Temporal trends in percutaneous coronary interventions thru the drug eluting stent era: Insights from 18,641 procedures performed over 12-year period.

BACKGROUND: The last decade, regarded as the DES era in PCI, has witnessed significant advances in the management of coronary disease. We aimed to assess temporal trends in the practice and outcome of percutaneous coronary intervention (PCI) during the drug eluting stent (DES) era. METHODS: We analyzed 18,641 consecutive PCI's performed between January 2004 and December 2016, distinguished by procedural date (Q1 : 2004-2006, n = 4,865; Q2 : 2007-2009, n = 4,977; Q3 : 2010-2012, n = 4,230; Q4 : 2013-2016, n = 4,569). RESULTS: At presentation, mean patients age was 65 (±11) years and 22.8% were females. Over time, there was a rise in the relative number of octogenarians (Q1 : 10.7% vs Q4 : 15.5%, P < 0.001) and an increase in the burden of most comorbidities (e.g., left ventricular dysfunction ≥ moderate and chronic kidney disease, P < 0.001 for both). Despite a 2-fold increase in the rate of complex interventions, and a 3-fold increase in the rate of unprotected left-main angioplasty (P < 0.001 for both), the radial approach was increasingly adopted (Q1 : 2% to Q4 : 63.5%, P < 0.001). DES implantation increased from 43% to 83% at the expense of bare metal stent (BMS) application, and accompanied by drug coated balloon sprout to 1.8%, P < 0.001. Kaplan-Meier survival curves revealed a time-based enhanced outcome, with a decreased rate of death, MI, target vessel revascularization and CABG over the years. CONCLUSIONS: In the last decade, PCI has evolved to offer better outcome to more elderly, sicker patient population, with more complex coronary disease interventions. The shift to second generation DES and to enhanced PCI techniques may explain part of this progress.

Comparison of platelet inhibition by prasugrel versus ticagrelor over time in patients with acute myocardial infarction.

High on-treatment platelet reactivity (HTPR) despite use of P2Y12 antagonists is associated with adverse cardiac events. The long-term variability in response to prasugrel and ticagrelor is unclear. Our aim was to assess residual platelet reactivity (PR) and rates of HTPR during treatment with prasugrel versus ticagrelor in patients with myocardial infarction (MI). 114 patients with MI treated with percutaneous coronary intervention (PCI) were included. Sixty-two patients were treated with prasugrel (mean age 58 ± 8 years, 21 % women, 29 % diabetes), and 52 patients with ticagrelor (mean age 63 ± 9, 19 % women, 37 % diabetes). Patients were tested for PR at 2-4 days and 30 days post-PCI, using the VerifyNow P2Y12 assay and the multiple-electrode aggregometry. Our results show a higher residual PR in patients treated with prasugrel than those treated with ticagrelor (VerifyNow: 65.4 ± 60.6 vs. 26.0 ± 24.2 P2Y12 reaction units, p < 0.001 at 2-4 days, and 67.3 ± 62.5 vs. 21.1 ± 26.1, p < 0.001 at follow-up). HTPR rates were higher in the prasugrel group (8.1-11.3 % vs. none with ticagrelor in the early test, and 8.7-10.9 % vs. none with ticagrelor at follow-up). In conclusion, in patients with MI undergoing PCI, treatment with ticagrelor resulted in greater platelet inhibition and lower HTPR rates compared with prasugrel, up to 30 days after the event.

Circulating reticulated platelets over time in patients with myocardial infarction treated with prasugrel or ticagrelor.

Reticulated platelets (RP) are young, hyperactive platelets that are increased during situations of enhanced platelet turnover such as acute myocardial infarction (AMI). The dynamics of RP levels after AMI is not established. We aimed to characterize the levels of circulating RP over time in patients with AMI. Patients with AMI treated with ticagrelor or prasugrel who underwent percutaneous coronary intervention (PCI) were tested for circulating RP using flow cytometry with Thiazole orange staining at 3 time points at 2-4 days, 30-60 days and 1 year post PCI. Platelet reactivity was assessed using the VerifyNow P2Y12 assay at these time points (results in platelet reactivity units-PRU). Thirty-five patients were included in the study (mean age 62.6 ± 9.1 years, 82.9 % males). Median RP levels were similar at the first and second time points (17.5 %, IQR 25-75: 10.8-22.4 % and 14.9 %, IQR 25-75: 9.7-26.8 %, respectively; p = 0.75). However, RP levels after 1 year were significantly lower as compared to the first and second time points (10.5 % (IQR 25-75: 5.3-18.1 %), p = 0.005 and p = 0.01, respectively). Residual platelet reactivity was very low at all 3 time points (median PRU 25, IQR 25-75: 7-53) and did not change significantly between them (p = 0.66). No significant correlation was found between levels of RP and PRU at any given time point. RP levels of patients with AMI treated with prasugrel or ticagrelor decrease over time after the acute event. However, RP levels over time do not correlate well with residual platelet reactivity.

