Two-year outcomes after first- or second-generation drug-eluting or bare-metal stent implantation in all-comer patients undergoing percutaneous coronary intervention: a pre-specified analysis from the PRODIGY study (PROlonging Dual Antiplatelet Treatment After Grading stent-induced Intimal hyperplasia studY).

OBJECTIVES: This study sought to assess device-specific outcomes after implantation of bare-metal stents (BMS), zotarolimus-eluting Endeavor Sprint stents (ZES-S), paclitaxel-eluting stents (PES), or everolimus-eluting stents (EES) (Medtronic Cardiovascular, Santa Rosa, California) in all-comer patients undergoing percutaneous coronary intervention. BACKGROUND: Few studies have directly compared second-generation drug-eluting stents with each other or with BMS. METHODS: We randomized 2,013 patients to BMS, ZES-S, PES, or EES implantation. At 30 days, each stent group received up to 6 or 24 months of clopidogrel therapy. The key efficacy endpoint was the 2-year major adverse cardiac event (MACE) including any death, myocardial infarction, or target vessel revascularization, whereas the cumulative rate of definite or probable stent thrombosis (ST) was the key safety endpoint. RESULTS: Clinical follow-up at 2 years was complete for 99.7% of patients. The MACE rate was lowest in EES (19.2%; 95% confidence interval [CI]: 16.0 to 22.8), highest in BMS (32.1%; 95% CI: 28.1 to 36.3), and intermediate in PES (26.2%; 95% CI: 22.5 to 30.2) and ZES-S (27.8%; 95% CI: 24.1 to 31.9) groups (chi-square test = 18.9, p = 0.00029). The 2-year incidence of ST in the EES group (1%; 95% CI: 0.4 to 2.2) was similar to that in the ZES-S group (1.4%; 95% CI: 0.7 to 2.8), whereas it was lower compared with the PES (4.6%, 95% CI: 3.1 to 6.8) and BMS (3.6%; 95% CI: 2.4 to 5.6) groups (chi-square = 16.9; p = 0.0001). CONCLUSIONS: Our study shows that cumulative MACE rate, encompassing both safety and efficacy endpoints, was lowest for EES, highest for BMS, and intermediate for PES and ZES-S groups. EES outperformed BMS also with respect to the safety endpoints with regard to definite or probable and definite, probable, or possible ST. (PROlonging Dual antiplatelet treatment after Grading stent-induced Intimal hyperplasia studY [PRODIGY]; NCT00611286).

[Noninvasive radiodiagnosis of late coronary stent stenoses].

OBJECTIVE: To study the diagnostic value of stress echocardiography (stress echoCG) in the early diagnosis of coronary stent stenoses in the late postoperative period. SUBJECTS AND METHODS: The study enrolled 39 men aged 37 to 58 years with symptoms of cardialgia, who had previously (3 to 8 years earlier) undergone balloon angioplasty and coronary artery stenting to treat coronary heart disease. To exclude coronary stent stenoses, all the patients had dobutamine stress echoCG, transesophageal atrial electrostimulation, and further coronary angiographies (CAG). RESULTS: Stress echoCG showed a lesion of the stented coronary artery in 34 patients and that of previously angiographically intact coronary arteries in 5 patients. According to CAG data, there was stenosis of > 70% in the coronary stent lumen in 16 patients and that of 40 to 70% in 12 patients. Six patients were found to have de novo stenoses in the previously stented coronary artery. Stress echoCG showed that the diagnostic accuracy and sensitivity of both stenoses of intracoronary stents and de novo ones in the stented artery and previously intact coronary arteries was 100%. CONCLUSION: Stress echoCG is a highly informative method for the early topical diagnosis of both stenoses of coronary stents and a stenotic lesion of previously intact portions of coronary arteries. The early diagnosis of coronary stent stenoses permits mini-invasive endovascular treatment to be performed.

Meditations on secondary revascularisation in the aftermath of the SYNTAX trial.

Many patients will experience a return of symptoms after their initial revascularisation procedure necessitating secondary revascularisation (SR). The options for this second procedure are inherently influenced by the primary method adopted for revascularisation. Patients with single vessel disease are most suited to percutaneous coronary intervention (PCI) for both primary and secondary revascularisation. The arrival of drug eluting stents, and evidence from trials of highly select populations has threatened the place of coronary artery bypass grafting (CABG) as the preferred method of revascularisation in those with multivessel disease. At present, and without robust evidence, PCI is increasingly being used to treat highly complex lesions, such that many question whether CABG is still has a role in primary revascularisation. The consequence for SR is that currently it is increasingly likely to be in response to in-stent restenosis, whereby previously it was performed in those with prior CABG. The recent SYNTAX trial has reaffirmed the position of CABG in the treatment of those with complex coronary disease. Consequently we believe that matters have turned a full circle, and expect that SR in the future is most likely to be in form of PCI on patients 8-15 years post primary CABG.

Secondary coronary revascularisation: an emerging issue.

Coronary revascularisation should be considered as a healthcare process rather than a series of episodic interventions. At a time when the number of surgical and interventional procedures worldwide continues to increase, secondary coronary revascularisation appears as an unavoidable subject. Atherosclerosis progression, long-term failure of surgical grafts or stents, and patient profile contribute to the increased risk of secondary revascularisation. The absence of a grouping category, however, has contributed to suboptimal implementation of evidence-based knowledge on the subject, which is scattered in the literature and scantily covered in clinical practice guidelines. Assembling a critical mass of expertise in the field results mandatory for comprehensive patient management and for highlighting avenues for future research. Knowledge sharing between physicians, interventionalists and surgeons appears indispensable to reduce unilateral decision-making. Awareness of all health professionals about the likelihood of repeated revascularisation appears as the first step towards a process-oriented and holistic management of patients requiring coronary revascularisation.

The influence of low dose atorvastatin on inflammatory marker levels in patients with acute coronary syndrome and its potential clinical value.

BACKGROUND: High-dose statins are used in acute coronary syndromes (ACS) to reduce inflammation. The aim of the study was the evaluation of the influence of low-dose atorvastatin (20 mg) on selected inflammatory parameters and clinical outcomes after ACS. METHODS: Seventy eight patients (pts) with ACS were randomly divided into group A (39 pts) taking atorvastatin, and group NA (39 pts) not taking any statin for the following six weeks. C-reactive protein (CRP), interleukin-6 (IL-6), monocyte chemoattractant protein-1 (MCP-1) and tumour necrosis factor alpha (TNFa) levels were measured on the first and the fifth days and six weeks after ACS. RESULTS: There was no significant CRP and IL-6 level decrease in group A (CRP--62%; IL-6-73%) or group NA (CRP-44%; IL-6-62%). There was also no significant change in TNFa levels. The MCP-1 level finally reached the level of significant difference (p < 0.04). Cardiovascular events (MACE) and the restenosis rates did not differ between the groups. CONCLUSIONS: Low-dose atorvastatin does not have a significant influence on cooling down inflammation in ACS, and MCP-1 can be used as an early indicator of statin anti-inflammatory activity. Furthermore, it does not reduce MACE or restenosis rates despite its influence on MCP-1 levels.