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Kite TA, Ladwiniec A, Greenwood JP, Gale CP, Anantharam B, More R, Hetherington SL, Khan SQ, O'Kane P, Rakhit R, Chase A, Barber S, Waheed G, Berry C, Flather M, McCann GP, Curzen N, Banning AP, Gershlick AH. Very early invasive strategy in higher risk non-ST-elevation acute coronary syndrome: the RAPID NSTEMI trial. Heart 2024; 110:500-507. [PMID: 38103913 PMCID: PMC10958296 DOI: 10.1136/heartjnl-2023-323513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/27/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVE To investigate whether a very early invasive strategy (IS)±revascularisation improves clinical outcomes compared with standard care IS in higher risk patients with non-ST-elevation acute coronary syndrome (NSTE-ACS). METHODS Multicentre, randomised, controlled, pragmatic strategy trial of higher risk patients with NSTE-ACS, defined by Global Registry of Acute Coronary Events 2.0 score of ≥118, or ≥90 with at least one additional high-risk feature. Participants were randomly assigned to very early IS±revascularisation (<90 min from randomisation) or standard care IS±revascularisation (<72 hours). The primary outcome was a composite of all-cause mortality, new myocardial infarction or hospitalisation for heart failure at 12 months. RESULTS The trial was discontinued early by the funder due to slow recruitment during the COVID-19 pandemic. 425 patients were randomised, of whom 413 underwent an IS: 204 to very early IS (median time from randomisation: 1.5 hours (IQR: 0.9-2.0)) and 209 to standard care IS (median: 44.0 hours (IQR: 22.9-72.6)). At 12 months, there was no significant difference in the primary outcome between the early IS (5.9%) and standard IS (6.7%) groups (OR 0.93, 95% CI 0.42 to 2.09; p=0.86). The incidence of stroke and major bleeding was similar. The length of hospital stay was reduced with a very early IS (3.9 days (SD 6.5) vs 6.3 days (SD 7.6), p<0.01). CONCLUSIONS A strategy of very early IS did not improve clinical outcomes compared with a standard care IS in higher risk patients with NSTE-ACS. However, the primary outcome rate was low and the trial was underpowered to detect such a difference. TRIAL REGISTRATION NUMBER NCT03707314.
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Affiliation(s)
- Thomas A Kite
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Andrew Ladwiniec
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - John P Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds and the Department of Cardiology Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds and the Department of Cardiology Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Ranjit More
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Simon Lee Hetherington
- Department of Cardiology, Kettering General Hospital NHS Foundation Trust, Kettering, UK
| | - Sohail Q Khan
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter O'Kane
- The Royal Bournemouth Hospital, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Roby Rakhit
- Department of Cardiology, Royal Free Hospital and Institute of Cardiovascular Sciences, University College London, London, UK
| | | | - Shaun Barber
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Ghazala Waheed
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Colin Berry
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, Golden Jubilee National Hospital and University of Glasgow, Glasgow, UK
| | - Marcus Flather
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Gerry P McCann
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Adrian P Banning
- Department of Cardiology, John Radcliffe Hospital, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Anthony H Gershlick
- Department of Cardiovascular Sciences and the NIHR Leicester Biomedical Research Centre, Glenfield Hospital, University of Leicester and University Hospitals of Leicester NHS Trust, Leicester, UK
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2
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Ryan M, Ezad SM, Webb I, O’Kane PD, Dodd M, Evans R, Laidlaw L, Khan SQ, Weerackody R, Bagnall A, Panoulas VF, Rahman H, Strange JW, Fath-Ordoubadi F, Hoole SP, Stables RH, Curzen N, Clayton T, Perera D. Percutaneous Left Ventricular Unloading During High-Risk Coronary Intervention: Rationale and Design of the CHIP-BCIS3 Randomized Controlled Trial. Circ Cardiovasc Interv 2024; 17:e013367. [PMID: 38410944 PMCID: PMC10942170 DOI: 10.1161/circinterventions.123.013367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/04/2024] [Indexed: 02/28/2024]
Abstract
INTRODUCTION Percutaneous coronary intervention for complex coronary disease is associated with a high risk of cardiogenic shock. This can cause harm and limit the quality of revascularization achieved, especially when left ventricular function is impaired at the outset. Elective percutaneous left ventricular unloading is increasingly used to mitigate adverse events in patients undergoing high-risk percutaneous coronary intervention, but this strategy has fiscal and clinical costs and is not supported by robust evidence. METHODS CHIP-BCIS3 (Controlled Trial of High-Risk Coronary Intervention With Percutaneous Left Ventricular Unloading) is a prospective, multicenter, open-label randomized controlled trial that aims to determine whether a strategy of elective percutaneous left ventricular unloading is superior to standard care (no planned mechanical circulatory support) in patients undergoing nonemergent high-risk percutaneous coronary intervention. Patients are eligible for recruitment if they have severe left ventricular systolic dysfunction, extensive coronary artery disease, and are due to undergo complex percutaneous coronary intervention (to the left main stem with calcium modification or to a chronic total occlusion with a retrograde approach). Cardiogenic shock and acute ST-segment-elevation myocardial infarction are exclusions. The primary outcome is a hierarchical composite of all-cause death, stroke, spontaneous myocardial infarction, cardiovascular hospitalization, and periprocedural myocardial infarction, analyzed using the win ratio. Secondary outcomes include completeness of revascularization, major bleeding, vascular complications, health economic analyses, and health-related quality of life. A sample size of 250 patients will have in excess of 80% power to detect a hazard ratio of 0.62 at a minimum of 12 months, assuming 150 patients experience an event across all follow-up. CONCLUSIONS To date, 169 patients have been recruited from 21 National Health Service hospitals in the United Kingdom, with recruitment expected to complete in 2024. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05003817.