Relation between ticagrelor response and levels of circulating reticulated platelets in patients with non-ST elevation acute coronary syndromes.

Antiplatelet responses to clopidogrel and prasugrel are highly variable and subject to significant rates of high on-treatment platelet reactivity (HTPR) after percutaneous coronary intervention (PCI). The proportion of circulating young reticulated platelets (RPs) inversely correlates with responsiveness to both agents. We aimed to determine the relationship between RPs and on-treatment platelet reactivity in ticagrelor-treated patients. Patients with non-ST-elevation acute coronary syndromes (NSTE-ACS) treated with PCI and ticagrelor were tested for platelet reactivity using the VerifyNow P2Y12 assay and multiplate aggregometry. RPs levels were determined using flow cytometry with thiazole orange staining. Tests were performed at 2-4 and 30 days post-PCI. Fifty three patients were included (mean age 62.6 ± 9.8 years, 18.9 % women, 35.8 % diabetes), of which 41 patients (77 %) completed follow-up. Variability in response to ticagrelor was very low according to both assays with no identified cases of HTPR at either time-point. In addition, there were no differences in platelet reactivity, as analyzed by the VerifyNow P2Y12 assay, or in the proportion of RPs between the two time points (p > 0.5). With the multiplate assay, platelet reactivity increased between the two time-points (8.6 ± 6.0 vs. 15.5 ± 11 AU*min; p = 0.0007). There was no significant correlation between RPs and platelet reactivity at both time-points and using both assays (p > 0.5). There were no cases of HTPR up to 30-days post-PCI in patients with NSTE-ACS treated with ticagrelor. In this cohort, no correlation between % RPs and platelet reactivity was observed. Attenuation of RP-induced platelet reactivity as a novel mechanism for ticagrelor's benefit requires further investigation.

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.

Long-term outcome of patients with antiphospholipid syndrome who undergo percutaneous coronary intervention.

OBJECTIVES: Patients with antiphospholipid antibody syndrome (APS) have an increased risk of atherothrombotic complications. There are limited data regarding the outcome of patients with APS who undergo percutaneous coronary intervention (PCI). Accordingly, we aimed to assess the long-term outcomes of these patients. METHODS: Nineteen APS patients who underwent PCI between the years 2003 and 2008 were compared to 380 patients who had undergone PCI during the same period (PCI group) and were matched by age (±5 years), gender, diabetes and hypertension. In addition, APS patients were compared to 1,458 patients with ST segment elevation myocardial infarction (MI) who were treated with PCI during the same period. Six-month to 4-year clinical outcomes were evaluated. RESULTS: The indication for PCI in the APS group was acute coronary syndrome in 52.6% of patients. After 1 year of follow-up, patients with APS had higher rates of target vessel revascularization than the other two groups, which translated to higher rates of major adverse cardiac events. There were no differences in MI or mortality rates between the groups. CONCLUSIONS: Patients with APS who undergo PCI have worse long-term clinical outcomes, driven by higher rates of revascularization, than other patients undergoing PCI. Further study is warranted to examine the mechanisms underlying these findings.

A comparative analysis of major clinical outcomes using drug-eluting stents versus bare metal stents in diabetic versus nondiabetic patients.

