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1.
Artigo em Inglês | MEDLINE | ID: mdl-31642609

RESUMO

BACKGROUND: Interatrial septum (IAS) dissection due to transseptal puncture (TSP) is a rare, underreported complication of the procedure. Data on the mechanism, diagnosis, and management of this complication are lacking. METHODS: We conducted a systematic review of all reported cases of IAS dissection with or without associated LA hematoma due to TSP, by thoroughly searching MEDLINE and EMBASE through May 2019. RESULTS: After screening of n = 882 studies, eight studies with a total of 19 patients addressed the complication of IAS dissection and/or LA hematoma secondary to TSP. Median age was 63 years with a 1:1 male to female ratio. Ablation of atrial fibrillation was the most frequently reported procedure (84%). Diagnosis was established using fluoroscopy with contrast injection (58%), TEE (32%) or intracardiac echocardiography (5%). The mechanism identified involved puncture of the septum secundum portion of the IAS, leading to transient needle passage into the extracardiac space. In the majority of patients, the hematoma remained localized in the IAS and management was conservative with progressive resolution of the hematoma during follow-up (95%). Two patients (11%) required further intervention by either pericardiocentesis or surgical drainage due to hemodynamic instability. CONCLUSIONS: IAS dissection with or without hematoma after TSP remains an underdiagnosed entity. The main mechanism involves lesion to the septum secundum portion of the IAS, resulting in needle passage into the extracardiac space and local bleeding. Although conservative management may be sufficient in the majority of cases, interventional cardiologists should be familiar with this complication and its diagnosis.

2.
Lancet ; 394(10205): 1243-1253, 2019 10 05.
Artigo em Inglês | MEDLINE | ID: mdl-31488372

RESUMO

BACKGROUND: Newer-generation drug-eluting stents that combine ultrathin strut metallic platforms with biodegradable polymers might facilitate vascular healing and improve clinical outcomes in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention (PCI) compared with contemporary thin strut second-generation drug-eluting stents. We did a randomised clinical trial to investigate the safety and efficacy of ultrathin strut biodegradable polymer sirolimus-eluting stents versus thin strut durable polymer everolimus-eluting stents in patients with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI. METHODS: The BIOSTEMI trial was an investigator-initiated, multicentre, prospective, single-blind, randomised superiority trial at ten hospitals in Switzerland. Patients aged 18 years or older with acute STEMI who were referred for primary PCI were eligible to participate. Patients were randomly allocated (1:1) to either biodegradable polymer sirolimus-eluting stents or durable polymer everolimus-eluting stents. Central randomisation was done based on a computer-generated allocation sequence with variable block sizes of 2, 4, and 6, which was stratified by centre, diabetes status, and presence or absence of multivessel coronary artery disease, and concealed using a secure web-based system. Patients and treating physicians were aware of group allocations, whereas outcome assessors were masked to the allocated stent. The experimental stent (Orsiro; Biotronik; Bülach, Switzerland) consisted of an ultrathin strut cobalt-chromium metallic stent platform releasing sirolimus from a biodegradable polymer. The control stent (Xience Xpedition/Alpine; Abbott Vascular, Abbott Park, IL, USA) consisted of a thin strut cobalt-chromium stent platform that releases everolimus from a durable polymer. The primary endpoint was target lesion failure, a composite of cardiac death, target vessel myocardial reinfarction (Q-wave and non-Q-wave), and clinically-indicated target lesion revascularisation, within 12 months of the index procedure. All analyses were done with the individual participant as the unit of analysis and according to the intention-to-treat principle. The trial was registered with ClinicalTrials.gov, number NCT02579031. FINDINGS: Between April 26, 2016, and March 9, 2018, we randomly assigned 1300 patients (1623 lesions) with acute myocardial infarction to treatment with biodegradable polymer sirolimus-eluting stents (649 patients and 816 lesions) or durable polymer everolimus-eluting stents (651 patients and 806 lesions). At 12 months, follow-up data were available for 614 (95%) patients treated with biodegradable polymer sirolimus-eluting stents and 626 (96%) patients treated with durable polymer everolimus-eluting stents. The primary composite endpoint of target lesion failure occurred in 25 (4%) of 649 patients treated with biodegradable polymer sirolimus-eluting stents and 36 (6%) of 651 patients treated with durable polymer everolimus-eluting stents (difference -1·6 percentage points; rate ratio 0·59, 95% Bayesian credibility interval 0·37-0·94; posterior probability of superiority 0·986). Cardiac death, target vessel myocardial reinfarction, clinically-indicated target lesion revascularisation, and definite stent thrombosis were similar between the two treatment groups in the 12 months of follow-up. INTERPRETATION: In patients with acute STEMI undergoing primary PCI, biodegradable polymer sirolimus-eluting stents were superior to durable polymer everolimus-eluting stents with respect to target lesion failure at 1 year. This difference was driven by reduced ischaemia-driven target lesion revascularisation in patients treated with biodegradable polymer sirolimus-eluting stents compared with durable polymer everolimus-eluting stents. FUNDING: Biotronik.


