Lifelong Aspirin for All in the Secondary Prevention of Chronic Coronary Syndrome: Still Sacrosanct or Is Reappraisal Warranted?

Four decades have passed since the first trial suggesting the efficacy of aspirin in the secondary prevention of myocardial infarction. Further trials, collectively summarized by the Antithrombotic Trialists' Collaboration, solidified the historical role of aspirin in secondary prevention. Although the benefit of aspirin in the immediate phase after a myocardial infarction remains incontrovertible, a number of emerging lines of evidence, discussed in this narrative review, raise some uncertainty as to the primacy of aspirin for the lifelong management of all patients with chronic coronary syndrome (CCS). For example, data challenging the previously unquestioned role of aspirin in CCS have come from recent trials where aspirin was discontinued in specific clinical scenarios, including early discontinuation of the aspirin component of dual antiplatelet therapy after percutaneous coronary intervention and the withholding of aspirin among patients with both CCS and atrial fibrillation who require anticoagulation. Recent primary prevention trials have also failed to consistently demonstrate net benefit for aspirin in patients treated to optimal contemporary cardiovascular risk factor targets, indicating that the efficacy of aspirin for secondary prevention of CCS may similarly have changed with the addition of more modern secondary prevention therapies. The totality of recent evidence supports further study of the universal need for lifelong aspirin in secondary prevention for all adults with CCS, particularly in stable older patients who are at highest risk for aspirin-induced bleeding.

Drug-eluting or bare-metal stents for percutaneous coronary intervention: a systematic review and individual patient data meta-analysis of randomised clinical trials.

BACKGROUND: New-generation drug-eluting stents (DES) have mostly been investigated in head-to-head non-inferiority trials against early-generation DES and have typically shown similar efficacy and superior safety. How the safety profile of new-generation DES compares with that of bare-metal stents (BMS) is less clear. METHODS: We did an individual patient data meta-analysis of randomised clinical trials to compare outcomes after implantation of new-generation DES or BMS among patients undergoing percutaneous coronary intervention. The primary outcome was the composite of cardiac death or myocardial infarction. Data were pooled in a one-stage random-effects meta-analysis and examined at maximum follow-up and a 1-year landmark. Risk estimates are reported as hazard ratios (HRs) with 95% CIs. This study is registered in PROSPERO, number CRD42017060520. FINDINGS: We obtained individual data for 26 616 patients in 20 randomised trials. Mean follow-up was 3·2 (SD 1·8) years. The risk of the primary outcome was reduced in DES recipients compared with BMS recipients (HR 0·84, 95% CI 0·78-0·90, p<0·001) owing to a reduced risk of myocardial infarction (0·79, 0·71-0·88, p<0·001) and a possible slight but non-significant cardiac mortality benefit (0·89, 0·78-1·01, p=0·075). All-cause death was unaffected (HR with DES 0·96, 95% CI 0·88-1·05, p=0·358), but risk was lowered for definite stent thrombosis (0·63, 0·50-0·80, p<0·001) and target-vessel revascularisation (0·55, 0·50-0·60, p<0·001). We saw a time-dependent treatment effect, with DES being associated with lower risk of the primary outcome than BMS up to 1 year after placement. While the effect was maintained in the longer term, there was no further divergence from BMS after 1 year. INTERPRETATION: The performance of new-generation DES in the first year after implantation means that BMS should no longer be considered the gold standard for safety. Further development of DES technology should target improvements in clinical outcomes beyond 1 year. FUNDING: Bern University Hospital.

Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients.

