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Noma S, Miyachi H, Fukuizumi I, Matsuda J, Sangen H, Kubota Y, Imori Y, Saiki Y, Hosokawa Y, Tara S, Tokita Y, Akutsu K, Shimizu W, Yamamoto T, Takano H. Adjunctive Catheter-Directed Thrombolysis during Primary PCI for ST-Segment Elevation Myocardial Infarction with High Thrombus Burden. J Clin Med 2022; 11:jcm11010262. [PMID: 35012003 PMCID: PMC8745791 DOI: 10.3390/jcm11010262] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 12/26/2021] [Accepted: 12/31/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND High coronary thrombus burden has been associated with unfavorable outcomes in patients with ST-segment elevation myocardial infarction (STEMI), the optimal management of which has not yet been established. METHODS We assessed the adjunctive catheter-directed thrombolysis (CDT) during primary percutaneous coronary intervention (PCI) in patients with STEMI and high thrombus burden. CDT was defined as intracoronary infusion of tissue plasminogen activator (t-PA; monteplase). RESULTS Among the 1849 consecutive patients with STEMI, 263 had high thrombus burden. Moreover, 41 patients received t-PA (CDT group), whereas 222 did not receive it (non-CDT group). No significant differences in bleeding complications and in-hospital and long-term mortalities were observed (9.8% vs. 7.2%, p = 0.53; 7.3% vs. 2.3%, p = 0.11; and 12.6% vs. 17.5%, p = 0.84, CDT vs. non-CDT). In patients who underwent antecedent aspiration thrombectomy during PCI (75.6% CDT group and 87.4% non-CDT group), thrombolysis in myocardial infarction grade 2 or 3 flow rate after thrombectomy was significantly lower in the CDT group than in the non-CDT group (32.2% vs. 61.0%, p < 0.01). However, the final rates improved without significant difference (90.3% vs. 97.4%, p = 0.14). CONCLUSIONS Adjunctive CDT appears to be tolerated and feasible for high thrombus burden. Particularly, it may be an option in cases with failed aspiration thrombectomy.
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Affiliation(s)
- Satsuki Noma
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Hideki Miyachi
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
- Correspondence: hidep-@nms.ac.jp; Tel.: +81-3-3822-2131
| | - Isamu Fukuizumi
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Junya Matsuda
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Hideto Sangen
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yoshiaki Kubota
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yoichi Imori
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yoshiyuki Saiki
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yusuke Hosokawa
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Shuhei Tara
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Yukichi Tokita
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Koichi Akutsu
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Wataru Shimizu
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
| | - Takeshi Yamamoto
- Division of Cardiovascular Intensive Care, Nippon Medical School Hospital, Tokyo 113-8603, Japan; (S.N.); (I.F.); (J.M.); (H.S.); (Y.I.); (Y.S.); (Y.H.); (S.T.); (Y.T.); (K.A.); (W.S.); (T.Y.)
| | - Hitoshi Takano
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo 113-8603, Japan; (Y.K.); (H.T.)
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Optimal Timing of Invasive Coronary Angiography following NSTEMI. J Interv Cardiol 2020; 2020:8513257. [PMID: 32206045 PMCID: PMC7073472 DOI: 10.1155/2020/8513257] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/17/2020] [Indexed: 11/18/2022] Open
Abstract
Objective To obtain a real-world perspective of the optimal timing of angiography performed within 24 hours of admission with non-ST elevation myocardial infarction (NSTEMI). Background Current guidelines recommend angiography within 24 hours of hospitalisation with NSTEMI. The recent VERDICT trial found that angiography within 12 hours of admission with NSTEMI was associated with improved cardiovascular outcomes among high-risk patients. We compared the outcomes of real-world NSTEMI patients undergoing angiography within 12 hours of admission with those of patients undergoing angiography 12 to 24 hours after admission. Methods NSTEMI patients without life-threatening features who received angiography within 24 hours of admission were obtained from the SPUM-ACS registry, a cohort of consecutive patients admitted with acute coronary syndromes to four university hospitals in Switzerland. Cox models assessed for an association between door-to-catheter time and one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, and stroke). Results Of 2672 NSTEMI patients, 1832 met the inclusion criteria. Among them, 1464 patients underwent angiography within 12 hours (12 h group) compared with 368 patients between 12 and 24 hours (12-24 h group). Multiple logistic regression identified out-of-hours admission as the only factor associated with delayed angiography. After 2 : 1 propensity score matching, 736 patients from the 12 h group and 368 patients from the 12-24 h group demonstrated no significant difference in rates of one-year MACE (7.7% vs. 7.3%, HR: 1.050, 95% CI 0.637-1.733, p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (. Conclusions In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of admission was not associated with improved one-year cardiovascular outcomes when compared with angiography 12 and 24 hours after admission, even among high-risk patients.
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Angiographic features of patients with coronary plaque erosion. Int J Cardiol 2019; 288:12-16. [PMID: 30928256 DOI: 10.1016/j.ijcard.2019.03.039] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Revised: 02/19/2019] [Accepted: 03/19/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Although an in vivo diagnosis of coronary plaque erosion has become possible by optical coherence tomography (OCT), angiographic characteristics of erosion have not been studied. The aim of this study was to investigate the angiographic features of plaque erosion in patients with non-ST elevation acute coronary syndromes (NSTE-ACS). METHODS Patients with NSTE-ACS who underwent OCT of the culprit lesion were collected at 11 institutions from 6 countries. Patients were classified as erosion or non-erosion based on OCT images. Angiographic features of both groups were compared. RESULTS Among 494 cases with NSTE-ACS, 242 had plaque erosion and 252 had non-erosion. Compared to non-erosion group, erosion patients had less multivessel disease (28.5% vs. 49.6%, p < 0.001), lower Jeopardy score (4.2 vs. 5.0, p < 0.001), lower Gensini score (21.3 vs. 25.6, p = 0.014), and lower Syntax score (8.9 vs. 11.5, p < 0.001). With regard to the culprit lesion morphology, plaque erosion group had smaller reference diameter (2.8 mm vs. 3.0 mm, p = 0.032), less frequent type B2/C lesions (51.2% vs. 71.8%, p < 0.001), and lower prevalence of calcification (4.1% vs. 13.9%, p < 0.001) and thrombus (16.5% vs. 28.2%, p = 0.002). In the mid left anterior descending artery (LAD), erosion was significantly more frequent than non-erosion (30.2% vs. 21.8%, p = 0.034). CONCLUSIONS Patients with NSTE-ACS caused by plaque erosion have less complex angiographic features both at the 3-vessel level and at the culprit lesion level. Plaque erosion was frequently found in the mid LAD.
