Long-term quality of life and clinical outcomes in patients with resistant hypertension treated with renal denervation.

INTRODUCTION: Pharmacological treatment combined with lifestyle modifications is an effective treatment for arterial hypertension. However, there are still patients who do not respond to standard treatments. Patients with pharmacologically resistant hypertension may benefit from renal denervation (RDN). AIM: To assess long-term quality of life (QoL) after RDN and effectiveness in reduction of blood pressure (BP) in patients with resistant hypertension. MATERIAL AND METHODS: From 2011 to 2014, 12 patients with previously diagnosed resistant hypertension, treated by RDN, were included in this study. The QoL was assessed using a standardized Polish version of the Nottingham Health Profile questionnaire (NHP). RESULTS: The median age was 54 (IQR: 51-57.5) years. Mean baseline ambulatory pre-procedural systolic/diastolic BP was 188/115 ±29.7/18 mm Hg. The mean values of systolic/diastolic BP measured perioperatively and 3, 6, 12 and 24 months postoperatively were 138/86, 138/85, 146/82, 152/86, and 157/91. All p-values for mean systolic and diastolic BP before versus successive time points after RDN were statistically significant; p-value for all comparisons < 0.05. Improvement of QoL was only observed in two sections of the NHP questionnaire: emotional reaction and sleep disturbance. The analysis of the NHP index of Distress (NHP-D) showed a lower distress level perioperatively and 3, 6, 12 and 24 months after RDN as compared to baseline. The RDN was not associated with any significant adverse events. CONCLUSIONS: Patients with pharmacologically resistant hypertension treated with RDN achieved significant reduction in BP during 24-month follow-up. Furthermore, a significant improvement in the QoL was observed in those patients.

No clinical benefit from manual thrombus aspiration in patients with non-ST-elevation myocardial infarction.

INTRODUCTION: There are scarce data on the usefulness of manual thrombectomy among patients with non-ST-elevation myocardial infarction (NSTEMI). Early positive reports were not supported by the clinical outcome in the recent TATORT-NSTEMI (Thrombus Aspiration in Thrombus Containing Culprit Lesions in Non-ST-Elevation Myocardial Infarction) study. AIM: To analyze the long-term outcome of NSTEMI patients treated with manual thrombectomy during percutaneous coronary intervention (PCI) in the Polish multicenter National Registry of Drug Eluting Stents (NRDES) study. MATERIAL AND METHODS: There were 13 catheterization laboratories in Poland that enrolled patients in NRDES Registry in 2010-2011. Patients with a diagnosis of NSTEMI were divided into two groups: those that were treated with manual thrombectomy for their primary PCI (T) and those who were not (NT). RESULTS: There were 923 patients diagnosed with NSTEMI in NRDES. Aspiration thrombectomy was used in 71 (7.7%) patients and the remaining 852 (92.3%) NSTEMI cases were treated without thrombectomy during the index PCI. Thrombectomy was more often used in patients with TIMI less than 1, thrombus grades 4 and 5 and older male patients. Percutaneous coronary interventions complications such as distal embolization and slow flow were more often observed in the thrombectomy subgroup. Overall mortality at 1 year was 1.69% in the T and 5.92% in the NT group (p = 0.24 and p = 0.32 after propensity score matching adjustment with p = 0.11 in the multivariate logistic regression model). CONCLUSIONS: There was no mortality benefit from thrombus aspiration in NSTEMI patients at 1-year follow-up.

Association of plasma miR-223 and platelet reactivity in patients with coronary artery disease on dual antiplatelet therapy: A preliminary report.