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Affiliation(s)
- Matthew Ryan
- School of Cardiovascular and Metabolic Medicine & Sciences at the British Heart Foundation Centre of Research Excellence, King’s College London, United Kingdom (M.R., S.M.E., H.R., D.P.)
| | - Saad M. Ezad
- School of Cardiovascular and Metabolic Medicine & Sciences at the British Heart Foundation Centre of Research Excellence, King’s College London, United Kingdom (M.R., S.M.E., H.R., D.P.)
| | - Ian Webb
- King’s College Hospital National Health Service (NHS) Foundation Trust, London, United Kingdom (I.W.)
| | - Peter D. O’Kane
- University Hospitals Dorset NHS Foundation Trust, Bournemouth, United Kingdom (P.D.O.)
| | - Matthew Dodd
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, United Kingdom (M.D., R.E., T.C.)
| | - Richard Evans
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, United Kingdom (M.D., R.E., T.C.)
| | - Lynn Laidlaw
- Patient and Public Contributor, London School of Hygiene & Tropical Medicine, United Kingdom (L.L.)
| | - Sohail Q. Khan
- University Hospitals Birmingham NHS Foundation Trust, United Kingdom (S.Q.K.)
| | | | | | | | - Haseeb Rahman
- School of Cardiovascular and Metabolic Medicine & Sciences at the British Heart Foundation Centre of Research Excellence, King’s College London, United Kingdom (M.R., S.M.E., H.R., D.P.)
| | - Julian W. Strange
- University Hospitals Bristol NHS Foundation Trust, United Kingdom (J.W.S.)
| | | | - Stephen P. Hoole
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom (S.P.H.)
| | | | - Nick Curzen
- University of Southampton, United Kingdom (N.C.)
| | - Tim Clayton
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, United Kingdom (M.D., R.E., T.C.)
| | - Divaka Perera
- School of Cardiovascular and Metabolic Medicine & Sciences at the British Heart Foundation Centre of Research Excellence, King’s College London, United Kingdom (M.R., S.M.E., H.R., D.P.)
- Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom (D.P.)
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3
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Maqableh GM, Yuan M, Moody W, Baig S, Khan SQ. Giant left sinus of Valsalva aneurysm as a rare cause of acute myocardial infarction: a case report. Eur Heart J Case Rep 2024; 8:ytae047. [PMID: 38328598 PMCID: PMC10849118 DOI: 10.1093/ehjcr/ytae047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 01/09/2024] [Accepted: 01/23/2024] [Indexed: 02/09/2024]
Abstract
Background Sinus of Valsalva aneurysm (SVA) is a rare but potentially life-threatening condition. Acute myocardial infarction (MI) is a rare consequence of aneurysmal dilatation of one or more sinuses of Valsalva. We present a case of an unruptured and partially thrombosed left SVA, presenting as anterior MI and congestive heart failure. Case summary A 55-year-old gentleman was admitted with pulmonary oedema and a late presenting ST-elevation MI with Q wave. After initial treatment on furosemide infusion, a coronary angiography showed significant stenosis in both his left main stem (LMS) and left anterior descending artery (LAD). This is likely a result of external compression, potentially from the enlarged left sinus of Valsalva. A subsequent transthoracic echocardiogram and transoesophageal echocardiogram (TOE) confirmed large SVA involving the left coronary cusp measured 9.9 cm compressing both LMS and LAD. Discussion Left SVAs are rare and frequently asymptomatic, typically being identified incidentally. Due to the close proximity of the left coronary system, they can present with myocardial ischaemia due to extrinsic compression of the coronary system. We were able to perform a comprehensive multi-modality assessment of left SVA, which helped establish this unusual diagnosis and guide management. Transthoracic echocardiogram and TOE helped assess the SVA and demonstrated the thrombus in situ, aortic valve insufficiency, and cardiac function. The computed tomography scan aided in accurately defining the extent of the aneurysm and the extent of compression of the left coronary system and cardiac magnetic resonance scan was able to demonstrate viability in LAD and circumflex territory.
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Affiliation(s)
- Ghaith M Maqableh
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
- Cardiology Department, Faculty of Medicine, Al Balqa Applied University, Amman 19117, Jordan
| | - Mengshi Yuan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
| | - William Moody
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Shanat Baig
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Sohail Q Khan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
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4
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Maqableh GMY, Khan KA, Shahid F, Khan SQ. Role of Optical Coherence Tomography in Chronic Spontaneous Coronary Artery Dissection-Diagnosis and Management. Heart Views 2023; 24:119-121. [PMID: 37305332 PMCID: PMC10249635 DOI: 10.4103/heartviews.heartviews_101_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Accepted: 02/16/2023] [Indexed: 06/13/2023] Open
Abstract
Spontaneous coronary artery dissection is an underdiagnosed cause of acute coronary syndrome, often occurring in younger females. Such a diagnosis should always be considered in this demographic. In this case report, we focus on the importance of optical coherence tomography in the diagnosis and management of this condition in the elective setting.