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Custodio-Sánchez P, Damas-De Los Santos F, Peña-Duque MA, Coutiño-Castelán D, Arias-Sánchez E, Abundes-Velasco A, Castro-Alvarado O, Colon-Arias FA, Alvarenga-Fajardo C, Hernández-Fonseca C, Rodríguez-Barriga E, Hernández-Padilla A. [Deferred versus immediate stenting in patients with ST - segment elevation myocardial infarction and residual large thrombus burden reclassified in the culprit lesion]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2018; 88:432-440. [PMID: 29706554 DOI: 10.1016/j.acmx.2018.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/01/2018] [Accepted: 03/05/2018] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Reclassification of a large thrombus burden is an independent predictor of major adverse cardiac events and no-reflow in patients with ST- segment elevation myocardial infarction (STEMI). Patients with a greater residual thrombus burden have worse microvascular dysfunction and greater myocardial damage. METHODS A retrospective analysis was performed on 833 STEMI patients who underwent primary percutaneous coronary intervention. The final residual thrombus burden was reclassified after the lesion was wired, and a thrombus aspiration or balloon dilatation was performed to restore and stabilise a thrombolysis in myocardial infarction (TIMI) 2-3 flow. Deferred stenting (DEI) was compared with immediate stenting (ISI) group, and the primary outcome was the incidence of no-/slow-reflow (TIMI ≤ 2, or TIMI 3 with myocardial blush grade < 2). RESULTS Overall, 47 patients (6.8%) had a residual large thrombus burden reclassified. The right coronary artery was the culprit vessel in 34 cases. More patients had coronary ectasia in the DSI group (P=.005). Fewer patients in the DSI had no-/slow-reflow (36% vs. 58%), and the myocardial blush grade 3 was more frequent in the DSI group (P=.005). After repeat coronary angiography in the DSI group, stenting was not performed in 56%, and oral anticoagulation was more frequent in the follow-up (P=.031). Major cardiac adverse events were similar between groups. There was a tendency to better left ventricular function in the DSI group (P=.056). CONCLUSIONS Deferred stenting may be an efficient option in STEMI patients with a residual large thrombus burden reclassified after achieving a stable TIMI 2-3 flow.
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Affiliation(s)
- Piero Custodio-Sánchez
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México.
| | - Félix Damas-De Los Santos
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Marco A Peña-Duque
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Daniel Coutiño-Castelán
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Eduardo Arias-Sánchez
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Arturo Abundes-Velasco
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Oscar Castro-Alvarado
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Franklyn A Colon-Arias
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Carlos Alvarenga-Fajardo
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - César Hernández-Fonseca
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Erika Rodríguez-Barriga
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
| | - Adolfo Hernández-Padilla
- Departamento de Cardiología Intervencionista, Instituto Nacional de Cardiología Ignacio Chávez, Ciudad de México, México
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Pigoń K, Nowak-Radzik E, Młyńczak T, Banasik G, Nowalany-Kozielska E, Tomasik A. Cost assessment of treatment of acute myocardial infarction and angiographically visible coronary thrombus. J Comp Eff Res 2018; 7:471-481. [PMID: 29376402 DOI: 10.2217/cer-2017-0094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM Study was aimed to assess the real-world costs of manual thrombectomy (MT) in selected ST-segment elevation myocardial infarction patients with intracoronary thrombus (IT). METHODS Study group (IT+) comprised 51 patients with MT applied and control group (IT-) comprised 56 patients without IT who underwent angioplasty alone. Costs comprised hospital care and cost of disposable materials used during primary angioplasty. RESULTS Complex management of patients with IT is more expensive, though allows to achieve clinical outcomes comparable to low-risk ST-segment elevation myocardial infarction patients without IT. CONCLUSION A complex pharmaco-interventional strategy, with glycoprotein IIB/IIIA inhibitor and MT, though more expensive, may prove cost-effective.
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Affiliation(s)
- Katarzyna Pigoń
- Students' Scientific Group at II Department of Cardiology in Zabrze, Faculty of Medicine with Dentistry Division, Medical University of Silesia, Katowice, ul. Skłodowskiej 10, Zabrze 41-800, Poland
| | - Edyta Nowak-Radzik
- Students' Scientific Group at II Department of Cardiology in Zabrze, Faculty of Medicine with Dentistry Division, Medical University of Silesia, Katowice, ul. Skłodowskiej 10, Zabrze 41-800, Poland
| | - Tomasz Młyńczak
- Students' Scientific Group at II Department of Cardiology in Zabrze, Faculty of Medicine with Dentistry Division, Medical University of Silesia, Katowice, ul. Skłodowskiej 10, Zabrze 41-800, Poland
| | - Grzegorz Banasik
- II Department of Cardiology in Zabrze, Faculty of Medicine with Dentistry Division in Zabrze, Medical University of Silesia, Katowice, ul. Skłodowskiej 10, Zabrze 41-800, Poland
| | - Ewa Nowalany-Kozielska
- II Department of Cardiology in Zabrze, Faculty of Medicine with Dentistry Division in Zabrze, Medical University of Silesia, Katowice, ul. Skłodowskiej 10, Zabrze 41-800, Poland
| | - Andrzej Tomasik
- II Department of Cardiology in Zabrze, Faculty of Medicine with Dentistry Division in Zabrze, Medical University of Silesia, Katowice, ul. Skłodowskiej 10, Zabrze 41-800, Poland
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Kim TG, Shin SD, Song KJ, Lee YJ, Lee EJ, Ro YS, Ahn KO. Association between time to percutaneous coronary intervention and hospital mortality in non–STEMI: a prospective multicenter observational study. Am J Emerg Med 2015; 33:1591-6. [DOI: 10.1016/j.ajem.2015.06.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 06/18/2015] [Accepted: 06/18/2015] [Indexed: 12/22/2022] Open
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Optical coherence tomography assessment and quantification of intracoronary thrombus: Status and perspectives. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2015; 16:172-8. [DOI: 10.1016/j.carrev.2015.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 12/20/2014] [Accepted: 01/14/2015] [Indexed: 11/15/2022]
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Scalone G, Brugaletta S, Garcia-Garcia HM, Martin-Yuste V, Azpeitia Y, Otsuki S, Gomez O, Freixa X, Masotti M, Sabaté M. Frequency and predictors of thrombus inside the guiding catheter during interventional procedures: an optical coherence tomography study. Int J Cardiovasc Imaging 2014; 31:239-46. [DOI: 10.1007/s10554-014-0544-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 09/29/2014] [Indexed: 10/24/2022]
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Abstract
Acute coronary syndrome is associated with a high incidence of thrombus. The presence of coronary thrombus is often not appreciated on coronary angiography; however, simultaneous use of angioscopy or intravascular ultrasound increases the detection of thrombus. Forceful coronary injection, passage of intracoronary devices, balloon angioplasty and stenting in the presence of thrombus contribute to distal embolization by disrupting the thrombus. Clinically, intracoronary thrombus is associated with higher rates of death, myocardial infarction and target vessel revascularization. Removal of thrombus results in the improvement of markers of perfusion, which includes resolution of ST segment elevation, higher myocardial blush grade, and an increase in final thrombolysis in myocardial infarction flow as well as lower mortality. In this article, the authors discuss different mechanical thrombectomy devices and the literature available for their use in acute coronary syndrome.
