Comparación de seguridad y efectividad entre los accesos radiales derecho e izquierdo en la intervención coronaria percutánea / Comparison of safety and effectiveness between the right and left radial artery approach in percutaneous coronary intervention

Introducción y objetivos: Existen pocos estudios que comparen los accesos por la radial izquierda (ARI) y por la radial derecha en intervenciones coronarias percutáneas (ICP) en población general y practicadas por cirujanos con diferentes grados de experiencia en intervencionismo. El objetivo de nuestro estudio es comparar la seguridad y el beneficio clínico con cada acceso en pacientes no seleccionados con síndrome coronario agudo (SCA) y angina estable (AE). Métodos: Para evitar los posibles sesgos de un estudio no aleatorizado, se usó la puntuación de propensión para comparar ambos accesos radiales. Se recogieron datos de 18.716 pares con AE y 46.241 con SCA sometidos a ICP con implante de stent entre 2014 y 2017, en 151 centros terciarios con cardiología intervencionista en Polonia (registro nacional de Polonia [ORPKI]). Resultados: No se encontraron diferencias en cuanto a mortalidad y complicaciones periprocedimiento en AE. El ARI se asoció con mayores dosis de radiación independientemente de la presentación clínica (AE, 1.067,0±947,10 frente a 1.007,4±983,5 mGy; p=0,001; SCA, 1.212,7±1.005,5 frente a 1.053,5±1.029,7 mGy; p=0,001). En los pacientes con SCA, el ARI se asoció con mayor cantidad de contraste (174,2±75,4 frente a 167,2±72,1ml; p=0,001). Además, en los pacientes con SCA y ARI, las complicaciones periprocedimiento como disección coronaria (el 0,16 frente al 0,09%; p=0,008), fenómeno de no reflow (el 0,65 frente al 0,49%; p=0,005) y hemorragia en el sitio de punción (el 0,09 frente al 0,05%; p=0,04) resultaron más frecuentes. No hubo diferencias en la mortalidad entre los 2 grupos (p=0,90). Conclusiones: Los resultados que se presentan podrían estar en relación con una menor experiencia en el ARI. Ambos accesos son seguros en los pacientes con AE, pero el ARI se asoció con una mayor frecuencia de complicaciones periprocedimiento de ICP en el SCA (AU)

Introduction and objectives: There is a paucity of data comparing the left radial approach (LRA) and right radial approach (RRA) for percutaneous coronary intervention (PCI) in all-comers populations and performed by operators with different experience levels. Thus, we sought to compare the safety and clinical outcomes of the RRA and LRA during PCI in “real-world” patients with either stable angina or acute coronary syndrome (ACS). Methods: To overcome the possible impact of the nonrandomized design, a propensity score was calculated to compare the 2 radial approaches. The study group comprised 18 716 matched pairs with stable angina and 46 241 with ACS treated with PCI and stent implantation between 2014 and 2017 in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry). Results: The rates of death and periprocedural complications were similar for the RRA and LRA in stable angina patients. A higher radiation dose was observed with PCI via the LRA in both clinical presentations (stable angina: 1067.0±947.1 mGy vs 1007.4±983.5 mGy, P=.001; ACS: 1212.7±1005.5 mGy vs 1053.5±1029.7 mGy, P=.001). More contrast was used in LRA procedures but only in ACS patients (174.2±75.4mL vs 167.2±72.1mL, P=.001). Furthermore, periprocedural complications such as coronary artery dissection (0.16% vs 0.09%, P=.008), no-reflow phenomenon (0.65% vs 0.49%, P=.005), and puncture site bleeding (0.09% vs 0.05%, P=.04) were more frequently observed with the LRA in ACS patients. There was no difference in mortality between the 2 groups (P=.90). Conclusions: Our finding of poorer outcomes with the LRA may be related to lower operator experience with this approach. While both the LRA and RRA are safe in the setting of stable angina, the LRA was associated with a higher rate of periprocedural complications during PCI in ACS patients (AU)

Evaluation of profilin 1 as a biomarker in myocardial infarction.

