RÉSUMÉ
Robotic percutaneous coronary intervention (R-PCI) is an emerging technology designed to improve operator safety and procedural precision. The interventional cardiologist is able to manipulate guidewires, catheters and devices from a specific cockpit. A number of studies evaluating R-PCI have shown high procedural success rates with low complications. R-PCI advantages include the possibility to perform an accurate stent positioning, to reduce the operator radiation exposure and orthopedic injuries. However, there is a limited experience regarding R-PCI in complex anatomies, that may still require manual assistance. Moreover, the technique is limited by current incompatibility with specific materials, the lack of tactile feedback and the possibility to robotically manage only one wire/device at the same time. Globally, R-PCI is a novel approach with future interesting implications, but further investigations are necessary to overcome current limitations.
Sujet(s)
Maladie des artères coronaires , Intervention coronarienne percutanée , Interventions chirurgicales robotisées , Robotique , Humains , Intervention coronarienne percutanée/méthodes , Interventions chirurgicales robotisées/méthodes , Robotique/méthodes , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND: The aim of this study was to assess in-hospital and long-term results of the novo unprotected left main (UPLM) percutaneous coronary intervention (PCI) in patients with acute coronary syndrome (ACS) or stable coronary artery disease (CAD), in an unselected population admitted to a single high- volume cath-lab without on-site cardiac surgery. METHODS: From 2008 to 2011, among 317 PCI performed in patients with the novo UPLM stenosis, 49 patients presented ST-elevation myocardial infarction (STEMI), 152 non ST-elevation MI/unstable angina (NSTEMI/UA), 116 stable CAD. RESULTS: In-hospital mortality was 20% in STEMI, 5.3% in NSTEMI/UA and 1.7% in stable CAD patients (P<0.001). Two-year total mortality was 24.5%, 25.6% and 6% in the 3 groups, and cardiac death was 20%, 13.8% and 3.4% (P=0.002). Left main target lesion revascularization (TLR) was similar in the 3 groups, as the clinically-driven TLR (10% vs. 11% vs. 7.7%, P=0.642), with neither definite nor probable stent thrombosis. Multivariate analysis showed the following independent predictors of 2-year mortality: bare-metal stent use (OR 4.53, P<0.001), Syntax Score >32 (OR 3.53, P=0.012), ACS as the indication (OR 3.24, P=0.012), peripheral artery disease (OR 2.20, P=0.042), and age >75 years (OR 2.09, P=0.05). CONCLUSIONS: Our experience showed acceptable results of UPLM PCI in STEMI patients, where short-term prognosis was related to hemodynamic conditions, good results in NSTEMI/UA patients where mortality increased in the follow-up due to comorbidities, and very good results in patients with stable CAD.
Sujet(s)
Syndrome coronarien aigu/thérapie , Maladie des artères coronaires/thérapie , Intervention coronarienne percutanée/méthodes , Syndrome coronarien aigu/mortalité , Syndrome coronarien aigu/physiopathologie , Sujet âgé , Sujet âgé de 80 ans ou plus , Angor instable/mortalité , Angor instable/thérapie , Maladie des artères coronaires/mortalité , Sténose coronarienne/thérapie , Femelle , Mortalité hospitalière , Humains , Mâle , Adulte d'âge moyen , Analyse multifactorielle , Infarctus du myocarde sans sus-décalage du segment ST/épidémiologie , Infarctus du myocarde sans sus-décalage du segment ST/mortalité , Infarctus du myocarde sans sus-décalage du segment ST/thérapie , Pronostic , Études rétrospectives , Infarctus du myocarde avec sus-décalage du segment ST/épidémiologie , Infarctus du myocarde avec sus-décalage du segment ST/mortalité , Infarctus du myocarde avec sus-décalage du segment ST/thérapie , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
Anabolic steroid abuse, aimed at increasing muscle mass, has been growing in recent years. We describe a case of a 25-year-old bodybuilder who, after taking nandrolone and stanozolol, presented with Takotsubo syndrome. The angiography showed a normal coronary anatomy with the absence of stenosis. The left ventricular function was completely normalised after 1 week.
