Pathways mediating the interaction between endothelial progenitor cells (EPCs) and platelets.

INTRODUCTION: Endothelial progenitor cells (EPCs) have an important role in the process of vascular injury repair. Platelets have been shown to mediate EPC recruitment, maturation and differentiation. Yet, the mechanism underlying this interaction is unclear. We, therefore, aimed to examine whether direct contact between platelets and EPCs is essential for the positive platelets-EPC effect, and to investigate the main mediators responsible for the improvement in EPCs function. METHODS: Human EPCs were isolated from donated buffy coats and cultured in either: 1. EPCs co-incubated with platelets placed in a 1 µm-Boyden chamber. 2. EPCs incubated with or without platelets in the presence or absence of bFGF/PDGF Receptor inhibitor (PDGFRI). After 7 days culture, EPCs ability to form colonies, proliferate and differentiate was examined. Culture supernatants were collected and growth factors levels were evaluated using ELISA. Growth factors mRNA levels in EPCs were evaluated using RT-PCR. RESULTS AND CONCLUSIONS: After 7 days culture, EPCs functional properties were higher following co-incubation with platelets (directly or indirectly), implying that direct contact is not essential for the platelet's positive effect on EPCs. This effect was reduced by PDGFRI inhibition. Additionally, higher levels of PDGFB in EPCs-platelets supernatant and higher levels of PDGFC mRNA in EPCs co-incubated with platelets were found. In contrast, FGF and other potential mediators that were examined and inhibited did not significantly affect the interaction between platelets and EPCs. Thus, we conclude that PDGF has a central role in the interaction between platelets and EPCs. Further study is required to examine additional aspects of EPC-platelets interaction.

Utility of immune monitoring in heart transplant recipients on everolimus-based immune suppression.

BACKGROUND: Everolimus provides effective immune suppression (IS) after heart transplant (HTx). Its pharmacologic properties differentiate everolimus from other IS drugs. A non-invasive immune monitoring (IM) assay test appears to predict the immune state in HTx recipients on standard calcineurin-inhibitor-based IS. The utility of IM in HTx recipients on everolimus-based IS was evaluated. METHODS: Between June 2005 and June 2011, 34 adult HTx recipients followed up at our center received everolimus and had 381 IM assays that were performed at six months to 16-yr post-transplant. Results of the IM assay were correlated with infection and rejection episodes that occurred during the IM testing. RESULTS: In the everolimus-based IS group, there were 18 infectious episodes and four rejection episodes. The average IM score was significantly lower during infection than at steady state (188 ± 122 vs. 338 ± 137 ng/mL ATP, p < 0.001) and not significantly different during rejection when compared with steady state (430 ± 132 vs. 338 ± 137 ng/mL ATP, p = 0.5). CONCLUSIONS: The non-invasive IM assay predicts infectious risk in HTx recipients on everolimus-based IS. Its inconclusive association with rejection was probably due to the small number of rejections. Serial longitudinal IM may allow proper adjustment of everolimus doses.

Effect of intensive glycaemic control on endothelial progenitor cells in patients with long-standing uncontrolled type 2 diabetes.

AIMS: Endothelial progenitor cells (EPCs) have an important role in repair following vascular injury. However, in patients with diabetes, EPC number and function are markedly reduced. It is unclear whether intensive glycaemic control can modify EPC properties in diabetic patients. We aimed to examine whether glycaemic control can improve EPC number and function in patients with long-standing uncontrolled type 2 diabetes. METHODS AND RESULTS: Thirty-five patients with treated type 2 diabetes and HgA1c ≥ 8.5% were included. Patients were tested at baseline and after 3-4 months of an intensive glycaemic control programme, with the aim of achieving HgA1c of 7%. The diabetes group was compared to 20 patients without diabetes (control). Circulating EPC levels were assessed by flow cytometry for expression of VEGFR2, CD133, and CD34. The capacity of the cells to form colony-forming units (CFUs), and their migration and viability were quantified after 1 week of culture. Patients with diabetes (mean age 61.1 ± 7 years, 28.6% women, disease duration of 19.2 ± 8 years) had a baseline HgA1c of 9.4 ± 0.8%. After the glycaemic control period, HgA1c decreased to 8 ± 0.8%. Circulating EPC levels increased significantly after the intensive control period and reached a level similar to the control group. The number of EPC CFUs also increased significantly after glycaemic control but remained lower than the control group. All EPC functional assays improved following the glycaemic control. CONCLUSIONS: In patients with uncontrolled long-standing type 2 diabetes, intensive glycaemic control was associated with an increase in the levels of circulating EPCs, and improvement in their functional properties.

