Myonecrosis after revascularization procedures

Preventive effects of nitric oxide donors in contrast-induced nephropathy in patients undergoing coronary artery angiography: an updated systematic review and meta-analysis of 13 randomized controlled trials

BACKGROUND

Contrast-induced nephropathy (CIN) is associated with increased mortality and morbidity in patients undergoing coronary angiography (CAG) and percutaneous coronary intervention (PCI). We aimed to assess the latest evidence on the preventive effects of nitric oxide (NO) donors in CIN patients undergoing CAG/PCI.

METHODS

We conducted a comprehensive systematic review and meta-analysis of RCTs from PubMed, Web of Science, Scopus, Embase, and Cochrane searches until May 5th, 2024. Dichotomous data were pooled using risk ratio (RR), and continuous data were pooled using mean difference (MD), both with a 95% confidence interval (CI), using (R version 4.3).

RESULTS

Our analysis included 13 RCTs encompassing 3,550 patients. NO donors were significantly associated with a decreased incidence of CIN compared to placebo either as an oral administration (RR: 0.33 with 95% CI [0.26, 0.42], P < 0.01) or IV infusions (RR: 0.56 with 95% CI [0.40, 0.78], P < 0.01). Moreover, NO donors were significantly associated with decreased serum creatinine levels compared to placebo either as an oral administration (MD: - 0.07 with 95% CI [- 0.10, - 0.04], P < 0.01) or IV infusions (MD: - 0.07 with 95% CI [- 0.09, - 0.04], P < 0.01). In terms of safety, NO donors were significantly associated with a decreased incidence of major adverse cardiac events (MACE) compared to placebo as an oral administration (RR: 0.64 with 95% CI [0.45, 0.89], P < 0.01). However, there was no significant difference between NO donors as IV infusions and placebo in MACE (RR: 0.68 with 95% CI [0.38, 1.21], P = 0.18). Finally, NO donors were significantly associated with a decreased incidence of all-cause mortality compared to placebo as an oral administration (RR: 0.58 with 95% CI [0.36, 0.94], P = 0.03). Nevertheless, there was no statistically significant difference in all-cause mortality between IV infusions of NO donors and placebo (RR: 1.84 with 95% CI [0.40, 8.52], P = 0.44).

CONCLUSION

NO donors as adjunct therapy are associated with reduced incidence of CIN and decreased serum creatinine levels, either as an oral or IV administration. They were also associated with reduced incidence of MACE, all-cause mortality, and recurrent myocardial infarction as an oral administration, which makes this simple, low-cost intervention an important therapeutic option in patients undergoing CAG/PCI.

Predictive Value of Myocardial Markers for Early Postoperative Mortality in Children with Congenital Heart Disease

To investigate the influencing factors of postoperative creatine kinase-MB (CK-MB) elevation in children with congenital heart disease and its peak value in predicting early postoperative mortality. The clinical data of 521 children with congenital heart disease under the age of 14 who underwent elective surgery in Beijing Children's Hospital from December 2018 to December 2020 were retrospectively analyzed. Stepwise multiple linear regression was used to analyze independent risk factors for postoperative CK-MB elevation, receiver operating characteristic (ROC) curve was used to determine the predictive value of postoperative CK-MB peak, CK peak, and LDH peak on mortality, and linear correlation and regression analysis were used to analyze the interdependence among postoperative CK-MB peak, CK peak, and LDH peak, and multivariate Logistic regression was used to identify independent risk factors for early postoperative mortality. Preterm birth (P = 0.004), ventriculotomy (P = 0.009), the re-establish of bypass (P = 0.007), cardiopulmonary bypass time (P = 0.024), deep hypothermic circulatory arrest time (P = 0.000), assisted ventilation time (P = 0.049), CK peak (P = 0.000), and LDH peak (P = 0.000) were independently associated with increased postoperative CK-MB elevation. The ROC curve showed that CK-MB peak had the strongest predictive value for death (AUC = 0.924), followed by LDH peak (AUC = 0.864) and CK peak (AUC = 0.758). The cut-off value of the postoperative CK-MB peak was 144.5 IU/L, with a sensitivity of 87% and a specificity of 97%. CK-MB peak was moderately correlated with CK peak (Pearson Correlation coefficient r = 0.514, P = 0.000) and strongly correlated with LDH peak (Pearson Correlation coefficient r = 0.601, P = 0.000). Multivariate analysis showed that delayed chest closure (OR = 4.865, P = 0.004) and postoperative CK-MB peak (OR = 1.031, P = 0.000) were independent risk factors for postoperative mortality. The postoperative CK-MB peak has a certain predictive value for the early postoperative mortality of children with congenital heart disease. It is affected by many factors, and the risk of mortality is significantly increased in children with severely elevated postoperative CK-MB.

Intravascular lithotripsy for the treatment of peri-stent calcific lesions in saphenous vein grafts: A case series report

BACKGROUND

Coronary artery bypass grafting (CABG) is a cornerstone treatment for coronary artery disease, with the use of saphenous vein grafts (SVGs) being prevalent. However, SVGs are susceptible to high failure rates due to graft inflammation, intimal hyperplasia, and atherosclerosis, leading to a substantial number of patients requiring revascularization. Percutaneous coronary intervention (PCI) of SVGs poses unique challenges, including increased risk of distal embolization and perforation due to the grafts' structure and atherosclerotic nature. The role of intravascular lithotripsy (IVL) in calcific SVG lesions has not been elucidated.

METHODS

We retrospectively analyzed four cases of patients treated with IVL for SVG stenosis at Leiden University Medical Centre between May 2019 and December 2023. Quantitative coronary analysis and intravascular ultrasound were utilized to assess procedural success and mid- to long-term clinical outcomes were reported as well.

RESULTS

In all 4 cases, IVL was performed in stent (2 due to calcific in-stent neoatherosclerosis; 2 bail-out due to extrinsic stent calcification). No major adverse cardiovascular events (MACE) were reported during mid- to long-term follow-up. The procedure demonstrated effective calcium cracking, leading to optimal stent expansion and minimal residual stenosis with a low risk of procedural complications.

CONCLUSIONS

IVL represents a promising approach for managing calcified peri-stent SVG lesions, showing potential for safe and effective revascularization with minimal complications. These findings suggest that IVL could be incorporated into the treatment paradigm for calcified peri-stent SVG stenosis, warranting further investigation in larger, prospective studies to validate its efficacy and safety.

Trans-Coronary Sinus Intra-Septal Radiofrequency Ablation (TIRA) for Hypertrophic Obstructive Cardiomyopathy: First-in-Human Results

BACKGROUND

Current treatments for hypertrophic obstructive cardiomyopathy (HOCM), including medication, surgery, and alcohol septal ablation (ASA), have limitations in terms of efficacy and safety. To address these challenges, we developed the trans-coronary intra-septal radiofrequency ablation (TIRA) device.

METHODS

This first-in-human trial was conducted to assess the efficacy and safety of the TIRA device. Moreover, evaluations were conducted before the procedure and at 3, 6, and 12 months post-procedure using computed tomography, magnetic resonance imaging, echocardiography, and the 6 min walk distance (6MWD) test.

RESULTS

Four patients were enrolled, and follow-up imaging at 3, 6, and 12 months showed a reduction in the interventricular septal (IVS) thickness (baseline mean: 22.6 mm; 12-month mean: 18.9 mm) and a decrease in the LVOT pressure gradient at 12 months (resting baseline mean: 84.64 mmHg; resting 12-month mean: 43.56 mmHg; Valsalva baseline mean: 129.96 mmHg; Valsalva 12-month mean: 108.16 mmHg). However, reductions in the IVS thickness on echocardiography and improvements in 6MWD were observed in only two patients.