Sujet(s)
Anabolisants/effets indésirables , Androgènes/effets indésirables , Douleur thoracique/étiologie , Nandrolone/effets indésirables , Troubles liés à une substance/diagnostic , Syndrome de tako-tsubo/induit chimiquement , Adulte , Anabolisants/administration et posologie , Androgènes/administration et posologie , Électrocardiographie , Humains , Injections musculaires , Mâle , Nandrolone/administration et posologie , Syndrome de tako-tsubo/diagnostic , Résultat thérapeutique , HaltérophilieRÉSUMÉ
Acute ST-elevation myocardial infarction (STEMI) usually results from coronary atherosclerotic plaque disruption with superimposed thrombus formation. Detection of coronary thrombi is a poor prognostic indicator, which is mostly proportional to their size and composition. Particularly, intracoronary thrombi impair both epicardial blood flow and myocardial perfusion, by occluding major coronary arteries and causing distal embolization, respectively. Thus, although primary percutaneous coronary intervention is the preferred treatement strategy in STEMI setting, the associated use of adjunctive antithrombotic drugs and/or percutaneous thrombectomy is crucial to optimize therapy of STEMI patients, by improving either angiographical and clinical outcomes. This review article will focus on the prognostic significance of intracoronary thrombi and on current antithrombotic pharmacological and interventional strategies used in the setting of STEMI to manage thrombotic lesions.
RÉSUMÉ
The in-hospital management of patients on warfarin undergoing coronary stent implantation (PCI-S) is variable, and the in-hospital outcome incompletely defined. To determine the adherence to the current recommendations, and the incidence of adverse events, we carried out the prospective, multicenter, observational WARfarin and coronary STENTing (WAR-STENT) registry (ClinicalTrials.gov identifier NCT00722319). All consecutive patients on warfarin undergoing PCI-S at 37 Italian centers were enrolled and followed for 12 months. Outcome measures were: major adverse cardiovascular events (MACE), including cardiovascular death, non-fatal myocardial infarction, need for urgent revascularization, stroke, and venous thromboembolism, and major and minor bleeding. In this paper, we report the in-hospital findings. Out of the 411 patients enrolled, 92% were at non-low (ie, moderate or high) thromboembolic risk. The radial approach and bare-metal stents were used in 61% and 60% of cases, respectively. Drug-eluting stents were essentially reserved to patients with diabetes, which in turn, significantly predicted the implantation of drug-eluting stents (odds ratio [OR], 2.02; 95% confidence interval [CI], 1.29-3.17; P=.002). The in-hospital MACE and major bleeding rates were 2.7% and 2.1%, respectively. At discharge, triple therapy (TT) of warfarin, aspirin, and clopidogrel was prescribed to 76% of patients. Prescription of TT was significantly more frequent in the non-low thromboembolic risk group. Non-low thromboembolic risk, in turn, was a significant predictor of TT prescription (OR, 11.2; 95% CI, 4.83-26.3; P<.0001). In conclusion, real-world warfarin patients undergoing PCI-S are largely managed according to the current recommendations. As a consequence, the risk of in-hospital MACE and major bleedings appears limited and acceptable.
Sujet(s)
Syndrome coronarien aigu/thérapie , Prise en charge de la maladie , Endoprothèses à élution de substances , Patients hospitalisés , Intervention coronarienne percutanée , Endoprothèses , Warfarine/usage thérapeutique , Sujet âgé , Sujet âgé de 80 ans ou plus , Anticoagulants/effets indésirables , Anticoagulants/usage thérapeutique , Fibrillation auriculaire/traitement médicamenteux , Femelle , Humains , Incidence , Mâle , Adulte d'âge moyen , Infarctus du myocarde/épidémiologie , , Études prospectives , Enregistrements , Études rétrospectives , Facteurs de risque , Accident vasculaire cérébral/épidémiologie , Thromboembolie/épidémiologie , Warfarine/effets indésirablesRÉSUMÉ
BACKGROUND: The optimal antiplatelet regimen in elective patients undergoing complex percutaneous coronary interventions (PCIs) is uncertain. We aimed to assess the impact of glycoprotein IIb/IIIa (GpIIb/IIIa) inhibition with eptifibatide in clinically stable subjects with diffuse coronary lesions. METHODS: Patients with stable coronary artery disease undergoing PCI by means of implantation of >33 mm of drug-eluting stent were single-blindedly randomized to heparin plus eptifibatide versus heparin alone. The primary end point was the rate of abnormal post-PCI creatine kinase-MB mass values. Secondary end points were major adverse cardiovascular events (MACEs) (ie, cardiac death, myocardial infarction, or urgent revascularization) and MACE plus bailout GpIIb/IIIa inhibitor use. RESULTS: The study was stopped for slow enrollment and funding issues after including a total of 91 patients: 44 were randomized to heparin plus eptifibatide, and 47, to heparin alone. Analysis for the primary end point showed a trend toward lower rates of abnormal post-PCI creatine kinase-MB mass values in the heparin-plus-eptifibatide group (18 [41%]) versus the heparin-alone group (26 [55%], relative risk 0.74 [95% CI 0.48-1.15], P = .169). Similar nonstatistically significant trends were found for rates of MACE, their components, or MACE plus bailout GpIIb/IIIa inhibitors (all P > .05). Notably, heparin plus eptifibatide proved remarkably safe because major bleedings or minor bleeding was uncommon and nonsignificantly different in both groups (all P > .05). CONCLUSIONS: Given its lack of statistical power, the INSTANT study cannot definitively provide evidence against or in favor of routine eptifibatide administration in stable patients undergoing implantation of multiple drug-eluting stent for diffuse coronary disease. However, the favorable trend evident for the primary end point warrants further larger randomized studies.
