Platelet aggregation and risk of stent thrombosis or bleeding in interventionally treated diabetic patients with acute coronary syndrome.

BACKGROUND: Platelet aggregation monitoring in diabetic patients treated with coronary interventions (PCI) for an acute coronary syndrome (ACS) is a promising way of optimizing treatment and outcomes in this high risk group. The aim of the study was to verify whether clopidogrel response measured by Multiplate analyzer (ADPtest) in diabetic ACS patients treated with PCI predicts the risk of stent thrombosis or cardiovascular mortality and bleeding. METHODS: Into this prospective, observational study 206 elective PCI patients were enrolled. Two cutoff points of ADPtest were used in analysis to divide patients into groups. One (345 AU x min) was calculated based on ROC curve analysis; this cutoff provided the best ROC curve fit, although it did not reach statistical significance. The other (468 AU x min) was accepted based on the consensus of the Working Group on On-Treatment Platelet Reactivity. The risk of stent thrombosis and mortality was assessed using Cox regression analysis and Kaplan-Meier curves. RESULTS: The risk of stent thrombosis was higher in the group of patients with impaired clopidogrel response for either cutoff value (for >354 AU x min - HR 12.33; 95% CI 2.49-61.1; P = 0.002). Cardiovascular mortality was also higher in the impaired clopidogrel response group (for >354 AU x min - HR 10.58; 95% CI 2.05-54.58; P = 0.005). We did not find a clear relation of increased clopidogrel response to the risk of bleeding. CONCLUSIONS: The results of this study show that in diabetic ACS patient group treated with PCI an impaired platelet response to clopidogrel measured by the Multiplate analyzer results in increased risk of stent thrombosis and cardiac death.

[Clinical evaluation of incomplete PTCA revascularization efficacy]. / Kliniczna ocena skutecznosci niepelnej rewaskularyzacji metoda przezskórnej sródnaczyniowej koronaroplastyki (PTCA).

UNLABELLED: Long term results of incomplete PTCA revascularization (IR) were estimated in 89 patients (P) with multivessel disease (MVD). P were divided into four groups according to severity and localization of stenoses on coronary angiography. Type A (n = 23): two or more stenoses greater than or equal to 70%, one of which localized in proximal segment was dilated, others in peripheral segments of major epicardial vessels or their branches were left. Type B (n = 30): stenosis greater than or equal to 70% in proximal part of one artery was dilated, other moderate stenoses 50-70% were left. Type C (n = 26): one coronary artery occluded, second vessel with stenosis greater than or equal to 70% was dilated. Type D (n = 10): one or two coronary arteries occluded, in two or three others stenosis 70%, vessel crucial for collateral flow was dilated. On follow-up (x 17.7 months), 57 (64.1%) P were completely free of angina, 23 (25.8%) had only mild effort angina with good response to NTG. Only 9 (10.1%) P required coronary bypass surgery, 6 of them with type D MVD. CONCLUSIONS: 1. IR gives satisfactory long term results in P with type A, B, C of MVD; 2. IR is a palliative procedure in high risk surgical P with type D of MVD, but in some cases gives good clinical results.

[Complications of percutaneous transluminal coronary angioplasty (PTCA)]. / Powiklania zabiegów przezskórnej sródnaczyniowej koronaroplastyki (PTCA).

