Comparison of the Clinical and Metabolic Characteristics of Patients With Acute Coronary Syndromes Between the Pre- and Post-lockdown Periods.

INTRODUCTION: In 2020, the SARS-CoV-2 pandemic outbreak required restrictive measures to limit the spread of the virus. This study aimed to assess how changes in dietary habits and lifestyle associated with such measures have affected the characteristics of patients with acute coronary syndromes (ACS) in the post-lockdown period. In particular, we evaluated if the incidence of ACS was higher in younger patients, who were more negatively affected by lockdown measures. METHODS: We analysed 609 ACS patients and compared the clinical, laboratory, and angiographic characteristics of those admitted six months before lockdown (n = 312) and those admitted in the same six-month period after lockdown. Moreover, we compared several anthropometric and laboratory data between pre- and post-lockdown in younger (≤55 years old) and older patients. RESULTS: The incidence of ACS in young adults (≤55 years) was significantly higher in the post- vs. pre-lockdown period (17.5% vs. 10.9%, p = 0.019). A trend to a higher percentage of ST-elevation myocardial infarction (STEMI) was observed in the post-lockdown period together with a significantly lower incidence of non-STEMI (p = 0.033). Moreover, in the post-lockdown period, we observed in younger patients a significant increase in weight, body mass index, admission glycaemia, and triglycerides while in older patients, these parameters were significantly reduced. CONCLUSION: The lockdown may have negatively affected cardiovascular risk, thus increasing the incidence of ACS, particularly in younger patients who probably underwent more relevant lifestyle changes, with several consequent anthropometric and metabolic alterations. Such evidence should be considered to take preventive measures in case a new state of emergency occurs.

Vulnerable struts with CRE8, Biomatrix and Xience stents assessed with OCT and their correlation with clinical variables at 6-month follow-up: the CREBX-OCT study.

First-generation drug eluting stents (DES) reduced the incidence of restenosis and need for repeated target lesion revascularization but, in autoptic studies, frequently resulted in incomplete endothelial coverage, which is an important predictor of late adverse events and increased mortality after stent implantation. More recently, not only uncovered, but also malapposed or protruding struts have been considered vulnerable structures, as they are deemed to perturb blood flow, whereas only struts well embedded into the vessel wall are considered stable. We compared the number of uncovered and of other vulnerable (protruding or malapposed) struts among three different second-generation drug-eluting stents (DES) (Cre8, Biomatrix, Xience), using optical coherence tomography (OCT) 6 months after implantation. Moreover, we analyzed the relationship between the percentage of vulnerable struts and the clinical characteristics of patients. 60 patients with stable angina or non-ST-Elevation acute coronary syndrome and indication to percutaneous angioplasty were randomly assigned to receive one of the three DES. After 6 months, OCT images were obtained. After 6 months, OCT images were obtained (1289 cross sections; 10,728 struts). None of the three DES showed non-coated struts or areas of stent thrombosis. Significant differences in the average number of protruding struts (Cre8: 33.9 ± 12.6; Biomatrix: 26.2 ± 18.1; Xience: 13.2 ± 8.5; p < 0.001) and in the proportion of malapposed struts (Cre8: 0.7%; Biomatrix: 0.9%; Xience: 0.0%; p = 0.040) and of incomplete stent apposition area (Cre8: 10.4%; Biomatrix: 4.7%; Xience: 0.7%; p < 0.001) were observed. No significant difference was found in neointimal hyperplasia area with a not significant tendency toward greater minimal and maximal struts thickness for Biomatrix. In comparison with Cre8 and Biomatrix, Xience showed a significantly lower proportion of vulnerable struts in all clinical sub-groups considered. In the group of 60 patients a significant relation was found between age and number of vulnerable struts (p = 0.014). The three second-generation DES were similarly effective in permitting neo-intimal formation and complete struts coating 6 months after implantation, but Cre8 and Biomatrix showed a greater proportion of protruding and malapposed struts.Trail Registry: Clinical Trials.gov Identifier: NCT02850497.

