Restrictive or Liberal Transfusion Strategy in Myocardial Infarction and Anemia.

BACKGROUND: A strategy of administering a transfusion only when the hemoglobin level falls below 7 or 8 g per deciliter has been widely adopted. However, patients with acute myocardial infarction may benefit from a higher hemoglobin level. METHODS: In this phase 3, interventional trial, we randomly assigned patients with myocardial infarction and a hemoglobin level of less than 10 g per deciliter to a restrictive transfusion strategy (hemoglobin cutoff for transfusion, 7 or 8 g per deciliter) or a liberal transfusion strategy (hemoglobin cutoff, <10 g per deciliter). The primary outcome was a composite of myocardial infarction or death at 30 days. RESULTS: A total of 3504 patients were included in the primary analysis. The mean (±SD) number of red-cell units that were transfused was 0.7±1.6 in the restrictive-strategy group and 2.5±2.3 in the liberal-strategy group. The mean hemoglobin level was 1.3 to 1.6 g per deciliter lower in the restrictive-strategy group than in the liberal-strategy group on days 1 to 3 after randomization. A primary-outcome event occurred in 295 of 1749 patients (16.9%) in the restrictive-strategy group and in 255 of 1755 patients (14.5%) in the liberal-strategy group (risk ratio modeled with multiple imputation for incomplete follow-up, 1.15; 95% confidence interval [CI], 0.99 to 1.34; P = 0.07). Death occurred in 9.9% of the patients with the restrictive strategy and in 8.3% of the patients with the liberal strategy (risk ratio, 1.19; 95% CI, 0.96 to 1.47); myocardial infarction occurred in 8.5% and 7.2% of the patients, respectively (risk ratio, 1.19; 95% CI, 0.94 to 1.49). CONCLUSIONS: In patients with acute myocardial infarction and anemia, a liberal transfusion strategy did not significantly reduce the risk of recurrent myocardial infarction or death at 30 days. However, potential harms of a restrictive transfusion strategy cannot be excluded. (Funded by the National Heart, Lung, and Blood Institute and others; MINT ClinicalTrials.gov number, NCT02981407.).

Evaluation of intracoronary hyperoxemic oxygen therapy in acute anterior myocardial infarction: The IC-HOT study.

BACKGROUND: In the randomized AMIHOT-II trial, supersaturated oxygen [SSO2 ] delivered into the left anterior descending (LAD) artery via an indwelling intracoronary infusion catheter following primary percutaneous coronary intervention (PCI) significantly reduced infarct size in patients with anterior ST-segment elevation myocardial infarction (STEMI) but resulted in a numerically higher incidence of safety events. OBJECTIVES: The IC-HOT study evaluated the safety of SSO2 therapy selectively delivered to the left main coronary artery (LMCA) for 60 minutes after PCI in patients with anterior STEMI. METHODS: SSO2 therapy was administered to the LMCA after stent implantation in 100 patients with anterior STEMI and proximal or mid-LAD occlusion presenting within 6 hours of symptom onset. The primary endpoint was the 30-day composite rate of net adverse clinical events (NACE) (death, reinfarction, clinically driven target vessel revascularization, stent thrombosis, severe heart failure, or TIMI major/minor bleeding) compared against an objective performance goal of 10.7%. Cardiac magnetic resonance imaging was performed at 4 and 30 days to assess infarct size. RESULTS: SSO2 delivery was successful in 98% of patients. NACE at 30 days occurred 7.1% of patients (meeting the primary safety endpoint of the study); there were no deaths, only one stent thrombosis and one case of severe heart failure. Median [interquartile range] infarct size was 24.1% [14.4%, 31.6%] at 4 days and 19.4% [8.8%, 28.9%] at 30 days. CONCLUSION: Following primary PCI in acute anterior STEMI, infusion of SSO2 via the LMCA was feasible and was associated with a favorable early safety profile.