BACKGROUND: Although transcatheter aortic-valve replacement (TAVR) is an accepted alternative to surgery in patients with severe aortic stenosis who are at high surgical risk, less is known about comparative outcomes among patients with aortic stenosis who are at intermediate surgical risk. METHODS: We evaluated the clinical outcomes in intermediate-risk patients with severe, symptomatic aortic stenosis in a randomized trial comparing TAVR (performed with the use of a self-expanding prosthesis) with surgical aortic-valve replacement. The primary end point was a composite of death from any cause or disabling stroke at 24 months in patients undergoing attempted aortic-valve replacement. We used Bayesian analytical methods (with a margin of 0.07) to evaluate the noninferiority of TAVR as compared with surgical valve replacement. RESULTS: A total of 1746 patients underwent randomization at 87 centers. Of these patients, 1660 underwent an attempted TAVR or surgical procedure. The mean (±SD) age of the patients was 79.8±6.2 years, and all were at intermediate risk for surgery (Society of Thoracic Surgeons Predicted Risk of Mortality, 4.5±1.6%). At 24 months, the estimated incidence of the primary end point was 12.6% in the TAVR group and 14.0% in the surgery group (95% credible interval [Bayesian analysis] for difference, -5.2 to 2.3%; posterior probability of noninferiority, >0.999). Surgery was associated with higher rates of acute kidney injury, atrial fibrillation, and transfusion requirements, whereas TAVR had higher rates of residual aortic regurgitation and need for pacemaker implantation. TAVR resulted in lower mean gradients and larger aortic-valve areas than surgery. Structural valve deterioration at 24 months did not occur in either group. CONCLUSIONS: TAVR was a noninferior alternative to surgery in patients with severe aortic stenosis at intermediate surgical risk, with a different pattern of adverse events associated with each procedure. (Funded by Medtronic; SURTAVI ClinicalTrials.gov number, NCT01586910 .).

Percutaneous Alginate Hydrogel Endomyocardial Injection with a Novel Dedicated Catheter Delivery System: An Animal Feasibility Study.

The objective of this preclinical study was to evaluate the feasibility and safety of transcatheter endocardial alginate hydrogel injection (TEAi) in a large animal model, utilizing the high-stiffness XDROP® alginate hydrogel in combination with the dedicated EndoWings® catheter-based system. All swine (n = 9) successfully underwent TEAi without complications. Acute results from a subset of animals (n = 5) demonstrated the ability of the catheter to access a wide range of endomyocardial areas and achieve consecutive circumferential hydrogel distribution patterns within the mid-left ventricular wall. Histological examinations at 6 months (n = 4) demonstrated that the XDROP® remained localized within the cardiac tissue. In addition, serial echocardiographic imaging showed that XDROP® had no adverse impacts on LV systolic and diastolic functions. In conclusion, this innovative combination technology has the potential to overcome the translational barriers related to alginate hydrogel delivery to the myocardium.

Late cardiac remodeling after primary percutaneous coronary intervention-five-year cardiac magnetic resonance imaging follow-up.

BACKGROUND: Primary percutaneous coronary intervention (PPCI) preserves function and improves survival. The late effects of PPCI on left ventricular remodeling, however, have not yet been investigated on cardiac magnetic resonance imaging (CMRI). METHODS AND RESULTS: Twenty-five patients with acute myocardial infarction (AMI) treated with PPCI underwent CMRI within 10 days, at 4 months and at 5 years. Left ventricular ejection fraction (LVEF), end-diastolic volume (EDV) and end-systolic volume were quantified on cine images. Infarct mass and transmural extent of infarction were quantified on contrast-enhanced imaging. In all patients EDV increased significantly in the early phase (192 ± 40 ml to 211 ± 49 ml, P ≤ 0.01) and LVEF improved significantly (42 ± 9% to 46 ± 9%, P=0.02). In the late phase (>4 months) no significant changes were observed (LVEF 44 ± 9%, P=0.07; EDV 216 ± 68 ml, P=0.38). Three different groups could be identified. One-third (32%) had no dilatation at all; one-third (32%) had limited dilatation at 4 months without progression later; and 36% had progressive dilatation both at 4 months and at late follow-up. This third group had an average increase in EDV of 20% in the acute phase followed by an additional 13%. The strongest predictor for progressive dilatation was infarct mass. CONCLUSIONS: Even in the era of PPCI for AMI followed by optimal medical therapy, one-third of patients had progressive dilatation, which was best predicted by infarct mass.

Contextualizing National Policies Regulating Access to Low-Dose Aspirin in America and Europe Using the Full Report of a Transatlantic Patient Survey of Aspirin in Preventive Cardiology.