Sujet(s)
Angioplastie coronaire par ballonnet/méthodes , Sténose coronarienne/thérapie , Endoprothèses à élution de substances , Infarctus du myocarde/prévention et contrôle , Peptides/administration et posologie , Sujet âgé , Angioplastie coronaire par ballonnet/effets indésirables , Angioplastie coronaire par ballonnet/mortalité , Coronarographie/méthodes , Sténose coronarienne/imagerie diagnostique , Sténose coronarienne/mortalité , Eptifibatide , Femelle , Études de suivi , Héparine/administration et posologie , Humains , Estimation de Kaplan-Meier , Mâle , Adulte d'âge moyen , Infarctus du myocarde/anatomopathologie , Antiagrégants plaquettaires/administration et posologie , Modèles des risques proportionnels , Appréciation des risques , Indice de gravité de la maladie , Méthode en simple aveugle , Statistique non paramétrique , Analyse de survie , Résultat thérapeutiqueRÉSUMÉ
Dronedarone is the antiarrhythmic drug with the most complete and wide literature preceding its marketing. Most of these studies showed a good efficacy along with an excellent risk profile, especially in low- and medium-risk patients. Recently, updates of European, American and even Italian guidelines gave dronedarone its own spot into the antiarrhythmic armamentarium, recommending its use both for rhythm control and rate control in non-permanent atrial fibrillation. In Italy, however, dronedarone prescription is still possible only when amiodarone is not tolerated, making dronedarone a mere second choice of its older "relative". Moreover, patients taking dronedarone must undergo a strict alanine aminotransferase and bilirubin follow-up, which usefulness in predicting drug-induced liver damage (probably idiosyncratic in nature and therefore unpredictable) is far from demonstrated. The aim of this review is to sum up actual evidences on dronedarone, describe how these evidences had been differently transposed by panel of experts and drug agencies into guidelines and recommendations, and define the current difficulties encountered by the cardiologist in the correct use of this new antiarrhythmic agent in clinical practice.
Sujet(s)
Amiodarone/analogues et dérivés , Antiarythmiques/administration et posologie , Antiarythmiques/effets indésirables , Fibrillation auriculaire/traitement médicamenteux , Rythme cardiaque/effets des médicaments et des substances chimiques , Défaillance hépatique aigüe/induit chimiquement , Algorithmes , Amiodarone/administration et posologie , Amiodarone/effets indésirables , Dronédarone , Humains , Tests de la fonction hépatique , Guides de bonnes pratiques cliniques comme sujetRÉSUMÉ
OBJECTIVES: This study sought to assess whether transradial intervention, by minimizing access-site bleeding and vascular events, improves outcomes in patients with ST-segment elevation myocardial infarction compared with the transfemoral approach. BACKGROUND: Bleeding and consequent blood product transfusions have been causally associated with a higher mortality rate in patients with myocardial infarction undergoing coronary angioplasty. METHODS: We identified all adults undergoing percutaneous intervention for acute myocardial infarction in Emilia-Romagna, a region in the north of Italy of 4 million residents, between January 1, 2003, and July 30, 2009, at 12 referral hospitals using a region-mandated database of percutaneous coronary intervention procedures. Differences in the risk of death at 2 years between patients undergoing transfemoral versus transradial intervention, assessed on an intention-to-treat basis, were determined from vital statistics records and compared based on propensity score adjustment and matching. RESULTS: A total of 11,068 patients were treated for acute myocardial infarction (8,000 via transfemoral and 3,068 via transradial route). According to analysis of matched pairs, the 2-year, risk-adjusted mortality rates were lower for the transradial than for the transfemoral group (8.8% vs. 11.4%; p = 0.0250). The rate of vascular complications requiring surgery or need for blood transfusion were also significantly decreased in the transradial group (1.1% vs. 2.5%, p = 0.0052). CONCLUSIONS: In patients undergoing angioplasty for acute myocardial infarction, transradial treatment is associated with decreased 2-year mortality rates and a reduction in the need for vascular surgery and/or blood transfusion compared with transfemoral intervention.
