to SAVR. There was no significant difference between the various THVs and SAVR in cardiovascular mortality, myocardial infarction, NYHA class III-IV, and endocarditis. Conclusions: Newer generation TAVI devices, especially Sapien 3 and Evolut R/Pro are associated with improved outcomes compared to SAVR and other devices of the older generation.

Feasibility and safety of the antecubital venous access for right heart catheterization in patients with pulmonary hypertension.

BACKGROUND: The diagnosis of pulmonary arterial hypertension requires right heart catheterization (RHC) which is typically performed via proximal venous access (PVA). Antecubital venous access (AVA) is an alternative approach for RHC that can minimize complications, decrease procedural duration and allow for immediate patient recovery. A direct comparison between the two procedures in patients with pulmonary hypertension (PH) is lacking. OBJECTIVES: To determine the feasibility, safety, and adoption rates of AVA-RHC as compared with ultrasound-guided PVA in a subpopulation of patients with PH. METHODS: All patients who underwent RHC for evaluation of PH between December 2014 and March 2017 at a single large academic medical center were included in this study. Demographic, procedural and outcomes data were retrieved from the medical records. RESULTS: In total, 159 RHC were included (124 AVA, 35 PVA). The duration of RHC was significantly shorter in the AVA compared with PVA group (53 (IQR 38-70) vs. 80 (IQR 56-95) min, respectively, p < 0.001). 19% of AVA (24/124) procedures were switched to PVA. Failed attempts at AVA were more common in scleroderma (50% failure rate). Success rate of AVA increased from 81.2% to 93.3% from the first to last quartile. Fluoroscopy time was similar in both groups, the difference between the groups in the radiation dose are not statistically significant (54.5 (IQR 25-110) vs. 84.5 (IQR 30-134)). CONCLUSION: AVA-RHC is a feasible and safe alternative to PVA in patients with PH who are evaluated for pulmonary arterial hypertension diagnosis. Our experience and rapid adoption rate support the use of AVA as the preferred access site for RHC in uncomplicated PH patients.

Feasibility and safety of exclusive echocardiography-guided intravenous temporary pacemaker implantation.

BACKGROUND: The standard approach for urgent trans-venous temporary cardiac pacemaker (TVTP) implantation is fluoroscopy guidance. The delay in activation of the fluoroscopy-room and the transfer of unstable patients may be life-threatening. Echocardiography-guided TP implantation may increase the safety of the patients by obviating the need for in-hospital transfer. We examined the feasibility and safety of echocardiography-guided vs. fluoroscopy-guided TVTP implantation. METHODS: From January 2015 to September 2017 data for consecutive patients who needed emergent TVTP implantation were retrospectively reviewed. Ultrasound-guided TVTP protocol that was introduced in our center in January 2015 involved ultrasound guidance for both central venous access and pacing lead positioning. Access sites included femoral, subclavian, or jugular veins. Electrodes were placed in the right ventricular apex by means of echocardiographic monitoring in intensive care unit or by fluoroscopic guidance. Endpoints were achievement of successful ventricular pacing and procedural complications. RESULTS: Sixty-six patients (17 echocardiography-guided and 49 fluoroscopy-guided) were included. There were no differences in pacing threshold between the echocardiography-guided group and the fluoroscopy-guided group (0.75 ± 0.58 mA vs. 0.57 ± 0.35 mA, p = 0.24). The access site for implantation was femoral vein in 27% for the fluoroscopy-guided vs. none for the echocardiography-guided approach (p = 0.015). One hematoma and one related infection occurred in the fluoroscopy-guided group. The need for electrode repositioning was observed in 1 patient in each group. There were no procedural-related deaths in either group. CONCLUSIONS: Echocardiography-guided temporary cardiac pacing is a feasible and safe alternative to fluoroscopy-guided approach and significantly lowers the need for in-hospital transfer.

Pulmonary artery hypertension following coronary artery bypass grafting: a case report.

Post-operative pulmonary complications in coronary artery bypass grafting (CABG) surgery are mostly reversible. We report a patient who developed pulmonary arterial hypertension (PAH) post-CABG and did not have pulmonary hypertension prior to surgery. PAH Group 1 was diagnosed after right and left heart catheterization. To the best of our knowledge, this is the only reported case of a patient developing PAH post-CABG surgery. This could be explained by immunological and/or haemostatic changes triggered by cardiopulmonary bypass. We hope that as more knowledge is gained regarding the pathophysiology of PAH, cases like these could be better understood.

Grade 3 ischemia on the admission electrocardiogram predicts failure of ST resolution and of adequate flow restoration after primary percutaneous coronary intervention for acute myocardial infarction.