Assuntos
Implantes Absorvíveis , Prótese Vascular , Stents Farmacológicos , Everolimo/uso terapêutico , Imunossupressores/uso terapêutico , Intervenção Coronária Percutânea/métodos , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Sirolimo/uso terapêutico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Polímeros , Método Simples-Cego
3.
Am J Cardiol ; 124(8): 1305-1314, 2019 Oct 15.
Artigo em Inglês | MEDLINE | ID: mdl-31455501

RESUMO

Early initiation of reperfusion therapy remains the cornerstone of successful management for ST-elevation myocardial infarction (STEMI). Rapid restoration of coronary blood flow relies on prompt recognition of the typical ST-segment elevation on a 12-lead electrocardiogram (ECG)-a surrogate for coronary occlusion or critical stenosis-allowing timely activation of the STEMI protocol cascade, with a major positive impact in mortality and clinical outcomes. However, atypical, very high risk ECG patterns-known as "STEMI equivalents"-are present in 10% to 25% of patients with ongoing myocardial ischemia in need of urgent primary percutaneous coronary intervention. Though briefly mentioned in the current recommendations, structured clinical data on those specific ECG presentations are lacking. By thoroughly searching MEDLINE and EMBASE we conducted a structured review of non-STEMI, albeit very high risk, ECG patterns of acute coronary syndrome, often associated with coronary occlusion or critical stenosis. After screening 997 studies, we identified the following distinct "STEMI equivalent" ECG patterns: Wellens' syndrome, de Winter sign, hyperacute T waves, left bundle branch block-including paced rhythm-and right bundle branch block. For each pattern, a brief summary of the existing evidence, together with the sensitivity, specificity, and positive predictive value-whenever available-are presented. In conclusion, prompt recognition of "STEMI equivalent" ECG patterns is crucial for every physician or paramedic dealing with acute coronary syndrome patients in the emergency department or the prehospital setting, as misinterpretation of those high risk presentations can lead to reperfusion delays and worse outcomes.

4.
Ann Vasc Surg ; 2019 Jul 31.
Artigo em Inglês | MEDLINE | ID: mdl-31376549

RESUMO

BACKGROUND: Clavicular fracture or sternoclavicular luxation is observed in 10% of all polytrauma patients and is frequently associated with concomitant intrathoracic life-threatening injuries. Posterior sternoclavicular luxation is well known to induce underlying great vessels damage. The gold standard treatment usually is a combined orthopedic and cardiovascular surgical procedure associating vascular repair, clavicular open reduction, and internal fixation. METHODS: A 59-year-old wheelchair ridden, institutionalized woman, known for psychiatric disorder, severe scoliosis, malnutrition, and chronic obstructive pulmonary disease was admitted in our hospital for chronic chest pain 3 months after a stairway wheelchair downfall. A thoracic computed tomography (CT) scan revealed a voluminous ascending aortic pseudoaneurysm (63 × 58 mm, orifice 5 mm) consecutive to perforation following posterior sternoclavicular luxation. The patient refused all therapies and was lost to follow-up. Six months later, she was readmitted for a symptomatic superior vena cava syndrome. Thoracic CT scan revealed pseudoaneurysm growth with innominate vein thrombosis and superior vena cava subocclusion. Pseudoaneurysm orifice was stable. In the presence of symptoms with massive facial edema and inability to open her eyelids, the patient accepted an endovascular treatment. RESULTS: The procedure was performed under general anesthesia using both fluoroscopic and transesophageal echocardiographic guidance. Through a femoral arterial access, a 10-mm atrial septal defect occluder device was used to seal successfully the pseudoaneurysm orifice. The superior vena cava was then opened with a 26-mm nitinol high radial force stent through a femoral venous access. Postoperative course was uneventful. At 3-month follow-up, the patient remains symptom free and a CT scan confirmed pseudoaneurysm thrombosis and superior vena cava permeability. CONCLUSION: Post-traumatic sternoclavicular posterior luxation is a cause of great vessels and ascending aorta injuries. Minimally invasive endovascular approaches can be considered to treat vascular injuries and their consequences, especially in elderly patients and those at high risk for surgery.