Sujet(s)
Angioplastie coronaire par ballonnet/méthodes , Infarctus du myocarde/thérapie , Sujet âgé , Angioplastie coronaire par ballonnet/instrumentation , Intervalles de confiance , Femelle , Indicateurs d'état de santé , Humains , Italie , Estimation de Kaplan-Meier , Modèles logistiques , Mâle , Analyse multifactorielle , Infarctus du myocarde/mortalité , Infarctus du myocarde/anatomopathologie , Score de propension , Études prospectives , Enregistrements , Statistiques comme sujetRÉSUMÉ
Adjunctive therapy with abciximab has been proven to reduce mortality and reinfarction in patients with ST-elevation myocardial infarction (STEMI) referred to invasive management. Standard abciximab regimen consists of an intravenous (IV) bolus followed by a 12-h IV infusion. Experimental studies and small clinical trials suggest the superiority of intracoronary (IC) injection of abciximab over the IV route. We aimed to perform a meta-analysis of randomized controlled trials to assess the clinical efficacy and safety of IC vs. IV abciximab administration in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). The primary endpoint was mortality, while recurrent myocardial infarction and target vessel revascularization (TVR) were selected as secondary endpoints. The safety endpoint was the risk of major bleeding complications. A total of six randomized trials were finally included in the meta-analysis, enrolling a total of 1246 patients. Compared to IV route, IC abciximab was associated with a significant reduction in mortality (odds ratio, OR [95% confidence interval (CI)] =0.43 [0.20-0.94], p=0.03), and TVR (OR [95% CI] =0.53 [0.29-0.99], p=0.05). No differences in terms of recurrent myocardial infarction (OR [95% CI] =0.54 [0.23-1.28], p=0.17) or major bleeding complications (OR [95% CI] =0.91 [0.46-1.79], p=0.79) were observed between the two strategies. The present meta-analysis showed that IC administration of abciximab is associated with significant benefits in mortality at short-term follow-up compared to IV abciximab administration, without any excess of major bleeding in STEMI patients undergoing PPCI. However, further trials are warranted to establish the optimal strategy of abciximab treatment in this setting.