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Affiliation(s)
- Ghaith Mohammad Yousef Maqableh
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Department of Cardiology, Faculty of Medicine, Al Balqa Applied University, Amman, Jordan
| | - Kumail Abbas Khan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Farhan Shahid
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sohail Q. Khan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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5
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Shah N, Demetriades P, Maqableh GM, Khan SQ, Shahid F. Aortic cusp perforation during rotational atherectomy: a case report. Eur Heart J Case Rep 2023; 7:ytad171. [PMID: 37123646 PMCID: PMC10133995 DOI: 10.1093/ehjcr/ytad171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 11/23/2022] [Accepted: 04/03/2023] [Indexed: 05/02/2023]
Abstract
Background Rotational atherectomy has become increasingly utilised over the past decade. Although a relatively safe procedure in appropriately trained physicians' hands, there are a number of recognised complications. Case summary We describe the case of a 64-year-old female who presented with chest pain and was diagnosed with non-ST-segment elevation acute coronary syndrome. A transthoracic echocardiogram (TTE) showed normal biventricular function and no valve disease. Invasive coronary angiogram was performed which revealed a severely calcified ostial right coronary artery (RCA) disease which was felt to be the culprit of the presentation. Balloon dilatation was unsuccessful, therefore, rotational atherectomy with an Amplatz left 0.75 guide and a 1.5 mm rota-burr was utilised and improved calcium burden. This was complicated by ostial dissection, treated with stenting. A TTE following the procedure revealed moderate aortic regurgitation (AR). The patient was discharged as she remained asymptomatic. An outpatient transoesophageal echocardiogram performed eight months later showed evidence of severe eccentric AR. Cardiac magnetic resonance imaging confirmed severe AR with left ventricular dilatation. Repeat angiogram 10 months after index procedure revealed in-stent restenosis, and the patient was accepted by heart multidisciplinary team for aortic valve replacement and grafting of RCA. Discussion As the field of rotational atherectomy continues to expand, we propose that novel complications such as reported in this case may become recognised. Finally, we stress the importance of multi-modality imaging in the investigation and timely planning of interventions in the management of these patients.
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Affiliation(s)
| | - Polyvios Demetriades
- Department of cardiology, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2GW, UK
| | - Ghaith M Maqableh
- Department of cardiology, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2GW, UK
- Cardiology Department, Faculty of Medicine, Al Balqa Applied University, Amman, Salt 19117, P.O. Box 20, Jordan
| | - Sohail Q Khan
- Department of cardiology, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2GW, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
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6
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Murad S, Khan K, Abdulelah Z, Leung J, Hsu YK, Shahid F, Ludman PF, Khan SQ. The 11-year outcome of PCI for treatment of left main stem disease. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Left Main Stem Disease (LMS) has historically been treated with coronary artery bypass surgery (CABG). However, not all patents with LMS are candidates for CABG due to co-morbidities. There is limited long-term follow-up of patients undergoing PCI in the real world. The primary objective of this study was to investigate the long-term mortality following LMS PCI.
Methods
We conducted a retrospective study of patients who had undergone PCI for LMS disease at our hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records and analyzed using Kaplain-Meier survival analysis. Follow-up was obtained through linkage with the Office of National Statistics.
Results
498 patients underwent LMS PCI (5.1% of the total PCI cases). The overall survival rate was 70%. Median survival following PCI was 1,196 days (IQR = 1,796). The mean age of the patients was 70.7 years; 70.5% were males. 70.9% of patients underwent PCI for Acute Coronary Syndrome (ACS), and 15.3% had STEMI. 33.7% of patients had a history of diabetes, 8% had stroke, 8.2% had COPD, and 8.8% had PVD. 51 patients went into cardiogenic shock, and 25 died prior to discharge.
Survival of the ACS group was significantly lower than the stable group (67% vs 77%, p<0.01); the STEMI group did not significantly differ from rest of the ACS group (62% vs 66%, p=0.87). Survival in those <60 years of age was significantly higher than in those >60 years (80% vs 68%; p<0.01). The presence of one or more co-morbidities was associated with higher survival compared to zero co-morbidities (74% vs 65%, p<0.01). Patients with a history of diabetes had a significantly lower survival rate than those without diabetes (63% vs 73%, p<0.01). Patients with an LV ejection fraction ≤35% had a significantly lower survival than those with an ejection fraction >35% (22% vs 29%, p<0.01); only 259 patients had data on LV function. Patients who developed cardiogenic shock had a significantly lower survival rate than those who did not develop shock (38% vs 70%; p<0.01). When these patients were excluded from the data set, the overall survival rate increased from 70% to 74%. Lastly, a multinomial analysis showed that the only independent predictors of mortality were age (p<0.01) and cardiogenic shock (p<0.01).
