Assuntos
Adenosina , Angioplastia Coronária com Balão , Angiografia Coronária/métodos , Oclusão Coronária/diagnóstico por imagem , Tomografia Computadorizada Espiral , Vasodilatadores , Doença Crônica , Oclusão Coronária/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos TestesAssuntos
Biomarcadores/sangue , Técnicas de Imagem Cardíaca , Doenças Cardiovasculares/diagnóstico , Testes de Função Cardíaca , Programas de Rastreamento , Índice Tornozelo-Braço , Doenças Assintomáticas , Artéria Braquial/fisiologia , Doenças Cardiovasculares/sangue , Doenças Cardiovasculares/fisiopatologia , Artérias Carótidas/diagnóstico por imagem , Complicações do Diabetes/diagnóstico , Elasticidade , Testes Genéticos , Humanos , Lipoproteínas/sangue , Anamnese , Pulso Arterial , Medição de Risco , Fatores de Risco , Túnica Íntima/diagnóstico por imagem , Ultrassonografia , VasodilataçãoRESUMO
OBJECTIVES: We sought to examine angiographic and clinical outcomes with sirolimus-eluting stents (SES) in total coronary occlusion (TCO) revascularization. BACKGROUND: Despite evaluation of drug-eluting stents beyond approved indications, few studies have evaluated their clinical benefit in TCO revascularization. METHODS: Among 15 centers in North America, 200 consecutive TCO patients (78.8% >6 weeks TCO age) were enrolled for treatment with SES. The primary end point was 6-month angiographic binary restenosis within the treated segment. RESULTS: Patient characteristics included: diabetes, 24.5%; prior infarction, 33.5%; and stent length, 45.9 mm median (quartile 1, 30.2 mm; quartile 2, 62.1 mm). A total of 199 patients (99.5%) were treated with SES, and procedural success was 98.0%. The 6-month binary restenosis rates were 9.5% in-stent, 12.4% in-segment, and 22.6% in-"working length" representing the entire treatment segment. Rates of 1-year target lesion revascularization, myocardial infarction, and target vessel failure were 9.8%, 1.0%, and 10.9%, respectively. Stent thrombosis occurred in 2 patients (1.0%). Using logistic regression modeling with propensity score adjustment, the absolute reduction in binary restenosis with SES compared with a historical bare-metal stent control was 37.7% (95% confidence interval [CI]: 27.2% to 48.3%, p < 0.001; odds ratio: 0.17, 95% CI: 0.09 to 0.30, p < 0.0001). Among 32 patients (16%) identified with stent fracture, target lesion revascularization was more common than patients without fracture (25.0% vs. 6.7%, p = 0.005). CONCLUSIONS: Despite greater lesion complexity than prior TCO trials, percutaneous revascularization with SES appears safe and results in substantial reductions in angiographic restenosis and failed patency and a low rate of repeat revascularization. These findings support the use of SES in TCO revascularization. (The ACROSS/TOSCA Trial; NCT00378612).