Deep sedation vs femoral block anesthesia: beat-by-beat hemodynamic impact on TAVI procedure.

BACKGROUND: In spite of the increased use of Trans-catheter Aortic Valve Implantation (TAVI) due to the better patient selection, well-trained operators and improved technology, the choice of the best anesthesia regimen remains an open question. In particular, it remains to be clarified whether deep sedation (DS) in spontaneous breathing or femoral local anesthesia (LA) is best. OBJECTIVE: This study compared the hemodynamic variations determined by deep sedation (DS) with spontaneous breathing and local femoral anesthesia (LA) in 2 groups of patients submitted to TAVI with two different kinds of anesthesia, using a beat-by-beat pulse contour method (MostCare®-UP). METHODS: 82 patients with severe aortic stenosis and similar baseline characteristics and indications underwent trans-femoral TAVI: 50 with LA and 32 with DS. All patients were submitted to minimally invasive hemodynamic monitoring. The following parameters were measured: pressure indexes: systolic, diastolic, mean (SysP, DiaP, MAP) and dicrotic (DicP) pressures; flow indexes: cardiac output (CO), stroke volume (SV); ventriculo-arterial coupling indexes (VAC): peripheral arterial elastance (EaP), systemic vascular resistance (SVR); cardiovascular system performance: cardiac cycle efficiency (CCE), dP/dtmax_rad. RESULTS: The TAVI procedure was successful in 89% of patients (VARC-2 criteria) with no difference between the 2 groups. Anesthesia induction determined a higher decrease of pressures in DS than in LA (P<0.01) with no differences in CO. The VAC parameters (EaP, SVR) decreased (P<0.01) in DS with an improvement in CCE (P<0.001); these parameters did not change in LA. The post-TAVI flow and VAC parameters, especially Ea, increased (P<0.05) more significantly in the LA group than in the DS group (P<0.001). Using logistic regression, the occurrence of the post-TAVI aortic regurgitation was correctly associated with the pressure gradient MAP-DicP in 63% of the study population (P=0.033). This association was more effectively detected in the LA group (78%, P=0.011) with a ROC AUC=0.779, than the DS group. CONCLUSION: The use of the pulse contour method to track the fast-hemodynamic changes during the TAVI procedure proved suitable for the aim. As expected, LA and DS induced different pre-TAVI hemodynamic conditions, which influenced the post-TAVI hemodynamic changes. The hemodynamic conditions induced by LA, enabled the occurrence of post-TAVI aortic regurgitation to be detected more effectively.

Mechanisms of late stent malapposition after primary stenting in ST-elevation myocardial infarction: a subanalysis of the selection trial.

BACKGROUND: One of the major predictors of late stent malapposition (LSM) is primary stenting in acute myocardial infarction. However, mechanisms of LSM are still under debate. METHODS: Patients with ST-elevation myocardial infarction (STEMI) and enrolled in the SELECTION trial (38 patients in the paclitaxel-eluting stent, PES, and 35 in the bare metal stent, BMS, cohort) were retrospectively analyzed to evaluate LSM, by means of intravascular ultrasound (IVUS) data recorded at the index and 7-month follow-up procedures. RESULTS: Stent malapposition was documented in 21 lesions in 21 patients (28.8%): in 8 of these 21 patients (38.1%) it was LSM. Although statistical significance was not reached, LSM was more frequent after PES than BMS implantation (15.8% vs. 5.7%). LSM was mainly located within the body of the stent (62.5% of the cases). At the LSM segment, a significant increase of vessel area (19.2 +/- 3.3 mm(2) vs. 21.9 +/- 5.3 mm(2), P = 0.04) and a reduction of plaque area (12.6 +/- 4.6 mm(2) vs. 9.1 +/- 3.9 mm(2), P = 0.04) were observed at IVUS between the index and follow-up procedure. CONCLUSIONS: After primary stenting for STEMI, LSM seems to be more frequent after PES rather than BMS implantation. In the STEMI setting, possible mechanisms leading to LSM include positive remodeling and plaque mass decrease.