OBJECTIVE: Profilin 1 (Pfn1) is likely to be involved in atherogenesis and myocardial infarction (MI). Clinical data on this subject are very limited. The aim of this study was to search for associations between serum Pfn1 and a number of parameters in MI patients: symptom onset to PCI time (OPT), myocardial necrosis markers, thrombolysis in myocardial infarction (TIMI) flow, antiplatelet drugs, heparin administration and typical atherosclerosis risk factors. PATIENTS AND METHODS: We included patients with type 1 MI (according to the Third Universal Definition of Myocardial Infarction) who were able to precisely determine the time of symptom onset. Exclusion criteria involved conditions potentially altering platelet function. We screened 114 patients and included 65. We assessed serum Pfn1 in three time points: on admission (Pfn1_0), 24 hours post PCI (Pfn1_24) and 48 hours post PCI (Pfn1_48) and correlated it with OPT, cardiac necrosis markers (troponin T, CK, CKMB), TIMI flow in the infarct-related artery, pre-hospital P2Y12-antagonist and heparin administration and known atherosclerosis risk factors. RESULTS: Patients with a shorter OPT had higher Pfn1_0 (838.5 vs. 687.1 pg/ml, p=0.007). Patients with impaired coronary flow post PCI had lower Pfn1_24 (748.2 vs. 925.2 pg/ml, p=0.017) and Pfn1_48 (744.5 vs. 879.8, p=0.031. Pfn1_24 and Pfn1_48 were lower in patients who received a P2Y12 antagonist prior to hospital admission. Diabetic patients presented with lower Pfn1_0 concentrations. CONCLUSIONS: This is the first study assessing Pfn1 in type 1 MI patients in relation to the chosen parameters. Pfn1 may be a biochemical tool to objectify information on OPT in MI patients. We found an association between Pfn1 and post-PCI TIMI flow, antiplatelet drug administration and diabetes mellitus.

Reduced plasma fibrin clot permeability and susceptibility to lysis are associated with increased risk of postthrombotic syndrome.

BACKGROUND: The postthrombotic syndrome (PTS) is a severe complication of deep vein thrombosis (DVT). Reduced plasma clot permeability and lysability have been linked to DVT and residual vein obstruction. OBJECTIVES We investigated whether altered fibrin clot properties are associated with the occurrence of PTS. PATIENTS AND METHODS: Plasma fibrin clot permeability (Ks ) and lysability were investigated in a cohort of 197 consecutive patients aged 18 to 65 years recruited 3 months following the first-ever DVT. Patients with severe thrombophilia or comorbidities known to adversely affect clot phenotype were ineligible. RESULTS: During a 1-year follow-up PTS developed in 48 (24%) patients, who were characterized by lower Ks , prolonged fibrin clot lysis time (CLT) and slower release of D-dimer from clots (D-Drate ), together with higher plasma D-dimer, C-reactive protein and thrombin-activatable fibrinolysis inhibitor (TAFI). No PTS-associated differences in fibrinogen, thrombin generation, factor VIII, other fibrinolysis proteins and the quality of anticoagulation were observed. Ks (r = -0.71), CLT (r = 0.45), D-Drate (r = -0.30) and TAFI activity (r = 0.38) were associated with the Villalta scale (all P < 0.05). Recurrent VTE occurred also more commonly in PTS patients during follow-up and the 26 (13.2%) patients had lower Ks , longer CLT and lower D-Drate (all P < 0.05). A multivariate model adjusted for age, body mass index, fibrinogen and glucose showed that independent predictors of PTS were idiopathic DVT, plasma D-dimer, Ks , D-Drate , tissue plasminogen activator and TAFI activity. CONCLUSIONS: This study demonstrates that formation of more compact fibrin clots displaying impaired susceptibility to lysis predisposes to PTS.