BACKGROUND: Failure of ST-segment resolution (STR) after primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction is associated with adverse outcome but currently cannot be predicted on admission. Our aim was to determine whether failure of STR can be predicted from clinical and electrocardiographic data available on admission and whether the adverse outcome associated with grade 3 ischemia (distortion of the terminal portion of the QRS complex) is mediated through impaired tissue reperfusion. METHODS: We prospectively studied 100 consecutive patients who underwent PPCI for a first ST-elevation myocardial infarction. Multiple variables available on admission were analyzed as predictors of STR. Electrocardiograms and angiograms were analyzed by blinded investigators. RESULTS: Grade 2 ischemia was found in 71 patients (71%) and 29 (29%) had grade 3 ischemia. Complete STR was observed in 42 (59%) of 71 patients with grade 2 ischemia as compared to 8 (28%) of 29 patients with grade 3 ischemia (P = .004). In a multivariate model, grade 3 ischemia was the sole predictor of failure of STR (odds ratio [OR] 0.26, 95% CI 0.1-0.72) and the strongest predictor of failure to achieve TIMI grade 3 flow (OR 0.07, CI 0.02-0.3) and TIMI myocardial perfusion grade 3 (OR 0.09, CI 0.02-0.4) after the procedure. CONCLUSIONS: Grade 3 ischemia is a strong independent predictor available on admission of failure to achieve myocardial reperfusion after PPCI, as assessed both electrocardiographically and angiographically. This association may underlie the larger infarcts associated with grade 3 ischemia and may allow the identification upon admission of patients who require more aggressive management to improve reperfusion.

Predicting survival with reperfusion arrhythmias during primary percutaneous coronary intervention for acute myocardial infarction.

BACKGROUND: The significance of arrhythmia occurring after successful recanalization of an occluded artery during treatment following primary percutaneous coronary intervention for ST-segment elevation myocardial infarction is controversial. OBJECTIVES: To study the association of reperfusion arrhythmia with short and long-term survival. METHODS: We used a prospective registry of consecutive STEMI patients undergoing PPCI. Patients with an impaired epicardial flow (TIMI flow grade < 3) at the end of the procedure were excluded. RESULTS: Of the 688 patients in the study group, 22% were women. Mean (+/- SD) age of the cohort was 61 (+/- 14) years and frequent co-morbidities included diabetes mellitus (25%), dyslipidemia (55%), hypertension (43%) and smoking (41%). RA was recorded in 200 patients (29%). Patients with RA had lower rates of diabetes (16% vs. 30%, P < 0.01) and hypertension (48% vs. 62%, P < 0.01), and a shorter median pain-to-balloon time (201 vs. 234 minutes, P < 0.01) than patients without RA. Thirty day mortality was 3.7% and 8.3% for patients with and without RA, respectively (P = 0.04). After controlling for age, gender and pain-to-balloon time the hazard ratio for mortality for patients with RA during a median follow-up period of 466 days was 0.46 (95% confidence interval 0.23-0.92). CONCLUSIONS: The occurrence of RA immediately following PPCI for acute STEMI is associated with better clinical characteristics and identifies a subgroup with a particularly favorable prognosis.

Intracoronary nitroprusside for the prevention of the no-reflow phenomenon after primary percutaneous coronary intervention in acute myocardial infarction. A randomized, double-blind, placebo-controlled clinical trial.

BACKGROUND: The aim of this study was to test whether nitroprusside (NTP) injected intracoronary immediately before primary angioplasty for acute ST-elevation acute myocardial infarction (STEMI) prevents no-reflow and improves vessel flow and myocardial perfusion. METHODS: Ninety-eight patients presenting with STEMI were evenly randomized to receive either NTP (60 microg) or placebo. The drug was selectively injected into the infarct-related artery, distal to the occlusion, in a double-blind manner. The primary end points were postintervention angiographic corrected thrombolysis in myocardial infarction frame count and the proportion of patients with complete (>70%) ST-segment elevation resolution. Secondary end points included myocardial blush score and clinical outcome at 6 months follow-up. RESULTS: Mean (+/-SD) age was 62 (+/-12) years, and 87% were men. Baseline characteristics (excluding sex) did not differ between groups. The corrected thrombolysis in myocardial infarction frame count after angioplasty was 20.8 (+/-18.6) and 20.3 (+/-21.3) in patients given NTP and placebo, respectively (P = .78). Complete ST-segment resolution was achieved in 61.7% and 61.2% of NTP and placebo subjects, respectively (P = .96). The distribution of myocardial blush score did not differ between groups. At 6 months, the rate of target lesion revascularization, myocardial infarction, or death occurred in 6.3% of the NTP group and 20.0% of the placebo group (P = .05). CONCLUSIONS: In patients with STEMI, selective intracoronary administration of a fixed dose of NTP failed to improve coronary flow and myocardial tissue reperfusion but improved clinical outcomes at 6 months.

[Diabetics with normal coronary arteries: clinical features and prognosis].