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Affiliation(s)
- Syed M Ahmed
- Interventional Cardiology, Jennie Edmundson Hospital, Council Bluff, Iowa, USA.
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Echavarría-Pinto M, Lopes R, Gorgadze T, Gonzalo N, Hernández R, Jiménez-Quevedo P, Alfonso F, Bañuelos C, Nuñez-Gil IJ, Ibañez B, Fernández C, Fernandez-Ortiz A, García E, Macaya C, Escaned J. Safety and efficacy of intense antithrombotic treatment and percutaneous coronary intervention deferral in patients with large intracoronary thrombus. Am J Cardiol 2013; 111:1745-50. [PMID: 23528026 DOI: 10.1016/j.amjcard.2013.02.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 02/17/2013] [Accepted: 02/17/2013] [Indexed: 11/26/2022]
Abstract
The optimal management of a large intracoronary thrombus in patients with acute coronary syndromes without an urgent need of revascularization is unclear. We investigated whether deferring percutaneous coronary intervention (PCI) after a course of intensive antithrombotic therapy (ATT) (glycoprotein IIb/IIIa inhibitors, enoxaparin, aspirin, and clopidogrel) improves the outcomes compared with immediate PCI. We studied 133 stable patients with ACS and a large intracoronary thrombus and without an urgent need for revascularization at angiography. The angiographic and in-hospital outcomes of a prospective cohort of 89 patients who had undergone deferred angiography with or without PCI after ATT (d-PCI) were compared with a historical cohort of 44 patients who had undergone immediate PCI, matched for age, gender, and Thrombolysis In Myocardial Infarction thrombus grade. The absolute thrombus volume was measured before and after ATT using dual quantitative coronary angiography. All d-PCI patients remained stable during ATT (60.0 ± 30.8 hours). A significant reduction in the Thrombolysis In Myocardial Infarction thrombus grade (4, range 4 to 5, vs 3, range 2 to 4; p <0.001), thrombus volume (51.1, range 32.1 to 83, vs 38.1, range 21.7 to 50.7 mm(3); p <0.001), stenosis severity (73.8 ± 25.8% vs 60.3 ± 32.5%; p <0.001) and better Thrombolysis In Myocardial Infarction flow (2, range 0 to 3, vs 3, 1.5 to 3; p <0.001) were noted after ATT. PCI, stenting, and thrombus aspiration were performed less frequently in the d-PCI group (76.4% vs 100%, p <0.001; 70.8% vs 93.2%, p = 0.003; and 21% vs 100%, p <0.001, respectively). However, distal embolization and slow and/or no-reflow were more common during immediate PCI (31.8% vs 9%; p = 0.001). No life-threatening or severe hemorrhagic complications were observed, although the rate of mild and/or moderate bleeding was similar between the 2 groups (6.8% in immediate PCI vs 7.9% in d-PCI; p = 0.829). In conclusion, compared with immediate PCI, d-PCI after ATT in selected, stabilized patients with ACS and a large intracoronary thrombus and without an urgent need for revascularization is probably safe and associated with a reduction in thrombotic burden, angiographic complications, and the need of revascularization. These benefits were observed without an increase in hemorrhagic complications.
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Huang PH, Bhatt DL. Adjunctive Pharmacotherapy for Thrombotic Coronary Lesions. Interv Cardiol Clin 2013; 2:375-387. [PMID: 28582143 DOI: 10.1016/j.iccl.2012.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Patients with unstable coronary syndromes are often found to have intracoronary thrombus on angiography. Despite advancements in catheter-based treatments for coronary disease, these lesions remain challenging, as percutaneous coronary intervention of thrombus-containing lesions may be associated with worse outcomes. This article reviews the literature on adjunctive pharmacotherapy in the treatment of thrombotic coronary lesions with special focus on ST-segment elevation myocardial infarction, lesions with high thrombus burden, and saphenous vein graft intervention.
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Affiliation(s)
- Pei-Hsiu Huang
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
| | - Deepak L Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA; Integrated Interventional Cardiovascular Program, Cardiovascular Division, VA Boston Healthcare System, 1400 VFW Parkway, Boston, MA 02132, USA.