Decreased plasma levels of microRNA-223 (miR-223), predominantly of platelet origin, were proposed as a surrogate marker of efficacy of antiplatelet therapy. However, higher on-treatment platelet reactivity was associated with lower plasma miR-223 in patients with coronary artery disease (CAD) on dual antiplatelet therapy (DAPT) including clopidogrel and aspirin. Our aim was to compare plasma miR-223 and platelet reactivity in CAD patients on DAPT with newer P2Y12 antagonists vs. clopidogrel. We studied 21 men with CAD admitted to our centre owing to a non-ST-elevation acute coronary syndrome, and with an uncomplicated hospital course. From the day of admission, the patients were receiving either clopidogrel (n = 11) or prasugrel/ticagrelor (n = 10) in addition to aspirin. Before discharge, miR-223 expression in plasma was estimated by quantitative polymerase chain reaction using the comparative Ct method relative to miR-16 as an endogenous control. Multiple electrode aggregometry was used to assess platelet aggregation in response to adenosine diphosphate (ADP). ADP-induced platelet reactivity was decreased in the patients treated with prasugrel or ticagrelor compared with those on clopidogrel (mean ± SD: 139 ± 71 vs. 313 ± 162 arbitrary units [AU]*min, p = 0.006), due to a more potent antiplatelet activity of the novel P2Y12 antagonists. Consequently, six out of seven patients in the lower tertile of the ADP-induced platelet aggregation were treated with the newer P2Y12 blockers, whereas six out of seven patients in the upper tertile were on clopidogrel. Plasma miR-223 was elevated with decreasing platelet reactivity (Spearman's rho = -0.52; p = 0.015 for trend), being significantly higher in the lower tertile of the ADP-induced platelet aggregation (median [range]: 1.06 [0.25-2.31]) vs. the upper tertile (0.20 [0.13-2.30]) (p = 0.04). In conclusion, our preliminary results argue against the notion of low plasma miR-223 as a marker of platelet responsiveness to DAPT. On the contrary, more potent platelet inhibition associated mainly with newer P2Y12 antagonists appears to coincide with higher miR-223 relative to the subjects with attenuated responsiveness to DAPT.

No long-term clinical benefit from manual aspiration thrombectomy in ST-elevation myocardial infarction patients. Data from NRDES registry.

BACKGROUND: Current STEMI guidelines recommend thrombectomy should be considered during primary PCI. Multiple data from randomized clinical trials, registries, and metanalysis have confirmed the efficacy of thrombectomy in terms of surrogate endpoints like better myocardial perfusion, less pronounced distal embolization, and conflicting results on lower all-cause mortality. Our aim was to analyze long-term outcome of STEMI patients treated with manual thrombectomy during primary PCI in a contemporary national registry. METHODS: There were 13 catheterization laboratories in Poland that enrolled patients in NRDES Registry. Patients were divided into two groups: those that were treated with manual thrombectomy for their primary PCI vs. those who were not. RESULTS: There were altogether 2,686 patients enrolled in the NRDES Registry of whom 1,763 were diagnosed with STEMI (66%). Aspiration thrombectomy was used in 673 of these cases (38%) and 1,090 (62%) patients were treated without thrombectomy during the index primary PCI. Overall mortality at 1 year was 11.03% in thrombectomy and 7.46% in no thrombectomy group respectively (P = 0.0292 which became insignificant after propensity score matching adjustment P = 0.613). Specific subgroup analyses revealed that there was no benefit from aspiration thrombectomy in neither subgroup. CONCLUSIONS: Manual aspiration thrombectomy in patients undergoing primary PCI for STEMI was not associated with improved long-term 1-year clinical outcome. Subgroup analysis did not reveal any specific setting in which thrombectomy would be clinically superior. © 2014 Wiley Periodicals, Inc.

Early abciximab administration before primary percutaneous coronary intervention improves clinical outcome in diabetic patients with ST-segment elevation myocardial infarction (EUROTRANSFER Registry).