CONCLUSIONS

No significant adverse events, such as arrhythmias or vascular injuries, were reported. These findings suggest that the TIRA device may be a safe and effective option for treating HOCM. However, further studies are required to confirm these results.

Elevated troponin I is associated with a worse long-term prognosis in patients undergoing beating-heart coronary surgery

OBJECTIVES

The impacts of elevated troponin I levels after coronary artery bypass grafting (CABG) on long-term outcomes were investigated.

METHODS

A total of 996 patients who underwent elective isolated CABG for stable or unstable angina were enrolled. Patients were divided into higher and lower groups based on 80th percentile postoperative peak troponin I (ppTnI) levels. The relationship between ppTnI and long-term clinical outcomes was analysed.

RESULTS

The median ppTnI was 1.55 (2.74) ng/ml and was significantly higher in the conventional CABG subgroup than in the beating-heart CABG subgroup: 4.04 (4.71) vs 1.24 (1.99) ng/ml, P < 0.001. The 80th percentile of ppTnI was 3.3 ng/ml in the beating-heart CABG subgroup and 8.9 ng/ml in the conventional CABG subgroup. In the conventional CABG subgroup (n = 150), 10-year overall survival showed no significant difference between the higher (≥8.9 ng/ml) and lower (<8.9 ng/ml) ppTnI groups: 71% (10%) vs 76% (5%), P = 0.316. However, the beating-heart CABG subgroup (n = 846) showed significantly worse 10-year overall survival in the higher ppTnI group (≥3.3 ng/ml) than in the lower ppTnI group (<3.3 ng/ml): 64% (6%) vs 73% (3%), P = 0.010. In the beating-heart CABG subgroup, multivariable analysis showed that ppTnI exceeding the 80th percentile was a risk factor for overall death (hazard ratio: 1.505, 95% confidence interval: 1.019-2.225, P = 0.040).

CONCLUSIONS

Higher ppTnI over the 80th percentile was associated with worse long-term survival in beating-heart CABG, but not in conventional CABG.

Association Between Contrast Volume-to-Creatinine Clearance Ratio and the Risk of Perioperative Myocardial Infarction After Elective Percutaneous Coronary Intervention

Although the use of iodinated contrast for percutaneous coronary intervention (PCI) has known toxicity issues, the association between the contrast volume-to-creatinine clearance (V/CrCl) ratio and perioperative myocardial infarction (PMI) is unclear. The present study is aimed to investigate the predictive value of V/CrCl ratio on the incidence of PMI, and to determine a relatively safe contrast media V/CrCl ratio cut-off value to prevent PMI undergoing elective PCI. The V/CrCl ratio were obtained from 5970 patients undergoing elective PCI for single-vessel lesions. Cardiac troponin I (cTnI) were measured at baseline, 8, 16, and 24 hours after PCI. PMI was defined as postprocedural > 5 × upper limit of normal. Receiver operating characteristic (ROC) curves were performed to identify the optimal sensitivity for the V/CrCl range. Multivariate regression model were used to assess the association between V/CrCl ratios and PMI. Eight hundred and ninety-seven patients (15.0%) developed PMI. There was a significant association between higher V/CrCl ratio and the development of PMI (P < 0.001 for the trend). ROC curve analysis indicated that V/CrCl ratio of 2.05 was a discriminator for PMI (area under the curve = 0.674). After adjusting for other potential risk factors, V/CrCl ratio > 2.05 remained significant associated with PMI (odds ratio, 1.921; 95% confidence interval, 1.311-2.815; P = 0.001). The finding of this study suggests the importance of minimizing the contrast media dose to avoid PMI development. Use of a contrast media dose based on renal function with a V/CrCl value < 2.05 might be valuable in preventing PMI.

Correlation between Carbonic Anhydrase Isozymes and the Evolution of Myocardial Infarction in Diabetic Patients

Simple Summary

Heart disease in diabetics presents distinctive characteristics both anatomically and physiopathologically compared to non-diabetics. In people with diabetes, high blood pressure has a high incidence (approximately one-third of diabetic patients have high blood pressure) and is a risk factor for diabetic macro- and microvascular complications. The correlation of these parameters could represent early markers of the prognosis and evolution of diabetic patients with acute myocardial infarction and their routine determination could be included in the biological algorithm of acute myocardial infarction, but understanding of this aspect must be deepened in the future. The results showed that diabetic patients develop acute myocardial infarction more frequently, regardless of age. The level of the enzymes of myocardial necrosis was higher in diabetics compared to non-diabetics, and acute coronary syndrome occurs mainly in diabetics with inadequate metabolic balance. Our research may provide useful information for the medical community.

Abstract

(1) Background: Myocardial infarction was, until recently, recognized as a major coronary event, often fatal, with major implications for survivors. According to some authors, diabetes mellitus is an important atherogenic risk factor with cardiac determinations underlying the definition of the so-called “diabetic heart”. The present study aims to establish a correlation between the evolution of myocardial infarction in diabetic patients, by determining whether lactic acid levels, the activity of carbonic anhydrase isoenzymes, and the magnitude of ST-segment elevation are correlated with the subsequent evolution of myocardial infarction. (2) Methods: The study analyzed 2 groups of 30 patients each: group 1 consisted of diabetic patients with acute myocardial infarction, and group 2 consisted of non-diabetic patients with acute myocardial infarction. Patients were examined clinically and paraclinical, their heart markers, lactic acid, and the activity of carbonic anhydrase I and II isozymes were determined. All patients underwent electrocardiogram and echocardiography analyses. (3) Results: The results showed that diabetics develop acute myocardial infarction more frequently, regardless of how much time has passed since the diagnosis. The value of myocardial necrosis enzymes was higher in diabetics than in non-diabetics, and acute coronary syndrome occurs mainly in diabetics with poor metabolic balance. Lethality rates in non-diabetic patients with lactic acid values above normal are lower than in diabetics. (4) Conclusions: Lactic acid correlated with the activity of isozyme I of carbonic dioxide which could be early markers of the prognosis and evolution of diabetic patients with acute myocardial infarction.

The impact of exogenous nitric oxide during cardiopulmonary bypass for cardiac surgery

OBJECTIVES

Cardiac surgery using cardiopulmonary bypass frequently provokes a systemic inflammatory response syndrome. This can lead to the development of low cardiac output syndrome (LCOS). Both of these can affect morbidity and mortality. This study is a systematic review of the impact of gaseous nitric oxide (gNO), delivered via the cardiopulmonary bypass (CPB) circuit during cardiac surgery, on post-operative outcomes. It aims to summarise the evidence available, to assess the effectiveness of gNO via the CPB circuit on outcomes, and highlight areas of further research needed to develop this hypothesis.

METHODS

A comprehensive search of Pubmed, Embase, Web of Science and the Cochrane Library was performed in May 2020. Only randomised control trials (RCTs) were considered.

RESULTS

Three studies were identified with a total of 274 patients. There was variation in the outcomes measures used across the studies. These studies demonstrate there is evidence that this intervention may contribute towards cardioprotection. Significant reductions in cardiac troponin I (cTnI) levels and lower vasoactive inotrope scores were seen in intervention groups. A high degree of heterogeneity between the studies exists. Meta-analysis of the duration of mechanical ventilation, length of ICU stay and length of hospital stay showed no significant differences.

CONCLUSION

This systematic review explored the findings of three pilot RCTs. Overall the hypothesis that NO delivered via the CPB circuit can provide cardioprotection has been supported by this study. There remains a significant gap in the evidence, further high-quality research is required in both the adult and paediatric populations.