Sujet(s)
Anticorps monoclonaux/administration et posologie , Fragments Fab d'immunoglobuline/administration et posologie , Infarctus du myocarde/traitement médicamenteux , Antiagrégants plaquettaires/administration et posologie , Abciximab , Angioplastie coronaire par ballonnet , Anticorps monoclonaux/effets indésirables , Anticorps monoclonaux/usage thérapeutique , Humains , Fragments Fab d'immunoglobuline/effets indésirables , Fragments Fab d'immunoglobuline/usage thérapeutique , Perfusions veineuses , Injections artérielles , Infarctus du myocarde/mortalité , Infarctus du myocarde/thérapie , Antiagrégants plaquettaires/effets indésirables , Antiagrégants plaquettaires/usage thérapeutique , Essais contrôlés randomisés comme sujet , Récidive , Résultat thérapeutiqueRÉSUMÉ
AIMS: Drug-eluting stents (DES) are a major advance in interventional cardiology; however concerns have been raised regarding their long-term safety due to the permanent nature of the polymer. New generation stents with biodegradable polymers (BDS) have recently been developed. The aim of this study was to perform a meta-analysis of randomised controlled trials (RCTs) comparing the safety and efficacy profile of BDS vs. durable polymer DES. METHODS AND RESULTS: The MEDLINE/CENTRAL and Google Scholar databases were searched for RCTs comparing safety and efficacy of BDS vs. DES. Safety endpoints were mortality, myocardial infarction (MI), and stent thrombosis (ST). Efficacy endpoints were target vessel revascularisation (TVR), target lesion revascularisation (TLR) and six-month in-stent late loss (ISLL). The meta-analysis included eight RCTs (n=7,481). At a median follow-up of nine months, as compared to DES, BDS use did not increase mortality (OR [95% CI] = 0.91 [0.69-1.22], p=0.53) or MI (OR [95% CI] = 1.14 [0.90-1.44], p=0.29). Rate of late/very late ST was significantly reduced in BDS patients (OR [95% CI] = 0.60 [0.39-0.91], p=0.02), as was six-month ISLL (mean difference [95% CI] = -0.07 [-0.12; -0.02] mm, p=0.004) in comparison with DES patients. Rates of TVR and TLR were comparable between BDS and DES. CONCLUSIONS: BDS are at least as safe as standard DES with regard to survival and MI, and more effective in reducing late ST, as well as six-month ISLL. Further large RCTs with long-term follow-up are warranted to definitively confirm the potential benefits of BDS.
Sujet(s)
Implant résorbable , Endoprothèses à élution de substances , Implant résorbable/effets indésirables , Endoprothèses à élution de substances/effets indésirables , Humains , Néovascularisation physiologique , Essais contrôlés randomisés comme sujet , Thrombose/étiologie , Thrombose/prévention et contrôleRÉSUMÉ
Although cardiac resynchronization therapy (CRT) is an effective treatment for chronic systolic heart failure with dyssynchrony, about one-third of patients do not respond favorably. The interaction between the pacing lead and the coronary sinus (CS) branches is of paramount importance for an effective resynchronization. Minor changes in lead position overtime could interfere with CRT mechanics, without affecting even biophysical parameters or ECG morphology. Although late post-implant CS lead dislodgement rate is consistent, lead movements have been little investigated and only with bi-dimensional methods. The aim of this study was (1) to develop a method for quantifying CS lead position in the 3D domain throughout the cardiac cycle and (2) to test it by comparing the CS lead position at implant and at follow-up, using chest fluoroscopy. Method performance, its accuracy and reproducibility were qualitatively and quantitatively assessed. Intra- and inter-observer percent discordance between trajectories were also computed. The accuracy of the procedure resulted in 0.3 ± 0.1 mm and its resolution was 0.5 mm. Intra- and inter-observer discordances were 2.2 ± 1.5 and 5.5 ± 3.6 mm, respectively. The proposed method for measuring the CS lead dynamic placement in 3D space seems accurate and reproducible. Investigating CS lead 3D dynamics could provide further insights into CRT mechanics.
Sujet(s)
Thérapie de resynchronisation cardiaque/méthodes , Sinus coronaire/imagerie diagnostique , Défaillance cardiaque/thérapie , Sujet âgé , Dispositifs de resynchronisation cardiaque , Électrodes implantées , Analyse de panne d'appareillage/méthodes , Femelle , Radioscopie , Migration d'un corps étranger/imagerie diagnostique , Humains , Mâle , Adulte d'âge moyenSujet(s)
Fibrillation auriculaire/chirurgie , Ablation par cathéter/effets indésirables , Échocardiographie/méthodes , Endosonographie , Fibrinolytiques/administration et posologie , Traitement thrombolytique/méthodes , Thrombose/traitement médicamenteux , Sujet âgé , Fibrillation auriculaire/imagerie diagnostique , Fibrillation auriculaire/physiopathologie , Échocardiographie tridimensionnelle , Études de suivi , Atrium du coeur , Cardiopathies/imagerie diagnostique , Cardiopathies/traitement médicamenteux , Cardiopathies/étiologie , Humains , Injections , Mâle , Thrombose/imagerie diagnostique , Thrombose/étiologieRÉSUMÉ
BACKGROUND: Despite the well-known prognostic impact of systolic dysfunction in unselected patients undergoing percutaneous coronary intervention (PCI), limited data are available on its current predictive role after PCI for unprotected left main disease (ULM). We thus appraised the prognostic role of left ventricular ejection fraction (LVEF) in patients undergoing PCI for ULM with drug-eluting stents (DES). METHODS: Consecutive eligible subjects were retrospectively enrolled in a national registry. Patients were divided into three groups: LVEF < 30%, LVEF 30-45%, and LVEF > 45%. Relevant baseline and outcome data were compared with bivariate and multivariable tests. RESULTS: A total of 975 subjects was included (LVEF < 30%: 46, LVEF 30-45%: 208, LVEF > 45%: 721). Patients with LVEF < 30% had several other unfavorable clinical features, including older age and higher EuroSCORE. Adverse event rates were different already at 7 days (p = 0.012 for all-cause death and p = 0.015 for major adverse cardiac events [MACE]), with even more significant trends up to 30 days and at long-term (p < 0.001 for death, and p < 0.001 for MACE). After a median of 18 months, risk of death totaled 39 versus 13 versus 8% (p < 0.001) and risk of MACE 44 versus 24 versus 22% (p = 0.003). Multivariable analyses showed however that reduced LVEF was not an independent predictor of adverse events at any time-point. CONCLUSIONS: Whereas reduced LVEF is apparently a significant predictor of adverse events after PCI with DES for ULM, its prognostic impact is mostly due to clustering with other adverse features.