Prognostic value of exercise stress test and dobutamine stress echo in patients with known coronary artery disease.

BACKGROUND: The aim of this study was to compare the feasibility of dobutamine stress echocardiography (DSE) and exercise stress test (EST) between patients in different age groups and to evaluate their proportional prognostic value in a population with established coronary artery disease (CAD). METHODS: The study sample included 323 subjects, subdivided in group 1 (G1), comprising 246 patients aged <75 years, and group 2 (G2), with 77 subjects aged >or=75 years. DSE and EST were performed before enrollment in a cardiac rehabilitation program; for prognostic assessment, end points were all-cause mortality and hard cardiac events (cardiac death or nonfatal myocardial infarction). RESULTS: During DSE, G2 patients showed worse wall motion score index (WMSI), but the test was stopped for complications in a comparable proportion of cases (54 G1 and 19 G2 patients, P = NS). EST was inconclusive in similarly high proportion of patients in both groups (76% in G1 vs. 84% in G2, P = NS); G2 patients reached a significantly lower total workload (6 +/- 1.6 METs in G1 vs. 5 +/- 1.2 METs in G2, P < 0.001). At multivariate analysis, a lower peak exercise capacity (HR 0.566, CI 0.351-0.914, P = 0.020) was associated with higher mortality, while a high-dose WMSI >2 (HR 5.123, CI 1.559-16.833, P = 0.007), viability (HR 3.354, CI 1.162-9.678, P = 0.025), and nonprescription of beta-blockers (HR 0.328, CI 0.114-0.945, P = 0.039) predicted hard cardiac events. CONCLUSION: In patients with known CAD, EST and DSE maintain a significant prognostic role in terms of peak exercise capacity for EST and of presence of viability and an extensive wall motion abnormalities at peak DSE.

Peripheral artery disease and amputations with Sodium-Glucose co-Transporter-2 (SGLT-2) inhibitors: A meta-analysis of randomized controlled trials.

BACKGROUND: Concerns have been raised on the risk of lower limb amputations with SGLT-2 inhibitors. Aim of the present metanalysis is the assessment of the effect of SGLT-2inhibitors on peripheral artery disease and lower limb amputations in randomized controlled trials performed in patients with type 2 diabetes. METHODS: A Medline and Embase search for "Canaglifozin" OR "Dapaglifozin" OR "Empaglifozin" OR "Ertuglifozin" OR "Ipraglifozin" OR Tofoglifozin" OR "Luseoglifozin" was performed, collecting randomized clinical trials (duration > 12 weeks) up to December 1st, 2018, comparing SGLT-2i at approved dose with placebo or other active comparators different from SGLT-2 inhibitors. Furthermore, unpublished studies were searched in the www.clinicaltrials.gov register. Separate analyses were performed for individual molecules of the class. In addition, a separate analysis was performed for placebo-controlled trials. Mantel-Haenszel odds ratio with 95% Confidence Interval (MH-OR) was calculated for all outcomes defined above. RESULTS: A total of 27 trials fulfilling the inclusion criteria was identified. The overall incidence of peripheral artery disease was increased with SGLT-2 inhibitors (MH-OR: 1.26 [1.04, 1.52]). The increase of risk was statistically significant only with canagliflozin. MH-OR for amputation in the three cardiovascular safety trials with SGLT-2 inhibitors was 1.22 [0.59-2.52]. CONCLUSIONS: At present, there is no reason to believe that empagliflozin or dapagliflozin increase the risk of either peripheral artery disease of lower limb amputations. Canagliflozin could be associated with a specific risk, which needs to be further investigated.

Intravascular lithotripsy for calcific coronary and peripheral artery stenoses.