Conclusion
Our results show that the real world 10-year mortality rate following LMS PCI is influenced by multiple factors including age, shock, and LV function. The high mortality rate was potentially due to the significant number of acute cases (70.1%) in non-operable patients. While factors such as age and past medical history are considered in the decision-making process regarding CABG vs PCI, we saw that specific subgroups within these factors may have decreased the effectiveness of PCI as a treatment for LMS disease, suggesting that deeper analysis into these risk factors is required when deciding between CABG and PCI for LMS disease management.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- S Murad
- Queen Elizabeth Hospital Birmingham , Birmingham , United Kingdom
| | - K Khan
- Queen Elizabeth Hospital Birmingham , Birmingham , United Kingdom
| | - Z Abdulelah
- King hussein medical center , Amman , Jordan
| | - J Leung
- Institute of Cardiovascular Sciences , Birmingham , United Kingdom
| | - Y K Hsu
- Institute of Cardiovascular Sciences , Birmingham , United Kingdom
| | - F Shahid
- Queen Elizabeth Hospital Birmingham , Birmingham , United Kingdom
| | - P F Ludman
- Queen Elizabeth Hospital Birmingham , Birmingham , United Kingdom
| | - S Q Khan
- Queen Elizabeth Hospital Birmingham , Birmingham , United Kingdom
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7
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Stables RH, Mullen LJ, Elguindy M, Nicholas Z, Aboul-Enien YH, Kemp I, O'Kane P, Hobson A, Johnson TW, Khan SQ, Wheatcroft SB, Garg S, Zaman AG, Mamas MA, Nolan J, Jadhav S, Berry C, Watkins S, Hildick-Smith D, Gunn J, Conway D, Hoye A, Fazal IA, Hanratty CG, De Bruyne B, Curzen N. Routine Pressure Wire Assessment Versus Conventional Angiography in the Management of Patients With Coronary Artery Disease: The RIPCORD 2 Trial. Circulation 2022; 146:687-698. [PMID: 35946404 DOI: 10.1161/circulationaha.121.057793] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Measurement of fractional flow reserve (FFR) has an established role in guiding percutaneous coronary intervention. We tested the hypothesis that, at the stage of diagnostic invasive coronary angiography, systematic FFR-guided assessment of coronary artery disease would be superior, in terms of resource use and quality of life, to assessment by angiography alone. METHODS We performed an open-label, randomized, controlled trial in 17 UK centers, recruiting 1100 patients undergoing invasive coronary angiography for the investigation of stable angina or non-ST-segment-elevation myocardial infarction. Patients were randomized to either angiography alone (angiography) or angiography with systematic pressure wire assessment of all epicardial vessels >2.25 mm in diameter (angiography+FFR). The coprimary outcomes assessed at 1 year were National Health Service hospital costs and quality of life. Prespecified secondary outcomes included clinical events. RESULTS In the angiography+FFR arm, the median number of vessels examined was 4 (interquartile range, 3-5). The median hospital costs were similar: angiography, £4136 (interquartile range, £2613-£7015); and angiography+FFR, £4510 (£2721-£7415; P=0.137). There was no difference in median quality of life using the visual analog scale of the EuroQol EQ-5D-5L: angiography, 75 (interquartile range, 60-87); and angiography+FFR, 75 (interquartile range, 60-90; P=0.88). The number of clinical events was as follows: deaths, 5 versus 8; strokes, 3 versus 4; myocardial infarctions, 23 versus 22; and unplanned revascularizations, 26 versus 33, with a composite hierarchical event rate of 8.7% (48 of 552) for angiography versus 9.5% (52 of 548) for angiography+FFR (P=0.64). CONCLUSIONS A strategy of systematic FFR assessment compared with angiography alone did not result in a significant reduction in cost or improvement in quality of life. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01070771.
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Affiliation(s)
- Rodney H Stables
- Liverpool Heart & Chest Hospital, UK (R.H.S., L.J.M., M.E., Y.H.A.-E., I.K.)
| | - Liam J Mullen
- Liverpool Heart & Chest Hospital, UK (R.H.S., L.J.M., M.E., Y.H.A.-E., I.K.)
| | - Mostafa Elguindy
- Liverpool Heart & Chest Hospital, UK (R.H.S., L.J.M., M.E., Y.H.A.-E., I.K.)
| | - Zoe Nicholas
- Coronary Research Group, University Hospital Southampton, UK (Z.N., N.C.)
| | | | - Ian Kemp
- Liverpool Heart & Chest Hospital, UK (R.H.S., L.J.M., M.E., Y.H.A.-E., I.K.)
| | | | - Alex Hobson
- Queen Alexandra Hospital, Portsmouth, UK (A.H.)
| | | | | | | | - Scot Garg
- Royal Blackburn Teaching Hospital, UK (S.G.)
| | | | - Mamas A Mamas
- Royal Stoke University Hospital, Stroke-on-Trent, UK (M.A.M., J.N.)
| | - James Nolan
- Royal Stoke University Hospital, Stroke-on-Trent, UK (M.A.M., J.N.)
| | | | - Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, UK (C.B.)
| | | | | | - Julian Gunn
- Northern General Hospital, Sheffield, UK (J.G.)
| | | | | | | | | | | | - Nick Curzen
- Faculty of Medicine, University of Southampton, UK (N.C.)
