A randomized study to compare bioactive titanium stents and everolimus-eluting stents in diabetic patients (TITANIC XV): 1-year results.

INTRODUCTION AND OBJECTIVES: Up to 25% of patients who undergo a percutaneous coronary intervention show some limitation in the use of drug-eluting stents. The aim of this study was to evaluate if titanium-nitride-oxide-coated stents could be a good alternative to everolimus-eluting stents in diabetic patients. METHODS: A total of 173 diabetic patients with lesions at moderate risk of restenosis (exclusion criteria: diameter < 2.5 mm or length > 28 mm in vessels < 3mm, chronic occlusion) were randomized to a titanium group (83 patients) or an everolimus group (90 patients). RESULTS: Baseline characteristics were well balanced; 28.3% of patients were insulin dependent. At 1 year, the incidence of major adverse cardiac events (death, nonfatal myocardial infarction, stroke, or repeat target vessel revascularization) was significantly higher in the titanium group than in the everolimus group (total, 14.5% vs 4.4%; P = .02; noninsulin-dependent subgroup, 9.7% vs 3.2%; P = .14; insulin-dependent subgroup, 28.6% vs 7.1%; P = .04). The incidence of death, nonfatal myocardial infarction, stroke, or any revascularization was 16.9% in the titanium group and 7.8% in the everolimus group (P = .06). Target lesion and vessel revascularizations occurred in 8.4% compared with 3.3% (P = .15) and in 13.3% compared with 3.3% (P = .01) in the titanium and everolimus groups, respectively. Angiographic follow-up at 9 months showed significantly less late lumen loss in the everolimus group (in-segment, 0.52 [standard deviation, 0.58) mm vs -0.05 [0.32] mm; in-stent, 0.76 [0.54] mm vs 0.13 [0.31] mm; P < .0001). CONCLUSIONS: The everolimus-eluting stent is superior to the titanium stent for clinical and angiographic end points in diabetic patients with lesions at moderate risk of restenosis.

Late gadolinium enhancement-cardiovascular magnetic resonance identifies coronary artery disease as the aetiology of left ventricular dysfunction in acute new-onset congestive heart failure.

AIMS: We evaluated the ability of late gadolinium enhancement (LGE) using cardiovascular magnetic resonance (CMR) to identify acute new-onset heart failure (HF) with left ventricular systolic dysfunction (LVSD), whether or not in relation to underlying coronary artery disease (CAD), in patients with no clinical evidence of associated ischaemic cardiomyopathy. METHODS AND RESULTS: Hundred consecutive patients admitted with acute new-onset decompensated HF and EF <40%, with no clinical or electrocardiographic data suggestive of CAD. The patients were classified according to the presence or absence of significant CAD (stenosis > or =70% in at least one major vessel). Twenty-one patients (21%) had significant CAD. Seventy-nine (79%) had no lesions. Eighteen of the 21 patients (85%) with CAD had subendocardial/transmural LGE. In the diagnosis of CAD, LGE has a sensitivity of 85.7% (95% CI, 80-91) and specificity of 92.4% (95% CI, 87-96), respectively, with a negative predictive value of 96% (95% CI, 90-99). It has an area under the receiver operating characteristic curve of 0.906 (95% CI, 0.814-0.998). CONCLUSION: In patients with new-onset HF and LVSD for whom there are no clinical and exploratory data suggestive of ischaemic heart disease, CMR with LGE is an excellent means of ruling out significant CAD and is a valid alternative to angiography.

[Long-term clinical and angiographic follow-up of drug-eluting stents in patients with ST-elevation acute myocardial infarction]. / Resultados clínicos y angiográficos tardíos de stents liberadores de fármacos en pacientes con infarto agudo de miocardio con elevación del ST.