Background Aspirin is widely administered to prevent cardiovascular disease (CVD). However, appropriate use of aspirin depends on patient understanding of its risks, benefits, and indications, especially where aspirin is available over the counter (OTC). Methods and Results We did a survey of patient-reported 10-year cardiovascular risk; aspirin therapy status; form of aspirin access (OTC versus prescription); and knowledge of the risks, benefits, and role of aspirin in CVD prevention. Consecutive adults aged ≥50 years with ≥1 cardiovascular risk factor attending outpatient clinics in America and Europe were recruited. We also systematically reviewed national policies regulating access to low-dose aspirin for CVD prevention. At each site, 150 responses were obtained (300 total). Mean±SD age was 65±10 years, 40% were women, and 41% were secondary prevention patients. More than half of the participants at both sites did not know (1) their own level of 10-year CVD risk, (2) the expected magnitude of reduction in CVD risk with aspirin, or (3) aspirin's bleeding risks. Only 62% of all participants reported that aspirin was routinely indicated for secondary prevention, whereas 47% believed it was routinely indicated for primary prevention (P=0.048). In America, 83.5% participants obtained aspirin OTC compared with 2.5% in Europe (P<0.001). Finally, our review of European national policies found only 2 countries where low-dose aspirin was available OTC. Conclusions Many patients have poor insight into their objectively calculated 10-year cardiovascular risk and do not know the risks, benefits, and role of aspirin in CVD prevention. Aspirin is mainly obtained OTC in America in contrast to Europe, where most countries restrict access to low-dose aspirin.

Drug-Eluting or Bare-Metal Stents for Left Anterior Descending or Left Main Coronary Artery Revascularization.

Background New-generation drug-eluting stents (DES) reduce target-vessel revascularization compared with bare-metal stents (BMS), and recent data suggest that DES have the potential to decrease the risk of myocardial infarction and cardiovascular mortality. We evaluated the treatment effect of DES versus BMS according to the target artery (left anterior descending [LAD] and/or left main [LM] versus other territories [no-LAD/LM]). Methods and Results The Coronary Stent Trialist (CST) Collaboration gathered individual patient data of randomized trials of DES versus BMS for the treatment of coronary artery disease. The primary outcome was the composite of cardiac death or myocardial infarction. Hazard ratios (HRs) with 95% CIs were derived from a 1-stage individual patient data meta-analysis. We included 26 024 patients across 19 trials: 13 650 (52.4%) in the LAD/LM and 12 373 (47.6%) in the no-LAD/LM group. At 6-year follow-up, there was strong evidence that the treatment effect of DES versus BMS depended on the target vessel (P-interaction=0.024). Compared with BMS, DES reduced the risk of cardiac death or myocardial infarction to a greater extent in the LAD/LM (HR, 0.76; 95% CI, 0.68-0.85) than in the no-LAD/LM territories (HR, 0.93; 95% CI, 0.83-1.05). This benefit was driven by a lower risk of cardiac death (HR, 0.83; 95% CI, 0.70-0.98) and myocardial infarction (HR, 0.74; 95% CI, 0.65-0.85) in patients with LAD/LM disease randomized to DES. An interaction (P=0.004) was also found for all-cause mortality with patients with LAD/LM disease deriving benefit from DES (HR, 0.86; 95% CI, 0.76-0.97). Conclusions As compared with BMS, new-generation DES were associated with sustained reduction in the composite of cardiac death or myocardial infarction if used for the treatment of LAD or left main coronary stenoses. Registration URL: https://www.crd.york.ac.uk/PROSPERO; Unique identifier: CRD42017060520.

Fibrinogen in relation to degree and composition of coronary plaque on intravascular ultrasound in patients undergoing coronary angiography.