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Singh M, Holmes DR, Gersh BJ, Frye RL, Lennon RJ, Rihal CS. Thirty-year trends in outcomes of percutaneous coronary interventions in diabetic patients. Mayo Clin Proc 2013; 88:22-30. [PMID: 23274017 DOI: 10.1016/j.mayocp.2012.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2012] [Revised: 08/08/2012] [Accepted: 09/14/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To characterize in-hospital and long-term outcomes after percutaneous coronary interventions (PCIs) in patients with diabetes mellitus (DM). PATIENTS AND METHODS Patients who underwent PCIs were grouped by era: group 1, October 9, 1979, to December 31, 1989 (408 with DM and 2684 without DM); group 2, January 1, 1990, to December 31, 1996 (1170 and 4664); group 3, January 1, 1997, to December 31, 2003 (2032 and 6584); and group 4, January 1, 2004, to December 31, 2008 (1412 and 4141). The main outcome measures were in-hospital mortality, major adverse cardiovascular events, long-term mortality, composites of mortality with revascularization, and ischemic events. RESULTS Patients with DM had significant declines in in-hospital adverse outcomes over time. These declines were similar to those observed in patients without DM. After adjusting for baseline risk, there was no significant change in the association between DM and in-hospital death or in-hospital major adverse cardiovascular events over time. The use of aspirin, β-blockers, angiotensin-converting enzyme inhibitors, lipid-lowering drugs, and thienopyridines all increased over time. The effect of DM on long-term survival and survival free of revascularization did not change significantly from group 2 to group 4. However, the effect of DM on survival free of myocardial infarction and stroke was reduced significantly, from a hazard ratio (95% CI) of 1.71 (1.51-1.92) in group 2 to 1.39 (1.20-1.60) in group 4 (P=.04). CONCLUSION Over 30 years, the improving outcomes in patients with diabetes who underwent PCIs have been similar to improvements in patients without DM. However, the risk-adjusted association of DM with long-term death, myocardial infarction, and stroke has decreased in the current era (group 4) compared with the bailout stent era (group 2).
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Affiliation(s)
- Mandeep Singh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA.
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Roule V, Sabatier R, Lognoné T, Bignon M, Idali M, Malcor G, Labombarda F, Milliez P, Grollier G. Thrombus in normal coronary arteries: retrospective study and review of case reports. Arch Cardiovasc Dis 2011; 104:216-26. [PMID: 21624788 DOI: 10.1016/j.acvd.2011.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Revised: 01/25/2011] [Accepted: 01/26/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Myocardial infarction is rarely caused by non-occlusive thrombus in angiographically normal coronary arteries. The cases reported in the literature are scarce and follow-up was usually short. The efficacy and tolerability of the exclusively medical treatment strategy used in most cases remain unknown. AIMS To evaluate efficacy of medical treatment and long-term prognosis in these patients. METHODS We retrospectively selected and analysed patients hospitalized in our centre between 1998 and 2008 for myocardial infarction caused by non-occlusive thrombus in angiographically normal coronary arteries (defined as stenosis<30%), who were exclusively medically treated. A long-term follow-up was performed. A review of the literature regarding such cases was carried out. RESULTS Sixteen patients were identified; apart from smoking, they had few conventional cardiovascular risk factors. Two patients died in hospital. The 14 survivors were followed up for an average of 4.9 years and only one death (non-cardiac cause) and one stroke (related to supraventricular arrhythmia) occurred in this period. Medical treatment included the use of glycoprotein IIb/IIIa inhibitors in 75% of cases. The literature review revealed 36 similar cases due to multiple aetiologies-particularly coronary artery spasm and prothrombotic coagulopathies. CONCLUSION Patients with myocardial infarction secondary to non-occlusive thrombus in angiographically normal coronary arteries seem to have a good long-term prognosis after the acute phase when treated with an exclusively medical strategy. However, initial clinical presentation was often severe, leading to early in-hospital death.
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Affiliation(s)
- Vincent Roule
- Department of Cardiology, Caen University Hospital, avenue Côte-de-Nacre, 14033 Caen, France.
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14
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Vavuranakis M, Vrachatis DA, Papaioannou TG, Archontakis S, Kalogeras KI, Kariori MG, Gafou A, Moldovan C, Tzamalis P, Stefanadis C. Residual Platelet Reactivity After Clopidogrel Loading in Patients With ST-Elevation Myocardial Infarction Undergoing an Unexpectedly Delayed Primary Percutaneous Coronary Intervention - Impact on Intracoronary Thrombus Burden and Myocardial Perfusion -. Circ J 2011; 75:2105-12. [DOI: 10.1253/circj.cj-11-0077] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Manolis Vavuranakis
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
| | - Dimitrios A. Vrachatis
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
| | - Theodore G. Papaioannou
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
| | - Stefanos Archontakis
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
| | - Konstantinos I. Kalogeras
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
| | - Maria G. Kariori
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
| | - Anthi Gafou
- Transfusion & Haemophilic Center, Hippokration Hospital
| | - Carmen Moldovan
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
| | - Panagiotis Tzamalis
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
| | - Christodoulos Stefanadis
- 1st Department of Cardiology, Hippokration Hospital, Medical School, National & Kapodistrian University of Athens
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15
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Lemesle G, Sudre A, Bouallal R, Delhaye C, Rosey G, Bauters C, Lablanche JM. Impact of thrombus aspiration use and direct stenting on final myocardial blush score in patients presenting with ST-elevation myocardial infarction. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2010; 11:149-54. [PMID: 20599164 DOI: 10.1016/j.carrev.2010.03.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2009] [Revised: 03/04/2010] [Accepted: 03/11/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Many studies have reported that low final thrombolysis in myocardial infarction (TIMI) flow and/or myocardial blush grade (MBG) are independent predictors of mortality in patients with ST-elevation myocardial infarction (STEMI). In addition, distal coronary embolization is a major pitfall of conventional percutaneous coronary intervention (PCI) in such a context. AIM This study aimed to assess the impact of thrombus aspiration (TA) use before primary PCI on final myocardial reperfusion in patients presenting with STEMI. METHODS From January to December 2006, 100 patients presenting with STEMI in our catheterization laboratory were considered for the present study. During this time period, 50 patients underwent TA before primary PCI for treatment of STEMI and were then matched 1:1 to 50 controls who underwent conventional primary PCI for treatment of STEMI without TA. Patients of the control group were chosen after matching on age+/-3 years, sex, history of diabetes, and distribution of the infarct related coronary artery during the same period. RESULTS Baseline clinical characteristics, initial TIMI flow and initial MBG of both groups were similar. There was a trend for a better final TIMI flow in the group with TA and the final MBG was significantly improved in the group with TA compared to the group without TA: final MBG of two or three in 70% versus 30% of the cases (P=.001). In addition, direct stenting was significantly more often used in the TA group (92% versus 64%, P=.001). There were four patients with evident distal embolizations in the group without TA and none in the group with TA. CONCLUSION TA use before primary PCI for STEMI treatment resulted in improved final myocardial reperfusion. Of importance, TA use may have led to a better choice of the stent size and more frequent direct stenting. This benefit may directly improve patient outcomes.