5.
Cardiovasc Revasc Med ; 20(5): 392-398, May 2019. ilus, tab
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-1006900

RESUMO

Introduction and objective: The edge vascular response (EVR) remains unknown in second generation drugeluting Resorbable Magnesium Scaffold (RMS), such as Magmaris. The aim of the study was to evaluate tissue modifications in the RMS edges over time, assessed by different invasive imaging modalities. Methods: The patients treated with the device were assessed by optical coherence tomography (OCT), grayscale intravascular ultrasound (IVUS), and virtual histology IVUS at baseline and 12 months. The EVR study performed a segment- and frame-level analysis of the 5 mm segments proximal and distal of the actual RMS. Results: The segment-level grayscale IVUS (n=10), virtual histology IVUS (n=10), and OCT (n=18) analysis did not showany significant changes after 12months, except for a fibrous plaque area (FPA) reduction of 0.5mm2 (p=0.017) in the proximal segment compared to baseline. In the frame-level analysis, IVUS evaluation revealed a vessel area decreased 2.80 ± 1.43 mm2 (p = 0.012) and 2.49 ± 1.53 mm2 (p = 0.022) in 2 proximal frames. This was accompanied by plaque area reduction of 0.88 ± 0.70 mm2 (p = 0.048) and a FPA decreased by 0.63 ± 0.48mm2 (p = 0.004) in one proximal frame. In 1 distal frame, there was a dense calcium area reduction of 0.10 ± 0.12 mm2 (p = 0.045), FPA and fibrous fatty plaque increased 0.54 ± 0.53 mm2 (p = 0.023) and 0.17 ± 0.16 mm2 (p = 0.016), respectively. By OCT, there was a lumen area decrease of 0.76 ± 1.51 mm2 (p = 0.045) in a distal frame. Conclusion: At 12 months, Magmaris EVR assessment does not show overall significant changes, except for a fibrous plaque area reduction in the proximal segment. This could be translated as a benign healing process a the edges of the RMS. Summary: The edge vascular response (EVR) remains unknown in second generation drug-eluting absorbable metal scaffolds (RMS), such as Magmaris. Patients treated with the device were assessed by multi invasive imagingmodalities [i.e. optical coherence tomography (OCT), grayscale intravascular ultrasound (IVUS), and virtual histology IVUS] evaluating the tissue changes over timein the segment- and frame-level analysis of the 5mm segments proximal and distal of the actual RMS. As a result, after 12months, Magmaris EVR assessment does not show overall significant changes, except for a fibrous plaque area reduction in the proximal segment, translating a benign healing process at the edges of the RMS.


Assuntos
Humanos , Ultrassonografia de Intervenção , Tomografia de Coerência Óptica
6.
Cardiovasc Revasc Med ; 20(5): 392-398, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31079817

RESUMO

INTRODUCTION AND OBJECTIVE: The edge vascular response (EVR) remains unknown in second generation drug-eluting Resorbable Magnesium Scaffold (RMS), such as Magmaris. The aim of the study was to evaluate tissue modifications in the RMS edges over time, assessed by different invasive imaging modalities. METHODS: The patients treated with the device were assessed by optical coherence tomography (OCT), grayscale intravascular ultrasound (IVUS), and virtual histology IVUS at baseline and 12 months. The EVR study performed a segment- and frame-level analysis of the 5 mm segments proximal and distal of the actual RMS. RESULTS: The segment-level grayscale IVUS (n = 10), virtual histology IVUS (n = 10), and OCT (n = 18) analysis did not show any significant changes after 12 months, except for a fibrous plaque area (FPA) reduction of 0.5mm2 (p = 0.017) in the proximal segment compared to baseline. In the frame-level analysis, IVUS evaluation revealed a vessel area decreased 2.80 ±â€¯1.43 mm2 (p = 0.012) and 2.49 ±â€¯1.53 mm2 (p = 0.022) in 2 proximal frames. This was accompanied by plaque area reduction of 0.88 ±â€¯0.70 mm2 (p = 0.048) and a FPA decreased by 0.63 ±â€¯0.48 mm2 (p = 0.004) in one proximal frame. In 1 distal frame, there was a dense calcium area reduction of 0.10 ±â€¯0.12 mm2 (p = 0.045), FPA and fibrous fatty plaque increased 0.54 ±â€¯0.53 mm2 (p = 0.023) and 0.17 ±â€¯0.16 mm2 (p = 0.016), respectively. By OCT, there was a lumen area decrease of 0.76 ±â€¯1.51 mm2 (p = 0.045) in a distal frame. CONCLUSION: At 12 months, Magmaris EVR assessment does not show overall significant changes, except for a fibrous plaque area reduction in the proximal segment. This could be translated as a benign healing process at the edges of the RMS. SUMMARY: The edge vascular response (EVR) remains unknown in second generation drug-eluting absorbable metal scaffolds (RMS), such as Magmaris. Patients treated with the device were assessed by multi invasive imaging modalities [i.e. optical coherence tomography (OCT), grayscale intravascular ultrasound (IVUS), and virtual histology IVUS] evaluating the tissue changes over time in the segment- and frame-level analysis of the 5 mm segments proximal and distal of the actual RMS. As a result, after 12 months, Magmaris EVR assessment does not show overall significant changes, except for a fibrous plaque area reduction in the proximal segment, translating a benign healing process at the edges of the RMS.