OBJECTIVE: The aim of this study was to provide additional insight into the role of fibrinogen in coronary artery disease by investigating the associations between plasma fibrinogen with both degree and composition of coronary atherosclerosis as determined by virtual histology-intravascular ultrasound. PATIENTS AND METHODS: In 581 patients undergoing coronary angiography for acute coronary syndrome (ACS) or stable angina pectoris, preprocedural blood samples were drawn for fibrinogen, C-reactive protein (CRP), interleukin-6, and plasminogen activator inhibitor-1 measurements, and virtual histology-intravascular ultrasound of a nonculprit coronary artery was performed. The degree [plaque volume, plaque burden (PB), and lesions with PB≥70%] and the composition of coronary atherosclerotic plaque (fibrous, fibrofatty, dense calcium, necrotic core tissue, and thin-cap fibroatheroma lesions) were assessed. RESULTS: Fibrinogen showed a tendency toward a positive association with PB [ß (95% CI): 2.55 (-0.52-5.61) increase in PB per ln(g/l) fibrinogen, P=0.09], which was driven significantly by an association in the ACS subgroup [ß (95% CI): 4.11 (0.01-8.21) increase in PB per ln(g/l) fibrinogen, P=0.049]. Fibrinogen was also related to the presence of lesions with PB 70% or more in both the full cohort [OR (95% CI): 2.27 (1.17-4.43), P=0.016] and ACS patients [OR (95% CI): 2.92 (1.17-7.29), P=0.022]. All associations were independent of established cardiovascular risk factors, but not CRP. Interleukin-6 and plasminogen activator inhibitor-1 did not provide incremental value to fibrinogen when examining the associations with degree of atherosclerosis. Substantial associations with plaque composition were absent. CONCLUSION: Fibrinogen is associated with degree of coronary atherosclerosis, especially in ACS patients. However, whether this association is independent of CRP might be questioned and needs further investigation.

Current percutaneous coronary intervention and coronary artery bypass grafting practices for three-vessel and left main coronary artery disease. Insights from the SYNTAX run-in phase.

OBJECTIVE: Percutaneous coronary intervention with drug-eluting stents is challenging coronary artery bypass grafting (CABG) as the gold standard for treatment of three-vessel and left main coronary disease. We evaluated the current practice pattern in hospitals throughout Europe and USA. METHODS: To qualify for participation in the SYNTAX (Synergy between PCI with TAXUS drug-eluting stent and Cardiac Surgery) study, a randomized trial comparing percutaneous coronary intervention with drug-eluting stent versus coronary artery bypass grafting for three-vessel and left main disease, 104 centers were asked to provide their case volume in 3 months in 2004. Anonymous procedural data were collected. RESULTS: A total of 12,072 patients were recorded. Coronary artery bypass grafting was the most frequently performed procedure (N=8895, 74%). Three-vessel disease (3VD) predominated in this population (N=8532, 71%) versus left main (N=3540, 29%). In the 3-month period, per center a mean of 8.3 patients with left main and 22.3 patients with three-vessel disease were treated by percutaneous coronary intervention, while 26.0 patients with left main and 60.3 patients with three-vessel disease were treated by coronary artery bypass grafting. In USA, percutaneous coronary intervention for left main and/or three-vessel disease was performed in 18% of the cases while this was performed in 29% of the cases in Europe. Of all CABG procedures, only 12% were done with total arterial grafting while 7% were treated with only venous grafts. CONCLUSIONS: In patients with multivessel or left main disease, still coronary artery bypass grafting remains the dominant revascularization strategy. Percutaneous coronary intervention is performed frequently without supporting data from the literature. Percutaneous coronary intervention for this indication is performed more often in Europe than in USA. Only a minority of the patients receives total arterial grafting in case of coronary artery bypass grafting. The SYNTAX trial with randomized and registry cohorts should provide guidance for selecting the preferred form of treatment.

A granular approach to improve reproducibility of the echocardiographic assessment of paravalvular regurgitation after TAVI.

Paravalvular leak (PVL) after transcatheter aortic valve implantation (TAVI) is challenging to quantitate. Transthoracic echocardiography (TTE) is the main tool used for the assessment of PVL but is modestly reproducible. We sought to develop a reproducible echocardiographic approach to assess PVL in the post-TAVI setting. Four observers independently analyzed eleven parameters of PVL severity in 50 pre-discharge TTE studies performed after TAVI. The parameters included color-Doppler parameters [jet circumferential extent (CE) and planimetered vena contracta area in the short-axis view and jet breadth and qualitative features in the long-axis views], continuous-wave Doppler parameters [jet velocity time integral (VTI) and pressure half time (PHT)], quantitative Doppler parameters (regurgitation volume and fraction and effective regurgitant orifice area), aortic diastolic flow reversal and valve stent eccentricity. Intraclass correlation coefficient (ICC) and coefficient of variation (CV) for numerical parameters and kappa coefficient (κ) for categorical parameters were calculated for inter- and intra-observer comparisons. Inter-observer ICC was highest and CV lowest for CE (0.88 and 0.36), jet origin breadth (0.82 and 0.39), jet qualitative features in long-axis views (0.87 and 0.26), jet VTI (0.87 and 0.04) and PHT (0.73 and 0.10). Similar results were found in intra-observer comparisons. A 2-step granular approach combining the most reproducible parameters was used to grade PVL by the four observers. Inter-observer agreement was achieved in 86 % of cases (κ = 0.79). Combining color Doppler and continuous wave Doppler parameters in a granular algorithm yields excellent reproducibility of PVL assessment by TTE.