Response to prasugrel and levels of circulating reticulated platelets in patients with ST-segment elevation myocardial infarction.

OBJECTIVES: The aim of this study was to determine whether response to prasugrel is associated with the proportion of circulating reticulated platelets (RPs) in patients with ST-segment elevation myocardial infarction (STEMI). BACKGROUND: Despite better pharmacodynamic properties and clinical efficacy of prasugrel compared with clopidogrel, antiplatelet responses to prasugrel are not uniform. The mechanism of this variability in response is not clear. RPs, young hyperactive forms, are increased during situations of enhanced platelet turnover. METHODS: Patients with STEMI treated with primary percutaneous intervention (PCI) and prasugrel were tested for platelet reactivity using purinergic receptor P2Y, G-protein coupled, 12 (P2Y12) assay and multiple electrode aggregometry (MEA). RP levels were determined using flow cytometry with thiazole orange staining. Tests were performed at 2 to 4 days and 30 days post-PCI. Platelet function was compared by varying levels of RPs, analyzed as continuous (regression analysis) and categorical (tertiles) variables. RESULTS: Sixty-two patients were included (mean age: 57.5 ± 8 years; 21.2% women; 27.7% diabetes). At the early time point, RP levels were strongly correlated with platelet reactivity when evaluated by the P2Y12 assay (Spearman's correlation coefficient: 0.55 for P2Y12 reaction units, -0.49 for percent inhibition) and MEA (Spearman's: 0.50). The upper tertile of RPs displayed higher platelet reactivity compared with the middle and lower tertiles, according to P2Y12 assay and MEA. Similar results with strong correlations between RP and platelet reactivity were noted at 30 days post-PCI. CONCLUSIONS: The proportion of circulating RPs strongly correlates with response to prasugrel in patients with STEMI treated with PCI. High levels of RPs are associated with increased platelet reactivity despite prasugrel treatment.

Retroperitoneal bleeding after cardiac catheterization: a 7-year descriptive single-center experience.

BACKGROUND: Retroperitoneal bleeding (RPB) is an unusual but potentially fatal vascular complication occurring after cardiac catheterization (CC). Contemporary data of RPB in the era of dual antiplatelet therapy and vascular closure devices are lacking. METHODS: We retrospectively examined all RPB cases that occurred after CC in the Rabin Medical Center between the years 2005 and 2011. RESULTS: Of 26,487 patients who underwent CC, a total of 48 patients (mean age 60.9 ± 13.8 years, 52.1% female) with RPB were identified (0.18%). The indication for CC was acute coronary syndrome (43.7%), myocardial infarction (35.4%), stable angina pectoris (8.3%), hemodynamic studies for valvular heart disease (10.4%) and others (2.1%). Coronary intervention was performed in 34 patients (70.9%) and a vascular closure device (VCD) was used in 16 patients (33.3%). Seventy-seven percent of patients were treated with clopidogrel, 20.8% with glycoprotein IIb-IIIa inhibitors and 85.4% with anticoagulation during CC. Median time to diagnosis of bleeding was 9.0 h, while the median time to bleeding differed between patients with and without a VCD (12 vs. 5 h, respectively). The clinical presentation of RPB was hemorrhagic shock in 39.6% of patients and 50.0% required at least one blood transfusion. Patients were managed either with conservative treatment (79.2%), angiography stenting (14.6%) or vascular surgery (6.2%). A total of 3 patients died during hospitalization, of which RPB was the etiology in 2 (4.2%). CONCLUSIONS: RPB which is a rare complication of CC is associated with younger age and female gender, as compared to patients without RPB. Onset of bleeding can be delayed in patients with VCDs. With careful and early diagnosis, most patients with RPB after CC can be managed conservatively.