INTRODUCTION AND OBJECTIVES: Drug-eluting stents (DES) have proven to be effective in reducing the rate of restenosis and have, therefore, been incorporated into the treatment of patients with ST-elevation acute myocardial infarction (STEMI). The aim of this study was to investigate long-term clinical and angiographic outcomes following the use of DESs in patients with STEMI. METHODS: A prospective study involving clinical and angiographic follow-up was performed in 81 patients with STEMI who underwent percutaneous coronary intervention including DES implantation. This group was compared with 82 patients with similar characteristics who were treated with bare-metal stents (BMS) in an earlier period. RESULTS: At one year, there was no significant difference between the groups in the mortality (2.5% in the DES group vs 7.3% in the BMS group; P=.15) or reinfarction rate (4.8% in the DES group vs. 4.8% in the BMS group; P=.98). The target lesion revascularization rate was significantly lower in the DES group (8.6% vs 23.2% in the BMS group; P=.001), as was the restenosis rate (13.8% vs. 30.9% in the BMS group; P=.02). Acute or subacute stent thrombosis was diagnosed in five patients (3 with a DES and 2 with a BMS; P=.64), and one late stent thrombosis was detected after a year, in a sirolimus-eluting stent. CONCLUSIONS: Implantation of a DES in patients with STEMI did not result in a reduction in either the mortality or reinfarction rate at 1 year compared with BMS implantation. However, there were reductions in the rates of restenosis and target lesion revascularization. The incidence of thrombosis was similar with the two types of stent.

[Stent thrombosis in the modern era: incidence, outcome and predictive factors]. / Trombosis del stent en la era moderna: incidencia, consecuencias y factores predictores.

Coronary stent thrombosis is a catastrophic complication of percutaneous coronary intervention. Its incidence is reported to be about 1%, though it can occur more frequently in high-risk patients, in high-risk lesions, and in multivessel procedures. We investigated the occurrence of stent thrombosis in 404 consecutive patients in a period when conventional and drug-eluting stents were both being used. We found an overall incidence of 2.23%, a mortality rate of 22.2%, and a non-fatal myocardial infarction rate of 66.6%. Predictors of stent thrombosis were acute myocardial infarction, multiple stent placement, poor ejection fraction, small stent diameter, the presence of residual dissection, and premature discontinuation of clopidogrel.

[Anomalous left coronary artery from the right sinus of Valsalva associated with coronary atheromatosis]. / Arteria coronaria izquierda anómala en el seno de Valsalva derecho asociada a ateromatosis coronaria.

Anomalous origin of the left coronary artery from the right sinus of Valsalva is an anatomical abnormality that is usually associated with myocardial ischemia and sudden death. Although this abnormality may coexist with obstructive atherosclerotic coronary disease, disease is not usually found in the anomalous course of the artery. When this coronary anomaly and obstructive coronary disease are both present, it is difficult to determine the cause of ischemic symptoms. We report a case in which three different diagnostic techniques were used to find the cause of ischemic symptoms in a patient whose left coronary artery originated anomalously in the right sinus of Valsalva and followed a course between the aorta and the pulmonary trunk and who had obstructive atherosclerotic lesions in the right coronary artery. The techniques were conventional angiography, which was used for the initial diagnosis, multislice computerized tomography, which was used to determine the anomalous course of the artery and its relationship with vascular structures, and exercise echocardiography, which was used to evaluate ischemia in the left coronary artery territory after treatment of the stenoses in the right coronary artery.

[Prognostic value of persistent ST-segment elevation after successful primary angioplasty]. / Valor pronóstico de la persistencia del segmento ST elevado después de una angioplastia primaria realizada con éxito.

INTRODUCTION AND OBJECTIVES: A variable percentage of patients with myocardial infarction treated with successful primary angioplasty and restoration of coronary flow show persistent ST-segment elevation, probably due to inadequate cellular reperfusion. We studied if persistent ST-segment elevation was a predictor of worse prognosis. PATIENTS AND METHODS: We comparatively studied the clinical and angiographic results of 116 acute myocardial infarction patients after successful primary angioplasty, which were classified into two groups depending on the persistence (> 50%) or reduction (