Assuntos
Reestenose Coronária/terapia , Vasos Coronários/efeitos dos fármacos , Stents Farmacológicos , Imunossupressores/uso terapêutico , Sirolimo/uso terapêutico , Idoso , Intervalos de Confiança , Angiografia Coronária , Doença da Artéria Coronariana/tratamento farmacológico , Doença da Artéria Coronariana/metabolismo , Doença da Artéria Coronariana/terapia , Reestenose Coronária/tratamento farmacológico , Vasos Coronários/patologia , Feminino , Indicadores Básicos de Saúde , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Estudos Prospectivos , Grau de Desobstrução VascularRESUMO
BACKGROUND: Primary percutaneous coronary angioplasty is an effective and widely adopted treatment for acute myocardial infarction. A simple method of determining prognosis after primary percutaneous coronary intervention (PCI) would facilitate appropriate care and expedite hospital discharge. Thus, we determined the prognostic importance of various measures of ST-segment-elevation recovery after primary PCI in a large, contemporary cohort of patients with ST-elevation myocardial infarction. METHODS AND RESULTS: We analyzed ECG data describing the magnitude and extent of ST-segment elevation and deviation before and early after (ie, 30 minutes) primary PCI in the study cohort of 4866 subjects with electrocardiographically high-risk ST-elevation myocardial infarction enrolled in the Assessment of PEXelizumab in Acute Myocardial Infarction (APEX-AMI) trial. Associations among 6 methods for calculating ST-segment recovery, biomarker estimates of infarct size (ie, peak creatine kinase, creatine kinase-MB, and troponin I and T), and prespecified clinical outcomes (ie, rates of 90-day death and 90-day death, heart failure, or shock) were examined. All ST-segment-recovery methods provided strong prognostic information regarding clinical outcomes. A simple ST-segment-recovery method of residual ST-segment elevation measurement in the most affected lead on the post-PCI ECG performed as well as complex methods that required comparison of pre- and post-PCI ECGs or calculation of summed ST-segment deviation in multiple leads (ie, worst-lead residual ST elevation: adjusted hazard ratio for 90-day death rate [reference <1 mm]: 1 to <2 mm, 1.23 [95% CI 0.74 to 2.03]; > or =2 mm, 2.22 [95% CI 1.35 to 3.65], corrected c-index=0.832; 90-day death/congestive heart failure/shock [reference <1 mm]: 1 to <2 mm, 1.55 [95% CI 1.06 to 2.26]; > or =2 mm, 2.33 [95% CI 1.59 to 3.41], corrected c-index=0.802). Biomarker estimates of infarct size declined in association with enhanced ST-segment recovery. CONCLUSIONS: An ECG performed early after primary PCI is a simple, widely available, inexpensive, and powerful prognostic tool applicable to patients with ST-elevation myocardial infarction.
Assuntos
Angioplastia Coronária com Balão/mortalidade , Anticorpos Monoclonais/administração & dosagem , Eletrocardiografia , Infarto do Miocárdio , Idoso , Anticorpos Monoclonais Humanizados , Estudos de Coortes , Terapia Combinada , Feminino , Insuficiência Cardíaca/mortalidade , Humanos , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Valor Preditivo dos Testes , Prognóstico , Recuperação de Função Fisiológica , Choque Cardiogênico/mortalidade , Anticorpos de Cadeia Única , Resultado do TratamentoRESUMO
BACKGROUND: Rescue percutaneous coronary intervention (PCI) is efficacious after clinical failure of fibrinolytic therapy and is recommended for those with persistent ischemia, hemodynamic, or electrical instability. We sought to describe the frequency of fibrinolytic failure (rescue eligibility) as well as the patient characteristics associated with rescue eligibility, rescue referral, and PCI. METHODS AND RESULTS: Eligibility, indication, and referral for guideline-based rescue PCI were adjudicated in 221 patients enrolled in the WEST trial. WEST treated patients at earliest medical contact and used a tenectaplase/enoxaparin regimen. Ninety patients (41%) were adjudicated with acute myocardial infarction as rescue eligible of whom 68 were referred for rescue PCI. Baseline characteristics did not predict rescue eligibility or referral. Emergency angiography before PCI performed a median of 82 minutes (interquartile range 50-99) after rescue referral showed TIMI flow grade 2 or 3 in 34 (50%). Percutaneous coronary intervention was adjudicated as successful in 58 of 60 attempts. Procedures began approximately 45 minutes sooner in patients initially admitted to PCI-capable hospitals. Compared to those with clinically successful fibrinolytic therapy, rescue eligible patients demonstrated higher median peak creatine phosphokinase (1889 [1243-3746] vs 999 [440-2048], P < .01) and 30-day median NT-proBNP levels (748 [391-1916] vs 431 [153-1016], P < .01). CONCLUSIONS: Rescue eligibility determined by guideline criteria is common after contemporary fibrinolysis and is not predicted by conventional baseline characteristics. Half of rescue-referred patients are patent at angiography: although contemporary PCI success rates are high, rescue eligibility is associated with larger infarctions.