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Affiliation(s)
- Gilles Lemesle
- Pôle de Cardiologie, Service de Cardiologie B et Centre Hémodynamique, Hôpital Cardiologique, Centre Hospitalier Régional et Universitaire de Lille, Cedex, France
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Sorajja P, Gersh BJ, Cox DA, McLaughlin MG, Zimetbaum P, Costantini C, Stuckey T, Tcheng JE, Mehran R, Lansky AJ, Grines CL, Stone GW. Impact of Delay to Angioplasty in Patients With Acute Coronary Syndromes Undergoing Invasive Management. J Am Coll Cardiol 2010; 55:1416-24. [DOI: 10.1016/j.jacc.2009.11.063] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Revised: 10/07/2009] [Accepted: 11/09/2009] [Indexed: 10/19/2022]
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Singh M, Peterson ED, Roe MT, Ou FS, Spertus JA, Rumsfeld JS, Anderson HV, Klein LW, Ho KK, Holmes DR. Trends in the Association Between Age and In-Hospital Mortality After Percutaneous Coronary Intervention. Circ Cardiovasc Interv 2009; 2:20-6. [DOI: 10.1161/circinterventions.108.826172] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background—
Temporal trends and contemporary data characterizing the impact of patient age on in-hospital outcomes of percutaneous coronary interventions are lacking. We sought to determine the importance of age by assessing the in-hospital mortality of stratified age groups in the National Cardiovascular Data Registry.
Methods and Results—
In-hospital mortality after percutaneous coronary intervention on 1 410 069 patients was age stratified into 4 groups—group 1 (age <40, n=25 679), group 2 (40 to 59, n=496 204), group 3 (60 to 79, n=732 574), and group 4 (≥80, n=155 612)—admitted from January 1, 2001, to December 31, 2006. Overall in-hospital mortality was 1.22%; in-hospital mortality was 0.60%, 0.59%, 1.26%, and 3.16% in groups 1 to 4, respectively,
P
<0.0001. Overall temporal improvement per calendar year in the adjusted in-hospital mortality after percutaneous coronary intervention was noted in most groups; however, this finding was significant only in the 2 older age groups, group 3 (odds ratio, 0.94; 95% CI, 0.92 to 0.96) and group 4 (odds ratio, 0.95; 95% CI, 0.92 to 0.97). The absolute mortality reduction was greatest in the most elderly group, those over the age of 80 years.
Conclusions—
In-hospital mortality after percutaneous coronary intervention has fallen for all age groups over the past 6 years. However, the largest absolute reduction was seen among patients 80 years of age or older.
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Affiliation(s)
- Mandeep Singh
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - Eric D. Peterson
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - Matthew T. Roe
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - Fang-Shu Ou
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - John A. Spertus
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - John S. Rumsfeld
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - H. Vernon Anderson
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - Lloyd W. Klein
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - Kalon K.L. Ho
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
| | - David R. Holmes
- From the Division of Cardiovascular Diseases (M.S., D.R.H), Mayo Clinic, Rochester, Minn; Duke Clinical Research Institute (M.T.R., F.-S.O., E.D.P.), Durham, NC; Mid America Heart Institute/UMKC (J.A.S.), Kansas City, Mo; Denver VA Medical Center (J.S.R.), Denver, Colo; University of Texas Health Science Center (H.V.A), Houston, Tex; Rush University Medical Center (L.W.K.), Chicago, Ill; and Beth Israel Deaconess Medical Center (K.K.L.H.), Boston, Mass
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Singh M, Rihal CS, Gersh BJ, Roger VL, Bell MR, Lennon RJ, Lerman A, Holmes DR. Mortality differences between men and women after percutaneous coronary interventions. A 25-year, single-center experience. J Am Coll Cardiol 2008; 51:2313-20. [PMID: 18549915 DOI: 10.1016/j.jacc.2008.01.066] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Revised: 01/02/2008] [Accepted: 01/14/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Our aim was to examine whether gender-based differences in mortality after percutaneous coronary interventions (PCIs) have changed in the past 25 years. BACKGROUND Women with coronary artery disease have a higher risk of adverse outcomes after PCIs than do men. Recent temporal trends in short-term and long-term mortality in women after PCIs are unknown. METHODS We performed a retrospective cohort study of 18,885 consecutive, unique patients who underwent PCIs between 1979 and 1995 (early group, n = 7,904, 28% women) and between 1996 and 2004 (recent group, n = 10,981, 31% women). Thirty-day and long-term mortality were compared by gender. RESULTS Compared with men, women undergoing PCIs were older and more likely to have diabetes mellitus, hypertension, or hypercholesterolemia. Overall, PCI was successful in 89% of women and 90% of men. In the recent group, 30-day mortality was significantly reduced compared with that in the early group in women (2.9% vs. 4.4%, p = 0.002) and men (2.2% vs. 2.8%, p = 0.04). However, long-term survival was similar between the early and recent groups among both men and women. After adjustment for risk factors, there was no difference between men and women from 1994 onward for either 30-day or long-term outcomes. CONCLUSIONS The 30-day mortality after PCI in men and women has decreased in the past 25 years. After accounting for baseline risks, no differences in short-term or long-term mortality were observed between men and women.
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Affiliation(s)
- Mandeep Singh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota 55905., USA.