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8
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Umar H, Sharma H, Osheiba M, Roy A, Ludman PF, Townend JN, Nadir MA, Doshi SN, George S, Zaphiriou A, Khan SQ. Changing trends in the incidence, management and outcomes of coronary artery perforation over an 11-year period: single-centre experience. Open Heart 2022; 9:openhrt-2021-001916. [PMID: 35483748 PMCID: PMC9052042 DOI: 10.1136/openhrt-2021-001916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 04/05/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Coronary artery perforation (CP) is a rare but life-threatening complication of percutaneous coronary intervention (PCI). This study aimed to assess the incidence, management and outcomes of CP over time. Methods A single-centre retrospective cohort study of all PCIs performed between January 2010 and December 2020. Patients with CP were divided into two cohorts (A+B), representing the two halves of the 11-year study. Results The incidence of CP was 68 of 9701 (0.7%), with an increasing trend over the two 5.5-year periods studied (24 of 4661 (0.5%) vs 44 of 5040 (0.9%); p=0.035). Factors associated with CP included chronic total occlusions (CTOs) (16 of 68 (24%) vs 993 of 9633 (10%); p<0.001), type C lesions (44 of 68 (65%) vs 4280 of 9633 (44%); p<0.001), use of intravascular ultrasound (IVUS) (12 of 68 (18%) vs 541 of 9633 (6%); p<0.001), cutting balloon angioplasty (3 of 68 (4%) vs 98 of 9633 (1%); p<0.001) and hydrophilic wires (24 of 68 (35%) vs 1454 of 9633 (15%); p<0.001). Cohorts A and B were well matched with respect to age (69±11 vs 70±12 years; p=0.843), sex (males: 13 of 24 (54%) vs 31 of 44 (70%); p=0.179) and renal function (chronic kidney disease: 1 of 24 (4%) vs 4 of 44 (9%); p=0.457). In cohort A, CP was most frequently caused by post-dilatation with non-compliant balloons (10 of 24 (42%); p=0.009); whereas in cohort B, common causes included guidewire exits (23 of 44 (52%)), followed by stent implantation (10 of 44 (23%)). The most common treatment modality in cohorts A and B was balloon inflation, which accounted for 16 of 24 (67%) and 13 of 44 (30%), respectively. The use of covered stents (16%) and coronary coils (18%) during cohort B study period did not impact all-cause mortality, which occurred in 2 of 24 (8%) and 7 of 44 (16%) (p=0.378) in cohorts A and B, respectively. Conclusion The incidence of CP is increasing as more complex PCI is performed. Factors associated with perforation include CTO or type C lesions and use of IVUS, cutting balloon angioplasty or hydrophilic wires.
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Affiliation(s)
- Hamza Umar
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.,Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Harish Sharma
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK .,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Mohammed Osheiba
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Ashwin Roy
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Peter F Ludman
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - M Adnan Nadir
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Sagar N Doshi
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Sudhakar George
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Alex Zaphiriou
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sohail Q Khan
- Cardiology Department, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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9
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Khan KA, Osheiba M, Mechery A, Khan SQ. ST-segment elevation myocardial infarction with plaque erosion, to stent or not to stent: utility of intracoronary optical coherence tomography (OCT) imaging-a case report. Eur Heart J Case Rep 2022; 6:ytac078. [PMID: 35295722 PMCID: PMC8922690 DOI: 10.1093/ehjcr/ytac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 09/27/2021] [Accepted: 02/01/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Treating acute myocardial infarction in the setting of insignificant coronary obstruction is an emerging challenge especially with the application of intracoronary imaging like intravascular ultrasound and optical coherence tomography (OCT). The cardiologists dealing with such patients may consider not to stent if there is intracoronary imaging evidence of minimal thrombus without plaque rupture and the vessel appears patent with settling of chest pain and electrocardiogram (ECG) changes. CASE SUMMARY A 47-year-old gentleman presented direct to the emergency department after experiencing retrosternal chest pain with an ECG showing hyperacute anterior T waves. He had ongoing chest pain and was therefore brought to the cardiac cath lab on the primary percutaneous coronary intervention (PCI) pathway. The first picture showed that the proximal left anterior descending (LAD) was occluded (TIMI 0 flow) with evidence of large thrombus burden. Pre-dilating with a 2.5 × 15 mm balloon did not change flow. Aspiration with an Export catheter was carried out for several runs. Most of the thrombus was successfully removed; however, some of it did go into the distal LAD but was successfully retrieved with aspiration catheter. The diagonal branch was occluded with thrombus which was wired followed by thrombus aspiration establishing TIMI II flow. The procedure was covered with Eptifibatide boluses and heparin. After thrombectomy, angiographically there was no obvious lesion present within the LAD. Optical coherence tomography confirmed only mild atheroma with a small amount of plaque and minimal thrombus. There was OCT evidence of plaque erosion without any plaque rupture. The area was above 9 mm2 and we decided not to treat that with a stent. The right coronary artery had an anterior take-off and was unobstructed. In conclusion, the patient had successful primary PCI to LAD with thrombus aspiration and balloon angioplasty only. He was placed on 12 months of dual antiplatelets therapy with Aspirin and Prasugrel. DISCUSSION This case highlights the rare presentation of patients with acute myocardial infarction with plaque erosion and the usefulness of OCT in formulating a management plan.