OBJECTIVES: We aim to explore the clinical outcome of drug-eluting stents (DES) versus bare-metal stents (BMS) implantation in diabetics versus nondiabetic patients. BACKGROUND: Diabetic patients sustain worse long-term clinical outcomes after percutaneous coronary interventions (PCI) when compared with nondiabetics. The use of DES decreases the rate of repeat revascularization in this population but data concerning long-term clinical benefits, such as myocardial infarction (MI) or mortality is scant. METHODS: We analyzed data from a comprehensive registry of 6,583 consecutive patients undergoing PCI at our center. A propensity score was used for analysis of outcomes and for matching (DES vs. BMS). Outcome parameters were total mortality, MI, repeat target vessel revascularization (TVR) rates, and risk-adjusted event-free survival. Within this cohort, we identified 2,571 nondiabetic patients and these were compared with 1,826 diabetic coronary patients. RESULTS: Mean and median follow up time was 3 and 3.25 years, respectively. Overall, diabetics had higher rates of major-adverse cardiovascular events (MACE) at 4 years compared with nondiabetics (23.03 vs. 31.96 P > 0.001). DES use was associated with lower rates of TVR in both groups [diabetics hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.42-0.76, P < 0.001, nondiabetics HR = 0.73, 95% CI: 0.55-0.97, P = 0.03] while sustained decreased rates of both mortality and MI were evident solely among diabetics (HR = 0.71, 95% CI: 0.56-0.89, P = 0.004 in diabetic vs. HR = 0.88, 95% CI: 0.69-1.13, P = 0.3). CONCLUSIONS: In a "real-world," unselected population and extended clinical use, DES in diabetics was associated with sustained decreased rates of MI, death, TVR, and MACE while this benefit was attenuated in the nondiabetic population.

Cardiomyopathy associated with Ceutzfeld-Jakob disease: a diagnosis of exclusion: a case report.

BACKGROUND: Creutzfeldt-Jakob disease (CJD), the most common prion disease in humans, is primarily known for its adverse neurological impact and inevitable mortality. Data regarding myocardial involvement in CJD are scarce. CASE SUMMARY: A 54-year-old female patient, presented with progressive effort dyspnoea, was diagnosed with unexplained non-ischaemic cardiomyopathy. An extensive cardiac work-up including cardiac magnetic resonance imaging (MRI) did not reveal any underlying aetiology. Simultaneously, the patient developed involuntary limb movements and progressive cognitive decline. Thalamic high-signal abnormalities on diffusion-weighted images were apparent on brain MRI. Based on these findings, she was subsequently referred to a neurology department, where she suddenly died the day after her admission. Brain autopsy demonstrated spongiform encephalopathy. A genetic analysis performed to her son revealed a mutation in the PRNP gene; all of these were consistent with CJD. DISCUSSION: This case describes the clinical association of CJD and cardiomyopathy and the diagnosis prion-induced cardiomyopathy by exclusion. It is not inconceivable that the coexistence of these two clinical entities may be related to genetic expression and contemporaneously deposition of infectious prions in myocardial muscle and brain tissue. Awareness of this possible association could be of important public-safety concern, and merits further collaborative cardiac-neurological work-up to elucidate this phenotype among patients with unexplained cardiomyopathy with neurological symptoms that resemble CJD.

Effect of no-reflow during primary percutaneous coronary intervention for acute myocardial infarction on six-month mortality.

No-reflow is a frequent event during percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI), and it may affect cardiac prognosis. We evaluated the occurrence of no-reflow as a predictor of outcomes in patients who underwent PCI for AMI. We prospectively collected data from 599 consecutive patients who underwent stent-based PCI for ST-elevation AMI by identifying those with no-reflow (Thrombosis In Myocardial Infarction [TIMI] grade <3 flow at completion of the procedure) and analyzing their baseline characteristics and clinical outcomes. Patients with no-reflow (n = 40, 6.7%) were older (67 +/- 13 vs 60 +/- 13 years, p = 0.002) and had longer ischemic times (5.5 +/- 3.7 vs 4.4 +/- 3.0 hours, p = 0.04) with more TIMI grade 0/1 flow at presentation (90% vs 64%, p = 0.001). No-reflow occurred mostly (73%) after stenting and often required intra-aortic balloon pump counterpulsation (30% vs 4.3%, p <0.001). Peak creatine kinase level was higher in patients with no-reflow (2,700 +/- 1,900 vs 2,000 +/- 1,800, p = 0.03) and more often associated with moderate or severe left ventricular dysfunction (68% vs 45%, p = 0.006) and increased 6-month mortality (12.5% vs 4.3%, p = 0.04). By multivariate analysis, no-reflow was an independent predictor of long-term mortality (odds ratio 3.4, p = 0.02). In addition, renal failure (odds ratio 4.39, p = 0.0025) and preprocedure TIMI grade 0/1 flow (odds ratio 2.1, p = 0.003) were independent predictors of no-reflow. In conclusion, the association of no-reflow with longer ischemic time and worse initial TIMI flow may indicate the presence of highly organized thrombus burden with higher propensity for distal embolization. Regardless of its mechanism, no-reflow was an independent predictor of increased mortality.