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19
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Mortality differences between men and women after percutaneous coronary interventions. A 25-year, single-center experience. J Am Coll Cardiol 2008. [PMID: 18549915 DOI: 10.1016/j.jacc.2008.01.066s0735-1097(08)01128-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVES Our aim was to examine whether gender-based differences in mortality after percutaneous coronary interventions (PCIs) have changed in the past 25 years. BACKGROUND Women with coronary artery disease have a higher risk of adverse outcomes after PCIs than do men. Recent temporal trends in short-term and long-term mortality in women after PCIs are unknown. METHODS We performed a retrospective cohort study of 18,885 consecutive, unique patients who underwent PCIs between 1979 and 1995 (early group, n = 7,904, 28% women) and between 1996 and 2004 (recent group, n = 10,981, 31% women). Thirty-day and long-term mortality were compared by gender. RESULTS Compared with men, women undergoing PCIs were older and more likely to have diabetes mellitus, hypertension, or hypercholesterolemia. Overall, PCI was successful in 89% of women and 90% of men. In the recent group, 30-day mortality was significantly reduced compared with that in the early group in women (2.9% vs. 4.4%, p = 0.002) and men (2.2% vs. 2.8%, p = 0.04). However, long-term survival was similar between the early and recent groups among both men and women. After adjustment for risk factors, there was no difference between men and women from 1994 onward for either 30-day or long-term outcomes. CONCLUSIONS The 30-day mortality after PCI in men and women has decreased in the past 25 years. After accounting for baseline risks, no differences in short-term or long-term mortality were observed between men and women.
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20
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EL-JACK SEIFS, SUWATCHAI PORNRATANARANGSI, STEWART JAMEST, RUYGROK PETERN, ORMISTON JOHNA, WEST TEENA, WEBSTER MARKWI. Distal Embolization during Native Vessel and Vein Graft Coronary Intervention with a Vascular Protection Device: Predictors of High-Risk Lesions. J Interv Cardiol 2007; 20:474-80. [DOI: 10.1111/j.1540-8183.2007.00308.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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21
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Matar F, Donoghue C, Rossi P, Vandormael M, Sullebarger JT, Kerenski R, Jauch W, Gloer K, Ebra G. Angiographic and clinical outcomes of bivalirudin versus heparin in patients with acute coronary syndrome undergoing percutaneous coronary intervention. Can J Cardiol 2006; 22:1139-45. [PMID: 17102832 PMCID: PMC2569056 DOI: 10.1016/s0828-282x(06)70951-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Heparin with adjunctive glycoprotein IIb/IIIa platelet receptor (GP IIb/IIIa) inhibitors has demonstrated its effectiveness in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Bivalirudin, a direct thrombin inhibitor, has recently been shown to be an effective alternative for patients undergoing elective PCI. OBJECTIVES To assess the angiographic and clinical outcomes of adjunctive pharmacological strategies in a high-risk population presenting with ACS. METHODS Of 891 consecutive PCI patients with ACS, 304 received bivalirudin (60.5% male, 68+/-11 years) and were compared with 283 who received heparin (58.7% male, 66+/-12 years). A 30-day major adverse cardiac event was defined as the occurrence of cardiac death, nonfatal myocardial infarction, urgent revascularization or major hemorrhage. RESULTS Adjunctive GP IIb/IIIa inhibitors were used in 14.1% of the bivalirudin group and in 72.4% of the heparin group (P<0.010). The occurrence of Thrombolysis In Myocardial Infarction (TIMI) flow less than grade 3 was lower and the achievement of angiographic success was higher in the bivalirudin group than in the heparin group (5.2% versus 8.2%, 94.7% versus 89.7%, P=0.039 and P<0.010, respectively). There was no difference between groups in the incidence of bleeding events (bivalirudin 2.0% versus heparin 3.5%, P not significant) and in 30-day major adverse cardiac events (bivalirudin 8.3% versus heparin 5.7%, P=0.223). CONCLUSIONS In the high-risk cohort undergoing PCI, bivalirudin with provisional GP IIb/IIIa inhibitors achieved better angiographic results. Although not powered to show a difference, and while acknowledging that a selection bias could have affected the data, the present study showed that bivalirudin may be as clinically effective and safe as heparin with adjunctive GP IIb/IIIa inhibitors.
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Affiliation(s)
- Fadi Matar
- Cardioquest Research Laboratories, Florida Cardiovascular Institute, Tampa, USA.
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22
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Choi SW, Saltzman AJ, Dabreo A, Salomon RN, Gray JG, Senseney-Mellor H, Gosnell MR, Waxman S. Low power ultrasound delivered through a PTCA-like guidewire: preclinical feasibility and safety of a novel technology for intracoronary thrombolysis. J Interv Cardiol 2006; 19:87-92. [PMID: 16483346 DOI: 10.1111/j.1540-8183.2006.00110.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Low power ultrasound delivered through an angioplasty-like guidewire may be effective for intracoronary thrombolysis. We evaluated the preclinical feasibility and safety of such wire. METHODS AND RESULTS In 15 anesthetized Yucatan minipigs, the ultrasonic wire was advanced percutaneously into all three coronaries. Each coronary was randomized to long activation (6 minutes), short activation (3 minutes), or control (3 minutes indwelling, no activation). The energy delivered was 0.14 +/- 0.01 W/cm of active length (20 kHz). No changes in heart rate, rhythm, or arterial pressure occurred during wire positioning or activation. Mean lumen diameter (MLD) by quantitative angiography was not significantly different pre- and postintervention (2.36 +/- 0.12 mm vs 2.36 +/- 0.11 mm for long activation, P = 0.96; 2.33 +/- 0.15 mm vs 2.34 +/- 0.14 mm for short activation, P = 0.54; 2.30 +/- 0.12 mm vs 2.33 +/- 0.12 mm for control, P = 0.21). There were no angiographic stenoses at 60 or 90 days follow-up. Compared with baseline, MLD at follow-up increased in all the three groups (2.40 +/- 0.13 mm vs 2.53 +/- 0.11 mm, P = 0.004 for long activation; 2.37 +/- 0.17 mm vs 2.52 +/- 0.14 mm, P = 0.023 for short activation; 2.20 +/- 0.12 mm vs 2.33 +/- 0.11 mm, P = 0.001 for the control group). By histology, there were no clinically significant pathologic changes in coronary morphology. CONCLUSION Use of a transverse cavitation therapeutic wire is feasible and well tolerated acutely in the normal porcine coronary. At 60 and 90 days, no angiographically apparent damage, no clinically significant pathologic changes, and no adverse events were seen. This technology may be safely used during percutaneous coronary intervention. Further studies are justified to evaluate its efficacy for intracoronary thrombus ablation.