Sujet(s)
Angioplastie coronaire par ballonnet/instrumentation , Maladie des artères coronaires/thérapie , Endoprothèses à élution de substances , Débit systolique , Dysfonction ventriculaire gauche/complications , Fonction ventriculaire gauche , Sujet âgé , Sujet âgé de 80 ans ou plus , Angioplastie coronaire par ballonnet/effets indésirables , Angioplastie coronaire par ballonnet/mortalité , Cause de décès , Loi du khi-deux , Maladie des artères coronaires/complications , Maladie des artères coronaires/mortalité , Maladie des artères coronaires/physiopathologie , Femelle , Humains , Italie , Modèles logistiques , Mâle , Adulte d'âge moyen , Infarctus du myocarde/étiologie , Infarctus du myocarde/mortalité , Odds ratio , Sélection de patients , Conception de prothèse , Enregistrements , Études rétrospectives , Appréciation des risques , Facteurs de risque , Facteurs temps , Résultat thérapeutique , Dysfonction ventriculaire gauche/mortalité , Dysfonction ventriculaire gauche/physiopathologieRÉSUMÉ
BACKGROUND: Stent thrombosis (ST) is a new, rare, cause of STEMI. Few data are available about incidence and clinical impact of shock complicating acute myocardial infarction due to ST (st-STEMI). METHODS: From January 2004 to March 2007, 92 st-STEMI patients were observed: 14 (15.2%) of them presented with cardiogenic shock and were evaluated in the present analysis. In particular, clinical and angiographic characteristics of survivors and non-survivors to PCI were compared. RESULTS: St-STEMI was related to left main or multivessels stent thrombosis in 35.7% of cases; whereas in 93% of cases st-STEMI occurred in a territory with previous myocardial infarction. All patients underwent IABP implantation immediately before coronary angiography, whereas Impella LP 2.5 pump was used in 21% of cases when persistent cardiac low-output signs were recorded. PCI was successful in 80% of cases. In-hospital survival was 28.6%. Death occurred within the first 48 h in the majority of patients. At six-months all patients survived to the acute phase were alive. Survivors had significantly lower thrombus grade after wire passage (p=0.03) and, albeit not significant, they showed a higher rate of very late ST, longer times from symptoms onset to revascularization, and higher TIMI flow grade either before and after PCI. CONCLUSION: The incidence of cardiogenic shock in st-STEMI is high, particulary it seems to be two times higher than the rate reported during myocardial infarction. One third of cases is related to left main or multiple vessels ST. Shock in st-STEMI represents a dramatic event with very low in-hospital and early survival.