BACKGROUND: Diabetes is an important determinant of prognosis in patients with ST-segment elevation myocardial infarction (STEMI). Limited data are available concerning benefits and risks of upstream abciximab administration in diabetic patients. Thus, the objective of the study was to assess the impact of early abciximab administration before primary angioplasty (PCI) for STEMI in diabetic patients. METHODS: Data were gathered for 1650 consecutive STEMI patients transferred for primary PCI from hospital networks in seven countries in Europe from November 2005 to January 2007 (the EUROTRANSFER Registry population). Patients were stratified by diabetes mellitus presence and then by abciximab administration strategy (early - more than 30 min before PCI vs. late). RESULTS: Diabetes mellitus was diagnosed in 262 (15.9%) patients. Patients with diabetes mellitus were high-risk individuals, with advanced age, higher prevalence of comorbidities and increased risk of ischemic events during follow-up in comparison to non-diabetic patients. A total of 1086 patients who received abciximab were identified. Strategy of early abciximab administration was associated with enhanced infarct-related artery patency before PCI, and improved epicardial flow after PCI in both diabetic and non-diabetic patients. Importantly, early abciximab in diabetic patients led to the decrease in ischemic events, including 30-day (OR 0.260, 95% CI 0.089-0.759, p = 0.012) and 1-year (OR 0.273, 95% CI 0.099-0.749, p = 0.012) mortality reduction. However, only a trend toward improved survival was confirmed after adjustment for potential confounders. On the contrary, the reduction of 30-day (OR 0.620, 95% CI 0.334-1.189, p = 0.16) and 1-year (OR 0.643, 95% CI 0.379-1.089, p = 0.10) mortality rates was not significant among non-diabetic patients. CONCLUSIONS: Early administration of abciximab improves infarct-related artery patency before and after primary PCI, and leads to improved survival in diabetic STEMI patients.

Impact of infarct related artery patency after early abciximab administration on one-year mortality in patients with ST-segment elevation myocardial infarction (data from the EUROTRANSFER Registry).

BACKGROUND: Spontaneous early infarct related artery (IRA) recanalisation before primary percutaneous coronary intervention (pPCI) has a favourable impact on outcome. However, the role played by pharmacotherapy driven patency prior to pPCI is still a matter of debate. AIM: To assess the role of early IRA patency (TIMI flow 2 or 3) after early abciximab administration in patients with ST-segment elevation myocardial infarction (STEMI) transferred for pPCI. METHODS: Data was gathered for 1,650 consecutive STEMI patients transferred for pPCI from hospital networks in seven countries in Europe between November 2005 and January 2007. We identified 691 patients who were pretreated with abciximab before transportation to a cathlab hospital and underwent PCI. RESULTS: Angiography showed early IRA patency (TIMI flow 2 or 3) in 233 (33.7%) patients, and occluded IRA (TIMI flow 0 or 1) in 458 (66.3%) patients. In patients with patent IRA, in baseline angiography the rate of TIMI 3 flow and ECG ST-segment resolution 〉 50% after PCI was higher compared to patients with occluded IRA. One year mortality was significantly lower in patients with patent IRA, 1.3% vs 7% (OR 0.17; CI 0.05-0.6; p = 0.001). In multivariable Cox regression analysis, IRA patency at baseline was identified as an independent predictor of one-year mortality. CONCLUSIONS: Infarct related artery recanalisation after early pharmacological pretreatment in STEMI patients undergoing transportation for pPCI is associated with better post-procedural myocardial perfusion and lower one-year mortality.

Timing of events in STEMI patients treated with immediate PCI or standard medical therapy: implications on optimisation of timing of treatment from the CARESS-in-AMI trial.

OBJECTIVES: Early angioplasty after thrombolysis is now recommended for ST-elevation myocardial infarction, but the current guidelines propose a wide time-window ranging between 3 and 24h after lytic administration. To identify the optimal timing for PCI after thrombolysis, we analyzed frequency and time course of the adverse events in patients randomized in the multicenter CARESS-in-AMI trial. METHODS: 598 high-risk patients with STEMI recruited in the CARESS-in-AMI study, were divided into the Immediate PCI group (IMM, n=298), Rescue PCI group (RES, n=107) and Standard Treatment Arm without rescue PCI (STA, n=193). RESULTS: RES patients had worse pre-procedural TIMI flow and post-procedural blush grade. At 30 days, there were 23 deaths: 11 (10.3%) in RES, 9 (3%) in IMM and 3 (1.6%) in STA (p<0.001). There were 22 episodes of refractory ischemia or re-infarction: 17 (8.8%) in the STA group, 4 (1.6%) in IMM and 1 (0.9%) in RES (p<0.001). In the RES group 10/11 (90.9%) deaths occurred before day 5. In the STA group, all deaths and the majority of ischemic events occurred after day 3. A reduction of risk of death was observed if PCI after thrombolysis was performed within 3.35 h from initial hospitalization. CONCLUSIONS: The mortality benefit of immediate referral to PCI after pharmacological treatment for STEMI derives from a reduction in the time to reperfusion of patients with failed thrombolysis in need of rescue PCI. In patients with evidence of successful reperfusion, "elective" PCI within 3 days may be sufficient to reduce the recurrent ischemic events.