Long-term prognostic value of late gadolinium enhancement and periprocedural myocardial infarction after uncomplicated revascularization: MASS-V follow-up

AIMS

Cardiac biomarkers elevation is common after revascularization, even in absence of periprocedural myocardial infarction (PMI) detection by imaging methods. Thus, late gadolinium enhancement cardiac magnetic resonance (LGE-CMR) may be useful on PMI diagnosis and prognosis. We sought to evaluate long-term prognostic value of PMI and new LGE after revascularization.

METHODS AND RESULTS

Two hundred and two patients with multivessel coronary disease and preserved ventricular function who underwent elective revascularization were included, of whom 136 (67.3%) underwent coronary artery bypass grafting and 66 (32.7%) percutaneous coronary intervention. The median follow-up was 5 years (4.8-5.8 years). Cardiac biomarkers measurement and LGE-CMR were performed before and after procedures. The Society for Cardiovascular Angiography and Interventions definition was used to assess PMI. Primary endpoint was composed of death, infarction, additional revascularization, or cardiac hospitalization. Primary endpoint was observed in 29 (14.3%) patients, of whom 13 (14.9%) had PMI and 16 (13.9%) did not (P = 0.93). Thirty-six (17.8%) patients had new LGE. Twenty (12.0%) events occurred in patients without new LGE and 9 (25.2%) in patients with it (P = 0.045). LGE was also associated to increased mortality, with 4 (2.4%) and 4 (11.1%) deaths in subjects without and with it (P = 0.02). LGE was the only independent predictor of primary endpoint and mortality (P = 0.03 and P = 0.02). Median LGE mass was estimated at 4.6 g. Patients with new LGE had a greater biomarkers release (median troponin: 8.9 ng/mL vs. 1.8 ng/mL and median creatine kinase-MB: 38.0 ng/mL vs. 12.3 ng/mL; P < 0.001 in both comparisons).

CONCLUSIONS

New LGE was shown to be better prognostic predictor than biomarker-only PMI definition after uncomplicated revascularization. Furthermore, new LGE was the only independent predictor of cardiovascular events and mortality.

CLINICAL TRIAL REGISTRATION

http://www.controlled-trials.com/ISRCTN09454308.

Long-Term Clinical Outcomes of Percutaneous Coronary Intervention in Saphenous Vein Grafts in a Low to Middle-Income Country

Background Revascularization of saphenous vein grafts (SVGs) is challenging and debated for the last few decades. The percutaneous revascularization of SVGs was reported to have poorer long-term outcomes than native coronary artery revascularization. Purpose We aim to study the peri-procedural complications and long-term outcomes of the percutaneous revascularization of SVGs in a low-middle-income country. Methods In this retrospective study, we included 110 patients who underwent percutaneous revascularization from January 2011 to March 2020 and followed them retrospectively for long-term outcomes and major adverse cardiovascular events. Results The mean age was 71 ±9, and 81% were male. The most common reason for the presentation was non-ST segment elevation myocardial infarction (NSTEMI) (46%). The mean follow-up period of the study was 48±27 months. The most common comorbidity was hypertension (86%). A drug-eluting stent (80%) was placed in most of the patients, followed by a bare-metal stent (BMS) (14%) and percutaneous balloon angioplasty (POBA) (6%). We did not find any significant difference in major adverse cardiac events (MACE) (P=0.48), target vessel revascularization (TVR) (p=0.69), and target lesion revascularization (TLR) (p=0.54) with drug-eluting stent (DES) as compared to either BMS or POBA. The mean period from coronary artery bypass grafting (CABG) to SVG percutaneous coronary intervention (PCI) was 15± 5.5 years. Multivariate Cox regression analysis showed that an acute coronary syndrome (ACS) event, stroke, and female sex were independently associated with MACE. Conclusion The long-term outcomes of SVG PCI are not affected by the types of stents. Female gender, ACS, and stroke are the independent predictors of MACE after SVG PCI, and statin therapy has a positive impact on the long-term outcomes of SVG PCI.

Diagnostic dilemma of perioperative myocardial infarction after coronary artery bypass grafting: A review

Coronary artery bypass grafting (CABG) is one of the most commonly performed cardiac procedures in the United States (US) and Europe. In the US, perioperative morbidity and mortality related to CABG are below 5%. One of the most significant complications following CABG, however, is perioperative myocardial infarction (PMI). Cardiac biomarkers, intra- and post-operative echocardiography, and electrocardiography are routinely used to monitor for evidence of PMI. In this review, we seek to summarize how each of these modalities is used in the clinical setting to differentiate PMI from expected procedure-related changes, and how these findings impact patients' outcomes. We conclude that while no perfect diagnostic test for the detection of clinically meaningful PMI exists, using a combination of existing modalities with knowledge of expected post-procedure changes allows for early and reliable detection. Future development is needed to create more sensitive and specific modalities for the detection of PMI in patients undergoing CABG.

The Effect of Pharmacological Preconditioning with Nicorandil before Elective Coronary Stenting on the Long-Term Prognosis of Patients with Stable Coronary Artery Disease

Aim. To study nicorandil prescription effects before elective percutaneous coronary intervention (PCI) to prevent myocardial injury and 4a type acute myocardial infarction (MI, primary endpoint) and cardiovascular events (CVE) in the first year after PCI (secondary endpoint) in patients with stable coronary artery disease.

Material and methods. 182 patients with stable coronary artery disease were included into the study and were randomized into two groups: nicorandil treatment group (n=90) and a control group with a standard medical treatment (n=92). Nicorandil was prescribed orally: 2 days before PCI – 30 mg/day; on the day of PCI – 20 mg 2 hours before intervention and 10 mg 6-12 hours after PCI; over the next 30 days – 30 mg/day. High sensitivity troponin I (hs-Tr) and creatine kinase-MB tests were carried out before PCI, 24 and 72 hours after the intervention; the 4a type MI was diagnosed according to the 4th Universal Definition. Non-fatal myocardial infarction, nonfatal stroke, death from cardiovascular diseases, repeat revascularization (PCI, coronary artery bypass surgery due to aggravation), hospital admissions for angina pectoris recurrence (without interventions) and death from any causes were considered as cardiovascular events. Data on adverse outcomes were collected over the hospital stay, and then 30, 180 and 365 days after the hospital discharge.

Results. 4a type MI was diagnosed in 14 patients (8%), in women – 12% and in men – 6%. There was a significant decrease in the incidence of type 4a MI in the nicorandil group (n=3; 3%) compared with the control group (n=11; 12%; p=0.05). Secondary endpoint was recorded in 21% of patients. The relationship was found between 4a type MI and the incidence of CVE the next year after the PCI (p=0.01). In patients with type 4a MI CVE odd ratio increases 5.8 times with confidence interval from 1.5426 to 21.6024. According to the logistic regression analysis the significant relationship between hs-Tr growth 24 hours after the PCI and CVE incidence next year after the PCI was found with cutting value 389.8 pg/ml, AUC=0.641 (p=0.04).

Сonclusion. Peroral nicorandil 30 mg/day 2 days before PCI, 20 mg 2 hours before surgery and 10 mg 6-12 hours after PCI, and 30 mg/day next 30 days after PCI decreases the risk of intraoperative myocardial injury and CVE in the next year after PCI.