Heavily calcified lesions may be difficult to dilate adequately with conventional balloons and stents, which causes frequent periprocedural complications and higher rates of target lesion revascularisation (TLR). High-pressure non-compliant balloon angioplasty may be of insufficient force to modify calcium and, even when successful, may be limited in its ability to modify the entire calcified lesion. Scoring and cutting balloons hold theoretical value but data to support their efficacy are lacking and, because of their high lesion crossing profile, they often fail to reach the target lesion. Rotational and orbital atherectomy target superficial calcium; however, deep calcium, which may still impact on vessel expansion and luminal gain, is not affected. Intravascular lithotripsy (IVL), based on lithotripsy for renal calculi, is a new technology which uses sonic pressure waves to disrupt calcium with minimal impact to soft tissue. Energy is delivered via a balloon catheter, analogous to contemporary balloon catheters, with transmission through diluted ionic contrast in a semi-compliant balloon inflated at low pressure with sufficient diameter to achieve contact with the vessel wall. With coronary and peripheral balloons approved in Europe, peripheral balloons approved in the USA and multiple new trials beginning, we review the indications for these recently introduced devices, summarise the clinical outcomes of the available trials and describe the design of ongoing studies.

Reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial.

BACKGROUND: Observational studies suggest that open visiting policies are preferred by most patients and visitors in intensive care units (ICUs), but no randomized trial has compared the safety and health outcomes of unrestrictive (UVP) and restrictive (RVP) visiting policies. The aim of this pilot, randomized trial was to compare the complications associated with UVP (single visitor with frequency and duration chosen by patient) and RVP (single visitor for 30 minutes twice a day). METHODS AND RESULTS: Two-month sequences of the 2 visiting policies were randomly alternated for 2 years in a 6-bed ICU, with 226 patients enrolled (RVP/UVP, n=115/111). Environmental microbial contamination, septic and cardiovascular complications, emotional profile, and stress hormones response were systematically assessed. Patients admitted during the randomly scheduled periods of UVP received more frequent (3.2+/-0.2 versus 2.0+/-0.0 visits per day, mean+/-SEM) and longer (2.6+/-0.2 versus 1.0+/-0.0 h/d) visits (P<0.001 for both comparisons). Despite significantly higher environmental microbial contamination during the UVP periods, septic complications were similar in the 2 periods. The risk of cardiocirculatory complications was 2-fold (odds ratio 2.0; 95% CI, 1.1 to 3.5; P=0.03) in the RVP periods, which were also associated with a nonsignificantly higher mortality rate (5.2% versus 1.8%; P=0.28). The UVP was associated with a greater reduction in anxiety score and a significantly lower increase in thyroid stimulating hormone from admission to discharge. CONCLUSIONS: Despite greater environmental microbial contamination, liberalizing visiting hours in ICUs does not increase septic complications, whereas it might reduce cardiovascular complications, possibly through reduced anxiety and more favorable hormonal profile.

[Percutaneous treatment of coronary chronic total occlusions: state of the art]. / Il trattamento delle occlusioni coronariche croniche: stato dell'arte.

Successful percutaneous coronary intervention of chronic total occlusions (CTO) is associated with favorable clinical outcomes in selected subsets of patients. The success rate of CTO interventions greatly increased over the last decades, thanks to the development of dedicated materials and interventional strategies. Nevertheless, CTO interventions are still challenging with higher complication rates and lower success rates compared to standard percutaneous coronary interventions. Dedicated CTO operators are warranted in order to minimize the rate of complications and to achieve a success rate near to 90%. This state of the art paper is aimed to provide updated evidences on the clinical benefit of CTO recanalization and to describe specific interventional techniques for CTO recanalization.

APpropriateness Assessment in Antiplatelet THerapY (APATHY) registry: Insight from current clinical practice.