Haptoglobin polymorphism in relation to coronary plaque characteristics on radiofrequency intravascular ultrasound and near-infrared spectroscopy in patients with coronary artery disease.

BACKGROUND: Conflicting results exist regarding the association between a common Haptoglobin (Hp) polymorphism and risk of coronary artery disease. We investigated the association of three functionally different anti-oxidant and anti-inflammatory Hp phenotypes (Hp1-1, Hp2-1, Hp2-2) with invasively measured degree and composition of coronary atherosclerosis as determined by intravascular ultrasound (-virtual histology) (IVUS(-VH)) as well as near-infrared spectroscopy (NIRS). METHODS: Non-culprit coronary artery segments of 581 patients with acute coronary syndrome (ACS) or stable angina pectoris were imaged with IVUS(-VH). In 203 patients, the segments were also imaged with NIRS. Pre-procedural blood samples were drawn for Hp phenotyping. Degree (segment plaque volume, segment plaque burden (PB); presence of lesions with PB≥70%) and composition (segment fractions of fibrous, fibro-fatty, dense calcium, and necrotic core tissue; presence of IVUS-VH derived thin-cap fibroatheroma lesions) of coronary atherosclerosis were measured. RESULTS: No differences were present between the three Hp phenotypes with regard to degree and composition of coronary atherosclerosis in the full cohort. However, ACS patients with a Hp2-1 or Hp2-2 phenotype had a higher segment PB percentage (ß[95% CI]: 3.88[0.31-7.44], p=0.033), increased prevalence of lesions with PB≥70% (OR[95% CI]: 3.61[1.06-12.30], p=0.040), and a tendency towards a higher segment plaque volume (ß[95% CI]: 1.29[-0.04-2.62], p=0.056) in multivariable analyses. CONCLUSIONS: Although in the full cohort no associations could be demonstrated between Hp phenotypes and plaque characteristics, a significant association was present between phenotypes resulting from a genotype containing a Hp2 allele (Hp2-1 or Hp2-2) and a higher degree of atherosclerosis in patients with ACS.

Diagnostic and Prognostic Implications of Coronary Flow Capacity: A Comprehensive Cross-Modality Physiological Concept in Ischemic Heart Disease.

OBJECTIVES: The purpose of this study is to evaluate whether coronary flow capacity (CFC) improves discrimination of patients at risk for major adverse cardiac events (MACE) compared with coronary flow reserve (CFR) alone, and to study the diagnostic and prognostic implications of CFC in relation to contemporary diagnostic tests for ischemic heart disease (IHD), including fractional flow reserve (FFR). BACKGROUND: Although IHD results from a combination of focal obstructive, diffuse, and microcirculatory involvement of the coronary circulation, its diagnosis remains focused on focal obstructive causes. CFC comprehensively documents flow impairment in IHD, regardless of its origin, by interpreting CFR in relation to maximal flow (hyperemic average peak flow velocity [hAPV]), and overcomes the limitations of using CFR alone. This is governed by the understanding that ischemia occurs in vascular beds with substantially reduced hAPV and CFR, whereas ischemia is unlikely when hAPV or CFR is high. METHODS: Intracoronary pressure and flow were measured in 299 vessels (228 patients), where revascularization was deferred in 154. Vessels were stratified as having normal, mildly reduced, moderately reduced, or severely reduced CFC using CFR thresholds derived from published data and corresponding hAPV percentiles. The occurrence of MACE after deferral of revascularization was recorded during 11.9 years of follow-up (quartile 1: 10.0 years, quartile 3: 13.4 years). RESULTS: Combining CFR and hAPV improved the prediction of MACE over CFR alone (p = 0.01). After stratification in CFC, MACE rates throughout follow-up were strongly associated with advancing impairment of CFC (p = 0.002). After multivariate adjustment, mildly and moderately reduced CFC were associated with a 2.1-fold (95% confidence interval: 1.1 to 4.0; p = 0.017), and 7.1-fold (95% confidence interval: 2.9 to 17.1; p < 0.001) increase in MACE hazard, respectively, compared with normal CFC. Severely reduced CFC was identified by FFR ≤0.80 in 90% of cases, although ≥40% of vessels with normal or mildly reduced CFC still had an FFR ≤0.80. CONCLUSIONS: CFC provides a cross-modality platform for the diagnosis and risk-stratification of IHD and enriches the interpretation of contemporary diagnostic tests in IHD.