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Affiliation(s)
- Sung W Choi
- Division of Cardiology, Center for Translational Cardiovascular Research, Tufts-New England Medical Center, Boston, Massachusetts, USA
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Gilchrist IC. Platelet glycoprotein IIb/IIIa inhibitors in percutaneous coronary intervention: focus on the pharmacokinetic-pharmacodynamic relationships of eptifibatide. Clin Pharmacokinet 2004; 42:703-20. [PMID: 12846593 DOI: 10.2165/00003088-200342080-00001] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Eptifibatide is a truncated derivative of the naturally occurring rattlesnake venom protein known as barbourin. It is a cyclic heptapeptide that mimics the tertiary structure found in the parent compound which allows it to bind receptors with the KGD (Lys-Gly-Asp) peptide recognition sequence. Specifically, eptifibatide is a competitive antagonist for the activated platelet glycoprotein IIb/IIIa receptor. Its mechanism of action involves preventing the binding and cross-linking of fibrinogen to the platelet surface. This binding site for fibrinogen is associated with five Ca2+ ions that help maintain the tertiary structure of the receptor and affect the affinity of other ligands such as eptifibatide. Arterial injury induced by percutaneous coronary interventions (PCI) such as balloon angioplasty and stenting, and the spontaneously occurring disease process known as the acute coronary syndrome (ACS), share a common underlying pathophysiology. In both situations, disruption of integrity of the arterial wall initiates a cascade of platelet activation, adhesion and aggregation. Ultimately, this process may proceed to arterial thrombosis unless controlled or modified. Advances in understanding how the platelet plays a pivotal role in this process have significantly enhanced therapy for patients with ACS and have resulted in important reductions in thrombotic complications from PCI procedures. Central to these advances has been evolving understanding of platelet-inhibiting pharmaceutical agents such as eptifibatide. The development of a rational administration regimen for eptifibatide parallels the growth in the understanding of the underlying mechanisms of platelet receptor functions. The binding of eptifibatide to the receptor involves displacement of receptor-associated Ca2+ from the activated binding site. Early in the clinical development of eptifibatide, this was poorly appreciated and resulted in an underestimation of the appropriate doses for this agent. Through a series of small clinical trials and laboratory studies, deficiencies in the early administration regimens were identified and a more effective dose schedule was determined. Modelling of the drug based on its two-compartment pharmacokinetics further defined the role of a newer double-bolus initiation of therapy verses the original single-bolus approach. In a large-scale clinical trial using this double-bolus followed by infusion regimen in PCI procedures, clinical efficacy was shown to be significantly improved over placebo and the earlier, low-dose regimens used in the original trials of eptifibatide.
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Affiliation(s)
- Ian C Gilchrist
- Division of Cardiology, Pennsylvania State University, The Milton S. Hershey Medical Center, Hershey, PA 17033-0850, USA.
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Abstract
Risk stratification and risk-benefit ratios are extremely important in guiding patient-physician interactions as well as patient and family counseling. Risks associated with percutaneous transluminal coronary angioplasty are (1) compromise of the vessel lumen or vessel integrity, (2) unsuccessful procedure, and (3) restenosis. Predicting mortality risk depends on the specific patient population to be treated and on the specific mortality model used. The most common models are those from New York State, the American College of Cardiology, the Northern New England Cooperative Group, the University of Michigan, and The Cleveland Clinic Foundation. As more data and sophisticated analyses become available, risk stratification will become more accurate as long as the approach used is straightforward, makes intuitive sense, and is easy and efficient to apply.
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Affiliation(s)
- David R Holmes
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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25
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Ross MJ, Herrmann HC, Moliterno DJ, Blankenship JC, Demopoulos L, DiBattiste PM, Ellis SG, Ghazzal Z, Martin JL, White J, Topol EJ. Angiographic variables predict increased riskfor adverse ischemic events after coronarystenting with glycoprotein IIb/IIIa inhibition. J Am Coll Cardiol 2003; 42:981-8. [PMID: 13678916 DOI: 10.1016/s0735-1097(03)00913-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES We sought to assess whether pre-procedural angiographic characteristics are associated with adverse clinical outcomes after coronary stenting with glycoprotein IIb/IIIa inhibition. BACKGROUND Ischemic complications after balloon angioplasty are associated with pre- and post-procedural angiographic variables. However, in the current era of stenting with IIb/IIIa inhibition, it is unknown whether angiographic features assessed before intervention confer an increased risk of adverse procedural and subsequent clinical outcomes. METHODS In the Do Tirofiban and ReoPro Give Similar Efficacy Outcomes? Trial (TARGET), 4,809 patients undergoing planned stenting were randomized to tirofiban or abciximab. Baseline demographic, clinical, and angiographic variables were obtained. Clinical end points were recorded at 30 days and six months. The relationship between angiographic variables and adverse clinical outcomes was assessed. RESULTS Patients with the combination of thrombus, lesion eccentricity, and lesion length >20 mm had a 21.4% composite incidence of death, myocardial infarction, or urgent target vessel revascularization (TVR) at 30 days, compared with 4.2% in those patients without these high-risk features (hazard ratio [HR] 3.24, p < 0.001). After adjustment, the risk was independently associated with thrombus (HR 1.40, p = 0.034), eccentricity (HR 1.67, p < 0.001), and lesion length >20 mm (HR 1.89, p < 0.001). The risk of six-month TVR was independently associated with left anterior descending coronary artery lesions (HR 1.46, p < 0.001), restenotic lesions at baseline (HR 1.58, p = 0.006), and lesion length (HR 1.19, p = 0.03). CONCLUSIONS Patients with thrombus, eccentric lesions, or lesion length >20 mm are at high risk for ischemic outcomes after coronary stenting, despite IIb/IIIa inhibition. Further research into novel anti-thrombotic therapies or procedural strategies is necessary for these patients.