Coronary artery aneurysms: case report and review of transcatheter management strategies.

There is no consensus on the best management of coronary artery aneurysms (CAA) in adults. We describe two patients with CAA and review transcatheter approaches to exclude them from the circulation.

Unprotected left main disease managed with drug-eluting stents: long-term outcome of 100 patients with increased surgical risk.

OBJECTIVES: The purpose of this study was to determine long-term clinical outcomes in high surgical risk patients (pts) with unprotected left main (ULM) disease who were managed with drug-eluting stents (DES). BACKGROUND: The long-term efficacy of unprotected left main (ULM) stenting with DES remains uncertain. METHODS: From June 2003 to December 2005, 100 pts with increased surgical risk underwent ULM stenting with DES. Patient risk was estimated by EuroSCORE. Disease was confined to the ostium/main stem in Group A (31 pts) and involved the bifurcation in Group B (69 pts). Study endpoints were MI, TVR, and death. RESULTS: Mean age was 68 +/- 1 years, EF 52 +/- 1%. Mean EuroSCORE was 5.2 +/- 0.4, and 41% pts had a EuroSCORE of >6. In Group A, 87% of lesions were directly stented. In Group B, 61% of pts received one stent and 39% received two stents. Primary success was 95%. Follow-up data (mean 28 +/- 1 months) were obtained in all patients. Restenosis occurred at the proximal stent margin in 5/9 pts. There were 12 cardiac deaths (88% cardiac survival) and 9 noncardiac deaths (79% total survival). In Group B, 5 pts died suddenly: 3 within the first week and 2 additional pts after 1 year. Sudden death did not occur in Group A. All cause event-free survival was 65% in Group A and 67% in Group B. CONCLUSION: A substantial number of late adverse events occurred in both ostial and bifurcation groups with equal frequency. Until definitive data from randomized trials are available, ULM stenting should be performed only in patients with prohibitive surgical risk.

Sorting through new biomarkers.

Early diagnosis of acute coronary syndromes (ACS) allows for efficient risk stratification, appropriate targeted therapies, and faster patient disposition within crowded emergency departments. Although only troponin testing is recommended for routine use in the 2007 American College of Cardiology/American Heart Association guidelines for non-ST-elevation ACS, emerging data support selected use of other biomarkers, including B-type natriuretic peptides (BNPs) and C-reactive protein. There remains a need to identify additional biomarkers in ACS to enhance risk stratification and to help guide therapeutic decisions in this increasingly complex area of cardiovascular medicine. Cardiac biomarkers may help to diagnosis ACS before cardiomyocyte necrosis, to influence the decision for early invasive treatment, and to provide a means of monitoring response to therapy. In this review, we assess new data in ACS with respect to troponins, BNPs, myeloperoxidase, fatty acid-binding protein, and monocyte chemoattractant protein-1. We also discuss novel biomarkers including growth deficient factor-15 and neopterin.

Mortality in patients with ST-segment elevation myocardial infarction who do not undergo reperfusion.

Reperfusion therapy reduces mortality in patients presenting with ST-segment elevation myocardial infarctions (STEMI). However, some patients may not receive thrombolytic therapy or undergo primary percutaneous coronary intervention. The decision making and clinical outcomes of these patients have not been well described. In this study, 139 patients were identified from a total of 1,126 patients with STEMI who did not undergo reperfusion therapy at a high-volume percutaneous coronary intervention center from October 2006 to March 2011. Clinical data, reasons for no reperfusion, management, and mortality were obtained by chart review. The mean age was 80 ± 13 years (61% women, 31% diabetic, and 37% known coronary artery disease). Of the 139 patients, 72 (52%) presented with primary diagnoses other than STEMI, and 39 (28%) developed STEMI >24 hours after admission. The most common reasons for no reperfusion were advanced age, co-morbid conditions, acute or chronic kidney injury, delayed presentation, advance directives precluding reperfusion, patient preference, and dementia. Eighty-four patients (60%) had ≥ 3 reasons for no reperfusion. Factors associated with hospital mortality were cardiogenic shock, intubation, and advance directives prohibiting reperfusion after physician consultation. In hospital and 1-year mortality were 53% and 69%, respectively. In conclusion, at a high-volume percutaneous coronary intervention center, most patients presenting with STEMI underwent immediate catheterization. The decision for no reperfusion was multifactorial, with advanced age reported as the most common factor. Outcomes were poor in this population, and fewer than half of these patients survived to hospital discharge.