Two-year outcomes for patients with severe symptomatic aortic stenosis treated with transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) is an emerging technique for the treatment of severe symptomatic aortic stenosis. Little has been reported about the use of different devices and multiple catheter-based options and anesthetic techniques in the same institution. We report the long-term clinical experience in treating patients with severe symptomatic aortic stenosis using TAVI. We analyzed the outcomes of 153 TAVI-treated patients who were followed for ≤2 years. All patients were at very high risk of surgical valve replacement. The Medtronic-CoreValve device was used in 59.5% and the Edwards-SAPIEN device in 40.5% of the patients. The primary end point was death from any cause during follow-up. The mean ± SD patient age was 81.1 ± 6 years, and 62% of the patients were women. The procedural success rate was 97.4%. At 30 days of follow-up, the all-cause mortality was 3.9%. Two-year follow-up data were obtained for 108 patients, with 85.5% survival of treated patients. The 30-day stroke rate was 3.9%. No significant differences in mortality were found when angioplasty was performed before or during TAVI compared with TAVI alone. Multivariate analysis showed that increased baseline creatinine (hazard ratio 1.55, 95% confidence interval 1.01 to 2.42, p = 0.049) and increased logistic European System for Cardiac Operative Risk Evaluation score (hazard ratio 1.03, 95% confidence interval 1.01 to 1.06, p = 0.048) predicted all-cause mortality. In conclusion, the clinical outcome of TAVI is favorable. The use of both procedural devices and multiple techniques in the same institution is feasible and potentially desirable.

Clinical profile and outcome of patients with severe aortic stenosis at high surgical risk: single-center prospective evaluation according to treatment assignment.

BACKGROUND: The study sought to assess the clinical profile, outcome, and predictors for mortality of "real-world" high-risk severe aortic stenosis patients according to the mode of treatment assigned. METHODS: Patients were referred to a dedicated clinic for meticulous screening and multidisciplinary team assessment and 343 were finally assigned treatment (age 81.3 ± 7.2 years, 42.3% men): transcatheter aortic valve replacement (TAVR) with the Edwards SAPIEN or CoreValve device, 100 (29.2%); surgical aortic valve replacement (SAVR), 61 (17.8%); balloon valvuloplasty (as definitive therapy), 27 (7.9%); medication only, 155 (45.2%). No patient was lost to follow-up. RESULTS: The balloon valvuloplasty group had a significantly higher 1-month mortality rate (18.5%) than the TAVR group (3%, P = 0.006) and medical therapy group (3.9%; P = 0.004), without significant difference from the SAVR group (11.5%, P = 0.5). One-year cumulative survival was significantly higher in the TAVR group (92%) than in the other groups (SAVR 71%, balloon valvuloplasty 61.5%, medication 65%; all P < 0.001). Among survivors, 1-year rates of high functional class (NYHA I/II) were as follows: TAVR, 84.6%; SAVR, 63.3%; balloon valvuloplasty, 18.2%; medication, 21.4% (TAVR vs. SAVR, P = 0.04; SAVR vs. balloon valvuloplasty or medical therapy, P = 0.01). On multivariate regression analysis, renal failure (hazard ratio [HR] = 5.3, P < 0.001), not performing TAVR (HR = 4.9, P < 0.001), and pulmonary pressure (10 mm Hg, HR = 1.2, P = 0.02) were independent predictors of 1-year mortality. CONCLUSIONS: TAVR, performed in carefully selected high-risk patients, is associated with an excellent survival rate and high functional class. Patients treated with another of the available modalities, including SAVR, had a worse outcome, regardless of which alternative treatment they receive.

Feasibility of myocardial perfusion imaging with half the radiation dose in obese patients using ordered-subset expectation maximization with resolution recovery software.