Predictors of infarct-related artery patency following combined lytic therapy in patients with ST-segment elevation myocardial infarction treated with immediate percutaneous coronary intervention.

BACKGROUND AND AIM: Patency of infarct-related artery (IRA) before percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) is associated with better outcomes. Little is known of the clinical or angiographic predictors of IRA recanalisation after administration of combined fibrinolytic therapy before PCI. METHODS: A total of 225 STEMI patients, admitted to remote hospitals with anticipated transfer time to cathlab > 90 min were enrolled. All patients received a half dose of alteplase and a full dose of abciximab at the remote hospital and were immediately transferred for angiography. In angiographic analysis, the culprit lesion (CL) was defined as the minimal lumen diameter (MLD) point in IRA (CLMLD) (in group with occluded IRA, measurement was done after the first pass of the guidewire). RESULTS: Occluded IRA (TIMI 0+1) was found in 14.2% of patients (n = 32) and patent IRA (TIMI 2+3) in 85.8% (n = 193) at baseline angiography. Baseline and angiographic characteristics were similar in both groups, except for a higher rate of smoking in the TIMI 2+3 group (73.1% vs 50%; p = 0.009) and longer distance from CLMLD point to the nearest proximal side branch in the TIMI 0+1 group (21.2 ± 10.3 mm vs 13.8 ± 11.2 mm; p = 0.002). In multivariate analysis, smoking and distance from CLMLD to the nearest proximal side branch were independent predictors of IRA patency at baseline. CONCLUSIONS: Angiographic (anatomical) IRA parameter as distance from CLMLD point to nearest proximal side branch may influence the efficacy of combined fibrinolytic therapy before PCI despite the similar clinical characteristics and time delay to angiography. Smoking has a paradoxical beneficial effect on combined thrombolytic therapy effectiveness.

Drug-eluting versus bare-metal stents in ST-segment elevation myocardial infarction: a mortality analysis from the EUROTRANSFER Registry.

AIM: To assess the patterns of drug-eluting stent (DES) and bare-metal stent (BMS) implantation and associated real-life outcomes in patients with ST-segment elevation myocardial infarction (STEMI) transferred for primary percutaneous coronary intervention (PCI). METHODS: Data were gathered for 1,650 consecutive STEMI patients transferred for primary PCI from hospital networks in seven countries of Europe from November 2005 to January 2007. We identified 1,428 patients with ≥1 stent implanted (86.5%). DES were implanted in 382 patients (26.8%) and BMS in 1,046 patients (73.2%) of 1,428 who received stent. RESULTS: High variability in DES use among countries participating in the registry (range from 6.8 to 72.1%) was observed. The use of DES in STEMI declined during the fourth quarter of 2006 through the first quarter of 2007. In the assessed population, age, previous PCI, systolic and diastolic pressures on admission, clopidogrel before admission, left anterior descending artery as the infarct-related artery, and thrombus aspiration device use were identified as the independent predictors of DES implantation. Use of DES was associated with significantly lower rates of ischemic events during follow-up (1-year mortality: BMS vs. DES: 6.7% vs. 3.1%; p = 0.014), but observed difference was no longer significant after adjustment for propensity score (adjusted OR (95% CI): 0.55 (0.28-1.06); p = 0.07). CONCLUSIONS: In this large, prospective European registry, the presence of large geographical and temporal variation of DES utilization in STEMI in Europe was confirmed. DES in STEMI appear to be as safe as BMS, with similar mortality after adjustment for potential confounders and trend toward lower 1-year mortality in patients treated with DES.

Thrombus aspiration followed by direct stenting: a novel strategy of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Results of the Polish-Italian-Hungarian RAndomized ThrombEctomy Trial (PIHRATE Trial).