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Affiliation(s)
- Kumail Abbas Khan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
| | - Mohammed Osheiba
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Cardiology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Anthony Mechery
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
| | - Sohail Q Khan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
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10
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Maqableh GM, Osheiba M, Mechery A, Khan SQ. Successful rotational atherectomy of left main stem with double kiss crush stenting using double guiding catheter: a case report. Eur Heart J Case Rep 2021; 5:ytab481. [PMID: 35047735 PMCID: PMC8759481 DOI: 10.1093/ehjcr/ytab481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/13/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Coronary artery bypass grafting is the preferred revascularization procedure for patients with multivessel disease, and those with complex left main disease, as it is associated with a survival advantage in this group of patients. Sometimes however surgical management is not the treatment of choice due to many factors including ongoing chest pain, haemodynamic instability, or patient preference. In these situations, percutaneous coronary intervention (PCI) offers an alternative revascularization strategy. In this case study, we present a successful PCI with rotational atherectomy (RA) for distal left main stem (LMS), left anterior descending (LAD), and circumflex artery (CX) using a double guide catheter technique in a patient with severe calcific disease.
Case summary
A 63-year-old female was diagnosed with a non-ST-elevation myocardial infarction. Coronary angiography showed significant distal LMS disease with a severe proximal/ostial calcified lesion of the LAD and a possible thrombotic lesion at the ostium of the CX. She had ongoing haemodynamic instability with chest pain however could not be offered immediate surgical revascularization. We therefore elected to proceed to complex bifurcation LMS coronary intervention using RA under intravascular ultrasound (IVUS) guidance achieving an excellent final result with TIMI III flow.
Discussion
This case demonstrates that RA using the double catheter technique (also known as Ping-Pong) can be safely performed with minimal complication rates and with very favourable angiographic and IVUS results. The clinical outcome was excellent with early discharge.
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Affiliation(s)
- Ghaith M Maqableh
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
- Cardiology Department, Faculty of Medicine, Al Balqa Applied University, Amman, Jordan
| | - Mohammed Osheiba
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
- Cardiology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Anthony Mechery
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
| | - Sohail Q Khan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Birmingham B15 2TH, UK
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B15 2TT, UK
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11
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Elsherif A, Nadir A, Ludman PF, Khan SQ. Retrieval of Entrapped Catheter-Mounted Axial Flow Pump From Mitral Subvalvular Apparatus Using a Snare Catheter. JACC Case Rep 2021; 3:1494-1498. [PMID: 34693349 PMCID: PMC8511436 DOI: 10.1016/j.jaccas.2021.06.041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/10/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
Axial-flow ventricular assist devices are being increasingly used to support hemodynamically compromised patients undergoing percutaneous coronary intervention. Periprocedural valvular complications have been recognized in a few case reports. We present a unique case of entanglement of the Impella within he mitral subvalvular apparatus, retrieved successfully using a snare under fluoroscopic guidance. (Level of Difficulty: Advanced.)
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Key Words
- ACS, acute coronary syndrome
- CA, coronary angiography
- CABG, coronary artery bypass graft
- CMR, cardiac magnetic resonance
- ECG, electrocardiogram
- LVEF, left ventricular ejection fraction
- MI, myocardial infarction
- PCI, percutaneous coronary intervention
- TEE, transesophageal echocardiography
- TTE, transthoracic echocardiography
- axial-flow pump
- double kiss crush stenting
- left main stem
- left ventricular assist device
- mechanical circulatory support
- mitral valve injury
- percutaneous coronary intervention
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Affiliation(s)
- Ahmed Elsherif
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Cardiology Department, Faculty of Medicine, Suez Canal University Hospital, Egypt
| | - Adnan Nadir
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Peter F Ludman
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Sohail Q Khan
- Department of Interventional Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, United Kingdom
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12
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Hussain S, Osman S, Osheiba M, Choy CH, Mortimer N, Ludman P, Townend J, Nadir A, Doshi S, George S, Zaphiriou A, Khan SQ. The effect of the COVID-19 pandemic on time to angiography and outcomes in patients presenting with non-ST elevation myocardial infarction. European Heart Journal. Acute Cardiovascular Care 2021. [PMCID: PMC8135338 DOI: 10.1093/ehjacc/zuab020.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Funding Acknowledgements Type of funding sources: None. Background Covid-19 pandemic has had a profound impact on healthcare service delivery. Acute cardiovascular care however remains a priority despite the pandemic. Patients presenting with non-ST elevation MI (NSTEMI) have been poorly characterised during the pandemic. Methods We conducted a retrospective study of patients diagnosed with NSTEMI during the peak of the pandemic between April-May 2020 at our tertiary centre in the UK. Data was collected from electronic patient clinical records including time from admission to angiography, length of stay, mortality, prescription of secondary prevention pharmacotherapy and referral to cardiac rehabilitation. We compared this data to the same time period in 2019. Results As can be seen from Table 1, in 2020, the mean age, median time to angiography and length of stay were all significantly lower than the control period of 2019. Prescription of secondary prevention medication (Aspirin, P2Y12 inhibitor, Beta-blocker, Statin and ACEi/ARB) and referral to cardiac rehabilitation also improved in 2020, however neither was statistically significant. During the 2020 period, 1 patient died due to late presentation NSTEMI and multi-organ failure. There were 3 deaths in 2019: complications following coronary bypass surgery, upper GI bleed and a subarachnoid haemorrhage. Conclusion Our results show that the mean age of the patients presenting with NSTEMI during the peak of Covid-19 pandemic was younger suggesting that elderly patients failed to present. Compared to 2019, there was significant improvement in patient treatment times with a significantly shorter stay in hospital, probably as a result of the reduction in elective activity allowing un-restrained access to the catheter labs. We also saw improvement in prescription for secondary prevention and referral to cardiac rehabilitation services during this time suggesting that there may have been improved focus on these aspects of care again.