Effects of Curcuminoids on Myocardial Injury After Percutaneous Coronary Intervention

The rise of cardiac troponin post-percutaneous coronary intervention (PCI) is associated with a high risk of long-term cardiovascular events. Previous studies have shown that curcuminoids decreased myocardial injury post-coronary bypass graft surgery through anti-oxidant and anti-inflammatory effects. We sought to examine whether curcuminoids could prevent PCI-related myocardial injury. One-hundred enrolled patients receiving elective PCI were randomized to obtain curcuminoids or placebo 4 g/day at least 1 day before and after the scheduled PCI. Cardiac troponin-T and 12-lead electrocardiogram were evaluated before PCI and at 24 and 48 h post-PCI. The definitions of PCI-related myocardial injury and myocardial infarction were in line with the third universal definition of myocardial infarction. Baseline characteristics of patients and procedures did not differ between the curcuminoids and placebo groups. The mean age was 63.9 ± 10.8 years. The incidence of PCI-related myocardial injury was not different between curcuminoids and placebo groups (32% vs. 38%, P = .675). The peak high-sensitive cardiac troponin T levels after PCI were not different between the curcuminoids and placebo groups (201.0 ± 547.0 ng/L vs. 187.0 ± 703.9 ng/L respectively, P = .912). Further, the high-sensitive C-reactive protein levels post-PCI were similar in patients receiving curcuminoids and placebo (7.2 ± 18.8 mg/dL vs. 6.6 ± 17.5 mg/dL, respectively, P = .873). We found that short-term treatment with curcuminoids did not reduce the occurrence of PCI-related myocardial injury. We did not observe the role of anti-oxidative and anti-inflammatory effects of curcuminoids in the PCI-related myocardial injury.

Angiographic and Midterm Outcomes of Bioresorbable Vascular Scaffold for Coronary Bifurcation Lesions

Data on the angiographic and clinical performance of bioresorbable vascular scaffolds (BVS) for bifurcation lesions treatment are still limited. Data were examined of 107 patients with at least 1 coronary bifurcation lesion involving a side branch ≥2mm. Angiographic and clinical outcomes were collected. Optical coherence tomography analysis was performed in a subgroup of patients. Between July 2009 and December 2015, 423 patients underwent PCI with Absorb BVS. A total of 110 lesions were identified as bifurcations, of which 24.5% were classified as true bifurcation lesions. Lesion complexity B2/C was 68.1%. Ninety-five out of 110 lesions were treated by provisional stenting technique while 2 stenting strategy was the final approach in 15 lesions. Procedural success of main branch was 100% whereas side-branch impairment at the end of the procedure was 4.5%. The mean follow-up was 21 months with one-third of the patients followed up for at least 2 years. The overall target lesion failure and scaffold/stent thrombosis rate at 1 year was 7.8% and 3.9%, respectively. In conclusion the results of the present analysis suggest the BVS implanted in bifurcations lesions are associated with procedural safety and angiographic success as well as acceptable target lesion failure rate at 1 year.

Ten-Year Follow-Up of Off-Pump and On-Pump Multivessel Coronary Artery Bypass Grafting: MASS III

It was a randomized trial, and 308 patients undergoing revascularization were randomly assigned: 155 to off-pump coronary artery bypass (OPCAB) and 153 to on-pump coronary artery bypass (ONCAB). End points were freedom from death, myocardial infarction, revascularization, and cerebrovascular accidents. The rates for 10-year, event-free survival for ONCAB versus OPCAB were 69.6% and 64%, (hazard ratio [HR]: 0.88; 95% confidence interval [CI] 0.86-1.02; P = .41), respectively. Adjusted Cox proportional hazard ratio was similar (HR: 0.92; 95% CI 0.61-1.38, P = .68). A difference occurred between the duration of OPCAB and ONCAB, respectively (4.9 ± 1.5 vs 6.6 ± 1.1 h, P < .001). Statistical differences occurred between OPCAB and ONCAB in the length of intensive care unit (ICU) stay (20 ± 2.5 vs 48 ± 10 hours, P < .001), time to extubation (5.5 ± 4.2 vs 10.2 ± 3.5 hours, P < .001), hospital stay (6.7 ± 1.4 vs 9.2 ± 1.3 days, P < .001), higher incidence of atrial fibrillation (AF; 33 vs 5 patients, P < .001), and blood requirements (46 vs 64 patients, P < .001). Grafts per patient was higher in ONCAB (3.15 vs 2.55 grafts, P < .001). No difference existed between the groups in primary composite end points at 10-year follow-up. Although OPCAB surgery was related to a lower number of grafts and higher incidence of AF, it had no effects related to long-term outcomes.

Prevention of minor myocardial injury after elective percutaneous coronary intervention: comparison of ticagrelor versus clopidogrel

BACKGROUND

Elective percutaneous coronary intervention (ePCI) may cause minor elevation of cardiac enzymes, so-called minor myocardial injury (MMI) which can be due to different pathophysiological mechanism (e.g. distal embolisation, side branch occlusion, increased platelet activation triggered by the intracoronary metallic stents). We aimed to compare the effectiveness of ticagrelor versus clopidogrel for the prevention of MMI and major adverse clinical events (MACEs) after ePCI.

METHODS

Study population consisted of two groups of patients based on the treatment: Group I, receiving clopidogrel (n = 104), Group II, receiving ticagrelor (n = 96). Cardiac troponin I (cTnI), CK-MB were studied before and 12 hours after the procedure. Elevation of cTnI greater than 0.06 ng/ml was considered as MMI. All patients were also evaluated for the MACEs (death, myocardial infarction, stroke and transient ischaemic attack).

RESULTS

Fifty-two of 200 patients (26%) had MMI after the procedure. The minor myocardial injury was significantly more prevalent in clopidogrel group than that of ticagrelor group (33% vs. 19%, p = .03). Myocardial infarction (MI) and MACEs were significantly higher in the clopidogrel group (15% vs. 6%, for MI, p = .04; 16% vs. 6%, for MACEs, p = .03, respectively). Multivariate analysis demonstrated antiplatelet treatment, saphenous graft intervention, type-C lesion as independent predictors of MMI.

CONCLUSIONS

Present study showed that the combination of ticagrelor and aspirin was more effective than combination of clopidogrel and aspirin in decreasing MMI and MACEs after elective stenting.

Incidence, predicting factors, and clinical outcomes of periprocedural myocardial infarction after percutaneous coronary intervention for chronic total occlusion in the era of new-generation drug-eluting stents

OBJECTIVE

This study aimed to examine predictors and clinical outcomes of periprocedural myocardial infarction (PMI) after chronic total occlusion (CTO) intervention.

BACKGROUND

There are limited data on the clinical implications of PMI after CTO intervention in the new-generation drug-eluting stent (DES) era.

METHODS

We enrolled 337 patients who underwent CTO intervention and met the study criteria. We evaluated the incidence and predictors of PMI, defined as an increase in creatine kinase-MB ≥3× the upper limit of normal (ULN) after intervention and compared the occurrence rates of major adverse cardiac and cerebrovascular events (MACCE, defined as the composite of cardiac death, myocardial infarction, stent thrombosis, target-vessel revascularization, or cerebrovascular accidents) between the PMI and non-PMI groups.

RESULTS

PMI occurred in 23 (6.8%) patients after CTO intervention. Significant independent predictors were previous bypass surgery [odds ratio (OR) = 5.52, 95% confidence interval (CI) = 1.17-25.92; P = 0.03], Japan-CTO score ≥3 (OR = 7.06, 95%CI = 2.57-19.39; P < 0.001), side branch occlusion (OR = 4.21, 95%CI = 1.13-15.66; P = 0.03), and longer procedure time (OR = 4.18, 95%CI = 1.35-12.99; P = 0.01). During a median follow-up of 29.6 months, the PMI group had a significantly higher MACCE rate than the non-PMI group (23.7 vs. 5.6%, P = 0.008 by log-rank test). PMI was an independent predictor of MACCE (HR = 4.26, 95%CI = 1.35-13.43; P = 0.01). The MACCE rate gradually increased in a CK-MB-dependent fashion and was highest in patients with ≥10× ULN (P = 0.005).

CONCLUSION

Previous bypass surgery, high Japan-CTO score, side branch occlusion, and longer procedure time were strongly related to PMI occurrence after CTO intervention. PMI was significantly associated with worse clinical outcomes in the new-generation DES era.