BACKGROUND: Previous studies with thrombectomy showed different results, mainly due to use of thrombectomy as an additional device not instead of balloon predilatation. The aim of the present study was to assess impact of aspiration thrombectomy followed by direct stenting. METHODS: Patients with ST elevation myocardial infarction (STEMI) <6 hours from pain onset and occluded infarct-related artery in baseline angiography were randomized into aspiration thrombectomy followed by direct stenting (TS, n = 100) or standard balloon predilatation followed by stent implantation (n = 96). The primary end point of the study was the electrocardiographic ST-segment elevation resolution >70% (STR > 70%) 60 minutes after primary angioplasty (percutaneous coronary intervention [PCI]). Secondary end points included angiographic myocardial blush grade (MBG) after PCI, combination of STR > 70% immediately after PCI and MBG grade 3 (optimal myocardial reperfusion), Thrombolysis In Myocardial Infarction flow after PCI, angiographic complications, and in-hospital major adverse cardiac events. RESULTS: Aspiration thrombectomy success rate was 91% (crossing of the lesion with thrombus reduction and flow restoration). There was no significant difference in STR ≥ 70% after 60 minutes (53.7% vs 35.1%, P = .29). STR > 70% immediately after PCI (41% vs 26%, P < .05), MBG grade 3 (76% vs 58%, P < .03), and optimal myocardial reperfusion (35.1% vs 11.8%, P < .001) were more frequent in TS. There was no difference in between the groups in 6-month mortality (4% vs 3.1%, P = .74) and reinfarction rate (1% vs 3.1%, P = .29). CONCLUSIONS: Aspiration thrombectomy and direct stenting is safe and effective in STEMI patients with early presentation (<6 hours). The angiographic parameters of microcirculation reperfusion and ECG ST-segment resolution directly after PCI were significantly better in thrombectomy group despite the lack of the difference in ST-segment resolution 60 minutes after PCI.

Thrombus aspiration in ST elevation myocardial infarction: comparative efficacy in patients treated early and late after onset of symptoms.

BACKGROUND: Restoration of myocardial perfusion is the goal of percutaneous coronary intervention (PCI) in patients with ST elevation myocardial infarction. A major predictor of no-reflow is the increasing time to treatment (TTT). Thrombus aspiration (TA) is reported to improve myocardial reperfusion as compared with standard PCI (SP). OBJECTIVE: To investigate the influence of TTT on TA efficacy. DESIGN: Pooled analysis of individual patients' data of three prospective randomised trials comparing TA and SP. PATIENTS: A total of 299 patients (150 in TA group and 149 in SP group) entered the study. The study population was divided into three subgroups according to the TTT: < or = 3 h (short TTT subgroup), >3 h to < or = 6 h (intermediate TTT subgroup), >6 h to < or = 12 h (long TTT subgroup). MAIN OUTCOME MEASURES: The goal of the study was the comparison of optimal myocardial reperfusion, defined as the combination of myocardial blush grade 2 or 3 at post-PCI angiography and ST resolution more than 70% at post-PCI ECG, between SP and TA according to TTT. RESULTS: In the SP group, increasing TTT was associated with a decreased rate of optimal reperfusion (27.4% vs 17.9% vs 10%, p for trend=0.06), whereas in the TA group the same trend was not seen (40.9% vs 33.8% vs 50%, p for trend=0.93). In a multivariate logistic regression model, a significant interaction (p=0.04) between time to treatment and thrombus aspiration was observed. CONCLUSIONS: TA limits the adverse effects of TTT prolongation on myocardial reperfusion.