Table 1 | 2019 | 2020 | p-value |
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Age (years) | 71.2 ± 12.2 | 65.0 ± 12.1 | p < 0.01 | Number of NSTEMI patients | 56 | 59 | p = NS | Number of NSTEMI patients undergoing angiography | 50 | 53 | p = NS | Median time to angiography (hours) | 68.6 | 14 | p < 0.01 | Median length of stay (days) | 5 (IQR 2:8) | 2 (IQR 1:4) | p < 0.01 | Referral to cardiac rehabilitation | 77.4% | 84.5% | p = NS | Prescription of secondary prevention medication | 69.8% | 72.4% | p = NS |
Table 1- Comparison of NSTEMI patients in 2019 and 2020 Abstract Figure. Box and whisker plot for hospital stay ![]()
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Affiliation(s)
- S Hussain
- University of Birmingham, Medical School, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - S Osman
- University of Birmingham, Medical School, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - M Osheiba
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - CH Choy
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - N Mortimer
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - P Ludman
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - J Townend
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - A Nadir
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - S Doshi
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - S George
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - A Zaphiriou
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
| | - SQ Khan
- Queen Elizabeth Hospital Birmingham, Department of Cardiology, Birmingham, United Kingdom of Great Britain & Northern Ireland
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13
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Jawad-Ul-Qamar M, Sharma H, Vetrugno V, Sandhu K, Ludman PF, Doshi SN, Townend JN, Osheiba M, Zaphiriou A, Khan SQ. Contemporary use of excimer laser in percutaneous coronary intervention with indications, procedural characteristics, complications and outcomes in a university teaching hospital. Open Heart 2021; 8:openhrt-2020-001522. [PMID: 33863837 PMCID: PMC8055138 DOI: 10.1136/openhrt-2020-001522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/22/2021] [Accepted: 03/02/2021] [Indexed: 11/28/2022] Open
Abstract
Background Excimer laser coronary atherectomy (ELCA) can be used as an adjunctive percutaneous coronary intervention treatment for challenging, heavily calcified lesions. Although previous studies have documented high rates of complication and restenosis, these predate the introduction of the smaller 0.9 mm laser catheter. As the coronary complexity has increased, there has been a renewed interest in the ELCA. This study investigates the indications, procedural characteristics, complications and outcomes of ELCA in a contemporary coronary interventional practice. Methods This single-centre study retrospectively analysed 50 patients treated with ELCA between January 2013 and January 2019. Results Patients had a mean age of 67.9±11.4 years with a male predominance (65.3%). 25 (50%) cases were performed in patients with stable angina. Failure to deliver the smallest available balloon/microcatheter was the most frequent indication in 32 (64%) cases for ELCA use. 30 (60%) of the procedures were performed via radial access. The 0.9 mm X-80 catheter was used in 41 (82%) of cases, delivering on average 9000±3929 pulses. ELCA-related complications included 2 coronary dissections and 1 perforation, all of which were covered with stents. No major complications could be directly attributed to the use of ELCA. There was one death and one case of stent thrombosis within 30 days of the procedure. Conclusion ELCA can be performed safely via the radial approach with a 0.9 mm catheter with a high success rate by suitably trained operators. The low procedure-related complications with contemporary techniques make this a very useful tool for complex coronary interventions, especially for difficult to dilate lesions and chronic total occlusion vessels.
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Affiliation(s)
- Muhammad Jawad-Ul-Qamar
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Harish Sharma
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Vincenzo Vetrugno
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK.,Cardiology Division, Azienda Ospedaliero-Universitaria di Modena Ospedale Civile di Baggiovara, Modena, Italy
| | - Kully Sandhu
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Peter F Ludman
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sagar N Doshi
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Jonathan N Townend
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Mohammed Osheiba
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Alex Zaphiriou
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Sohail Q Khan
- Department of interventional cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, UK .,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
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14
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Al-Lawati K, Osheiba M, Lester W, Khan SQ. Management of acute myocardial infarction in a patient with idiopathic thrombocytopenic purpura, the value of optical coherence tomography: a case report. Eur Heart J Case Rep 2020; 4:1-5. [PMID: 33442592 PMCID: PMC7793035 DOI: 10.1093/ehjcr/ytaa460] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/11/2020] [Accepted: 11/05/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Treating myocardial infarction in the setting of immune thrombocytopenic purpura (ITP) is always a challenge especially if the platelet count is labile. Cardiologists dealing with such patients should keep a delicate balance between thrombotic and bleeding complications. CASE SUMMARY A 50-year-old gentleman with treatment-challenging ITP presented with acute inferior ST elevation myocardial infarction after receiving recent intravenous immunoglobulin. Using optical coherence tomography (OCT) guidance, it was decided to treat him with percutaneous old balloon angioplasty especially with the labile nature of his platelet count. Subsequently, dual antiplatelet therapy was a challenge and he remained on clopidogrel for a period of only 10 weeks. CONCLUSION This case highlights the rare presentation of patients with ITP with thrombotic complications and the usefulness of OCT in formulating a management plan.