Current State of the Art in Approaches to Saphenous Vein Graft Interventions

Saphenous vein grafts (SVGs), used during coronary artery bypass graft surgery for severe coronary artery disease, are prone to degeneration and occlusion, leading to poor long-term patency compared with arterial grafts. Interventions used to treat SVG disease are susceptible to high rates of periprocedural MI and no-reflow. To minimise complications seen with these interventions, proper stents, embolic protection devices (EPDs) and pharmacological selection are crucial. Regarding stent selection, evidence has demonstrated superiority of drug-eluting stents over bare-metal stents in SVG intervention. The ACCF/AHA/SCA American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Society for Cardiovascular Angiography and Interventions guidelines recommend the use of EPDs during SVG intervention to decrease the risk of periprocedural MI, distal embolisation and no-reflow. The optimal pharmacological treatment for slow or no-reflow remains unclear, but various vasodilators show promise.

Serum Creatine Kinase-MB Isoenzyme Activity among Subjects with Uncomplicated Essential Hypertension: Any Sex Differences

Hypertension (high blood pressure) is a major health challenge and more women than men are affected by the condition. Complications as a result of this condition often lead to disabilities and premature death. The objective of this study was to evaluate creatine kinase-MB (CK-MB) activity in uncomplicated hypertension and to know whether sex differences exist in the activity of the enzyme. Serum creatine kinase-MB isoenzyme activity, troponin I, and lipid profile were evaluated in 140 male and 100 female Nigerians with hypertension. The control group was comprised of 100 (50 males and 50 females) normotensive subjects. Measured parameters were assayed using Selectra Pros chemistry analyzer. The means were compared between males and females using Students't-test. The mean CK-MB activity of the female hypertensive subjects was significantly higher (p < 0.001) than the males. Similarly, the mean cardiac troponin I (cTnI) of the female hypertensive subjects was significantly higher (p < 0.001) than the males. Conversely, the mean CK-MB activity of the female normotensive subjects was significantly lower (p < 0.001) than the male counterparts. There was no difference in the levels of cTnI between male and female normotensive subjects. Serum CK-MB activity was higher in female than male hypertensive subjects. In the light of these results, cardiac markers should be routinely done in the evaluation of hypertensive subjects and sex-specific consideration may be recognized in the management of these patients.

Rosuvastatin for Reduction of Myocardial Damage during Coronary Angioplasty - the Remedy Trial

BACKGROUND

Periprocedural myocardial infarction (MI) is a frequent complication of percutaneous coronary intervention (PCI). Statins might reduce its incidence. The aims of the present study are to assess whether such benefit is a class-effect or whether differences exist between various lipid-lowering strategies and whether cardioprotection is exerted by increasing circulating endothelial progenitor cells (EPCs).

METHODS

The REMEDY study will enroll a total of 1080 patients submitted to elective PCI. Eligible patients will be randomized into 4 groups: 1) placebo; 2) atorvastatin (80 mg + 40 mg before PCI); 3) rosuvastatin (40 mg twice before PCI); and 4) rosuvastatin (5 mg) and ezetimibe (10 mg) twice before PCI. Peri-procedural MI is defined as an elevation of markers of cardiac injury (either CK-MB or troponin I or T) values >5x the upper reference limit estimated at the 99th percentile of the normal distribution, or a rise >20 % in case of baseline values already elevated. EPCs will be assessed before, at 24 h and - in a subset of diabetic patients - at 3 months after PCI (EPC-substudies). The primary endpoint of the main REMEDY study is the rate of peri-procedural MI in each of the 4 treatment arms. Secondary endpoints are the combined occurrence of 1-month major adverse events (MACE, including death, MI, or the need for unplanned revascularization); and any post-procedural increase in serum creatinine. Endpoints of the EPC-substudies are the impact of tested regimens on 1) early (24-h) and 3-month EPC levels and functional activity; 2) stent strut re-endothelialization and neointimal hyperplasia; 3) 1-year MACE. REMEDY will add important information on the cardioprotective effects of statins after PCI.

Elevated preoperative HMGB1 as predictor of myocardial injury post-percutaneous coronary intervention

In this study, we evaluated the impact of preoperative high mobility group box 1 (HMGB1) on myocardial injury post-percutaneous coronary intervention.We evaluated 302 consecutive patients who underwent percutaneous coronary intervention. They were divided into equal tertiles based on their preoperative HMGB1 levels. Creatine kinase-MB and troponin I levels were measured at baseline, 8- and 24-hours after the procedure, while clinical outcomes were followed up for 1 year.The occurrence of post-procedural myocardial injury was significantly higher in the tertile comprising of patients with elevated HMGB1 levels. Moreover, these patients showed significantly higher post-procedural peak values of creatine kinase-MB and troponin I in comparison to patients with lower HMGB1 levels. Event-free survival was significantly associated with HMGB1 levels, with worst event-free survival in patients with elevated HMGB1 levels.Elevated preoperative HMGB1 was a predictor of myocardial injury after percutaneous coronary intervention, and was associated with the worst clinical outcomes during 1-year follow up.

Diagnosing Perioperative Myocardial Infarction in Cardioth oracic and Vascular Surgery

Patients undergoing cardiac and high-risk noncardiac surgery have a high incidence of perioperative myocardial infarction. The early diagnosis of perioperative myocardial injury in these patients is complicated. In the perioperative period, there is a high incidence of nonspecific electrocardiographic changes and cardiac biomarker release. It is becoming increasingly imortant to differentiate myocardial necrosis from nonspecific changes because of the need for early intervention and the poential long term implications of a perioperative myocardial event. Although sensitive and specific assays to assess myoardial damage have been developed, specific thresholds to establish the occurrence a significant perioperative event have not been firmly defined. This review will attempt to outline the current evidence supporting the use of clinical symptoms, electrocardiographic changes, and cardiac biomarkers in the diagnosis of perioperative myocardial infarction and the longerm implication of these findings.

Role of endothelin in microvascular dysfunction following percutaneous coronary intervention for non-ST elevation acute coronary syndromes: a single-centre randomised controlled trial

OBJECTIVES

Percutaneous coronary intervention (PCI) for acute coronary syndromes frequently fails to restore myocardial perfusion despite establishing epicardial vessel patency. Endothelin-1 (ET-1) is a potent vasoconstrictor, and its expression is increased in atherosclerosis and after PCI. In this study, we aim to define the role of endothelin in regulating coronary microvascular blood flow and myocardial perfusion following PCI in patients with non-ST elevation acute coronary syndromes (NSTACS), by assessing whether adjunctive therapy with a selective endothelin A (ETA) receptor antagonist acutely improves postprocedural coronary microvascular blood flow.

METHODS

In a randomised, double-blinded, placebo-controlled trial, 23 NSTACS patients were enrolled to receive an intracoronary infusion of placebo (n=11) or BQ-123 (n=12) immediately before PCI. Post-PCI coronary microvascular blood flow and myocardial perfusion were assessed by measuring Doppler-derived average peak velocity (APV), and cardiac biomarker levels were quantified.

RESULTS

Compared with the placebo group, APV was significantly higher in the drug group immediately after PCI (30 (20, 37) vs 19 (9, 26) cm/s; p=0.03). Hyperaemic APV, measured post-adenosine administration, was higher in the BQ-123 group, but the difference did not achieve statistical significance (56 (48, 72) vs 46 (34, 64) cm/s; p=0.090). Maximum coronary flow reserve postprocedure was not different between the two groups (2.1 (1.6, 2.3) vs 2.5 (1.8, 3.0)). Per cent change in creatine kinase isoenzyme MB from the time of PCI to 8 and 16 hours post-PCI was significantly lower in the drug group compared with the placebo group (-17 (-26, -10) vs 26 (-15, 134); p=0.02 and -17 (-38, 14) vs 107 (2, 446); p=0.007, respectively).