7.
EuroIntervention ; 2019 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-30803936

RESUMO

AIMS: We evaluated the safety and performance of a magnesium-based sirolimus-eluting metal scaffold at 3-year follow-up to assess vessel response 2 years beyond scaffold resorption. METHODS AND RESULTS: BIOSOLVE-II is an international, multi-center first-in man study, including 123 patients with de novo lesions. Pre-dilatation was mandatory and post-dilatation was left to the discretion of the investigators. Dual antiplatelet therapy was recommended for 6 months. At 3 years, 91.1% of patients were angina-free and 8.0% were on dual antiplatelet therapy. Target lesion failure rate was 6.8% (n=8; 2 cardiac deaths, 1 target-vessel myocardial infarction and 5 target lesion revascularizations). No probable or definite scaffold thrombosis was observed. Imaging follow-up was voluntary and serial angiographic assessment at 6, 12, and 36 months was available in 25 patients. In these, a slight increase in in-segment and in-scaffold late lumen loss and diameter stenosis was observed between 12 and 36 months (by 0.11±0.28mm and 0.13±0.30mm for late lumen loss, and by 3.8±10.1% and 4.1±10.2% for diameter stenosis). CONCLUSIONS: Two years beyond the resorption period of a sirolimus-eluting bioresorbable metal scaffold built from a proprietary magnesium alloy, complication rates remained low. In the patients with serial angiographic assessment, late lumen loss and diameter stenosis did not increase substantially beyond the resorption period.

8.
Rev Med Suisse ; 15(N° 632-633): 27-30, 2019 Jan 09.
Artigo em Francês | MEDLINE | ID: mdl-30629363

RESUMO

This review article provides a broad overview of the novelties in cardiology in 2018. Advances in interventional cardiology and cardiovascular prevention, heart failure, electrophysiology and non-invasive cardiovascular imaging have provided important new insights in the pathophysiology, diagnosis and treatment of ischemic and valvular heart disease, heart failure, rhythm disorders and cardiomyopathies. This article provides an overview of the most relevant articles published in 2018.


Assuntos
Cardiologia , Cardiologia/tendências
9.
Cardiovasc. revasc. med ; 20: 392-386, May 2019. ilus., tab
Artigo em Inglês | Sec. Est. Saúde SP, SESSP-IDPCPROD, Sec. Est. Saúde SP | ID: biblio-998567

RESUMO

INTRODUCTION AND OBJECTIVE: The edge vascular response (EVR) remains unknown in second generation drugeluting Resorbable Magnesium Scaffold (RMS), such as Magmaris. The aim of the study was to evaluate tissue modifications in the RMS edges over time, assessed by different invasive imaging modalities. METHODS: The patients treated with the device were assessed by optical coherence tomography (OCT), grayscale intravascular ultrasound (IVUS), and virtual histology IVUS at baseline and 12 months. The EVR study performed a segment- and frame-level analysis of the 5 mm segments proximal and distal of the actual RMS. RESULTS: The segment-level grayscale IVUS (n=10), virtual histology IVUS (n=10), and OCT (n=18) analysis did not showany significant changes after 12months, except for a fibrous plaque area (FPA) reduction of 0.5mm2 (p=0.017) in the proximal segment compared to baseline. In the frame-level analysis, IVUS evaluation revealed a vessel area decreased 2.80 ± 1.43 mm2 (p = 0.012) and 2.49 ± 1.53 mm2 (p = 0.022) in 2 proximal frames. This was accompanied by plaque area reduction of 0.88 ± 0.70 mm2 (p = 0.048) and a FPA decreased by 0.63 ± 0.48mm2 (p = 0.004) in one proximal frame. In 1 distal frame, there was a dense calcium area reduction of 0.10 ± 0.12 mm2 (p = 0.045), FPA and fibrous fatty plaque increased 0.54 ± 0.53 mm2 (p = 0.023) and 0.17 ± 0.16 mm2 (p = 0.016), respectively. By OCT, there was a lumen area decrease of 0.76 ± 1.51 mm2 (p =0.045) in a distal frame. CONCLUSION: At 12 months, Magmaris EVR assessment does not show overall significant changes, except for a fibrous plaque area reduction in the proximal segment. This could be translated as a benign healing process at the edges of the RMS. SUMMARY: The edge vascular response (EVR) remains unknown in second generation drug-eluting absorbable metal scaffolds (RMS), such as Magmaris. Patients treated with the device were assessed by multi invasive imagingmodalities [i.e. optical coherence tomography (OCT), grayscale intravascular ultrasound (IVUS), and virtual histology IVUS] evaluating the tissue changes over timein the segment- and frame-level analysis of the 5mm segments proximal and distal of the actual RMS. As a result, after 12months, Magmaris EVR assessment does not show overall significant changes, except for a fibrous plaque area reduction in the proximal segment, translating a benign healing process at the edges of the RMS.