BACKGROUND: We previously described the feasibility of myocardial perfusion imaging (MPI) with nearly half the radiation dose using ordered-subset expectation maximization with resolution recovery (OSEM-RR) processing. This study sought to determine if the findings can be expanded to obese patients. METHODS: Fifty obese patients (>100 kg) referred for MPI underwent stress-rest or rest-stress studies with a half dose of Tc-99m sestamibi in a 1-day protocol using OSEM-RR processing. Image quality and clinical results were compared with matched patients (by age, sex, weight, presence/probability of coronary artery disease) evaluated with standard "full-dose" Tc-99m sestamibi, mostly in a 2-day protocol. Dose activities were adjusted individually by weight. RESULTS: Mean Tc-99m activity was 33.4 ± 13.9 mCi in the half-dose group and 60 ± 10 mCi in the full-dose group (P < .0001). Respective mean effective doses per study were 10 ± 4 and 18 ± 3 mSv (P < .0001). Overall image quality was good-to-excellent in 94% of the half-dose group and 80% of the full-dose group (P < .045). There was no between-group difference in rate or size of ischemia or infarction, except for stress left ventricular ejection fraction. CONCLUSIONS: MPI with half the radiation dose is feasible in obese patients. Image quality is better than for full-dose MPI, and the procedure can be performed in 1 day.

Long-term outcome of patients with antiphospholipid syndrome who undergo percutaneous coronary intervention.

OBJECTIVES: Patients with antiphospholipid antibody syndrome (APS) have an increased risk of atherothrombotic complications. There are limited data regarding the outcome of patients with APS who undergo percutaneous coronary intervention (PCI). Accordingly, we aimed to assess the long-term outcomes of these patients. METHODS: Nineteen APS patients who underwent PCI between the years 2003 and 2008 were compared to 380 patients who had undergone PCI during the same period (PCI group) and were matched by age (±5 years), gender, diabetes and hypertension. In addition, APS patients were compared to 1,458 patients with ST segment elevation myocardial infarction (MI) who were treated with PCI during the same period. Six-month to 4-year clinical outcomes were evaluated. RESULTS: The indication for PCI in the APS group was acute coronary syndrome in 52.6% of patients. After 1 year of follow-up, patients with APS had higher rates of target vessel revascularization than the other two groups, which translated to higher rates of major adverse cardiac events. There were no differences in MI or mortality rates between the groups. CONCLUSIONS: Patients with APS who undergo PCI have worse long-term clinical outcomes, driven by higher rates of revascularization, than other patients undergoing PCI. Further study is warranted to examine the mechanisms underlying these findings.

Outcome of patients presenting with ST elevation myocardial infarct and cardiogenic shock: a contemporary single center's experience.

OBJECTIVES: Acute ST elevation myocardial infarction (STEMI) presenting with cardiogenic shock (CS) is associated with dismal prognosis. In the last years, significant advances have been made in reperfusion techniques and pharmacological treatment. Therefore, we aimed to assess the outcome of these patients during the past decade and identify major factors that impact their prognosis. METHODS: We identified 170 patients who presented with STEMI, CS, and underwent primary percutaneous coronary intervention (PCI) between 2001 and 2011. Patients were allocated into two groups based on period of presentation: 2001-2005 (n = 70) and 2006-2011 (n = 100). Clinical outcomes up to 6 months were evaluated. RESULTS: Patients in the latter period were younger, and had lower rates of renal failure and higher rates of stent use. Despite these differences, mortality did not differ and remained high in both periods (52-59% at 6 months). Time frames from onset of symptoms to arrival to the emergency department and to performance of coronary intervention were similar in both periods. Intra-aortic balloon pump use was similar in both periods. In multivariate analysis, factors associated with 1-month mortality were: diabetes (OR = 3.6, 1.4-9.4, p = 0.007), LVEF <40% (OR = 1.8, 1.3-2.6, p = 0.001), GFR <60 ml/min/m(2) (OR = 1.8, 1.3-2.4, p < 0.009) and glycoprotein IIb/IIIa inhibitor use (OR = 0.5, 0.2-1.1, p = 0.08). The combination of diabetes and renal failure was associated with particularly high mortality. CONCLUSIONS: Prognosis of patients presenting with STEMI, CS, and treated with primary PCI during the past decade, remains poor. Better risk-stratification may help improve their grave outcome.