Trial participation as a determinant of clinical outcome: differences between trial-participants and Every Day Clinical Care patients in the field of interventional cardiology.

BACKGROUND: This study examines differences in clinical outcome between trial-participants and non-participants after percutaneous coronary intervention (PCI). METHODS AND RESULTS: This study compromised of 11,931 consecutive patients who underwent PCI in a high volume center, during the period 2000 - 2009. Of these patients, 1787 (15%) participated in an interventional clinical trial with a follow-up period of at least six months. The maximum follow-up duration was 11.8 years, with a median of 3.8 years (IQR: 2.6 - 6.5). Baseline and procedural characteristics differed between trial-participants and non-participants. Trial-participants were more often male, were younger, had more cardiovascular risk factors and were treated more often for stable angina pectoris and single vessel disease. Overall mortality at maximum follow-up was lower for trial-participants compared to non-participants (8.1% versus 17.6%, p<0.001, adjusted HR, 0.62, 95% CI: 0.52-0.74). There was no difference in the incidence of non-fatal MI and CABG. Repeat PCI was seen more often in trial-participants (18.1% versus 30.7%, p<0.001, adjusted HR 1.91, 95%CI 1.73-2.10). Consequently, a higher incidence of the composite of mortality, repeat revascularization, and non-fatal MI was seen in the trail-participants (adjusted HR.1.36 95% CI 1.25 - 1.47), but this association was primarily driven by the occurrence of repeat PCI. CONCLUSION: Participants in clinical trials in the field of interventional cardiology with a follow-up of at least six months differed considerably from non-participants in baseline and procedural characteristics. Trial-participants had better survival than non-participants. In contrast, a two-fold higher incidence of repeat PCI was observed in trial-participants.

Life-years gained by smoking cessation after percutaneous coronary intervention.

Previous studies have shown that smoking cessation after a cardiac event reduces the risk of subsequent mortality in patients. The aim of this study was to describe the effect of smoking cessation in terms of prolonged life-years gained. The study sample comprised 856 patients who underwent percutaneous coronary intervention (PCI; balloon angioplasty) during 1980 to 1985. Patients were followed up for 30 years and smoking status at 1 year could be retrieved in 806 patients. The 27 patients who died within 1 year were excluded from the analysis. The median follow-up was 19.5 years (interquartile range 6.0 to 23.0). Cumulative 30-year survival rate was 29% in the group of patients who quit smoking and 14% in persistent smokers (p = 0.005). After adjustment for baseline characteristics at the time of PCI, smoking cessation remained an independent predictor of lesser mortality (adjusted hazard ratio 0.57, 95% confidence interval 0.46 to 0.71). The estimated life expectancy was 18.5 years in those who quit smoking and 16.4 years in the persistent smokers (p <0.0001). In conclusion, in patients with coronary heart disease who underwent PCI in the late 1980s, smoking cessation resulted in at least 2.1 life-years gained.

Comparison of long-term outcomes in STEMI and NSTE-ACS after coronary stent placement: an analysis in a real world BMS and DES population.