Sujet(s)
Défibrillateurs implantables , Infarctus du myocarde/thérapie , Choc cardiogénique/thérapie , Endoprothèses/effets indésirables , Thrombose/thérapie , Dysfonction ventriculaire gauche/thérapie , Sujet âgé , Bases de données factuelles , Endoprothèses à élution de substances/effets indésirables , Études de suivi , Humains , Adulte d'âge moyen , Infarctus du myocarde/étiologie , Infarctus du myocarde/physiopathologie , Études prospectives , Choc cardiogénique/étiologie , Choc cardiogénique/physiopathologie , Thrombose/complications , Thrombose/physiopathologie , Dysfonction ventriculaire gauche/étiologie , Dysfonction ventriculaire gauche/physiopathologieRÉSUMÉ
Coronary stent thrombosis (CST) is a major concern of interventional cardiology. Several risk factors for CST have been identified, but as a whole they do not explain the pathophysiology of CST. This study was designed to investigate whether acute infection-inflammation could facilitate the occurrence of CST. Forty-one patients, aged 66.6 +/- 11 years, consecutively admitted to our catheterization laboratory for acute, subacute or late CST, were retrospectively analysed. Transient acute infection-inflammation on admission for CST was diagnosed by predefined criteria. Prevalence of known risk factors for CST was also investigated. Twenty-one patients (51%) met predefined criteria for the occurrence of acute infection-inflammation. On admission, in these patients, levels of systemic humoral and cellular inflammatory markers were significantly higher than those of patients without recent or ongoing acute infection-inflammation (p < 0.05 for all). 62% of patients with acute infection-inflammation had less than two known risk factors for CST whereas only 37% patients without infection-inflammation showed less than two risk factors (p = 0.03) and showed more frequent interruption of antiplatelet treatment (17 vs. 2.4%, p = 0.02), mean longer stent length (20.5 +/- 4.8 vs. 16.5 +/- 5.1 mm, p = 0.02) and lower left ventricular ejection fraction before CST (42.9 +/- 14 vs. 47.3 +/- 11%, p = 0.02). In conclusion, acute infection-inflammation could play a role in facilitating the occurrence of CST in a subgroup with low risk profile for known risk factors. Our findings, if confirmed, could suggest new opportunities for prevention and treatment of CST.
Sujet(s)
Resténose coronaire/étiologie , Thrombose coronarienne/étiologie , Infections/complications , Inflammation/complications , Endoprothèses , Maladie aigüe , Sujet âgé , Sujet âgé de 80 ans ou plus , Angioplastie coronaire par ballonnet , Resténose coronaire/épidémiologie , Thrombose coronarienne/épidémiologie , Femelle , Humains , Inflammation/étiologie , Italie/épidémiologie , Mâle , Adulte d'âge moyen , Prévalence , Études rétrospectives , Facteurs de risque , Endoprothèses/effets indésirables , Débit systolique , Fonction ventriculaire gaucheRÉSUMÉ
AIMS: Percutaneous coronary intervention (PCI) is increasingly being used for unprotected left main (ULM) disease. Limited data are available on sex-related differences in this setting. We investigated gender-associated differences in patients undergoing stent-based PCI for ULM. METHODS AND RESULTS: We analysed baseline, procedural and long-term data of patients with ULM undergoing stent-based PCI at participating centres. The primary end-point was the long-term rate of major cardiovascular events rate (MACE, i.e., the composite of death, myocardial infarction, or target lesion revascularisation). The study population included 1,452 cases, with 27.8% females and 72.2% males. Women were older, more frequently diabetic, hypertensive or presenting with an acute coronary syndrome, and thus with a higher EuroSCORE, but were less commonly treated with drug-eluting stents (DES), in comparison to men (all p<0.01). After a median follow-up of 18 months, women showed an unadjusted higher risk of death (p=0.040), cardiac death (p=0.033), and the death/myocardial infarction (p=0.012). However, after multivariable adjustment, gender was no longer an independent predictor of death (hazard ratio=1.119 [0.804-1.558]), cardiac death (hazard ratio=1.045 [0.697-1.567]), or death/myocardial infarction (hazard ratio=0.531 [0.192-1.465]), given the predominant role of age, diabetes and EuroSCORE as independent predictors and confounders of the gender-based comparison. CONCLUSIONS: Women undergoing PCI for ULM present more often with an acute coronary syndrome, are treated less frequently with DES, and have more adverse events, but these gender biases are not confirmed after adjusting for confounders. Thus, stent-based PCI for ULM offers similarly favourable clinical results in women as well as in men.