[Transcatheter aortic-valve implantation].

Aortic valve stenosis is associated with severe morbidity and death within several years of symptom onset, and its accepted treatment is surgical aortic valve replacement. However, many affected patients are not referred for surgery because of old age and significant comorbidities. In recent years, an alternative treatment approach has been developed, transcatheter aortic-valve implantation. In this review we would like to describe this treatment modality and to present several cases performed in our center.

Clopidogrel response up to six months after acute myocardial infarction.

High on-treatment platelet reactivity (HTPR) despite clopidogrel therapy is associated with adverse cardiac events after acute myocardial infarction (AMI). Most studies to date have assessed clopidogrel response at a single time point before or after percutaneous coronary intervention (PCI). It is unclear, however, whether the HTPR phenotype is stable over time. Therefore, we aimed to examine response to clopidogrel in patients with AMI treated with PCI over a 6-month period. Patients (n = 57) with AMI treated with PCI were assessed for response to clopidogrel at 3 time points: in hospital, 30 days, and 6 months after index hospitalization. Response to clopidogrel was determined by the VerifyNow P2Y12 assay (reported as P2Y12 response units) and multiple electrode aggregometry (MEA; reported as aggregation units). HTPR was defined as ≥235 P2Y12 response units or ≥47 aggregation units. Patients' mean age was 54.5 ± 10.9 years, 91% were men, 19% had diabetes, and 74% were admitted with ST-segment elevation MI. HTPR based on MEA was observed in 22.8% of patients in hospital, 26.3% at 30 days, and 17.5% at 6 months (p = NS). HTPR based on the VerifyNow assay was observed in 38.6% of patients in hospital, 28.1% at 30 days, and 33.3% at 6 months (p = NS). Individual HTPR phenotypic assignment at baseline was stable in 73.7% (based on MEA) and 70.2% (based on VerifyNow) of patients at 6-month follow-up. In conclusion, this is the first study evaluating the stability of clopidogrel response over time after AMI. Rates of HTPR to clopidogrel therapy appear to be relatively stable up to 6 months after AMI.

The impact of intracoronary thrombus aspiration on STEMI outcomes.

BACKGROUND: Manual coronary thrombus aspiration was associated with improved outcomes of ST-elevation myocardial infarction (STEMI) patients. We aimed to evaluate the outcome of aspiration in a "real-world" setting of primary percutaneous coronary intervention (PPCI). METHODS AND MATERIALS: We analyzed the outcome of STEMI patients who underwent PPCI (initial Thrombolysis in Myocardial Infarction flow grade 0/1), comparing patients who underwent aspiration (ASP) to those who had standard (STD) therapy. Various subgroups outcomes were further analyzed. Clinical end points included mortality and major adverse cardiovascular events (MACE) at 30 days and at 1 year. RESULTS: One thousand thirty-five consecutive patients were included: 189 (18.26%) with ASP and 846 (81.74%) with STD. ASP patients were younger (58±12 vs. 61±13, P<.05) and had higher incidence of direct stenting compared to STD patients (34% vs. 16.7%, P<.05). No significant differences were noted in the outcome of ASP vs. STD at 30 days (mortality rate 4.2% vs. 4.5%, P=.9; MACE 6.9% vs. 9.8%, P=.2) and at 1 year (mortality rate 8.0% vs. 8.3%, P=.9; MACE 20.0% vs. 22.3%, P=.5). A significant advantage in favor of ASP was evident in patients with proximal culprit lesions, anterior infarcts, and right ventricular involvement. CONCLUSIONS: Although this was largely a negative study, when STEMI involved a large jeopardized myocardium, aspiration was associated with sustained improved clinical outcomes.