Assuntos
Humanos , Ultrassonografia de Intervenção , Tomografia de Coerência Óptica
10.
Atherosclerosis ; 277: 219-226, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30033338

RESUMO

BACKGROUND AND AIMS: Pulse pressure (PP) is a surrogate of aortic stiffness (AS) easily obtainable. The link between AS and cardio-vascular disease is documented, however, data regarding acute coronary syndrome (ACS) patients are scarce and contradictory. We aimed to assess the prognostic value of PP measured at admission, with regard to major adverse outcomes (all-cause mortality, recurrence of MI, and stroke), during the first year following an acute coronary syndrome (ACS). METHODS: The SPUM-ACS project is a prospective cohort study of patients with ACS conducted in 4 Swiss University hospitals. Patients with no PP at admission or with severe clinical heart failure or cardiogenic shock were excluded. Cox regression analyses were performed to determine associations between PP and outcomes (all-cause mortality, recurrence of myocardial infarction (MI), and stroke). Three multivariate Cox regression models were adjusted for hemodynamic, cardiovascular, and non-cardiovascular confounders, added successively. RESULTS: Of 5635 eligible patients, 5070 met the inclusion criteria. Mean patient age was 63 years (range: 54-72), 79.6% were male, and mean blood pressure and PP were 93.9 ±â€¯15.6 and 54 ±â€¯17 mmHg, respectively. Multivariate analyses confirmed the prognostic significance of PP for each 10-mmHg increase for the composite endpoint, hazard ratio (HR) 1.126 [1.051-1.206], p = 0.001; all-cause mortality, HR1.129 [1.013-1.260], p = 0.029; and recurrence of MI, HR1.206 [1.102-1.320], p < 0.001; but not for stroke, HR1.014[0.853-1.205]. CONCLUSIONS: PP measured at admission is a strong, independent prognostic marker predicting mortality and recurrence of MI after ACS. PP should be considered for the management of secondary prevention.

11.
J Cardiovasc Magn Reson ; 20(1): 50, 2018 Jul 23.
Artigo em Inglês | MEDLINE | ID: mdl-30037343

RESUMO

BACKGROUND: To investigate the influence of cardiovascular magnetic resonance (CMR) timing after reperfusion on CMR-derived parameters of ischemia/reperfusion (I/R) injury in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: The study included 163 reperfused STEMI patients undergoing CMR during the index hospitalization. Patients were divided according to the time between revascularization and CMR (Trevasc-CMR: Tertile-1 ≤ 43; 43 < Tertile-2 ≤ 93; Tertile-3 > 93 h). T2-mapping derived area-at-risk (AAR) and intramyocardial-hemorrhage (IMH), and late gadolinium enhancement (LGE)-derived infarct size (IS) and microvascular obstruction (MVO) were quantified. T1-mapping was performed before and > 15 min after Gd-based contrast-agent administration yielding extracellular volume (ECV) of infarct. RESULTS: Main factors influencing I/R injury were homogenously balanced across Trevasc-CMR tertiles. T2 values of infarct and remote regions increased with increasing Trevasc-CMR tertiles (infarct: 60.0 ± 4.9 vs 63.5 ± 5.6 vs 64.8 ± 7.5 ms; P < 0.001; remote: 44.3 ± 2.8 vs 46.1 ± 2.8 vs ± 46.1 ± 3.0; P = 0.001). However, T2 value of infarct largely and significantly exceeded that of remote myocardium in each tertile yielding comparable T2-mapping-derived AAR extent throughout Trevasc-CMR tertiles (17 ± 9% vs 19 ± 9% vs 18 ± 8% of LV, respectively, P = 0.385). Similarly, T2-mapping-based IMH detection and quantification were independent of Trevasc-CMR. LGE-derived IS and MVO were not influenced by Trevasc-CMR (IS: 12 ± 9% vs 12 ± 9% vs 14 ± 9% of LV, respectively, P = 0.646). In 68 patients without MVO, T1-mapping based ECV of infarct region was comparable across Trevasc-CMR tertiles (P = 0.470). CONCLUSION: In STEMI patients, T2 values of infarct and remote myocardium increase with increasing CMR time after revascularization. However, these changes do not give rise to substantial variation of T2-mapping-derived AAR size nor of other CMR-based parameters of I/R. TRIAL REGISTRATION: ISRCTN03522116 . Registered 30.4.2018 (retrospectively registered).

12.
Rev Med Suisse ; 14(608): 1097-1100, 2018 May 23.
Artigo em Francês | MEDLINE | ID: mdl-29797856

RESUMO

The last years, various large randomized studies have demonstrated the benefit of TAVI (transcatheter aortic valve implantation) over medical therapy or over conventional surgical treatment in inoperable or very high risk patients with symptomatic severe aortic stenosis. More recently, new data has also shown that among patients at intermediate risk, TAVI is at least as beneficial as surgical valve replacement. In this article, we will focus on the new recommendations of the European society of cardiology but also on issues that remain open.

