Incidence and outcome of surgical procedures after coronary bare-metal and drug-eluting stent implantation: a report from the CREDO-Kyoto PCI/CABG registry cohort-2.

BACKGROUND: There still remain safety concerns on surgical procedures after coronary drug-eluting stents (DES) implantation, and optimal management of perioperative antiplatelet therapy (APT) has not been yet established. METHODS AND RESULTS: During 3-year follow-up of 12 207 patients (DES=6802 patients and bare-metal stent [BMS] only=5405 patients) who underwent coronary stent implantation in the CREDO-Kyoto registry cohort-2, surgical procedures were performed in 2398 patients (DES=1295 patients and BMS=1103 patients). Surgical procedures (early surgery in particular) were more frequently performed in the BMS group than in the DES group (4.4% versus 1.9% at 42-day and 23% versus 21% at 3-year, log-rank P=0.0007). Cumulative incidences of death/myocardial infarction (MI)/stent thrombosis (ST) and bleeding at 30 days after surgery were low, without differences between BMS and DES (3.5% versus 2.9%, P=0.4 and 3.2% versus 2.1%, P=0.2, respectively). The adjusted risks of DES use relative to BMS use for death/MI/ST and bleeding were not significant (hazard ratio: 1.63, 95% confidence interval: 0.93 to 2.87, P=0.09 and hazard ratio: 0.6, 95% confidence interval: 0.34 to 1.06, P=0.08, respectively). The risks of perioperative single- and no-APT relative to dual-APT for both death/MI/ST and bleeding were not significant; single-APT as compared with dual-APT tended to be associated with lower risk for death/MI/ST (hazard ratio: 0.4, 95% confidence interval: 0.13 to 1.01, P=0.053). CONCLUSIONS: Surgical procedures were commonly performed after coronary stent implantation, and the risk of ischemic and bleeding complications in surgical procedures was low. In patients selected to receive DES or BMS, there were no differences in outcomes. Perioperative administration of dual-APT was not associated with lower risk for ischemic events.

Incidence and outcome of surgical procedures after sirolimus-eluting stent implantation: a report from the j-Cypher registry.

The incidence of surgical procedures after sirolimus-eluting stent (SES) implantation and, more importantly, the rate of perioperative stent thrombosis (ST) and/or other adverse events have not yet been adequately addressed. The incidence and outcome of the surgical procedures after SES implantation were prospectively evaluated in a large-scale multicenter registry of patients undergoing SES implantation. Among 12,824 patients enrolled in the registry, cumulative incidences of surgical procedures were 0.7% at 60 days, 5.1% at 1 year and 14.7% at 3 years. Surgical procedures were performed in 1,430 patients including non-coronary artery bypass graft (CABG) surgery in 1,275 patients and CABG in 189 patients. The incidences of death/myocardial infarction/ST (definite or probable) and ST (definite or probable) at 30 days after surgical procedures were 2.7 and 0.35%, respectively. Surgery performed within 60 days after SES implantation as compared with that performed beyond 60 days was associated with significantly higher incidences of death/myocardial infarction/ST (definite or probable) and ST (definite or probable) at 30 days after surgical procedures (6.4 vs. 2.5%: P = 0.02 and 2.2 vs. 0.23%: P = 0.002, respectively). Surgery within 60 days as well as hemodialysis and small body mass index were independent risk factors of death/myocardial infarction/ST (definite or probable) identified by multivariable analysis. Surgical procedures were required fairly often after SES implantation. The incidences of adverse cardiac events including ST after surgical procedures were acceptably low. Surgery within 60 days after SES implantation carried significantly higher risks as compared with those beyond 60 days.

Ten-year follow-up of familial hypercholesterolemia patients after intensive cholesterol-lowering therapy.

To prevent coronary artery disease, it is necessary for patients with familial hyper-cholesterolemia (FH) to maintain a low cholesterol level. Recently a combination therapy of low-density lipoprotein (LDL) apheresis and statins has been used for FH patients, but their long-term prognosis over 10 years is unknown. In this single center prospective report, 18 FH patients with severe coronary stenosis received LDL apheresis every 2 or 4 weeks and statin therapy for 9.8 +/- 3.0 years. Probucol was given to 17 of the 18 patients. We observed their clinical events as well as coronary stenosis findings and ejection fractions for 10.7 +/- 2.6 years. Total and LDL cholesterol levels before therapy were 345 +/- 46 and 277 +/- 48 mg/dL, respectively. Immediately following LDL-apheresis, these levels decreased to 104 +/- 7.5 and 66 +/- 16 mg/dL, respectively. There were no cardiac deaths and 4 patients were free from any coronary events. There was one noncardiac death. Nonfatal myocardial in-farction occurred in 2 patients and coronary bypass surgery was required in one patient. Twelve patients received additional coronary angioplasty. There was little change in coronary stenosis and ejection fraction following 10 years of the combination therapy. Univariate Cox regression analysis revealed that the calculated mean LDL cholesterol level was the predictive value of treatment efficacy (mean LDL cholesterol < 140 mg/dL, hazard ratio 0.23, P = 0.028). The combination therapy of LDL-apheresis and antilipid drugs delayed the progression of coronary atherosclerosis and prevented a major cardiac event, although complete inhibition was limited to a small group. Additional coronary angioplasty is likely to be required for a favorable clinical outcome in FH patients.

Differentiation between patients with takotsubo cardiomyopathy and those with anterior acute myocardial infarction.

BACKGROUND: There has not been a comparison of the electrocardiographic (ECG) finding of ST-segment elevation in the precordial leads in patients with takotsubo cardiomyopathy (TC) and those with anterior acute myocardial infarction (AMI), with regard to the location of the culprit lesion. METHODS AND RESULTS: The present study evaluated 18 patients with TC, and 85 with anterior AMI who were divided into 3 groups: group A had the culprit lesion proximal to both the first septal branch (S1) and the first diagonal branch (D1), group B had the culprit lesion proximal to either S1 or D1, and group C had the culprit lesion distal to both S1 and D1. In patients with TC, reciprocal ST-segment depression in the inferior leads was observed less frequently than in patients in groups A (p<0.0001) and B (p=0.0002), and abnormal Q waves and ST-segment elevation in the inferior leads were observed more frequently than in group A (p=0.0007, p=0.0057, respectively). The ECG findings in TC did not differ from those in group C. CONCLUSION: Electrocardiographic findings may differentiate TC from AMI with a proximal lesion of left anterior descending coronary artery, but not those with distal lesions.