Feasibility of myocardial perfusion imaging with half the radiation dose using ordered-subset expectation maximization with resolution recovery software.

OBJECTIVE: This study sought to assess the feasibility of performing myocardial perfusion imaging (MPI) with half the technetium activity using ordered-subset expectation maximization with resolution recovery (OSEM-RR), an iterative reconstruction software developed to improve count statistics and acquisition time. METHODS: Two hundred eighteen patients referred for MPI were randomly allocated to undergo stress-rest or rest-stress protocols with standard full-dose (FD) injections of technetium (Tc)-99m sestamibi or half-dose (HD) injections and OSEM-RR processing. Dose activities were adjusted individually by weight. The groups were compared for image quality and clinical results. RESULTS: The groups were similar for mean patient age, weight, and body mass index, sex distribution, pre-test probability of CAD and CAD prevalence. Mean Tc-99m activities for the low-dose and high-dose stages were as follows: FD group: 429 ± 85 MBq and 1132 ± 200 MBq; HD group: 263 ± 129 MBq and 629 ± 85 MBq (P < .0001 for both). Mean effective dose per study was 13.6 ± 1.4 mSv in the FD group and 7.7 ± 1.0 mSv in the HD group (P < .001). Over all image quality was good-to-excellent in 98% and 95% of the groups, respectively. However, when we analyzed the low-dose stage separately, image quality was slightly worse in the HD than the FD, though still within the good-to excellent range. CONCLUSIONS: MPI with nearly half the radiation dose is feasible with good image quality.

Comparison of late (3-year) registry data outcomes using bare metal versus drug-eluting stents for treating ST-segment elevation acute myocardial infarctions.

Clinical trial data have supported the safety and efficacy of drug-eluting stents (DES) in the treatment of patients with ST-segment elevation myocardial infarctions (STEMIs), but contemporary "real-world" registry data regarding the late safety profiles of DES are limited. This prospective registry-based study included 1,569 consecutive unselected patients with STEMIs who underwent emergency primary percutaneous coronary intervention from January 2001 to December 2009. Of the study cohort, 200 patients (12.7%) received DES, while 1,369 patients (87.3%) underwent bare-metal stent (BMS) placement. The primary end points of the study were all-cause mortality and target vessel revascularization at 1, 2, and 3 years. Survival status was assessed by municipal civil registries. Repeat revascularization procedures were prospectively collected in the hospital database. All-cause mortality was significantly lower in the DES group at 3 years (4.2% vs 13.5%, p = 0.007) compared to BMS-treated patients, but DES use was not an independent predictor of all-cause mortality (adjusted odds ratio 0.5, 95% confidence interval 0.2 to 1.2, p = 0.10). Target vessel revascularization was significantly lower in the DES group compared to the BMS group at 3 years (10.5% vs 21%, p = 0.001). DES use was an independent predictor of reduced target vessel revascularization (adjusted odds ratio 0.44, 95% confidence interval 0.25 to 0.77, p = 0.004). Late definite stent thrombosis occurring after 1 year occurred in 4 (2.5%) patients in the DES group compared to 6 (0.7%) in the BMS group (p = 0.05). DES use was an independent predictor of late stent thrombosis (adjusted odds ratio 8.6, 95% confidence interval 1.9 to 38, p = 0.004). In conclusion, this contemporary registry-based study of patients who underwent primary percutaneous coronary intervention for STEMI demonstrated improved revascularization rates without increased 3-year hazard of adverse clinical outcomes in DES-treated patients.

Drug eluting stenting in bifurcation coronary lesions long-term results applying a systematic treatment strategy.

