Mortality after percutaneous coronary revascularization: Prior cardiovascular risk factor control and improved outcomes in patients with diabetes mellitus.

OBJECTIVES: To assess the mortality in patients with diabetes mellitus (DM) following percutaneous coronary intervention (PCI) according to their insulin requirement and PCI setting (elective, urgent, and emergency). BACKGROUND: DM is a major risk factor to develop coronary artery disease (CAD). It is unclear if meticulous glycemic control and aggressive risk factor management in patients with DM has improved outcomes following PCI. METHODS: Retrospective analysis of prospectively collected data on 9,224 patients treated with PCI at a regional tertiary center between 2008 and 2011. RESULTS: About 7,652 patients were nondiabetics (non-DM), 1,116 had non-insulin treated diabetes mellitus (NITDM) and 456 had ITDM. Multi-vessel coronary artery disease, renal impairment and non-coronary vascular disease were more prevalent in DM patients. Overall 30-day mortality rate was 2.4%. In a logistic regression model, the adjusted odds ratios (95% confidence intervals [CI]) for 30-day mortality were 1.28 (0.81-2.03, P = 0.34) in NITDM and 2.82 (1.61-4.94, P < 0.001) in ITDM compared with non-DM. During a median follow-up period of 641 days, longer-term post-30 day mortality rate was 5.3%. In the Cox's proportional hazard model, the hazard ratios (95% CI) for longer-term mortality were 1.15 (0.88-1.49, P = 0.31) in NITDM and 1.88 (1.38-2.55, P < 0.001) in ITDM compared with non-DM group. Similar result was observed in all three different PCI settings. CONCLUSION: In the modern era of aggressive cardiovascular risk factor control in diabetes, this study reveals higher mortality only in insulin-treated diabetic patients following PCI for stable coronary artery disease and acute coronary syndrome. Importantly, diabetic patients with good risk factor control and managed on diet or oral hypoglycemics have similar outcomes to the non-diabetic population. © 2016 The Authors Catheterization and Cardiovascular Interventions Published by Wiley Periodicals, Inc.

Rotational Atherectomy in the Management of Ruptured and Entrapped Coronary Angioplasty Balloon.

Retention and entrapment of angioplasty device fragments is a rare consequence of percutaneous coronary intervention (PCI). Due to advances in retrieval devices and introduction of new interventional techniques the need for emergency surgery has reduced significantly. There might also be clinical scenarios were remnants of retained fragments might have to be left within the coronary vessel and this might be the most appropriate option. Here we report a case of a ruptured non-compliant angioplasty balloon that was entrapped in the right coronary artery and retained in situ after multiple failed attempts at percutaneous retrieval. Medical therapy failed and hence rotation atherectomy had to be performed followed by stent implantation, there by jailing the retained fragments underneath the stent struts. To our knowledge this is the first description of rotational atherectomy of an entrapped balloon to allow for percutaneous revascularization.

Antiplatelet therapy in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: a retrospective observational study of prasugrel and clopidogrel.

BACKGROUND: Primary percutaneous coronary intervention (PPCI) for ST-segment elevation myocardial infarction (STEMI) is a therapeutic success when supported by dual antiplatelet therapy. Prasugrel has been introduced as a potential alternative to clopidogrel alongside aspirin. We aimed to assess prasugrel versus clopidogrel mortality outcomes in patients admitted with STEMI undergoing PPCI. METHODS: Retrospective analysis of prospectively collected data of 1688 consecutive STEMI patients undergoing PPCI at a regional tertiary centre. Patients with age ≥75 years, weight<60 kg or history of cerebrovascular accident or TIA's, active bleeding or known hepatic impairment were excluded. All patients from March 2008 to 16 December 2009 belong to the Clopidogrel group and from 17 December 2009 to June 2011 belong to the Prasugrel group. RESULTS: A total of 866 patients were in the Clopidogrel group and 822 patients in the prasugrel group. In-hospital mortality was 1.7% in the Clopidogrel and 1.5% in Prasugrel group (P = 0.40). 30-day postdischarge mortality was 2.4% and 1.8% (P = 0.25) in the Clopidogrel and Prasugrel group, respectively. One-year mortality rate was recorded in 62 patients (3.7%): 39 (4.5%) in the Clopidogrel group and 23 (2.8%) in the prasugrel group. In the Cox proportional hazard model, the adjusted hazard ratio for all-cause mortality for the prasugrel group was 0.47 (95% CI: 0.253-0.881; P = 0.018). Independent predictors of one-year mortality postdischarge were age, admission creatinine and haemoglobin, admission heart rate, total ischaemic time, the presence of multivessel coronary artery disease, previous MI and post-PCI TIMI flow. CONCLUSION: In PPCI-treated STEMI patients, prasugrel is associated with a significant reduction in one-year mortality compared with clopidogrel.