Relationship between chronic obstructive pulmonary disease and in-hospital management and outcomes in patients with acute myocardial infarction.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is associated with unfavourable short- and long-term outcome in patients with coronary artery disease undergoing revascularisation procedures. AIM: To assess the associations of COPD with in-hospital management and mortality in patients with acute myocardial infarction (MI) admitted to hospitals without on-site invasive facilities. METHODS: We identified 81 (11.3%) patients with COPD and 633 (88.7%) without COPD treated in the Krakow Registry of Acute Coronary Syndromes from February 2005 to March 2005 and from December 2005 to January 2006. Data concerning in-hospital management and mortality were assessed. RESULTS: Patients with COPD were older and were more likely to have prior angina, prior heart failure symptoms, prior stroke, and lower left ventricular ejection fraction. Patients with COPD diagnosis were less likely to be transferred for invasive treatment [COPD (-) vs. COPD (+), 12.3 vs. 34.9%; p < 0.0001] and to receive aspirin and clopidogrel during index hospital stay. In-hospital mortality was higher in patients with COPD diagnosis [COPD (-) vs. COPD (+), 58 of 412 (14.1%) vs. 21 of 71 (29.6%); p = 0.002]. COPD was an independent predictor of in-hospital death in multivariate Cox regression analysis. CONCLUSIONS: Coexistence of COPD with acute MI may be associated with less frequent transfer for invasive treatment, less aggressive pharmacotherapy, and higher in-hospital mortality in patients admitted to community hospitals without on-site invasive facilities. These differences may be partially driven by a higher risk profile of COPD patients.

Angiographic perfusion score assessed in patients with acute myocardial infarction is correlated with cardiac magnetic resonance infarct size and N-terminal pro-brain natriuretic peptide in 6-month follow-up.

UNLABELLED: Angiographic Perfusion Score (APS) proposed as a simple, angiographic score linking epicardial and myocardial perfusion parameters before and after percutaneous coronary intervention (PCI) is a predictor of short-term outcome in patients with ST-segment elevation myocardial infarction (STEMI) treated with PCI. Aim of the study was to analyze the correlation between APS and both infarct size and left ventricular function in long-term follow-up. In a cohort of 68 patients with STEMI treated with PCI APS was calculated for infarct-related artery based on angiographic parameters and was defined as the sum of the Thrombolysis in Myocardial Infarction (TIMI) flow grade (0-3 points) and the TIMI myocardial perfusion grade (0-3 points) before and after PCI (range of points from 0 to 12). Full perfusion was defined as APS ≥ 10. Cardiac magnetic resonance (CMR) parameters and N-terminal pro-brain natriuretic peptide (NT pro-BNP) were assessed at 6 months. RESULTS: Median APS was 7.5 points. APS ≥ 10 was present in 42% of patients. The significant correlation was found between APS and: CMR infarct size (r = - 0.48; P = 0.0001), CMR left ventricular (LV) ejection fraction (r = 0.5; P = 0.002), LV end-diastolic volume index (r = - 0.37; P = 0.004), LV end-systolic volume index (r = -0.41; P = 0.001), NT pro-BNP (r = - 0.5; P = 0.02). Patients with APS ≥ 10 had significantly lower infarct size, LV volumes, higher EF and lower NT pro-BNP. APS assessed in patients with STEMI treated with PCI is a good predictor of infarct size and left ventricular function in 6-month follow-up.

Early abciximab administration before primary percutaneous coronary intervention improves clinical outcome in elderly patients transferred with ST-elevation myocardial infarction: data from the EUROTRANSFER registry.

BACKGROUND: Limited data are available concerning benefits and risks of early abciximab (EA) administration before primary percutaneous coronary intervention (PPCI) in elderly ST-segment elevation myocardial infarction (STEMI) patients. The objective of the study was to assess the impact of EA before PPCI in elderly (>or=65 years) patients. METHODS AND RESULTS: We identified 545 patients <65 years (354 with EA administration (>30 min before PPCI), 191 late abciximab (LA)), and 541 patients >or=65 years of age (373 EA, 168 LA) in the EUROTRANSFER Registry database. Elderly patients were more likely to have comorbidities, angiographic PCI complications, and bleeding events. EA promotes infarct-related artery patency before PPCI and improves myocardial reperfusion after PPCI in both age groups, but the risk of 30-day death (EA vs. LA: <65 years, 2.0% vs. 1.6%; p=0.999; >or=65 years, 5.9% vs. 14.3%; p=0.001) and 30-day death+reinfarction (EA vs. LA: <65 years, 2.5% vs. 2.1%; p=0.999; >or=65 years, 7.5% vs. 17.3%; p=0.001) was reduced in elderly patients only. There was no difference in bleedings, especially major bleedings requiring transfusion (EA vs. LA: patients <65 years, 2.3% vs. 0%, p=0.055; >or=65 years, 2.4% vs. 3%; p=0.448) between groups. CONCLUSIONS: Patients >or=65 years of age have a substantially increased risk of angiographic PCI complications, death and bleeding events compared with their younger counterparts. Strategy of EA before PPCI improves reperfusion parameters and clinical outcome in elderly patients and is not associated with elevated risk of major bleeding.