OBJECTIVES: To explore the long-term results following implantation of drug-eluting stents (DES) in bifurcation lesions according to contemporary "real world" practice. BACKGROUND: Limited information is available on the long-term outcomes of patients with bifurcation lesions who are treated using DES. A systematic approach for bifurcation lesion management was applied, using either a "provisional" single stent technique or a dedicated two stents strategy according to the side-branch diameter and severity of its ostial stenosis. METHODS: Four hundred one consecutive patients underwent bifurcation percutaneous coronary intervention (PCI) using DES and were included in our prospective registry. All adverse events were recorded up to 2 years and distinguished according to the planned PCI strategy (e.g., one versus two stents technique). RESULTS: A planned two stents strategy was used in 141 patients (35% of patients). In 260 patients (65%), the planned treatment involved stenting of the main branch only with "provisional" stenting of the side-branch according to procedural course. Thus, 24 patients (9.2%) needed additional stenting at the side-branch to complete the PCI. Cumulative major adverse cardiac event rate at 1 and 2 years was similar for both groups (11.4% vs. 14.8% at 1 year and 19.4% vs. 25.7% at 2 years for the single vs. two stents groups, accordingly, P = NS for both). Likewise, there was no difference in mortality, cardiac mortality, myocardial infarction, need for target lesions or target vessel revascularization, or definite stent thrombosis rate between the two groups at 6, 12, and 2 years follow-up. The rate of angiographically confirmed (i.e., definite) stent thrombosis did not differ between the two groups during follow-up. CONCLUSIONS: Our study revealed favorable long-term clinical results following DES implantation using a systematic, rather simplified approach towards bifurcation stenting and using either a single or double stenting technique.

Yield of a novel ultra-low-dose computed tomography device mounted on a dedicated cardiac SPECT system in improving the accuracy of myocardial perfusion imaging and the detection of chest abnormalities.

BACKGROUND: To examine the yield of an ultra-low-dose computed tomography (CT) transmission module for attenuation-correction (AC) on a dedicated cardiac camera in evaluation of SPECT-myocardial perfusion imaging (MPI) in the diagnosis of CAD and for additional chest abnormalities. METHODS: The study group included 150 patients with known or suspected CAD referred for technetium sestamibi SPECT MPI. CT transmission scanning (effective radiation 0.17 mSv) was performed after each gated SPECT scan. AC and non-corrected (NC) SPECT scans were evaluated on a 5-point scale using a 17-segment model, and the sum stress score (SSS) and sum rest score (SRS) were calculated for each condition. Overall image quality, sensitivity and normalcy rate (51 patients) and processing of 28 CT slices were screened for chest findings. RESULTS: CT-based AC significantly improved image quality (P = .01). Mean SSS was 3.8 ± 5.8 with AC and 6.1 ± 7.1 with NC (P < .001); the respective SRS values were 2.6 ± 6.3 and 3.9 ± 7.7 (P < .001). The sensitivity of detecting ≥70% stenosis was 71% and 86% (P = NS) and the normalcy rate was 30% and 89% (P < .0001) in NC and AC SPECT MPI, respectively. Chest CT: lung abnormalities in 31%, aortic calcifications in 27%, and hiatus hernia in 5%. CONCLUSIONS: Ultra-low-dose CT for AC of SPECT-MPI improves image quality, diagnostic accuracy and suggests detection of chest findings.

A comparative analysis of major clinical outcomes with drug-eluting stents versus bare metal stents in male versus female patients.

AIMS: To conduct a risk-adjusted gender-based analysis of clinical outcomes following drug-eluting stent (DES) versus bare metal stent (BMS) implantation in patients with coronary artery disease. METHODS AND RESULTS: We compared risk-adjusted total mortality rate, myocardial infarction, and event-free survival (defined as freedom from death, myocardial infarction and/or repeat revascularisation) in a consecutive cohort of 7,662 patients undergoing percutaneous coronary intervention at our institution, including 1,835 (25.4%) women. Follow-up was six months to 6.2 years (mean: 3.5 years; median: 3.6 years). The women were older than men and more likely to suffer from diabetes, hypertension or congestive heart failure. Smokers were more often men, and men were more likely to have had prior coronary bypass surgery compared to women. A DES was used in 39.9% of males and 39.5% of females. Both genders derived a significant long-term clinical benefit from DES compared to BMS; advantages were observed for mortality (men: HR=0.78, 95% CI: 0.64-0.96, p=0.016; women: HR=0.62, 95% CI: 0.45-0.85, p=0.003) and major adverse cardiac events (men: HR=0.73, 95% CI: 0.63-0.84, p<0.001; women: HR=0.76, 95% CI: 0.52-0.84, p=0.001). Among BMS-treated patients, women had worse cumulative clinical outcomes than men. DES eliminated the gender differences in cardiac prognosis. CONCLUSIONS: Our analysis indicated a profound prognostic advantage for DES versus BMS among both genders, though female patients appeared to derive the greatest benefit.