BACKGROUND: In clinical practice there is a gap between guidelines recommendation and antiplatelet strategies used for acute coronary syndrome (ACS). We sought to evaluate appropriateness of antiplatelet strategies employed in a tertiary center. METHODS AND RESULTS: From January to June 2014, 430 ACS were treated with percutaneous coronary intervention by 3 groups of interventional cardiologists. Aspirin and clopidogrel (52%) were the most commonly used antiplatelet therapies, being prasugrel associated with aspirin in 110 (25.5%) and ticagrelor in 97 (22.5%) ACS. Inappropriate use of prasugrel (Tia/Ictus) was found in 2 (1.8%) patients and not recommended use (>75years, without diabetes or previous myocardial infarction) in 11 (10%). Not recommended use of ticagrelor (plus warfarin) was found in 4 (4.4%). Switching from clopidogrel to prasugrel occurred in 29% [28 showing high residual platelet reactivity (HRPR: ADP 10µmol>70%), and 4 left main stenting], while from clopidogrel to ticagrelor occurred in 13.4% (all showing HRPR, but 1). The most powerful predictor for prescription of 3rd generation P2Y12 inhibitors was the HRPR (OR 5.473, 95%CI 2.41-12.43, p<0.0001), whereas the behavior of attending cardiologist (HR 0.674, 95%CI 0.573-0.847, p=0.001) and the older age reduced the probability of receiving it (OR0.963, 95%CI 0.943-0.984, p=0.001). CONCLUSIONS: Clopidogrel remained the most common P2Y12 inhibitor employed for ACS. Third generation P2Y12 inhibitor prescription was lower than the one expected by guidelines recommendations, and the switching was largely based on clopidogrel HRPR. These findings suggest the need for a greater effort to improve adherence of cardiology community to current guidelines.

COmparison between COronary THrombus aspiration with Angiojet® or Export® catheter in patients with ST-elevation myocardial infarction submitted to primary angioplasty: The COCOTH Study.

AIMS: To compare the effects of two thrombus aspiration devices, the manual catheter Export® and the more complex and expensive mechanical Angiojet®, on several indices of reperfusion in acute ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Clinical, hemodynamic and procedural characteristics of 185 STEMI patients, randomized to treatment with Export (n=95) or Angiojet (n=90) during primary percutaneous coronary intervention (PPCI) were analyzed. The primary endpoint was ST-segment elevation reduction 90 min after culprit vessel re-opening. Secondary endpoints included variations in some angiographic parameters (TIMI Flow, TIMI Frame Count and Myocardial Blush Grade) and Infarct Size and Severity at myocardial scintigraphy. A significant reduction in ST-elevation was observed in both groups after PPCI without significant differences between the two groups. No significant difference between Angiojet vs. Export was observed in ST-segment resolution >50% and ≥ 70%, in TIMI Flow, TIMI Frame Count and Myocardial Blush Grade before vs. after PPCI and in Infarct Size and Severity. CONCLUSIONS: PPCI with thrombus aspiration was effective in both groups of patients, without differences in myocardial reperfusion and necrosis indices. These results could support the routine use of manual devices during PPCI, reserving the more expensive Angiojet in case of manual device failure and persistent or massive intracoronary thrombosis, with favorable implications in terms of cost containment.

The diagnosis of heart failure in the community. Comparative validation of four sets of criteria in unselected older adults: the ICARe Dicomano Study.

OBJECTIVES: We sought to compare construct and predictive validity of four sets of heart failure (HF) diagnostic criteria in an epidemiologic setting. BACKGROUND: The prevalence estimates of HF vary broadly depending on the diagnostic criteria. METHODS: Data were collected in a survey of community dwellers who were > or =65 years of age living in Dicomano, Italy. At baseline, HF was diagnosed with the criteria of the Framingham, Boston, and Gothenburg studies and of the European Society of Cardiology (ESC). Left ventricular mass index and ejection fraction, left atrium systolic dimension, lower extremity mobility disability, summary physical performance score, and 6-min walk test were compared between HF and non-HF participants to test for construct validity of each set of criteria. Predictive validity was evaluated with follow-up assessment of cardiovascular mortality, incident disability, and HF-related hospitalizations. Comparisons were adjusted for demographics, comorbidity, and psychoaffective status. RESULTS: Of 553 participants, 11.9%, 10.7%, 20.8%, and 9.0% had HF, according to Framingham, Boston, Gothenburg, and ESC criteria, respectively. In terms of construct validity, Framingham and Boston criteria discriminated HF from non-HF participants better than Gothenburg and ESC criteria across the measures of cardiac function and global performance. The Boston criteria showed a superior predictive validity because they indicated a significantly greater adjusted risk of cardiovascular death (hazard ratio3.9, 95% confidence interval 1.2 to 13.2), incident disability, and hospitalizations in participants with HF. CONCLUSIONS: The Boston criteria are preferable to Framingham, Gothenburg, and ESC criteria for the diagnosis of HF in older community dwellers because they have good construct validity and more accurately predict cardiovascular death, incident disability, and hospitalizations.