BACKGROUND: Diabetic patients comprise a large proportion of patients referred for coronary angiography. Only a minority of these patients will be found to have normal coronary arteries. AIM: To characterize diabetic patients who have angiographically normal coronary arteries. METHODS: Case-control study based on a computerized database. RESULTS: Using our computerized database, 13,342 consecutive patients referred for coronary angiography were identified. Diabetes mellitus was diagnosed in 24% of cases. Angiographically normal coronary arteries were found in 151 (5%) and 1228 (12%) of diabetic and non-diabetic patients, respectively (p<0.01). Diabetic patients with angiographically normal coronary arteries were matched with 155 diabetic patients who were catheterized on the same day but were found to have coronary artery disease. The median follow-up period was 1,774 days. The age of the diabetic patients with normal coronary arteries and diabetic patients with coronary artery disease was 5710 and 6410 years old respectively (p<0.01). A total of 39% and 60% of diabetic patients with normal coronary arteries and with coronary artery disease respectively were males, (p<0.01). Dyslipidemia was diagnosed in 66 (43%) of the diabetic patients with normal coronary arteries and 87 (57%) of the diabetic patients with coronary artery disease (P<0.01). After controlling for age and sex, the finding of normal coronary arteries was associated with decreased mortality (OR: 0.47, 95% CI 0.23 to 0.95). CONCLUSIONS: In diabetic patients referred for angiography it is unusual to find angiogrtaphically normal arteries. These patients have a relatively benign prognosis, as opposed to diabetic patients with evident coronary disease.

Angiographic Characteristics of Catheter-Induced Spasm of the Left Main Coronary Artery.

Spasm of the left main coronary artery (LM) is considered to be rare. We investigated the angiographic characteristics of the LM in patients with combined LM and disease involving additional vessels, who underwent coronary artery bypass grafting (CABG) and underwent repeat coronary angiography within 5 years of the CABG, to examine the apparent frequency of spasm of the LM on initial angiography and its possible predictors. A retrospective analysis was performed of patients who underwent coronary angiography in our institute, who were found to have significant LM stenosis and disease involving additional vessels, underwent CABG and repeat coronary angiography within 5 years of the CABG. Data on angiographic characteristics of the LM on the initial angiogram were investigated. Of 84 patients, 17 (20%) were found to have a normal LM on repeat angiography (group A), and 67 (80%) demonstrated significant stenosis (group B). The degree of LM stenosis was milder in the initial angiogram in group A than in group B (64 ± 15% vs 72 ± 14%, p = 0.047). Most patients in group A demonstrated tubular LM stenosis at initial catheterization in comparison to group B (71% vs 18%). Using multivariate analysis, the only predictor for a normal LM at repeat catheterization was found to be tubular stenosis at initial catheterization (odds ratio 123, 95% confidence interval 4.0 to 3696). In conclusion, LM coronary spasm is a common finding, particularly in those with the appearance of tubular stenosis, and it should be excluded even in patients with additional coronary disease in certain instances to prevent unnecessary CABG.

Increased long term rates of stent thrombosis and mortality in patients given clopidogrel as compared to ticlopidine following coronary stent implantation.

BACKGROUND: Clopidogrel has largely replaced ticlopidine following coronary stent implantation. Recently, concern has been raised regarding the possibility of excess long term mortality in patients given clopidogrel rather than ticlopidine following coronary stenting. METHODS: We studied 1519 consecutive patients who underwent 2020 stent implantations and were discharged on dual antiplatelet regimens of either aspirin and ticlopidine or aspirin and clopidogrel given for up to 4 weeks. Thrombotic stent occlusion (TSO) was defined as ST elevation myocardial infarction in the stented artery territory associated with angiographic demonstration of complete stent occlusion. Mortality follow up was obtained for all patients by linkage to the Population Register. Follow up duration was 12 months. RESULTS: TSO occurred in 37 stents at a median of 29 days post procedure. Of these cases, six occurred in the ticlopidine group (0.7%) and 31 in the clopidogrel group (2.8%) (p<0.01). The median time to TSO was 34 days and 28 days in ticlopidine and clopidogrel treated patients, respectively (p<0.01). After controlling for multiple demographic, clinical and angiographic variables clopidogrel (vs. ticlopidine) treatment remained the sole predictor of TSO (OR: 5.4, 95% CI=1.2-24.1, p=0.028). Of even more concern, clopidogrel treatment was associated with an increased risk of 1 year mortality (OR: 1.8, 95% CI=1.2-2.8). CONCLUSIONS: Long term follow up after stent implantation in patients receiving the traditional 2-4 weeks course of dual antiplatelet therapy reveals increased rates of TSO and mortality in patients given clopidogrel as opposed to ticlopidine. Whether longer treatment with clopidogrel will change these observations deserves further study.