[The influence of medical art therapy on quality of life and compliance of medical treatment of patients with advanced heart failure].

BACKGROUND: Medical art therapy (MAT) enables people who are medically ill to express their feelings through art. In heart failure (HF) depression and anxiety are common. AIM: To evaluate the influence of guided group MAT on the quality of Life and compliance to medical therapy of patients with advanced HF. METHODS: Twenty advanced HF patients were randomly divided into two groups: ten in the intervention group (A) and ten in the control group (B). First and last visits were individual. During these visits the Ulman, (a MAT diagnostic tool), the Minnesota Living with HF and compliance questionnaires were recorded. Both groups met weekly for 6 weeks. A MAT therapist guided group A to express their feelings using art material. Group B met for a routine clinical visit only. RESULTS: Baseline Ulman, compliance and Minnesota scores were similar amongst the two groups. By the end of the study, the Ulman score improved significantly in group A compared to group B (95 +/- 10 to 82 +/- 14 p = 0.0006 vs. 86 +/- 10 to 81 +/- 12 p = 0.5) as was the compliance score (29 +/- 11 to 33 +/- 13 p = 0.05 vs. 36 +/- 5 to 366 p = 0.9). In group A, the Minnesota score improved significantly in 7 patients and did not change in 3, while in group B it improved in 2, did not change in 6 and worsened in 2. CONCLUSIONS: MAT improves the quality of life and compliance in advanced HF patients and it is recommended that it be integrated as part of the therapeutic arsenal in every HF clinic.

A comparative analysis of major clinical outcomes using drug-eluting stents versus bare metal stents in diabetic versus nondiabetic patients.

OBJECTIVES: We aim to explore the clinical outcome of drug-eluting stents (DES) versus bare-metal stents (BMS) implantation in diabetics versus nondiabetic patients. BACKGROUND: Diabetic patients sustain worse long-term clinical outcomes after percutaneous coronary interventions (PCI) when compared with nondiabetics. The use of DES decreases the rate of repeat revascularization in this population but data concerning long-term clinical benefits, such as myocardial infarction (MI) or mortality is scant. METHODS: We analyzed data from a comprehensive registry of 6,583 consecutive patients undergoing PCI at our center. A propensity score was used for analysis of outcomes and for matching (DES vs. BMS). Outcome parameters were total mortality, MI, repeat target vessel revascularization (TVR) rates, and risk-adjusted event-free survival. Within this cohort, we identified 2,571 nondiabetic patients and these were compared with 1,826 diabetic coronary patients. RESULTS: Mean and median follow up time was 3 and 3.25 years, respectively. Overall, diabetics had higher rates of major-adverse cardiovascular events (MACE) at 4 years compared with nondiabetics (23.03 vs. 31.96 P > 0.001). DES use was associated with lower rates of TVR in both groups [diabetics hazard ratio (HR) = 0.56, 95% confidence interval (CI): 0.42-0.76, P < 0.001, nondiabetics HR = 0.73, 95% CI: 0.55-0.97, P = 0.03] while sustained decreased rates of both mortality and MI were evident solely among diabetics (HR = 0.71, 95% CI: 0.56-0.89, P = 0.004 in diabetic vs. HR = 0.88, 95% CI: 0.69-1.13, P = 0.3). CONCLUSIONS: In a "real-world," unselected population and extended clinical use, DES in diabetics was associated with sustained decreased rates of MI, death, TVR, and MACE while this benefit was attenuated in the nondiabetic population.