Sujet(s)
Angioplastie coronaire par ballonnet/instrumentation , Maladie des artères coronaires/thérapie , Endoprothèses , Sujet âgé , Sujet âgé de 80 ans ou plus , Angioplastie coronaire par ballonnet/effets indésirables , Angioplastie coronaire par ballonnet/mortalité , Loi du khi-deux , Maladie des artères coronaires/mortalité , Femelle , Humains , Italie , Modèles logistiques , Mâle , Adulte d'âge moyen , Infarctus du myocarde/étiologie , Odds ratio , Modèles des risques proportionnels , Enregistrements , Études rétrospectives , Appréciation des risques , Facteurs de risque , Facteurs sexuels , Facteurs temps , Résultat thérapeutiqueRÉSUMÉ
In this study we investigated the impact of acute coronary syndromes (ACSs) on clinical outcomes in patients with unprotected left main coronary artery (ULMCA) stenosis treated with drug-eluting stents (DESs). In this multicenter, retrospective, observational study we enrolled 1,101 patients with ULMCA stenosis treated with DESs. Six hundred eleven patients presented with ACS and 490 had stable coronary artery disease. ACS was defined as the presence of unstable angina or non-ST-segment elevation myocardial infarction (MI). During 2-year follow-up, the adjusted hazard ratio of cardiac mortality and MI of patients with ACS versus stable patients was 2.42 (95% confidence interval 1.37 to 4.28, p = 0.002). We observed a stepwise risk increase, namely patients with stable coronary disease had the lowest risk, patients with unstable angina an intermediate risk, and patients with non-ST-segment elevation MI the highest risk. The increased risk of cardiac mortality and MI of patients with ACS was concentrated in the first year after DES implantation. In conclusion, patients with ULMCA stenosis and ACS treated with DESs have an increased risk of cardiac mortality and MI during the first year after the intervention compared to stable patients.
Sujet(s)
Syndrome coronarien aigu/complications , Angioplastie coronaire par ballonnet , Sténose coronarienne/thérapie , Endoprothèses à élution de substances , Syndrome coronarien aigu/anatomopathologie , Syndrome coronarien aigu/thérapie , Adulte , Sujet âgé , Sujet âgé de 80 ans ou plus , Études de cohortes , Sténose coronarienne/complications , Sténose coronarienne/mortalité , Femelle , Humains , Mâle , Adulte d'âge moyen , Études rétrospectives , Facteurs de risque , Analyse de survie , Résultat thérapeutiqueRÉSUMÉ
BACKGROUND: Myocardial salvage is often suboptimal after percutaneous coronary intervention in ST-segment elevation myocardial infarction. Posthoc subgroup analysis from a previous trial (AMIHOT I) suggested that intracoronary delivery of supersaturated oxygen (SSO(2)) may reduce infarct size in patients with large ST-segment elevation myocardial infarction treated early. METHODS AND RESULTS: A prospective, multicenter trial was performed in which 301 patients with anterior ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention within 6 hours of symptom onset were randomized to a 90-minute intracoronary SSO(2) infusion in the left anterior descending artery infarct territory (n=222) or control (n=79). The primary efficacy measure was infarct size in the intention-to-treat population (powered for superiority), and the primary safety measure was composite major adverse cardiovascular events at 30 days in the intention-to-treat and per-protocol populations (powered for noninferiority), with Bayesian hierarchical modeling used to allow partial pooling of evidence from AMIHOT I. Among 281 randomized patients with tc-99m-sestamibi single-photon emission computed tomography data in AMIHOT II, median (interquartile range) infarct size was 26.5% (8.5%, 44%) with control compared with 20% (6%, 37%) after SSO(2). The pooled adjusted infarct size was 25% (7%, 42%) with control compared with 18.5% (3.5%, 34.5%) after SSO(2) (P(Wilcoxon)=0.02; Bayesian posterior probability of superiority, 96.9%). The Bayesian pooled 30-day mean (+/-SE) rates of major adverse cardiovascular events were 5.0+/-1.4% for control and 5.9+/-1.4% for SSO(2) by intention-to-treat, and 5.1+/-1.5% for control and 4.7+/-1.5% for SSO(2) by per-protocol analysis (posterior probability of noninferiority, 99.5% and 99.9%, respectively). CONCLUSIONS: Among patients with anterior ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention within 6 hours of symptom onset, infusion of SSO(2) into the left anterior descending artery infarct territory results in a significant reduction in infarct size with noninferior rates of major adverse cardiovascular events at 30 days. Clinical Trial Registration- clinicaltrials.gov Identifier: NCT00175058.