CONCLUSIONS

Endothelin is a mediator of microvascular dysfunction during PCI in NSTACS, and adjunctive selective ETA antagonist may augment myocardial perfusion during PCI.

TRIAL REGISTRATION NUMBER

NCT00586820; Results.

Predictors and Prognostic Significance of Troponin-I Release following Elective Coronary Angioplasty

The objective of this study was to investigate the predictors and prognostic significance of post-procedural cardiac troponin (cTn)-I elevations in a consecutive series of patients who underwent elective percutaneous coronary intervention (PCI). cTn-I was measured in 100 patients immediately before and within 24 h after the elective PCI. Post-procedural cTn-I elevation was observed in 27 of the 100 patients. In multivariate analysis, basal haemoglobin values and the number of repeated balloon dilatations were found to be independent predictors of cTn-I elevation. During the follow-up period of 12 ± 1.2 months, the cTn-I-positive group had more major adverse cardiovascular events than the cTn-I-negative group (33.3% versus 16.4%, respectively), but the difference was not significant. An increase in cTn-I levels following elective PCI procedures was frequent but did not predict a poor long-term outcome.

Incidence and impact on prognosis of peri-procedural myocardial infarction in 2760 elective patients with stable angina pectoris in a historical prospective follow-up study

BACKGROUND

The clinical significance of myocardial infarction related to treatment with percutaneous coronary intervention (PCI) has been subject of great discussion. This subject has been studied for many years using different definitions of peri-procedural myocardial infarction and different biomarkers, the results have varied greatly depending on methods and time of the study. This study was to determine the incidence and prognostic significance of elevated cardiac biomarkers after elective PCI in patients with stable angina pectoris using the current cut-off set by the Third Universal Definition of Myocardial Infarction and current biomarkers.

METHODS

We performed a historical prospective follow-up study of all patients with stable angina pectoris who underwent elective PCI at Aalborg University Hospital, Denmark from January 1(st) 2000 to December 31(st) 2012. We stratified patients according to peak post-PCI troponin T (cTnT) and Creatine Kinase MB mass (CK-MBmass).

RESULTS

Follow-up for time to all-cause mortality was mean 5.8 years and total 15,891 years and mean 3.7 years and total 10,160 years for the combined endpoint of all-cause mortality and new onset heart failure. During the follow up period 399 of 2760 patients died (14.5 %) and 1095 (39.7 %) suffered the combined endpoint. Post-PCI concentration of cTnT and CK-MBmass was elevated above the defined cut-off in 419 patients (15.2 %) and 113 patients (4.1 %) respectively. There was no statistically significant difference between the groups in stratified analysis of the hazard rates by time regarding all-cause mortality for cTnT nor CK-MBmass. Regarding the combined endpoint the results were ambiguous. The results were unchanged in multivariable analyses that included age and gender.

CONCLUSION

The incidence of elevated biomarkers after elective PCI in patients with stable angina pectoris using the defined cut-off (>5 x URL) was 15.2 % using cTnT and 4.1 % using CK-MBmass. The independent prognostic value for both cardiac biomarkers of any cut-off showed no statistical significance for all-cause mortality, whereas the combined endpoint (all-cause mortality or new-onset heart failure) were ambiguous in both short- and long-term follow-up.

Efficacy of High-Intensity Atorvastatin for Asian Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Statins have proven cardioprotective effects, but higher doses are accompanied by various concerns and may not lead to superior clinical outcomes in Chinese/Asian populations.

OBJECTIVE

We designed a trial to test the efficacy of high-intensity statin therapy for the reduction of periprocedural myocardial infarction (MI) and 1-year major adverse cardiovascular events (MACEs, including cardiovascular death, spontaneous MI, unplanned revascularization) in an Asian population.

METHODS

A total of 798 Chinese patients with stable angina or acute coronary syndrome (ACS) were randomized to high-intensity atorvastatin (80 mg/d before percutaneous coronary intervention [PCI] and 40 mg/d thereafter for 1 year, n = 400) or moderate-intensity atorvastatin (20 mg/d for 1 year, n = 398). The primary end point was 1-year incidence of MACEs.

RESULT

In patients with stable angina, 1-year MACE rates were not significantly different between moderate- and high-intensity groups (7.6% vs 5.7%, P = 0.53). In contrast, in patients with ACS, the 1-year MACE rate was significantly higher in the moderate- than in the high-intensity atorvastatin group (16.8% vs 10.1%, P = 0.021; adjusted hazard ratio = 1.71, 95% CI = 1.08 to 2.77, P = 0.021).

CONCLUSIONS

Whereas stable angina patients derive similar benefit from moderate- and high-intensity atorvastatin therapy over the duration of 1 year after PCI, high-intensity statin therapy is superior in ACS patients.

Techniques and standards in intraoperative graft verification by transit time flow measurement after coronary artery bypass graft surgery: a critical review

Transit time flow measurement (TTFM) is a quality control tool for intraoperative graft evaluation in coronary artery bypass graft (CABG) surgery. A critical review of the literature available using TTFM in CABG surgery is the focus of this article. The main objectives will be to detail precise parameters for flow evaluation, to show limitations of TTFM and to prove its predictive impact on postoperative graft failure rate. Publications listed in the PubMed database were reviewed, searching for intraoperative graft verification in coronary surgery by TTFM, with postoperative imaging follow-up (FU) modality and with a special focus on publications released after European guidelines from 2010. Nine included publications revealed an overall graft failure rate of ∼12%. Mean graft flow had a positive predictive value in the largest study, and cut-offs, of at least 20 ml/min for internal mammary artery (IMA) grafts, therein partially confirming guidelines, and 30-40 ml/min for saphenous venous grafts (SVGs) were proposed. An explicit correlation between graft flow, patency rate and severity of coronary stenosis, by indicating the fractional flow reserve, was found for IMA grafts. Increased pulsatility index and increased systolic reverse flow probably predict worse outcome and may help identifying competitive flow. Diastolic filling, rarely indicated, could not be confirmed as the predictive marker. No significant correlation of TTFM and graft failure rate for radial and other arterial grafts could be found, partially due to the small number of these types of grafts analysed. Larger target vessels and lower postoperative CK-MB levels may predict better graft patency rates. Low sensitivity for TTFM to reliably detect graft failure is certainly a major issue, as found in randomized analyses. However, methodical limitations and varying threshold values for TTFM render a general consensus difficult. Influence of quantity (vessel territory distribution) and quality (myocardial scar) of the graft perfusion area, on TTFM and FU outcome, was not included by anyone and should be part of future research. TTFM is probably not the tool of choice to detect progressive late graft failure of SVG. Peroperative TTFM values should be correlated with one type of conduit, differentiating between early and late graft failure (by applying a uniform, appropriated definition), to precise and confirm threshold values.

Repeat revascularization: Percutaneous coronary intervention after coronary artery bypass graft surgery

Repeat myocardial revascularization procedures are markedly different from de novo interventions, with increased procedural risk and technical-demanding complexity. However the number of patients previously treated with coronary artery bypass graft (CABG) that need a repeat revascularization due to graft failure is increasing consistently. Late graft failure, usually caused by saphenous vein grafts (SVG) attrition, is certainly not uncommon. However PCI on degenerated SVG presents higher complication rate and worse clinical outcome compared with native arteries interventions. In acute graft failure setting, PCI represents a valuable option to treat postoperative myocardial infarction.

Rise of serum troponin levels following uncomplicated elective percutaneous coronary interventions in patients without clinical and procedural signs suggestive of myocardial necrosis

INTRODUCTION

The new definition of periprocedural myocardial infarction (type 4a MI) excludes patients without angina and electrocardiographic or echocardiographic changes suggestive of myocardial ischemia even though significant serum troponin elevations occur following percutaneous coronary intervention (PCI).