Serum NT-proBNP concentrations in the early phase do not predict the severity of systolic or diastolic left ventricular dysfunction among patients with ST-elevation acute myocardial infarction.

The cohort included 55 consecutive patients with first ST elevation acute myocardial infarction (STEAMI) who underwent reperfusion. Blood samples were drawn for N-terminal pro B-type natriuretic peptide (NT-proBNP), highly-sensitive C-reactive protein (hs-CRP), creatinine kinase (CK), cardiac troponin l (cTnl), and white blood cell (WBC) count within 24 hours of admission. Transthoracic echocardiography, performed within the same time frame, assessed left ventricular (LV) systolic function, as well as diastolic function. Variables significantly associated with poor systolic LV dysfunction were hs-CRP, peak CK, cTnl, and WBC. There was no significant correlation between NT-proBNP and systolic function early after STEAMI (p=0.49). Among patients with diastolic dysfunction, there was no significant correlation between NT-proBNP levels and peak mitral E-wave velocity to peak initial A-wave velocity (E/A ratio) (r =0.19, p=0.18) or E-wave deceleration time (r =0.22, p=0.15). Thus, NT-proBNP levels in the early phase after STEAMI were not indicative of systolic or diastolic function.

Type 2 myocardial infarction: A descriptive analysis and comparison with type 1 myocardial infarction.

BACKGROUND: While 'plaque rupture' is the paradigm of type 1 myocardial infarction (T1MI), T2MI is myocardial necrosis secondary to oxygen supply-demand mismatch. Being a heterogeneous and rather newly defined group, data are lacking about T2MI. METHODS: A retrospective review of medical records of patients diagnosed with T2MI in the Rabin Cardiology Center, Israel between the years 2007 and 2012 was performed. Following a descriptive analysis, we used multivariate time dependent models to estimate the association of T2MI with the risk for 30-day, 1-year, and 5-year all-cause-mortality and major adverse cardiovascular events (MACE), and compared it to a T1MI group matched for age, gender and electrocardiographic changes. RESULTS: The study included 107 T2MI (and 107 T1MI) patients. Sepsis, anemia, and atrial fibrillation were the most common etiologies. Triple anti-thrombotic therapy was given to 22% of T2MI patients (vs. 82% of T1MI patients, p<0.001). Twenty-five percent were managed using urgent percutaneous coronary intervention. Angiography unmasked acute plaque rupture in 29% of T2MI patients group. Compared to T1MI, T2MI was associated with higher all-cause-mortality rate: adjusted-hazard-ratio 7.14 (1.31-38.9) at 30 days, 3.42 (1.51-7.75) at 1 year, and 2.08 (1.14-3.81) at 5 years follow-up. MACE risk was consistent between T2 and T1MI patients. CONCLUSIONS: The most common T2MI triggers are sepsis, anemia, and atrial fibrillation. Compared to a T1MI population, T2MI is associated with higher short- and long-term mortality rates but equal cardiovascular mortality and MACE risk. As many as 30% may harbor plaque rupture and in fact have T1MI.

One-Year Outcomes After Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction With Varying Quantities of Coronary Artery Calcium (from a 13-Year Registry).