Thrombus aspiration in ST-elevation myocardial infarction: Does it actually impact long-term outcome?

BACKGROUND: The effect of thrombus aspiration on mortality is still controversial, with results which are often inconsistent in different randomized trials, real world registries and different follow-up duration. The aim of this analysis was to assess the effect on 30-day and 1-year mortality of thrombus aspiration during primary percutaneous coronary intervention (pPCI) for ST-elevation myocardial infarction (STEMI) compared with conventional PCI. METHODS: We used data from all the consecutive STEMI patients treated either with conventional PCI or thrombus aspiration between January 1, 2004 and January 1, 2012. Propensity matching score was calculated on the basis of several baseline and procedural characteristics in order to predict the probability for each patient of having been treated with thrombus aspiration. This propensity score analysis was used in order to select a cohort of patients treated with thrombus aspiration matched one-to-one with patients treated with conventional PCI. RESULTS: In total, 744 (53.1%) patients out of 1,400 enrolled were treated with thrombus aspiration. In the matched cohort, at 30-day follow-up 6.3% of patients in the conventional PCI group died compared to 4.7% in the thrombus aspiration group. The unadjusted hazard ratio (HR) for 30-day mortality was 1.01 (95% CI 0.33-3.14, p = 0.985). In the same cohort, 10.7% of patients died at 1-year in the conventional PCI group compared to 5.2% in the thrombus aspiration group. The 1-year unadjusted hazard ratio for mortality was 0.47 (95% CI 0.25-0.90, p = 0.025). The HR changed and was no longer significant after adjustment for differences in the use of glycoprotein (GP) IIb/IIIa inhibitors, lesion pre-dilatation and pre-procedural TIMI flow: 0.71 (95% CI 0.36-1.39, p = 0.322). CONCLUSIONS: Thrombus aspiration does not influence 30-day mortality, however it is associa­ted with 1-year survival benefit. GP IIb/IIIa inhibitors and thrombus aspiration may have an important synergistic role in leading to this long-term benefit.

Does advanced age affect the immediate and long-term results of direct-current external cardioversion of atrial fibrillation?

OBJECTIVES: To determine whether advanced age affects the immediate and long-term results of direct-current external cardioversion (ECV) of atrial fibrillation (AF), the sustained arrhythmia most commonly encountered in older patients. DESIGN: Retrospective analysis of medical records. SETTING: Intensive care unit. PARTICIPANTS: Two hundred fifty consecutive patients(age 34-100) with AF who underwent ECV following a standardized protocol in an intensive care unit. MEASUREMENTS: Immediate efficacy of ECV, defined as recovery of sinus rhythm, and maintenance of sinus rhythm over the follow-up were study outcomes. The univariate and multivariate associations of immediate efficacy of ECV and long-term results with clinical variables were analyzed. RESULTS: At univariate analysis, immediate efficacy of ECV (overall, 91.2%) was lower in older patients and in those with chronic obstructive pulmonary disease, higher for a 3- to 90-day pre-ECV duration of AF than for a duration of 2 days or less or more than 90 days, and independent of underlying cardiac disease, hypertension, diabetes mellitus, previous AF, and left atrial dimension. However, pre-ECV duration of AF was the only multivariate predictor of ECV immediate success. Major complications occurred in only three patients. Of 220 patients discharged in sinus rhythm, 211 were followed up for a mean period +/- standard deviation of 34 +/- 25 months. AF relapsed in 45.5% of them. At multivariate analysis, underlying cardiac disease was the only predictor of the relapse rate, and relapse rate was lower in coronary heart disease than in valvular heart disease, congestive heart failure, or lone AF. CONCLUSION: Immediate and long-term results of ECV of AF, an effective and safe procedure, are unaffected by age,at least after adjusting for several covariates.