13.
Eur Heart J Cardiovasc Pharmacother ; 4(3): 166-171, 2018 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-29370383

RESUMO

Aims: The circadian variation of platelet aggregation is well demonstrated. However, whether this has an impact on antiplatelet inhibition therapy is poorly documented. We aimed to observe whether ticagrelor-induced platelet inhibition follows a circadian rhythm. Methods and results: The study included 25 healthy volunteers (11 female; 14 male). Blood samples were collected every 4 h. Ticagrelor was added in vitro at a concentration that provided 50% inhibition of the maximum response using the VerifyNow System Platelet Reactivity Test® thus avoiding any bias induced by circadian gastrointestinal absorption. Platelet aggregation testing was subsequently performed using the VerifyNow. Circadian changes in total platelet count, percentage of platelets inhibition, Von Willebrand activity, and volunteers' physiological parameters were analysed by fitting individuals' data to a sine curve with a 24-h period. Volunteers' physiological parameters [heart rate (b.p.m.), systolic/diastolic blood pressure (mmHg), and body temperature (Celsius)] followed a significant mean circadian pattern of 6 b.p.m. (P < 0.001), 5 mmHg/7 mmHg (P < 0.002), and 0.3°C (P < 0.001), respectively. Ticagrelor-induced platelet inhibition was significantly lower at 13:00 (38.4%) than at any other time (45.2%) (P = 0.018). Percentage of inhibited platelets plotted against time followed a circadian rhythm (P < 0.001), with mean minimum/maximum values at 13:00/02:00, respectively. Von Willebrand activity also followed a circadian pattern (P < 0.001), with an amplitude of 12.24% and a maximum activity at 12:00. Conclusion: Ticagrelor-induced platelet inhibition follows a circadian rhythm, with the lowest mean values achieved at 13:00. These results deserve further studies in patients with coronary artery disease.

14.
Clin Res Cardiol ; 107(4): 338-346, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29222592

RESUMO

BACKGROUND: The clinical benefit of manual thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI) remains uncertain. This study assessed the impact of circadian rhythms on the effectiveness of manual TA. METHODS AND RESULTS: We conducted an observational study of patients enrolled in the Acute Myocardial Infarction in Switzerland Plus registry. STEMI patients undergoing PPCI with (TA group) or without (PCI-alone group) manual TA were divided based on time-of-day symptom onset: group 1 (00:00-05:59), group 2 (06:00-11:59), group 3 (12:00-17:59) and group 4 (18:00-23:59). The primary endpoint was circadian variation of myocardial infarction (MI) size. The secondary endpoint was in-hospital all-cause mortality. Between 2009 and 2014, 3648 patients underwent PPCI (TA, 49%). After propensity-score matching, 2860 patients were included. Minimal myocardial Injury was observed in groups 2 and 3 (peak creatine kinase level group 1, 2723 ± 148 U/l; group 2, 2493 ± 105 U/l; group 3, 2550 ± 106 U/l; group 4, 2952 ± 144 U/l; p = 0.044) in the TA group, whereas no time-of-day dependence was found in PCI-alone group. After periodic sinusoidal regression analysis, a circadian relationship between time-of-day symptom onset and MI size was demonstrated in the TA group (p < 0.001). In-hospital all-cause mortality was 3.4% in the TA group and 4.3% in the PCI-alone group (p = 0.20). CONCLUSIONS: In this large registry of STEMI patients, manual TA did not reduce in-hospital all-cause mortality. Nonetheless, there was a circadian dependence of TA effectiveness with greatest myocardial salvage for patients with symptom onset between 06:00 and 17:59.


Assuntos
Ritmo Circadiano , Intervenção Coronária Percutânea , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Trombectomia , Idoso , Distribuição de Qui-Quadrado , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Traumatismo por Reperfusão Miocárdica/etiologia , Traumatismo por Reperfusão Miocárdica/mortalidade , Traumatismo por Reperfusão Miocárdica/fisiopatologia , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/mortalidade , Pontuação de Propensão , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico por imagem , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/fisiopatologia , Suíça/epidemiologia , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
15.
JACC Cardiovasc Imaging ; 11(6): 813-825, 2018 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28823746