Coronary artery calcium (CAC) is associated with poor angiographic results and higher rates of complications after percutaneous coronary intervention (PCI). Limited data are available regarding the impact of angiographically evident CAC on long-term outcomes after primary PCI in patients presenting with ST-segment elevation myocardial infarction (STEMI). In this single-center, registry-based retrospective cohort analysis, we analyzed 2,143 consecutive patients presenting with STEMI who underwent primary PCI within 12 hours of symptom onset. Patients were divided based on degree of CAC (determined by visual inspection of angiograms) as follows: (1) moderate-to-severe CAC (n = 306; 14.3%) and (2) minimal-to-none CAC (n = 1,837; 85.7%). The primary end point was all-cause mortality at 1-year after PCI. Patients with moderate-to-severe CAC were older, women, and had higher rates of hypertension, chronic kidney disease, and peripheral vascular disease. Moderate-to-severe CAC was associated with higher rates of anterior myocardial infarction, advanced Killip class, and poor final angiographic results. At 1-year follow-up, rates of all-cause mortality were higher in the moderate-to-severe CAC cohort than those in the minimal-to-none CAC cohort (8.5% vs 4.7%; p = 0.008). However, after accounting for major clinical and angiographic characteristics, moderate-to-severe CAC on presenting STEMI angiogram was no longer predictive of 1-year all-cause mortality. In conclusion, advanced CAC burden occurs in ∼15% of patients undergoing primary PCI for STEMI and reflects a marker of adverse prognosis late into follow-up after PCI.

Comparison of outcomes up to six months of Heparin-Coated with noncoated stents after percutaneous coronary intervention for acute myocardial infarction.

We prospectively followed 238 patients who underwent percutaneous coronary intervention for acute ST-elevation myocardial infarction and compared the outcomes of patients who received heparin-coated stents (n = 124) with those of patients who received noncoated stents (n = 114). The clinical characteristics and adjunctive medications of the 2 groups were similar. The use of heparin-coated stents was associated with improved 30-day outcome but had no significant effect on 180-day outcome.

Safety and efficacy of a 6 French perclose arterial suturing device following percutaneous coronary interventions: a pilot evaluation.

BACKGROUND: Arterial access site management after percutaneous coronary intervention (PCI) is a matter of increasing importance in this era of potent antiplatelet pharmacotherapy. We evaluated the safety and efficacy of a 6 French (Fr) Perclose suturing device in achieving rapid hemostasis of the access site after PCI and thus improving patient comfort. METHODS: The 6 Fr Perclose (Prostar) device consists of a suture-based closure device delivered via introducer sheath designed for suturing of the arteriotomy puncture site. Over a 3-month period, the device was used in 48 consecutive PCI treated patients (age, 62 13 years; 70% male; 44% post myocardial infarction) and in-hospital groin complication rate was compared to 48 consecutive patients (age, 64 12 years; 64% male; 33% post myocardial infarction) who had manual compression hemostasis. RESULTS: Antiplatelet glycoprotein IIb/IIIa antagonists were used more frequently during and following the procedure in 58% of Perclose-treated patients versus 42% of the manual compression group (p = 0.019). Leg immobilization duration was 3 4 hours in all patients sutured by the device; in patients with manual compression, the sheath was removed at an average of 4.8 2.5 hours after termination of the PCI and an additional 6 hours of leg immobilization were subsequently required. No difference in overall major complication rate was found between groups (6.2% in suture-mediated patients versus 9.3% in manual compression group; p = 0.60). In 3 patients (6.2%) treated using the device, adjunctive manual compression was required in addition to groin suturing due to technical failure or residual oozing from the arteriotomy site. CONCLUSION: The 6 Fr Perclose device can be safely used to achieve rapid hemostasis and the device may hasten bed mobilization of PCI-treated patients despite frequent use of potent antiplatelet pharmacotherapy during coronary interventions.

Coronary bifurcation lesions: to stent one branch or both?

OBJECTIVE: The purpose of this study was to evaluate two different stent placement techniques for bifurcation lesions: 1) stenting of the main branch and balloon dilatation of the sidebranch versus 2) stenting of both branches. BACKGROUND: Percutaneous coronary intervention (PCI) of coronary bifurcation lesions remains challenging, and limited information is available regarding whether stent placement is necessary in both branches of the bifurcation using bare-metal stents. Methods. We prospectively followed all patients who underwent PCI for symptomatic bifurcation lesions at our center. All patients were carefully followed for subsequent clinical events. RESULTS: Between March 2001 and November 2002, a total of 50 patients were treated with either stenting of both vessels (double stent group; n = 32) or stenting of the parent vessel and balloon angioplasty of the sidebranch (single stent group; n = 18). Optimal angiographic success was 87.5% in the single stent group and 100% in the double stent group (p = 0.1). The post-procedure percent diameter stenosis of the sidebranch vessel was significantly higher in the single stent group (18 +/- 25% versus 4 +/- 8%; p = 0.005). At 6 months, the incidence of clinically driven repeat target lesion revascularization was 37.6% with 2 stents as compared to 5.6% using 1 stent (p = 0.01). Angiographic restenosis was documented in 40.6% using 2 bifurcation stents, as compared to 11% when using 1 stent (p = 0.05). By multivariable analysis adjusted for baseline differences, stenting the sidebranch was a borderline predictor for major adverse cardiac events at 6 months (odds ratio = 10.3; 95% confidence interval, 0.9-116; p = 0.053). CONCLUSION: For the treatment of true bifurcation lesions, a strategy of stenting both vessels using bare metal stents seems to be associated with worse long-term results, as compared to stenting only the parent vessel.

