Intra-aortic balloon counterpulsation in patients with acute myocardial infarction without cardiogenic shock. A meta-analysis of randomized trials.

BACKGROUND: Conflicting data on intra-aortic balloon counterpulsation (IABC) as adjunctive therapy in high-risk acute myocardial infarction (AMI) without cardiogenic shock (CS) have been published. We performed a meta-analysis of randomized trials evaluating the benefits of IABC in patients with AMI without CS. METHODS: We searched Medline, EMBASE, the Cochrane Central Register of Controlled Trials, and relevant Web sites for randomized trials comparing IABC versus no IABC in patients with AMI without CS. No language, publication date, or publication status restrictions were applied. Primary end point was all-cause death. Secondary end points were congestive heart failure (CHF), reinfarction, recurrent myocardial ischemia, cerebrovascular accidents (CVA), and bleeding (moderate to severe) according to per protocol definitions. RESULTS: Six trials were included (1,054 patients, 49.1% IABC vs 50.9% no IABC). At follow-up, counterpulsation does not reduce all-cause death (4.4% vs 4.1%, odds ratio [OR] [95% CI] 1.11 [0.49-2.54], P = .80), CHF (17.1% vs 18%, OR 0.92 [0.43-1.96], P = .83), or reinfarction (5.3% vs 7.7%, OR 0.68 [0.23-1.76], P = .42). Intra-aortic balloon counterpulsation versus no IABC significantly reduces recurrent myocardial ischemia (3.6% vs 20.3%, OR 0.15 [0.08-0.28], P < .00001), but it increases the risk of CVA (2% vs 0.3%, OR 4.39 [1.11-17.36], P = .03) and bleeding (21.4% vs 16.1%, respectively, OR 1.46 [1.05-2.04], P = .02). CONCLUSIONS: Counterpulsation does not reduce death, CHF, or reinfarction in patients with AMI without CS. The significant reduction of recurrent myocardial ischemia associated with IABC use is offset by a higher risk of CVAs and bleeding.

Angiographic outcomes with biodegradable polymer and permanent polymer drug-eluting stents.

BACKGROUND: In the Intracoronary Stenting and Angiographic Results: Test Efficacy of 3 Limus-Eluting Stents (ISAR-TEST-4) trial, we demonstrated the noninferiority of biodegradable polymer (BP) sirolimus-eluting stent to permanent polymer (PP) sirolimus/everolimus-eluting stent (Cypher/Xience-V) on the basis of clinical outcomes. In this study, we compare the antirestenotic efficacy of these stents in ISAR-TEST-4 patients with paired angiographic studies. METHODS: Patients with de novo coronary lesions in native vessels (excluding left main lesions) were randomly assigned to receive a BP stent or a PP stent. Endpoints of interest of this study were in-stent late lumen loss, in-segment binary restenosis, and restenosis morphology at 6-8-month follow-up angiogram. RESULTS: Of the 2,603 patients (3,372 lesions) enrolled in ISAR TEST-4 trial, 2,016 patients (2,637 lesions) underwent repeat angiographic examination 6-8 months after randomization: 1,006 patients (1,323 lesions) treated with BP stents and 1,010 patients (1,314 lesions) treated with PP stents. No difference was observed between BP and PP stents in in-stent late lumen loss (0.24 ± 0.6 vs. 0.26 ± 0.5 mm, respectively, P = 0.49) or in in-segment binary restenosis (11.6% [153 lesions] vs. 11.8% [155 lesions], P = 0.85). Focal pattern of restenosis was observed in the majority of patients receiving either BP or PP stents. The diffuse pattern of restenosis was observed in 26.8% of patients treated with BP stent and 26.5% of patients treated with PP stent (P = 0.79). CONCLUSION: Angiographic characteristics of restenosis after BP-based limus-eluting stents are similar to those of PP-based limus-eluting stents.

Prognostic value of uric acid in patients with acute coronary syndromes.

The association between uric acid and cardiovascular disease is incompletely understood. In particular, the prognostic value of uric acid in patients with acute coronary syndromes who undergo percutaneous coronary intervention has not been studied. This study included 5,124 patients with acute coronary syndromes who underwent percutaneous coronary intervention: 1,629 with acute ST-segment elevation myocardial infarction, 1,332 with acute non-ST-segment elevation myocardial infarction, and 2,163 with unstable angina. The primary end point was 1-year mortality. Patients were divided into quartiles according to uric acid level as follows: quartile 1, 1.3 to <5.3 mg/dl; quartile 2, 5.3 to <6.3 mg/dl; quartile 3, 6.3 to <7.5 mg/dl; and quartile 4, 7.5 to 18.4 mg/dl. There were 450 deaths during follow-up: 80 deaths in quartile 1, 77deaths in quartile 2, 72 deaths in quartile 3, and 221 deaths in quartile 4 of uric acid (Kaplan-Meier estimates of 1-year mortality 6.4%, 6.2%, 5.6%, and 17.4%, respectively; unadjusted hazard ratio 3.05, 95% confidence interval 2.54 to 3.67, p <0.001 for fourth vs first quartile of uric acid). After adjustment for traditional cardiovascular risk factors, renal function, and inflammatory status, the association between uric acid and mortality remained significant, with a 12% increase in the adjusted risk for 1-year mortality for every 1 mg/dl increase in the uric acid level. Uric acid improved the discriminatory power of the predictive model regarding 1-year mortality (absolute integrated discrimination improvement 0.008, p = 0.005). In conclusion, elevated levels of uric acid are an independent predictor of 1-year mortality across the whole spectrum of patients with acute coronary syndromes treated with percutaneous coronary intervention.