Transportation with very long transfer delays (>90 min) for facilitated PCI with reduced-dose fibrinolysis in patients with ST-segment elevation myocardial infarction: the Krakow Network.

BACKGROUND: The majority of ST-segment elevation myocardial infarction (STEMI) patients are admitted to centers without primary percutaneous coronary intervention (PCI) facilities. Purpose of the study was to determine safety and outcomes in STEMI patients with transfer delay to PCI>90 min receiving half-dose alteplase and abciximab before PCI (facilitated PCI with reduced-dose fibrinolysis). METHODS AND RESULTS: Outcomes of 669 STEMI patients (<12 h chest pain, non shock, fibrinolysis eligible, <75 years) with transfer delay to PCI>90 min who received half-dose alteplase and full-dose abciximab and were immediately transferred for PCI were compared with primary PCI effects in 1311 patients with transfer delay <90 min. Mean time from symptom-onset to PCI was longer (357 ± 145 min vs. 201 ± 177; P<0.001) in facilitated PCI with reduced-dose fibrinolysis group. In-hospital and 12-month outcomes were similar in both groups, however bleeding events were more frequent in facilitated PCI group (hemorrhagic stroke 0.9% vs. 0%; P<0.001; severe+moderate 5.5% vs. 2.3%; P<0.001). CONCLUSIONS: This is the first large report showing the safety and benefits of transportation with very long transfer delay (>90 min) for facilitated PCI with reduced-dose fibrinolysis in STEMI patients. In fact, pharmacological treatment (combotherapy) was effective in overcoming the deleterious effects of long time-delay on outcome, with similar survival as compared to short-time transportation, despite higher risk of major bleeding complication.

Early abciximab administration before transfer for primary percutaneous coronary interventions for ST-elevation myocardial infarction reduces 1-year mortality in patients with high-risk profile. Results from EUROTRANSFER registry.

BACKGROUND: There are conflicting data on the clinical benefit from early administration of abciximab from a large randomized trial and a registry. However, both sources suggest that a benefit may depend on the baseline risk profile of the patients. We evaluated the role of early abciximab administration in patients with ST-segment-elevation myocardial infarction (STEMI) referred for primary percutaneous coronary intervention stratified by the STEMI Thrombolysis In Myocardial Infarction (TIMI) risk score. METHODS: A total of 1,650 patients were enrolled into the EUROTRANSFER Registry. One thousand eighty-six patients received abciximab (66%). Abciximab was administered early in 727 patients (EA) and late in 359 patients (LA). We used the TIMI risk score for risk stratification. Patients with scores >or=3 constituted the high-risk group of 616 patients (56.7%), whereas 470 patients formed the low-risk cohort. Factoring in the timing of the abciximab administration resulted in 4 groups of patients who were compared for mortality at 1 year: EA/high-risk (n = 413); LA/high-risk (n = 203); EA/low-risk (n = 314); LA/low-risk (n = 156). Baseline difference was accounted for by means of propensity score. RESULTS: In high-risk patients, 1-year mortality was significantly lower with early abcximab compared to late administration (8.7% vs 15.8%; odds ratio 0.51, CI 0.31-0.85, P = .01). In multivariable Cox regression analysis, both early abciximab administration and patients' risk profile (TIMI score >or=3) were identified as independent predictors of 1-year mortality. CONCLUSIONS: Early abciximab administration before transfer for percutaneous coronary intervention in STEMI shows lower mortality at 1-year follow-up. This effect is confined to patients with higher risk profile as defined by TIMI risk score >or=3.

[Successful recanalisation of chronic total occlusion using retrograde approach]. / Udroznienie technika retrograde przewlekle zamknietej prawej tetnicy wiencowej.