Between 1981 and 1990, 714 patients underwent 756 percutaneous transluminal coronary angioplasty (PTCA) procedures. A total of 52 patients (6.9%) had major in-hospital complications: 5 patients (0.66%) died, Q-wave or non Q-wave myocardial infarction were observed in 13 patients (1.66%) during procedure and in 8 (1%) outside the catheterization laboratory, before discharge. Because of periprocedural occlusion 11 patients (1.5%) were managed with bypass surgery, 8 (1%) had a transient occlusion that was reopened with PTCA. 21 patients (2.8%) were not ++re-dilated but managed pharmacologically. Dissection, intracoronary thrombus and previous thrombolytic treatment were often associated with occlusion. The risk of dissection was related to lesion morphology. Long-(more than 1 cm) lesion, eccentric stenosis and tortuosity of the vessel segment undergoing dilatation were risk factors for occlusive dissection. There was a high risk of side branch occlusion if its take-off was narrowed and side branch originated from the target lesion. One of the most important risk predictors is the amount of jeopardized myocardium supplied by the target coronary artery. Acute closure of an artery supplying large amount of myocardium may cause abrupt hemodynamic collapse. Hypotension secondary to the artery occlusion may cause a decrease of the flow in the other coronary arteries, leading to cardiogenic shock. Although it is important to note that patients with unstable angina, intracoronary thrombus, long and complex lesion, severe multivessel disease and compromised left ventricular function are at higher risk of acute complication, PTCA is a relatively safe procedure.(ABSTRACT TRUNCATED AT 250 WORDS)

[Complex angioplasty (PTCA) in the treatment of coronary artery stenosis]. / Kompleksowa koronaroplastyka (PTCA) w leczeniu kilku zwezen tetnic wiencowych.

56 patients with more than one stenotic coronary artery were treated by complex PTCA with success rate of 96.4%. Complications occurred in 3.6% of pts. Restenoses were found in 9.4% of pts; only one of the dilated arteries were restenosed. 11.3% of pts had repeated PTCA, because of progression of stenosis in other than previously treated artery. Angina occurred earlier in pts with restenoses than in pts with progression of stenoses. Late efficacy (mean 19 months) of complex PTCA was high (90.7%).

[Percutaneous transluminal coronary angioplasty in patients with high risk bypass surgery]. / Przezskórna angioplastyka wiencowa u chorych z wysokim ryzykiem leczenia operacyjnego.

The purpose of this study was to assess the immediate and long-term results of incomplete percutaneous transluminal coronary angioplasty (PTCA) in high-risk coronary artery bypass surgery (CABG) patients. 24 pts (male-22, female-2, age - 39-60 years) were divided into 2 groups: I-8 pts with unstable angina pectoris who were definitely not CABG candidates because of very low ejection fraction (LVEF < 24%) and/or diffuse coronary atherosclerosis; II-16 pts selected for CABG only after failed PTCA. From this group 12 pts with unstable angina pectoris and history of myocardial infarction were at higher CABG risk because of LVEF < 40% and diffuse coronary atherosclerosis. 4 pts were poor surgical candidates because of coexistent medical disorders. The strategy of PTCA was to dilate first the most critical (culprit) lesion, responsible for the patient symptoms, usually situated in the artery supplying large area of viable myocardium. We did not achieve: complete revascularization in all our pts (incomplete revascularization by intent). Initial success rate of the PTCA in both groups was 100%. There were no serious complications. During follow-up (6 months--4 yrs) long-term clinical improvement was observed in 7 pts from group I (87.5%) and 14 pts from group II (87.5%). We conclude, that in most pts with unstable angina pectoris and with high-risk of CABG good immediate and long-term results of incomplete PTCA can be achieved.

Reversal of ischaemic systolic and diastolic left ventricular dysfunction by successful coronary angioplasty in patients with non-Q wave anterior myocardial infarction.