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Affiliation(s)
- Mitchell J Ross
- Division of Cardiology, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
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26
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Topaz O, Perin EC, Jesse RL, Mohanty PK, Carr M, Rosenschein U. Power thrombectomy in acute ischemic coronary syndromes. Angiology 2003; 54:457-68. [PMID: 12934766 DOI: 10.1177/000331970305400410] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracoronary thrombi are commonly found in patients with acute coronary syndromes. A large thrombus burden or a platelet-rich thrombus frequently resists pharmacologic therapy ("thrombolytic ceiling"). In such cases restoration of adequate antegrade coronary flow necessitates application of a mechanical force. Power thrombectomy is a revascularization strategy incorporating a mechanical device for removal of occlusive coronary thrombi in conjunction with or following administration of either platelet glycoprotein IIb/IIIa receptor inhibitors or thrombolytic agents, or both. Mechanical devices for power thrombectomy include ultrasound sonication, rheolytic thrombectomy (Angiojet), laser, transluminal extraction catheter, aspiration catheter, and to a limited extent, balloon angioplasty. In acute coronary syndromes the strategy of power thrombectomy aims to achieve the clinical advantages of more nearly complete vessel patency, improved antegrade flow, and enhanced preservation of myocardial tissue.
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Affiliation(s)
- On Topaz
- Cardiac Catheterization Laboratories, Division of Cardiology, Medical College of Virginia Hospital, Medical College of Virginia/Virginia Commonwealth University, Richmond, VA 23249, USA
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27
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Singh M, Rosenschein U, Ho KKL, Berger PB, Kuntz R, Holmes DR. Treatment of saphenous vein bypass grafts with ultrasound thrombolysis: a randomized study (ATLAS). Circulation 2003; 107:2331-6. [PMID: 12732601 DOI: 10.1161/01.cir.0000066693.22220.30] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Percutaneous coronary interventions (PCIs) in saphenous vein grafts (SVGs) with thrombus have a high frequency of distal embolization. Acolysis (therapeutic ultrasound) can break up thrombus in vitro in animal models and humans. Whether this is beneficial during percutaneous SVG interventions is unknown. METHODS AND RESULTS We performed a trial of coronary ultrasound thrombolysis in which patients with an acute coronary syndrome undergoing PCI in SVGs were randomly assigned to receive acolysis or abciximab. The primary end point was a successful procedure, defined as final luminal diameter stenosis 30% or less with Thrombolysis In Myocardial Infarction grade 3 flow and freedom from major adverse cardiac events (composite of death, Q-wave, and non-Q-wave myocardial infarction [MI], emergency bypass procedure, disabling stroke, and target lesion revascularization). Of 181 enrolled, 92 received acolysis and 89 abciximab. Angiographic procedural success was achieved in 63% of acolysis patients and 82% of abciximab patients (P=0.008). Incidence of major adverse cardiac events at 30 days was 25% with acolysis and 12% with abciximab (P=0.036), attributable mainly to a greater frequency of non-Q-wave MI with acolysis (19.6% versus 7.9%, P=0.03). The incidence of Q-wave MI was also higher with acolysis (5.4% versus 2.2%, P=nonsignificant). The primary end point was achieved in 53.8% of acolysis patients and 73.1% of abciximab patients (P=0.014). CONCLUSIONS Use of therapeutic ultrasound in vein graft lesions in patients with acute coronary syndrome had poor angiographic outcome and increased the incidence of acute ischemic complications.
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Affiliation(s)
- Mandeep Singh
- Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic, Rochester, Minn 55905, USA
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López-Palop R, Pinar E, Lozano I, Carrillo P, Saura D, Cortés R, Picó F, Valdés M. [Angiographic results of thrombectomy performed with two new devices in lesions with intracoronary thrombus]. Rev Esp Cardiol 2003; 56:271-80. [PMID: 12622957 DOI: 10.1016/s0300-8932(03)76863-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION AND OBJECTIVE The presence of intracoronary thrombus is associated with less favorable results of percutaneous coronary interventions. In recent years, new devices have been designed to improve the outcome of these procedures when an intracoronary thrombus is present. The results of two new systems of thrombectomy used in a single center are analyzed. METHODS Prospective observational registry of the use of two thrombectomy devices, X-SIZER (EndiCOR Medical Inc., San Clemente, California, USA) and RESCUE (Boston Scientific Scimed, Inc., Maple Grove, Minnesota, USA), between 1 June 2000 and 15 February 2002. RESULTS. One hundred thirty-nine devices were used in 137 patients (112 RESCUE and 27 X-SIZER). The main indication was primary angioplasty for acute myocardial infarction (80%). In 7 patients (5%), unscheduled thrombectomy was performed for unexpected complications that appeared during the procedure. In 75% of patients, IIb/IIIa inhibitors were given. In 10 cases (7%) the device did not reach the lesion. Complications derived from the use of the device were recorded in 3 cases (2.1%). TIMI flow improved from 1.28 1.1 before thrombectomy to 2.31 1.2 after the procedure. Improvement in the thrombus image was observed in 86%. The intervention was successful in 86%. CONCLUSIONS Thrombectomy with X-Sizer and Rescue improved the angiographic thrombus image in most cases and was associated to a low complication rate. Its efficacy compared to the conventional technique should be assessed in future trials.
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Affiliation(s)
- Ramón López-Palop
- Servicio de Cardiología. Hospital Universitario Virgen de la Arrixaca. Murcia. España.
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Kalaria VG, Rouch C, Bourdillon PD, Breall JA. Distal emboli protection in patients undergoing percutaneous coronary intervention after a recent myocardial infarction. Catheter Cardiovasc Interv 2002; 57:54-60. [PMID: 12203929 DOI: 10.1002/ccd.10257] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Devices to prevent distal atheroembolization are an important addition to the armamentarium of an interventional cardiologist. We report the use of PercuSurge, a distal balloon occlusion device, in two patients with recent myocardial infarction of differing etiologies. The first case is a patient with an old degenerated vein graft with thrombotic occlusion of greater than 48-hr duration and the second case is a patient with an embolic myocardial infarction in a native coronary artery. In both cases, significant thromboembolic debris was aspirated with technical success and no complications. These cases illustrate use of the PercuSurge device in patients after a recent myocardial infarction for preserving distal myocardial perfusion and microvascular integrity.
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Affiliation(s)
- Vijay G Kalaria
- Krannert Institute of Cardiology, Clarian Cardiovascular Center, Department of Medicine, Indiana University, Indianapolis, Indiana 46202, USA.
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31
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Affiliation(s)
- Theodore A Bass
- Cardiovascular Center, University of Florida Health Science Center, Jacksonville, Florida, USA
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