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.

Response to prasugrel and levels of circulating reticulated platelets in patients with ST-segment elevation myocardial infarction.

OBJECTIVES: The aim of this study was to determine whether response to prasugrel is associated with the proportion of circulating reticulated platelets (RPs) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Despite better pharmacodynamic properties and clinical efficacy of prasugrel compared with clopidogrel, antiplatelet responses to prasugrel are not uniform. The mechanism of this variability in response is not clear. RPs, young hyperactive forms, are increased during situations of enhanced platelet turnover. METHODS: Patients with STEMI treated with primary percutaneous intervention (PCI) and prasugrel were tested for platelet reactivity using purinergic receptor P2Y, G-protein coupled, 12 (P2Y12) assay and multiple electrode aggregometry (MEA). RP levels were determined using flow cytometry with thiazole orange staining. Tests were performed at 2 to 4 days and 30 days post-PCI. Platelet function was compared by varying levels of RPs, analyzed as continuous (regression analysis) and categorical (tertiles) variables. RESULTS: Sixty-two patients were included (mean age: 57.5 ± 8 years; 21.2% women; 27.7% diabetes). At the early time point, RP levels were strongly correlated with platelet reactivity when evaluated by the P2Y12 assay (Spearman's correlation coefficient: 0.55 for P2Y12 reaction units, -0.49 for percent inhibition) and MEA (Spearman's: 0.50). The upper tertile of RPs displayed higher platelet reactivity compared with the middle and lower tertiles, according to P2Y12 assay and MEA. Similar results with strong correlations between RP and platelet reactivity were noted at 30 days post-PCI. CONCLUSIONS: The proportion of circulating RPs strongly correlates with response to prasugrel in patients with STEMI treated with PCI. High levels of RPs are associated with increased platelet reactivity despite prasugrel treatment.

Clopidogrel response up to six months after acute myocardial infarction.

High on-treatment platelet reactivity (HTPR) despite clopidogrel therapy is associated with adverse cardiac events after acute myocardial infarction (AMI). Most studies to date have assessed clopidogrel response at a single time point before or after percutaneous coronary intervention (PCI). It is unclear, however, whether the HTPR phenotype is stable over time. Therefore, we aimed to examine response to clopidogrel in patients with AMI treated with PCI over a 6-month period. Patients (n = 57) with AMI treated with PCI were assessed for response to clopidogrel at 3 time points: in hospital, 30 days, and 6 months after index hospitalization. Response to clopidogrel was determined by the VerifyNow P2Y12 assay (reported as P2Y12 response units) and multiple electrode aggregometry (MEA; reported as aggregation units). HTPR was defined as ≥235 P2Y12 response units or ≥47 aggregation units. Patients' mean age was 54.5 ± 10.9 years, 91% were men, 19% had diabetes, and 74% were admitted with ST-segment elevation MI. HTPR based on MEA was observed in 22.8% of patients in hospital, 26.3% at 30 days, and 17.5% at 6 months (p = NS). HTPR based on the VerifyNow assay was observed in 38.6% of patients in hospital, 28.1% at 30 days, and 33.3% at 6 months (p = NS). Individual HTPR phenotypic assignment at baseline was stable in 73.7% (based on MEA) and 70.2% (based on VerifyNow) of patients at 6-month follow-up. In conclusion, this is the first study evaluating the stability of clopidogrel response over time after AMI. Rates of HTPR to clopidogrel therapy appear to be relatively stable up to 6 months after AMI.

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.

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.