The effect of PTCA on global and regional left ventricular systolic function, isovolumic relaxation, chamber and muscle stiffness were studied in 30 patients with angina pectoris, previous non-Q wave anterior myocardial infarction (AMI) and significant stenosis of the left anterior descending coronary artery (LAD). In 11 of the 30 patients the condition was stable, but it was unstable in 19. Left ventricular angiograms were obtained before and 4.85 +/- 3.67 months after PTCA. The RAO was in the 30 degree projection, with the silhouette of the left ventricle sliced into 90 regions; changes in left ventricular volume, pressure and anterior wall thickness during the full cardiac cycle, together with dp/dt were demonstrated. After PTCA, global ejection fraction increased from 68.77 +/- 5.96% to 76.57 +/- 3.18%, P < 0.001. Impaired contractility was found in 29/90 (32.2%) regions before PTCA and in 5/90 (5.6%) after PTCA, P < 0.001. The time constant of the isovolumic pressure fall decreased after PTCA (52.56 +/- 17.40 ms vs 39.61 +/- 11.26 ms, P < 0.01). Elastic chamber stiffness coefficient decreased (0.022 +/- 0.003 vs 0.008 +/- 0.004, P < 0.001) and peak rate of left ventricular filling increased (319.0 +/- 107.9 ml.min-1 vs 396.8 +/- 201.4 ml.min-1, P < 0.05) after PTCA. The muscle stiffness coefficient was within normal values before and did not change after PTCA. The study findings show that in patients with persistent angina pectoris after non-Q wave AMI, complex systolic and diastolic ischaemic dysfunction occurs. This dysfunction can be reversed after successful PTCA of LAD.

[Early and long-term outcome after coronary artery patency]. / Wczesne I odlegle wyniki po udroznieniu tetnic wiencowych.

The role of percutaneous transluminal coronary angioplasty (PTCA) in the management of chronically occluded coronary arteries is still controversial. Percutaneous transluminal coronary angioplasty of chronic total occlusion is associated with relatively low success rates and a high incidence of restenosis. The purpose of this analysis was to determine, from the records of our institution, the efficacy and long-term outcome of angioplasty performed for chronic total occlusion defined as complete occlusion (Thrombolysis in Myocardial Infraction [TIMI] grade 0). PTCA was performed in 212 consecutive patients with chronically occluded coronary arteries and was successful in 125 (59%) patients. Complications were not observed. Successful initial PTCA was related to the clinical duration of occlusion and the type of guidewire (the primary success rate with the conventional guidewire was 49 (48%) versus 76 (69.1%) with Magnum Meier System p < 0.01). Repeat angiography was performed for 65 (52.0%) consecutive patients with successful initial PTCA and demonstrated restenosis in 34 (52.3%). 17 patients were successfully treated by a second PTCA. Restenosis or reocclusion was not clearly related to the residual stenosis post PTCA. In addition, the grade of collateral supply was not different in the vessels with and without restenosis.

High-Pressure Bail-out Coronary Stenting Without Anticoagulation: Early Outcome and Follow-up Results.

PURPOSE:The purpose of this study is to assess the immediate outcome and long-term results of high pressure bail-out coronary stenting without subsequent anticoagulation. PATIENTS AND METHODS: Between June 1994 and September 1996, 32 consecutive patients (males 24, mean age 55 +/- 9.3 years) underwent bail-out stenting at a mean deployment pressure of 15.5 +/- 2.3 mmHg because of complicated PTCA. A total of 54 stents (Palmaz-Schatz, Micro, Gianturco Roubin and Wiktor) were implanted, from one to four stents into each vessel. After the procedure all patients were treated with ticlopidine 500 mg/day and acetylosalicylic acid 300 mg/day only. RESULTS: Stents were successfully delivered in all patients. In the cath lab procedural success was 96.9%. During the in-hospital phase, there was one (3.1%) acute stent thrombosis followed by urgent bypass surgery (CABG). Four (12.5%) non-Q wave myocardial infarctions occurred. There were no subacute stent thrombosis or hemorrhagic complications. Six month angiographic restudy in 28 patients showed restenosis in 13 (46.4%): 9 patients were treated successfully by rePTCA. At one year 13 (40.6%) major adverse cardiac events occurred: eleven (34.4%) target lesion revascularizations (9 PTCA, 2 CABG), one (3.1%) elective CABG surgery and one (3.1%) late cardiac death. Event-free survival was 93.8% at one month, 65.6% at six months, and 59.4% at one year. CONCLUSIONS: High pressure bail-out coronary stenting with antiplatelet regimen is an effective and safe procedure for treating complicated PTCA. Although the restenosis rate is high, in most cases in-stent restenosis can be treated by rePTCA. In 60% of patients clinical course at one year was uneventful.