Analysis of saphenous vein graft lesion composition using near-infrared spectroscopy and intravascular ultrasonography with virtual histology.

OBJECTIVE: To examine the composition of saphenous vein graft (SVG) lesions using two novel modalities, near-infrared spectroscopy (NIRS) and intravascular ultrasonography with virtual histology (IVUS-VH). METHODS: We performed NIRS and IVUS-VH imaging of 23 SVGs in 21 patients undergoing clinically-indicated angiography. RESULTS: Mean patient and SVG age was 66±7 and 10±7 years, respectively. SVG lesion location was aorto-ostial in 8 (35%), body in 13 (57%) and distal anastomotic in 2 (9%). Compared to anastomotic lesions, body lesions had larger mean lumen area (6.4±1.8 mm2 vs. 4.2±6.4 mm2, P=0.02) but similar mean plaque burden (73±5% vs. 70±10%, P=0.66). A NIRS lipid core plaque was identified in 9 of 13 body lesions vs. 1 of 10 anastomotic lesions (69% vs. 10%, P=0.005). SVG body lesions had higher lipid core burden index (LCBI) compared to anastomotic lesions (184±76 vs. 49±54, P<0.001). By IVUS-VH, SVG lesions had high % necrotic core (28±10%) and % dense calcium (13±10%), without any significant difference between body and anastomotic sites. Older SVG age was associated with higher lesion and vessel LCBI (r=0.76 and r=0.64, respectively, P<0.001), but was not associated with IVUS-VH determined plaque composition. Higher HDL-cholesterol was associated with lower lesion LCBI (r=-0.43, P=0.04). CONCLUSIONS: NIRS-measured lipid core plaque in SVGs increases with increasing SVG age and is infrequent in anastomotic lesions. No association was found between IVUS-VH plaque composition measurements and SVG lesion location or age.

Isolated disease of the ostium left anterior descending or circumflex artery: management using a left main stenting technique. Clinical outcome at 2 years.

BACKGROUND: Ostial disease of the left anterior descending (LAD) or circumflex (LCX) coronary artery is a challenge for the interventionalist. Focal ostial stenting may result in incomplete lesion coverage or plaque shift into the adjacent vessel, creating left main equivalent disease. The purpose of the present study was to address these concerns by using a left main bifurcation strategy with drug-eluting stents (DES) for the treatment of this problem. METHODS: The study population consisted of patients with isolated unprotected ostial stenosis of the LAD or LCX artery. Coronary stenting was performed using a bifurcational technique in which DES were deployed from the distal left main artery across the stenosis into the main branch. Post-deployment kissing balloon inflation with provisional side branch stenting was then performed. Clinical and angiographic follow up was obtained to assess the primary endpoint of death, non-fatal myocardial infarction (MI) or target lesion revascularization (TLR). RESULTS: Thirty-three patients (19 males, 14 females) with a mean age of 67 years were evaluated. Clinical follow up was available in all patients; the mean duration of follow up was 24 months. One cardiac death and 1 non-fatal MI occurred. Protocol-driven follow-up angiography with intravascular ultrasound (IVUS) was obtained at a mean of 11 months in 91% of patients. The incidence of TLR was 15%. CONCLUSION: Main branch stenting with post-stent deployment kissing balloon inflations and provisional side branch stenting may be a reasonable option for the treatment of ostial LAD or LCX disease.