RESUMO

OBJECTIVES: This study sought to investigate whether early post-infarction cardiac magnetic resonance (CMR) parameters provide additional long-term prognostic value beyond traditional outcome predictors in ST-segment elevation myocardial infarction (STEMI) patients. BACKGROUND: Long-term prognostic significance of CMR in STEMI patients has not been assessed yet. METHODS: This was a longitudinal study from a multicenter registry that prospectively included STEMI patients undergoing CMR after infarction. Between May 2003 and August 2015, 810 revascularized STEMI patients were included. CMR was performed at a median of 4 days after STEMI. Infarct size, microvascular obstruction (MVO), and left ventricular (LV) volumes and function were measured. Primary endpoint was a composite of all death and decompensated heart failure (HF). RESULTS: During median follow-up of 5.5 years (range 1.0 to 13.1 years), primary endpoint occurred in 99 patients (39 deaths and 60 HF hospitalization). MVO was a strong predictor of the composite endpoint after correction for important clinical, CMR, and angiographic parameters, including age, LV systolic function, and infarct size. The independent prognostic value of MVO was confirmed in all multivariate models irrespective of whether it was included as a dichotomous (presence of MVO, hazard ratio [HR]: 1.985 to 1.995), continuous (MVO extent as % LV, HR: 1.095 to 1.097), or optimal cutoff value (MVO extent ≥2.6% of LV; HR: 3.185 to 3.199; p < 0.05 for all). MVO extent ≥2.6% of LV was a strong independent predictor of all death (HR: 2.055; 95% confidence interval: 1.076 to 3.925; p = 0.029) and HF hospitalization (HR: 5.999; 95% confidence interval: 3.251 to 11.069; p < 0.001). Finally, MVO extent ≥2.6% of LV provided incremental prognostic value over traditional outcome predictors (net reclassification improvement index: 0.16 to 0.30; p < 0.05 for all models). CONCLUSIONS: Early post-infarction CMR-based MVO is a strong independent prognosticator in revascularized STEMI patients. Remarkably, MVO extent ≥2.6% of LV improved long-term risk stratification over traditional outcome predictors.

16.
EuroIntervention ; 14(6): 692-699, 2018 Aug 20.
Artigo em Inglês | MEDLINE | ID: mdl-29205157

RESUMO

AIMS: A novel ultrathin-strut biodegradable polymer sirolimus-eluting stent (BP-SES) (Orsiro; Biotronik, Bülach, Switzerland) was shown to be superior to a thin-strut durable polymer everolimus-eluting stent (DP-EES) (XIENCE Xpedition/Alpine; Abbott Vascular, Santa Clara, CA, USA) with respect to the primary endpoint of target lesion failure (TLF) at 12 months in the pre-specified subgroup of patients with ST-segment elevation myocardial infarction (STEMI) included in the BIOSCIENCE trial. We designed a large-scale, randomised, clinical trial to assess the clinical superiority of ultrathin-strut BP-SES over thin-strut DP-EES among patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). METHODS AND RESULTS: BIOSTEMI (NCT02579031) is a prospective, multicentre, randomised, controlled, superiority trial that will randomly assign 1,250 patients with STEMI undergoing PPCI to treatment with BP-SES or DP-EES. The primary endpoint of TLF, a composite of cardiac death, target vessel reinfarction, and clinically indicated target lesion revascularisation within 12 months, will be analysed with Bayesian models applied to the BIOSTEMI data set (n=1,250) using robust historical priors to incorporate historical information from the BIOSCIENCE STEMI subgroup (n=407). CONCLUSIONS: The BIOSTEMI trial will determine whether ultrathin-strut BP-SES are superior to thin-strut DP-EES with respect to TLF in patients with STEMI undergoing PPCI.

17.
Front Pharmacol ; 8: 738, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-29118712

RESUMO

Aims: Dual platelet inhibition using anti-P2Y12 drugs and aspirin is the standard of care in patients after percutaneous coronary interventions (PCI). Prasugrel and ticagrelor have been shown to be more potent than clopidogrel with less high on-treatment platelet reactivity. Whether differences in long-term adherence to these drugs can partly explain different antiplatelet efficacy has not been studied so far. The objective was to compare the long-term P2Y12 receptor inhibition and drug adherence to different anti-P2Y12 drugs, and to assess the impact of adherence on the pharmacodynamic effect. Methods: Monocentric, prospective, observational study. Stable outpatients treated with clopidogrel 75 mg once daily, prasugrel 10 mg once daily or ticagrelor 90 mg twice daily after PCI with stent implantation were included. Drug adherence was recorded during 6 months using electronic monitoring. Platelet responsiveness was assessed with the vasodilator-stimulated phosphoprotein platelet reactivity index (VASP-PRI) at inclusion, 3 and 6 months. Results: 120 patients had VASP-PRI and adherence data available. At 6-months, mean VASP-PRI (±SD) was 17.7 ± 11.0% with ticagrelor, 29.2 ± 15.5% with prasugrel and 47.2 ± 17.6% with clopidogrel (ANOVA, P < 0.0001). Median [IQR] taking adherence was 96 [82-100]% with ticagrelor, 100 [97-101]% with prasugrel and 100 [99-101]% with clopidogrel (p = 0.0001). Median [IQR] correct dosing was 88 [73-95]% with ticagrelor, 97 [92.5-98]% with prasugrel and 98 [96-99]% with clopidogrel (p = 0.0001). Anti-P2Y12 drug (p ≤ 0.001) and diabetes (p = 0.014) emerged as predictors of poor antiplatelet response after adjusting for age, BMI, sex, and CYP2C19∗2 carriers status. Conclusion: Drug adherence to anti-P2Y12 drugs assessed with electronic monitoring was very high. However, anti-P2Y12 drugs showed significant differences in antiplatelet activity, with newer anti-P2Y12 drugs ticagrelor and prasugrel exerting a stronger P2Y12 receptor inhibition. These data suggest that pharmacokinetic-pharmacodynamic differences between oral anti-P2Y12 drugs are more important than adherence in determining antiplatelet efficacy when adherence to prescription is high. The study was registered (Current Controlled Trials ISRCTN85949729).