BACKGROUND/OBJECTIVES: The prognostic difference between STEMI and NSTE-ACS after coronary stent placement remains unclear. We aimed to compare the short- and long-term event rates in patients presenting with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation acute coronary syndrome (NSTE-ACS) after percutaneous coronary intervention (PCI) with either bare-metal stents (BMS) or drug-eluting stents (DES). METHODS: Between 2000 and 2005 a total of 1749 STEMI and 1921 NSTE-ACS patients received either a BMS or DES in consecutive real world cohorts. Descriptive statistics and multivariate survival analyses were applied to compare the event rates in STEMI and NSTE-ACS during 4 years follow-up. RESULTS: NSTE-ACS patients had significantly higher clinical and angiographic risk profiles at baseline and were treated with less optimal medical therapy during follow-up. At 4 years follow-up, all-cause mortality was significantly higher in STEMI compared to NSTE-ACS after coronary stent placement (17.4% vs. 14.3%; HR 1.60, 95% CI 1.24-2.07). In a landmark analysis no difference was seen in all-cause mortality among STEMI en NSTE-ACS between 1 month and 4 years follow-up (HR 1.10, 95% CI 0.81-1.51). Cardiac death was more prevalent in STEMI patients, while the 4-year cumulative incidences of any myocardial infarction, any coronary revascularization, target lesion revascularization and definite stent thrombosis were similar in both ACS groups. CONCLUSIONS: Patients presenting with STEMI have a worse long-term prognosis compared to NSTE-ACS after coronary stent placement, due to higher short-term death rates. However, after the first month STEMI and NSTE-ACS patients have a comparable long-term survival.

Final results of the HEALING IIB trial to evaluate a bio-engineered CD34 antibody coated stent (Genous™Stent) designed to promote vascular healing by capture of circulating endothelial progenitor cells in CAD patients.

OBJECTIVE: To assess the safety and efficacy of the Genous™ endothelial progenitor cell (EPC) capturing stent in conjunction with HmG-CoA-reductase inhibitors (statins) to stimulate EPC recruitment, in the treatment of patients with de novo coronary artery lesions. METHODS AND RESULTS: The HEALING IIB study was a multi-center, prospective trial, including 100 patients. The primary efficacy endpoint was late luminal loss by QCA at 6-month follow-up (FU). Although statin therapy increased relative EPC levels by 5.6-fold, the angiographic outcome at 6 month FU was not improved in patients with an overall in-stent late luminal loss of 0.76±0.50 mm. The composite major adverse cardiac events (MACE) rate was 9.4%, whereas 6.3% clinically justified target lesion revascularizations (TLRs) were observed. 2 Patients died within the first 30 days after stent implantation due to angiographically verified in-stent thrombosis. At 12 month FU, MACE and TLR increased to 15.6% and 11.5% respectively and stabilized until 24 month FU. 18 Month angiographic FU showed a significant decrease in late luminal loss (0.67±0.54, 11.8% reduction or 10% by matched serial analysis, P=0.001). CONCLUSION: The HEALING IIB study suggests that statin therapy in combination with the EPC capture stent does not contribute to a reduction of in-stent restenosis formation for the treatment of de novo coronary artery disease. Although concomitant statin therapy was able to stimulate EPC recruitment, it did not improve the angiographic outcome of the bio-engineered EPC capture stent. Remarkably, angiographic late loss was significantly reduced between 6 and 18 months.

Stabilisation of atherosclerotic plaques. Position paper of the European Society of Cardiology (ESC) Working Group on atherosclerosis and vascular biology.

Plaque rupture and subsequent thrombotic occlusion of the coronary artery account for as many as three quarters of myocardial infarctions. The concept of plaque stabilisation emerged about 20 years ago to explain the discrepancy between the reduction of cardiovascular events in patients receiving lipid lowering therapy and the small decrease seen in angiographic evaluation of atherosclerosis. Since then, the concept of a vulnerable plaque has received a lot of attention in basic and clinical research leading to a better understanding of the pathophysiology of the vulnerable plaque and acute coronary syndromes. From pathological and clinical observations, plaques that have recently ruptured have thin fibrous caps, large lipid cores, exhibit outward remodelling and invasion by vasa vasorum. Ruptured plaques are also focally inflamed and this may be a common denominator of the other pathological features. Plaques with similar characteristics, but which have not yet ruptured, are believed to be vulnerable to rupture. Experimental studies strongly support the validity of anti-inflammatory approaches to promote plaque stability. Unfortunately, reliable non-invasive methods for imaging and detection of such plaques are not yet readily available. There is a strong biological basis and supportive clinical evidence that low-density lipoprotein lowering with statins is useful for the stabilisation of vulnerable plaques. There is also some clinical evidence for the usefulness of antiplatelet agents, beta blockers and renin-angiotensin-aldosterone system inhibitors for plaque stabilisation. Determining the causes of plaque rupture and designing diagnostics and interventions to prevent them are urgent priorities for current basic and clinical research in cardiovascular area.