AIM

To evaluate the incidence and predictors of serum troponin rise following elective PCI in patients without clinical and procedural signs suggestive of myocardial necrosis by using a high-sensitivite troponin assay (hsTnT).

MATERIAL AND METHODS

Three hundred and four patients (mean age: 60.8 ±8.8 years, 204 male) undergoing elective PCI were enrolled. Patients with periprocedural angina, electrocardiographic or echocardiographic signs indicating myocardial ischemia or a visible procedural complication such as dissection or side branch occlusion were excluded. Mild-moderate periprocedural myocardial injury (PMI) and severe PMI were defined as post-PCI (12 h later) elevation of serum hsTnT concentrations to the range of 14-70 ng/l and > 70 ng/l, respectively.

RESULTS

The median pre-procedural hsTnT level was 9.7 ng/l (interquartile range: 7.1-12.2 ng/l). Serum hsTnT concentration elevated (p < 0.001) to 19.4 ng/l (IQR: 12.0-38.8 ng/l) 12 h after PCI. Mild-moderate PMI and severe PMI were detected in 49.3% and 12.2% of patients, respectively. Post-procedural hsTnT levels were significantly higher in multivessel PCI, overlapping stenting, predilatation and postdilatation subgroups. In addition, post-procedural hsTnT levels were correlated (r = 0.340; p < 0.001) with the stent lengths.

CONCLUSIONS

High-sensitivite troponin measurements indicate a high incidence of PMI even though no clinical or procedural signs suggestive of myocardial ischemia exist. Multivessel PCI, overlapping stenting, predilatation, postdilatation and longer stent length are associated with PMI following elective PCI.

The prognostic role of troponin I elevation after elective percutaneous coronary intervention

OBJECTIVES

To assess the prognostic role of isolated troponin I (TnI) elevation after elective percutaneous coronary intervention (PCI) in patients with stable coronary artery disease.

BACKGROUND

The prognostic role of minor troponin elevation after PCI is controversial.

METHODS

A total of 1532 consecutive patients who underwent elective PCI were included. Follow-up data were obtained for 1432 of 1532 (93.4%) patients. The events taken into account in the follow-up included total mortality, cardiac death, hospitalization for acute myocardial infarction and/or unstable angina.

RESULTS

The following variables were identified as predictive of major adverse cardiac events (MACE) by univariate analysis: age 75 years at least (P = 0.012), ejection fraction less than 50% (P = 0.001), prior myocardial infarction (P = 0.031) and TnI 1.0 ng/ml at least after PCI (P = 0.04). The Cox-regression model identified the TnI elevation after PCI, the older age and the ejection fraction as independent predictors of MACE during follow-up (TnI: P = 0.042; older age: P = 0.001; ejection fraction: P = 0.003). In a subgroup of patients with preserved ejection fraction, the incidence of MACE was significantly higher in those with TnI of at least 1.0 ng/ml at least than in the ones with TnI less than 1.0 ng/ml, with the highest incidence among the older cohort. The multivariate analysis confirmed the TnI elevation 1.0 ng/ml at least after PCI and the older age as predictors of MACE.

CONCLUSION

This study documented that in clinically stable patients, minor TnI elevations after elective PCI are independent predictors of MACE during follow-up, as are older age and reduced ejection fraction. Additionally, TnI elevation was a predictor of MACE during follow-up in a subset of patients with preserved ejection fraction. The combination of TnI elevation and older age confers the highest risk of MACE.

Impact of percutaneous coronary intervention timing on 5-year outcome in patients with non-ST-segment elevation acute coronary syndromes. The 'wait a day' approach might be safer

Background

The OPTIMA trial was a randomised multicentre trial exploring the influence of the timing of percutaneous coronary intervention (PCI) on patient outcomes in an intermediate to high risk non-ST-elevation acute coronary syndrome (NSTE-ACS) population. In order to decide the best treatment strategy for patients presenting with NSTE-ACS, long-term outcomes are essential.

Methods

Five-year follow-up data from 133 of the 142 patients could be retrieved (94 %). The primary endpoint was a composite of death and spontaneous myocardial infarction (MI). Spontaneous MI was defined as MI occurring more than 30 days after randomisation. Secondary endpoints were the individual outcomes of death, spontaneous MI or re-PCI.

Results

No significant difference with respect to the primary endpoint was observed (17.8 vs. 10.1 %; HR 1.55, 95 % CI: 0.73–4.22, p = 0.21). There was no significant difference in mortality rate. However, spontaneous MI was significantly more common in the group receiving immediate PCI (11.0 vs. 1.4 %; HR 4.46, 95 % CI: 1.21–16.50, p = 0.02). We did not find a significant difference between the groups with respect to re-PCI rate.

Conclusion

There was no difference in the composite of death and spontaneous MI. The trial suggests an increased long-term risk of spontaneous MI for patients treated with immediate PCI.

Impact of Strut Width in Periprocedural Myocardial Infarction: A Propensity-Matched Comparison Between Bioresorbable Scaffolds and the First-Generation Sirolimus-Eluting Stent

OBJECTIVES

This study aimed to assess the clinical impact of strut width (evaluated by abluminal strut surface area [ASSA]) on periprocedural myocardial infarction (PMI) and clinical outcomes in patients treated with bioresorbable scaffolds (BRS) versus first-generation sirolimus-eluting stents (SES).

BACKGROUND

To date, there are no reports on the impact of ASSA on PMI and clinical outcomes.

METHODS

We compared the impact of ASSA on outcomes and PMI in propensity-matched patients treated with BRS and SES. The primary outcome was the incidence of major adverse cardiac events (MACE), defined as the combination of all-cause mortality, follow-up myocardial infarction, and target vessel revascularization, at 30-days and 1-year follow-ups. The secondary endpoint was the incidence of PMI.

RESULTS

After propensity-matched analysis, 499 patients (147 BRS patients vs. 352 SES patients) were evaluated. Mean ASSA was higher in patients treated with BRS versus SES (BRS: 132.3 ± 76.7 mm(2) vs. SES: 67.6 ± 48.4 mm(2), p < 0.001). MACE was not significantly different between groups (30-days MACE: BRS: 0% vs. SES: 1.4%, p = 0.16, and 1-year MACE: BRS: 15.7% vs. SES: 11.4%, p = 0.67). The incidence of PMI was significantly higher in the BRS group (BRS: 13.1% vs. SES: 7.5%, p = 0.05). Multivariable analyses indicated that treatment of left anterior descending artery and ASSA were independent predictors of PMI.

CONCLUSIONS

BRS implantation, compared with SES implantation, was associated with a higher incidence of PMI. MACE at 30 days and 1 year were not significantly different. Left anterior descending artery percutaneous coronary intervention and ASSA were independent predictors of PMI.

Glycosylated hemoglobin and the risk of periprocedural myocardial infarction in non-diabetic patients

BACKGROUND

Alterations of glucose homeostasis have been reported to occur even in non-diabetic patients, thus increasing the risk of cardiovascular events and worsening the outcome after an acute myocardial infarction (AMI). Still debated is the role of impaired glucose control in patients undergoing percutaneous coronary intervention (PCI), as hyperglycemia, represents an important pro-thrombotic stimulus, increasing platelet reactivity and potentially procedural complications. Therefore, the aim of our study was to assess the association between glycosylated hemoglobin and periprocedural myocardial infarction (PMI) in non-diabetic patients undergoing PCI.

METHODS

We included patients without history of diabetes undergoing elective PCI. PMI was defined as creatine kinase-MB increase by 3 times the upper limit normal or by 50% of an elevated baseline value, whereas periprocedural myonecrosis as Troponin I increase by 3× ULN or 50% of baseline.