Blood thrombogenicity is independently associated with serum TSH levels in post-non-ST elevation acute coronary syndrome.

CONTEXT: Higher serum TSH levels, both within the reference range and in those with subclinical hypothyroidism (SCH), have been associated with increased risk of atherosclerosis and cardiovascular (CV) events in a number of cross-sectional and longitudinal studies. OBJECTIVE: Our objective was to evaluate blood thrombogenicity in patients post-non-ST elevation acute coronary syndrome (NSTE-ACS) in relation to their thyroid function. DESIGN, PATIENTS, AND OUTCOME MEASURE: At 1 week after troponin-positive NSTE-ACS, 70 patients who had been treated with optimal antiplatelet and secondary prevention therapy were studied. Patients with known thyroid disease or on medications affecting thyroid function were excluded. Blood thrombogenicity was assessed using the ex vivo Badimon perfusion chamber. RESULTS: Serum TSH was associated with higher thrombus burden (ß = .30; P = .01) independent of other well-established CV risk factors. Patients with SCH (n = 12; 17%) had a higher thrombus burden than euthyroid individuals as evidenced by the area of the thrombus: mean (SD) 23 608 (10 498) vs 16 661 (10 902) µm(2)/mm (P = .02). However, this association was not evident when the analysis was limited to patients with serum TSH within the reference range. In addition, neither serum free T4 nor free T3 had any significant association with thrombus area. CONCLUSION: Serum TSH levels, particularly in the SCH range, are associated with higher thrombus burden despite optimal recommended secondary prevention therapy after NSTE-ACS. This may explain the higher CV risk seen in SCH patients. Future trials to assess the effect of individualized antithrombotic as well as thyroid hormone replacement therapy to reduce atherothrombotic risk in this population are needed.

Differences in thrombus structure and kinetics in patients with type 2 diabetes mellitus after non ST elevation acute coronary syndrome.

INTRODUCTION: Despite optimal secondary prevention therapy following non-ST elevation acute coronary syndrome (NSTE-ACS), recurrent thrombotic events are more frequent in patients with type 2 diabetes mellitus (T2DM). MATERIALS AND METHODS: This exploratory study was aimed to evaluate quantitative and qualitative aspects of thrombus. In 28 patients with and without T2DM treated with aspirin and clopidogrel we assessed thrombus quantity using an ex-vivo chamber, platelet reactivity, thrombus ultrastructure and thrombus kinetics one week after NSTE-ACS. RESULTS: T2DM was associated with increased thrombus [14861 (8003 to 30161) vs 8908 (6812 to 11996), µ(2)/mm, median (IQR), p=0.045] and platelet reactivity. In addition, diabetic thrombus showed lower visco-elastic tensile strength [(-0.2(-1.7 to 0.7) vs 1.0(-0.9 to 3.3), p=0.044)] and was more resistant to autolysis [(27.8(11.7 to 70.7) vs 78.8(68.5 to109.6) mm/min, p=0.002)]. On SEM, fibrin fibres in diabetes were thinner, with higher lateral interlinkage and mesh-like organisation. Thrombus quantity correlated inversely with thrombus retraction (r=-0.450 p=0.016) but not with platelet reactivity (r=0.153, p=0.544). CONCLUSIONS: Despite optimal antiplatelet therapy, T2DM patients after NSTE-ACS developed increased thrombus of lower tensile strength and slower retraction. SEM revealed loosely arranged fibrin fibres. Our data showed significant differences in the magnitude as well as structural and mechanistic characteristics of thrombus in patients with T2DM.

Admission heart rate predicts mortality following primary percutaneous coronary intervention for ST-elevation myocardial infarction: an observational study.

BACKGROUND: The prognostic value of admission heart rate (HR) on long-term mortality in ST-elevation myocardial infarction (STEMI) remains uncertain in the modern era of primary percutaneous coronary intervention (PPCI). This study aimed to assess the predictive value of admission HR on long-term mortality following PPCI and the influence of beta-blockers on postdischarge survival. METHODS: Retrospective analysis of prospectively collected data on 2310 PPCI-treated STEMI patients at a regional tertiary center between March 2008 and June 2010. RESULTS: Patients were classified according to admission HR into either low (≤70 beat per minute [bpm], n = 1015) or high HR group (>70 bpm, n = 1295). At a median follow-up of 559 days, all-cause mortality was 7.0% in the low HR group compared to 12.7% in the high-HR group. In the Cox proportional hazard model, adjusted for several confounders, the hazard ratio (95% confidence interval) for all-cause mortality in the high HR group was 1.59 (1.15-2.20; P = 0.005). Every 10-bpm increase in admission HR was associated with 17% increase in all-cause mortality. Beta-blockers on discharge was associated with a reduction in postdischarge mortality only in the high HR group (adjusted hazard ratio, 0.49 [0.31-0.77; P = 0.002]), but not in the low HR group (adjusted hazard ratio, 0.74 [0.37-1.49; P = 0.33]). CONCLUSIONS: Elevated admission heart rate in PPCI-treated STEMI patients is associated with long-term all-cause mortality. Beta blocker therapy improved postdischarge survival in patients with elevated admission heart rate.