Chronic total occlusion (CTO) is defined as an occlusion of a coronary vessels (TIMI 0 flow) lasting longer than 3 months. Successful recanalisation of CTO improves left ventricular function and survival. Retrograde technique can be used in patients, who have well-developed collaterals, when the antegrade approach is ineffective or difficult to perform. A 68-year-old male was referred for coronary angiography because of exercise angina chest pain. Coronary angiogram showed a CTO of RCA with collaterals from LAD. Following the unsuccessful traditional antegrade approach in 2004, we attempted a retrograde approach. The PCI procedure was performed successfully and without complications.

Impact of admission glucose level and presence of diabetes mellitus on mortality in patients with non-ST-segment elevation acute coronary syndrome treated conservatively.

Elevated glucose level on admission is common in patients with acute coronary syndrome (ACS) and has been shown to be a strong predictor of adverse outcome in patients both with and without diabetes. The purpose of the study was to assess the impact of admission glucose on in-hospital mortality in patients with non-ST-segment elevation ACS treated in hospitals without on-site invasive facilities. We identified 807 patients with non-ST-segment elevation ACS treated conservatively in the 29 hospitals participating in the Krakow Registry of Acute Coronary Syndromes; 763 patients with complete admission glucose data were stratified according to admission glucose level. Of these, 24.2% had admission glucose level <5, 50.6% had a level 5 to 6.9, 10.9% had a level 7 to 8.9, 6.7% had a level 9 to 10.9, and 7.6% had a level > or =11 mmol/L. In-hospital mortality was higher in patients with higher admission glucose (admission glucose <5, 5 to 6.9, 7 to 8.9, 9 to 10.9, and > or =11 mmol/L: 0.5%, 2.6%, 7.2%, 9.8%, and 24.1% respectively, p <0.0001). Similarly, significant mortality difference was observed in patient subgroups stratified by admission glucose level and presence of diabetes mellitus and cardiogenic shock. Independent predictors of in-hospital death were age, cardiogenic shock, admission glucose, chronic obstructive pulmonary disease, and renal insufficiency. In conclusion, admission glucose level is a strong predictor of in-hospital death in patients with non-ST-segment elevation ACS remaining in hospitals without on-site invasive facilities. Impact of admission glucose on mortality is independent of diabetes and cardiogenic shock presence.

Management and mortality in patients with non-ST-segment elevation vs. ST-segment elevation myocardial infarction. Data from the Malopolska Registry of Acute Coronary Syndromes.

BACKGROUND: According to the presenting electrocardiogram, acute myocardial infarction (MI) can by categorised generally as non-ST-segment elevation MI (NSTEMI) and ST-segment elevation MI (STEMI). AIM: To assess the impact of the different acute MI categories on in-hospital management and mortality in hospitals without on-site invasive facilities. METHODS: We identified 380 NSTEMI and 334 STEMI patients treated in the Malopolska Registry of Acute Coronary Syndromes from February to March 2005 and from December 2005 to January 2006. Data concerning in-hospital management and mortality were assessed. RESULTS: Patients with NSTEMI were older and were more likely to have prior angina, prior MI and prior heart failure symptoms than STEMI patients. The NSTEMI patients were less likely to be transferred for invasive treatment (23.9 vs. 41.9%, p <0.0001) and receive glycoprotein IIb/IIIa inhibitors during index hospital stay. The use of low-molecular-weight heparin, beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin II antagonists, nitrates and statins was more frequent in NSTEMI patients. Among patients treated non-invasively, in-hospital mortality was high, but was lower in NSTEMI than STEMI patients (12.1 vs. 22.7%, p <0.0001). Independent predictors of in-hospital death in this group were age, cardiogenic shock, chronic obstructive pulmonary disease, and STEMI. CONCLUSIONS: Despite current recommendations, NSTEMI patients are still less likely to be transferred for invasive treatment than STEMI patients. Among patients treated non-invasively during index hospital stay, NSTEMI is associated with more favourable prognosis than STEMI, but the risk of in-hospital death is high. The hospital network should implement more frequently the strategy of early and urgent invasive treatment of NSTEMI patients.