RESULTS

Our population is represented by 1199 patients, who were divided according to tertile values of glycosylated hemoglobin (HbA1c). Higher HbA1c was associated with ageing (p<0.001), hypertension (p=0.005), previous myocardial infarction (p=0.009), PCI (p<0.001) or CABG (p=0.001), treatment with diuretics (p<0.001), higher levels of glycemia (p<0.001) and white blood cells (p=0.02), multivessel coronary artery disease (p=0.03), higher rate of instent restenosis (p=0.02). HbA1c did not impact on periprocedural myocardial infarction (p=0.85; adjusted OR [95% CI]=0.91 [0.74-1.12], p=0.38) or myonecrosis (p=0.69; adjusted OR [95% CI]=0.95 [0.80-1.13], p=0.56). Similar results were obtained fasting glycemia for PMI (p=0.82, adjusted OR [95% CI]=0.90 [0.71-1.14], p=0.37) and myonecrosis (p=0.21, adjusted OR [95% CI]=1.02 [0.84-1.24], p=0.84) and confirmed in high-risk subsets of patients.

CONCLUSIONS

In non-diabetic patients undergoing elective PCI, neither glycosylated hemoglobin levels nor fasting glycemia are associated with the risk of periprocedural myocardial infarction and necrosis.

Effect of diabetes mellitus on periprocedural myocardial infarction in patients undergoing coronary stent implantation

BACKGROUND

Diabetic patients undergoing percutaneous coronary interventions are still regarded as a very high risk category because of an increased platelet reactivity and risk of complications, especially in patients with inadequate glycaemic control. However, although its prognostic effect on long-term outcome is well-defined, still unclear is the effect of diabetes on the risk of periprocedural myocardial infarction in patients undergoing percutaneous coronary interventions, which was therefore the aim of our study.

METHODS

Myonecrosis biomarkers were dosed at intervals from 6 to 48 h after nonemergent percutaneous coronary interventions. Periprocedural myocardial infarction was defined as creatine kinase-MB increase by three times the upper limit normal or by 50% of an elevated baseline value, whereas periprocedural myonecrosis as troponin I increase by three times the upper limit normal or 50% of baseline.

RESULTS

Of 1311 patients, diabetes mellitus was found in 458 patients (34.9%) and associated with age (p = 0.03), hypertension (p < 0.001), renal failure (p = 0.01), previous MI (p = 0.03), previous coronary revascularization (p < 0.001), higher fasting glycaemia and lower haemoglobin (p < 0.001), more severe coronary disease (p < 0.001), multivessel percutaneous coronary interventions (p = 0.03), coronary calcification (p = 0.003) and in-stent restenosis (p < 0.001) but lower presence of thrombus (p = 0.03). Diabetic patients were receiving significantly more frequent specific pharmacological treatment at admission. Diabetic status did not influence the risk of periprocedural myocardial infarction or periprocedural myonecrosis [adjusted OR(95%CI) = 0.90(0.64-1.27), p = 0.57 and adjusted OR(95%CI) = 0.92(0.70-1.21), p = 0.55]. Amongst diabetic patients, we did not observe any effect of chronic glycaemic control on periprocedural myocardial infarction.

CONCLUSIONS

Diabetic status, independent of chronic glycaemic control, is not associated with increased risk of periprocedural myocardial infarction and myonecrosis in patients undergoing percutaneous coronary interventions.

Embolization after percutaneous coronary intervention in acute coronary syndrome. Saphenous vein grafts versus native coronary arteries

AIMS

The aim of this study was to assess the occurrence of distal embolization and to quantify the amount of embolic material captured during stent implantation in native coronary arteries, as compared with saphenous vein grafts (SVG) in patients at different time periods after an acute coronary syndrome.

PATIENTS AND METHODS

In all, 104 patients presenting with unstable or stable angina underwent percutaneous coronary intervention (PCI) in 107 vessels and stent implantation in 112 lesions, 53 % of which were in SVG.

RESULTS

Device deployment and retrieval was successful in 111 lesions. Embolic material was detected in 74 % of the protection devices. Early PCI, during a 2-week period after the last ischemic episode, was associated with larger embolic load, especially in the right coronary artery. The length of the lesion was the only preprocedural independent variable that was found to be a significant predictor for the presence of emboli (p = 0.002). The stent diameter and the maximum dilatation pressure were the two procedural variables found to be significant predictors for the presence of emboli (p = 0.025 and p = 0.008, respectively). The irregularity of the lesion and the number of stents deployed were found to have a predictive correlation to the total area of the embolic particles (p = 0.04 and p = 0.005, respectively).

CONCLUSION

Distal embolization of atherosclerotic debris is a frequent phenomenon after PCI not only in SVG but also in native vessels. The amount of embolic material seems to be related to the atherosclerotic burden of the vessel and to the early timing of the procedure as related to acute coronary syndrome.

High-dose statin pretreatment decreases periprocedural myocardial infarction and cardiovascular events in patients undergoing elective percutaneous coronary intervention: a meta-analysis of twenty-four randomized controlled trials

BACKGROUND

Evidence suggests that high-dose statin pretreatment may reduce the risk of periprocedural myocardial infarction (PMI) and major adverse cardiac events (MACE) for certain patients; however, previous analyses have not considered patients with a history of statin maintenance treatment. In this meta-analysis of randomized controlled trials (RCTs), we reevaluated the efficacy of short-term high-dose statin pretreatment to prevent PMI and MACE in an expanded set of patients undergoing elective percutaneous coronary intervention.

METHODS

We searched the PubMed/Medline database for RCTs that compared high-dose statin pretreatment with no statin or low-dose statin pretreatment as a prevention of PMI and MACE. We evaluated the incidence of PMI and MACE, including death, spontaneous myocardial infarction, and target vessel revascularization at the longest follow-up for each study for subgroups stratified by disease classification and prior low-dose statin treatment.

RESULTS

Twenty-four RCTs with a total of 5,526 patients were identified. High-dose statin pretreatment was associated with 59% relative reduction in PMI (odds ratio [OR]: 0.41; 95% confidence interval [CI]: 0.34-0.49; P<0.00001) and 39% relative reduction in MACE (OR: 0.61; 95% CI: 0.45-0.83; P = 0.002). The benefit of high-dose statin pretreatment on MACE was significant for statin-naive patients (OR: 0.69; 95% CI: 0.50-0.95; P = 0.02) and prior low dose statin-treated patients (OR: 0.28; 95% CI: 0.12-0.65; P = 0.003); and for patients with acute coronary syndrome (OR: 0.52; 95% CI: 0.34-0.79; P = 0.003), but not for patients with stable angina (OR: 0.71; 95% CI 0.45-1.10; P = 0.12). Long-term effects on survival were less obvious.

CONCLUSIONS

High-dose statin pretreatment can result in a significant reduction in PMI and MACE for patients undergoing elective PCI. The positive effect of high-dose statin pretreatment on PMI and MACE is significant for statin-naïve patients and patients with prior treatment. The positive effect of high-dose statin pretreatment on MACE is significant for patients with acute coronary syndrome.

Making sense of high sensitivity troponin assays and their role in clinical care

Cardiac troponin assays have an established and undisputed role in the diagnosis and risk stratification of patients with acute myocardial infarction. As troponin assays gets more sensitive and more precise, the number of potential uses has rapidly expanded, but the use of this test has also become more complicated and controversial. Highly sensitive troponin assays can now detect troponin levels in most individuals, but accurate interpretation of these levels requires a clear understanding of the assay in the context of the clinical scenario. This paper provides a practical and up-to-date overview of the uses of highly sensitive troponin assays for diagnosis, prognosis, and risk stratification in clinical practice.