Limited utility of the subcostal view for the echocardiographic evaluation of left ventricular mass in epidemiological studies of older persons.

BACKGROUND: Epidemiological estimates of left ventricular mass are based on echocardiographic imaging from the parasternal view, which is often unavailable in subjects with obesity or lung disease. This study was undertaken to assess whether the subcostal view is a valid alternative to estimate left ventricular mass in an unselected older population. METHODS: In a cross-sectional study of all the residents in Dicomano, Italy, aged > or =65 years, echocardiography was performed with a systematic attempt to obtain both the parastermal and the subcostal views. RESULTS: The parasternal view was missing in 73/614 participants, 48 of whom were imaged from the subcostal view. In participants imaged from both views, the subcostal view underestimated left ventricular cavity dimension and, consequently, left ventricular mass [79.7 (1.3) vs. 93.3 (1.5) g/m2; p<0.001]. Furthermore, the subcostal view was only 25% sensitive for the diagnosis of hypertrophy. Several multivariate regression models, developed in an equation development subgroup and tested in a validation subgroup, failed to correct the prediction of left ventricular mass based on measures taken from the subcostal view, also after inclusion of demographic, anthropometric, and spirometric covariates. CONCLUSIONS: In unselected older persons, the subcostal view does not improve the accuracy of echocardiographic estimation of left ventricular mass, which remains biased in epidemiological studies.

Comparison between drug-eluting and bare metal stent on ST-elevation myocardial infarction outcome: should second-generation drug-eluting stent be preferred?

BACKGROUND AND PURPOSE: Although several studies reported that drug-eluting stents (DES) are able to reduce restenosis incidence without increasing mortality, concerns still exist about their safety in ST-segment elevation myocardial infarction (STEMI) patients mainly for a possible higher rate of in-stent thrombosis. Recent evidence suggests a better safety profile of second-generation DES, but data on their outcome in STEMI are still poor. In this study we evaluated the impact on mortality and target lesion revascularization (TLR) of DES or bare metal stent (BMS) implantation in STEMI patients submitted to primary angioplasty. METHODS AND SUBJECTS: We analyzed mortality and TLR in 1150 STEMI patients during a mean 43-month follow-up after DES (44.6%) or BMS (55.4%) implantation. A propensity score method was used to minimize bias. During follow-up, 223 deaths occurred. ESSENTIAL RESULTS: Unadjusted for potential confounders, DES implantation was associated with a significant reduction in all-cause mortality [hazard ratio (HR) 0.40; 95%CI 0.30-0.54] and TLR (HR 0.55; 95%CI 0.36-0.86); this latter was confirmed after propensity score analysis (HR 0.39; 95%CI 0.21-0.67). Second- (n=179) vs. first- (n=337) generation DES showed a further reduction in TLR (HR 0.17; 95%CI 0.05-0.57). Adjusted analyses showed a significant reduction in the combined end-point of all-cause mortality or TLR after both first- and second-generation DES vs. BMS implantation with a trend to a lower risk for second- vs. first-generation DES. PRINCIPAL CONCLUSIONS: DES implantation in STEMI patients showed a significant reduction in TLR and in the combined endpoint of TLR or mortality. Second-generation DES showed a more protective effect on the combined endpoint, suggesting that they would be preferred in this setting.

Breve historia de los stents coronarios / A brief history of coronary artery stents

No disponible