19.
J Cardiothorac Surg ; 12(1): 78, 2017 Sep 06.
Artigo em Inglês | MEDLINE | ID: mdl-28874169

RESUMO

BACKGROUND: Transcatheter aortic valve implantation is indicated in high-risk patients with aortic stenosis. We compared the clinical outcome of 180 consecutive patients who underwent transapical (TA) and transfemoral (TF) procedures in a single centre. METHODS: Ninety consecutive TA (TA-group) and 90 consecutive TF (TF-group) were performed from 2009 to 2014. Clinical variables were prospectively collected and retrospectively analysed for hospital outcomes and to identify risk factors for hospital mortality, vascular complications and stroke. RESULTS: Mean age was 80 ± 8.5 and 83 ± 8.4 years, in the TA and TF-group, respectively. TA-group presented higher prevalence of comorbidities: more vascular disease (79% vs 22%, p < 0.001), chronic pulmonary disease (32% vs 10%, p < 0.001), previous vascular surgery (14% vs 4%, p = 0.039), coronary disease (60% vs 40%, p = 0.007), and previous cardiac surgery (28% vs 17%, p = 0.073). Logistic Euroscore was 36 ± 15% in the TA-group and 25 ± 14% in the TF-group (p < 0.001), but hospital mortality was similar (TA:9%, TF:10%, p = 0.799). Access-related vascular complications occurred more often in transfemoral patients (TA:3%, TF:11%, p = 0.081) while major bleeding (TA:3%, TF:4%, p = 1) and stroke (TA:2%, TF:3%, p = 1) were equally distributed. Postoperative renal failure and dialysis were associated with impaired neurological outcome (p = 0.035 and p = 0.020, respectively). Mild to severe paravalvular leak was more prevalent in transfemoral patients (TA:5%, TF:25%, p < 0.001). CONCLUSIONS: In our experience, the TA and TF-group presented different risk profiles but mortality rate and adverse neurological outcome had a similar incidence. The transfemoral approach carried more vascular complications and paravalvular leaks but last-generation devices will improve this outcome.


Assuntos
Estenose da Valva Aórtica/cirurgia , Cateterismo Cardíaco/métodos , Cateterismo Periférico/métodos , Complicações Pós-Operatórias/epidemiologia , Medição de Risco/métodos , Substituição da Valva Aórtica Transcateter/métodos , Idoso de 80 Anos ou mais , Análise Fatorial , Feminino , Mortalidade Hospitalar/tendências , Humanos , Incidência , Masculino , Estudos Retrospectivos , Fatores de Risco , Índice de Gravidade de Doença , Taxa de Sobrevida/tendências , Resultado do Tratamento
20.
Clin Res Cardiol ; 106(12): 1026-1032, 2017 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-28856443

RESUMO

INTRODUCTION: High-sensitivity cardiac troponin assays have significantly improved the sensitivity of myocardial infarction detection by using cutoff values and early absolute changes. However, variation in repeated measures also depends on biological variability. This study aimed to assess the potential circadian component of this biological variability. METHODS: 17 healthy volunteers were recruited, and standardized conditions for physical activity, meals, exposure to light and duration of sleep were imposed. Blood samples were collected every 4 h and high-sensitivity troponin T assay with a limit of detection of 3 ng/l and a 99th percentile of 14 ng/l were used. Circadian variations were analyzed using the cosinor method. RESULTS: Statistically significant circadian variations were observed for body temperature, heart rate, and systolic/diastolic arterial blood pressures (p < 0.01 using both a non-adjusted cosinor model and a gender- and BMI-adjusted cosinor model). The amplitudes of the circadian variations were 18.93, 6, 15.35, and 1.92%, respectively. A statistically significant circadian biological variation of troponin blood concentrations was evidenced (p < 0.01 in both the non-adjusted cosinor model and the gender- and BMI-adjusted cosinor), with an amplitude of 20.5% (average: 4.39 ng/l; amplitude: 0.9 ng/l; peak at 06:00 and nadir at 18:00). DISCUSSION: This study demonstrates a circadian biological variation in blood troponin concentration in a healthy population. The amplitude of this variation challenges the cutoff value for instant rule-out of the rapid rule-in/rule-out of the recent European guidelines for the management of acute coronary syndromes. These findings deserve further investigation in a population at risk of myocardial infarction.


Assuntos
Ritmo Circadiano/fisiologia , Infarto do Miocárdio/sangue , Troponina T/sangue , Biomarcadores/sangue , Pressão Sanguínea , Feminino , Voluntários Saudáveis , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/fisiopatologia
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