Early discharge after primary percutaneous coronary intervention for ST-elevation myocardial infarction.

BACKGROUND: To assess safety of early discharge following primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Retrospective analysis of prospectively collected data of 2448 STEMI patients treated with PPCI surviving to hospital discharge. Post-discharge all-cause mortality was reported at 1, 7, and 30 days and long-term follow up. A total of 1542 patients (63.0%) were discharged within 2 days of admission (early discharge group) and 906 patients (37.0%) after 2 days (late discharge group). In both groups, no deaths were recorded 1 day post discharge. The early and late discharge group mortality figures for 7 days were 0 and 4 patients (0.04%) and between 7 and 30 days were 11 (0.7%) and 11 patients (1.2%), respectively. During a mean follow up of 584 days, 178 patients (7.3%) died: 67 in the early discharge group (4.3%) and 111 in the late discharge group (12.3%). CONCLUSIONS: This exploratory, observational study demonstrates that discharging low-risk STEMI patients within 2 days following PPCI is safe. For providers of health care, early discharge can help to allay the cost of providing a 24-hour PPCI service and adds to the recognized benefits arising from PPCI.

Increased atherothrombotic burden in patients with diabetes mellitus and acute coronary syndrome: a review of antiplatelet therapy.

Patients with diabetes mellitus presenting with acute coronary syndrome have a higher risk of cardiovascular complications and recurrent ischemic events when compared to nondiabetic counterparts. Different mechanisms including endothelial dysfunction, platelet hyperactivity, and abnormalities in coagulation and fibrinolysis have been implicated for this increased atherothrombotic risk. Platelets play an important role in atherogenesis and its thrombotic complications in diabetic patients with acute coronary syndrome. Hence, potent platelet inhibition is of paramount importance in order to optimise outcomes of diabetic patients with acute coronary syndrome. The aim of this paper is to provide an overview of the increased thrombotic burden in diabetes and acute coronary syndrome, the underlying pathophysiology focussing on endothelial and platelet abnormalities, currently available antiplatelet therapies, their benefits and limitations in diabetic patients, and to describe potential future therapeutic strategies to overcome these limitations.

Thrombus and antiplatelet therapy in type 2 diabetes mellitus. A prospective study after non-ST elevation acute coronary syndrome and a randomised, blinded, placebo-controlled study in stable angina.

Type 2 diabetes mellitus (T2DM) is associated with higher rates of thrombotic complications in patients with coronary artery disease (CAD) despite optimal medical therapy. Thrombus area was measured in T2DM and non-diabetic patients receiving aspirin and clopidogrel 7-10 days after troponin positive Non ST-elevation acute coronary syndrome (NSTE-ACS). Secondly, we assessed response to clopidogrel in naive patients with T2DM and stable CAD in a randomised controlled trial. Thrombus area was measured by Badimon chamber and platelet reactivity by VerifyNow®. In T2DM patients presenting with NSTE-ACS, thrombus area was greater compared to non-diabetic patients (mean ± SD, 20,512 ± 12,567 [n=40] vs. 14,769 ± 8,531 [n=40] µm²/mm, p=0.02) Clopidogrel decreased thrombus area among stable CAD patients with T2DM (mean ± SD, Clopidogrel [n=45]: 13,978 ± 5,502 to 11,192 ± 3,764 µm²/mm vs. placebo [n=45]: 13,959 ± 7,038 to 14,201 ± 6,780 µm²/mm, p<0.001, delta values: clopidogrel vs. placebo, mean ± SD, 2,786 ± 4,561 vs. -249 ± 2,478, p<0.0005). Only 44% of patients with CAD and T2DM responded to clopidogrel as per VerifyNow® (cut-off PRUz value of ≥ 240). Importantly, no correlation was observed between thrombus area and VerifyNow® values (rho 0.08, p=0.49). Thrombus area values were similar among hypo-responders and good responders to clopidogrel (mean thrombus area ± SD: 12,186 ± 4,294 vs. 10,438 ± 3,401; p=0.17). Type 2 diabetes mellitus is associated with an increased blood thrombogenicity among NSTE-ACS patients on currently recommended medical therapy. Thrombus area was significantly reduced in all stable CAD patients independently of their response to clopidogrel therapy.