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Affiliation(s)
- Kumayl Al-Lawati
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, B15 2TH Birmingham, UK
- Royal Hospital, National Heart Centre, Ministry of Health, Al-Ghubrah, Muscat, Oman
| | - Mohammed Osheiba
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, B15 2TH Birmingham, UK
- Cardiology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Will Lester
- Department of Haematology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, B15 2TH Birmingham, UK
| | - Sohail Q Khan
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, B15 2TH Birmingham, UK
- Institute of Cardiovascular Sciences, University of Birmingham, B15 2TT, UK
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15
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Montone RA, Vetrugno V, Camilli M, Russo M, Fracassi F, Khan SQ, Doshi SN, Townend JN, Ludman PF, Trani C, Niccoli G, Crea F. Macrophage infiltrates in coronary plaque erosion and cardiovascular outcome in patients with acute coronary syndrome. Atherosclerosis 2020; 311:158-166. [PMID: 32948317 DOI: 10.1016/j.atherosclerosis.2020.08.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/21/2020] [Accepted: 08/21/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND AND AIMS Plaque erosion (PE) is responsible for at least one-third of acute coronary syndrome (ACS), and inflammation plays a key role in plaque instability. We assessed the presence of optical coherence tomography (OCT)-defined macrophage infiltrates (MØI) at the culprit site in ACS patients with PE, evaluating their clinical and OCT correlates, along with their prognostic value. METHODS ACS patients undergoing OCT imaging and presenting PE as culprit lesion were retrospectively selected. Presence of MØI at culprit site was assessed. The incidence of major adverse cardiac events (MACEs), defined as the composite of cardiac death, recurrent myocardial infarction and target-vessel revascularization (TVR), was assessed [follow-up median (interquartile range, IQR) time 2.5 (2.03-2.58) years]. RESULTS We included 153 patients [median age (IQR) 64 (53-75) years, 99 (64.7%) males]. Fifty-one (33.3%) patients presented PE with MØI and 102 (66.7%) PE without MØI. Patients having PE with MØI compared with PE patients without MØI had more vulnerable plaque features both at culprit site and at non-culprit segments. MACEs were significantly more frequent in PE with MØI patients compared with PE without MØI [11 (21.6%) vs. 6 (5.9%), p = 0.008], mainly driven by a higher risk of cardiac death and TVR. At multivariable Cox regression, PE with MØI was an independent predictor of MACEs [HR = 2.95, 95% CI (1.09-8.02), p = 0.034]. CONCLUSIONS Our study demonstrates that among ACS patients with PE the presence of MØI at culprit lesion is associated with more vulnerable plaque features, along with a worse prognosis at a long-term follow-up.
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Affiliation(s)
- Rocco A Montone
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Vincenzo Vetrugno
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Massimiliano Camilli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Michele Russo
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Fracassi
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Sohail Q Khan
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Sagar N Doshi
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jonathan N Townend
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Peter F Ludman
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Carlo Trani
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
| | - Giampaolo Niccoli
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy.
| | - Filippo Crea
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Institute of Cardiology, Catholic University of the Sacred Heart, Rome, Italy
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16
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Vetrugno V, Sharma H, Townend JN, Khan SQ. What is the cause of hypotension? A rare complication of percutaneous coronary intervention of a chronic total occlusion: a case report. Eur Heart J Case Rep 2020; 3:1-5. [PMID: 32123803 PMCID: PMC7042146 DOI: 10.1093/ehjcr/ytz184] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 07/02/2019] [Accepted: 09/25/2019] [Indexed: 11/29/2022]
Abstract
Background In the last few years, complex techniques and advanced equipment became available to treat chronically occluded coronary arteries. Such procedures portend a series of possible complications that operators should be ready to quickly recognize and deal with. Case summary A 75-year-old lady with uncontrolled stable angina underwent percutaneous treatment of a chronically occluded right coronary artery. After balloon angioplasty and stenting, she developed a severe hypotension, refractory to fluid resuscitation and vasopressors. Computerized tomography scan demonstrated an intramural haematoma (IMH) of the right atrioventricular groove resulting in life-threatening pseudotamponade (or dry tamponade), as further confirmed by cardiac magnetic resonance imaging (MRI). The decision was for conservative management and haemodynamic support by intra-aortic balloon pump. Clinically, the patient improved and was discharged a few days later. Follow-up MRI confirmed resolution of the IMH. Discussion Severe hypotension during percutaneous treatment of chronically occluded coronary arteries may be related to various causes. Differential diagnosis is thus important in this setting and should include IMH, a rare but potentially fatal complication as it may cause compression of cardiac chambers and lead to pseudotamponade. A high index of suspicion is required to diagnose IMH but there are no clear guidelines for management of such cases.
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Affiliation(s)
- Vincenzo Vetrugno
- Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Francesco Vito 1, 00168 Rome, Italy.,Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, B15 2TH Birmingham, UK
| | - Harish Sharma
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, B15 2TH Birmingham, UK
| | - Jonathan N Townend
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, B15 2TH Birmingham, UK
| | - Sohail Q Khan
- Department of Cardiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, B15 2TH Birmingham, UK
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17
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Sharma H, Vetrugno V, Khan SQ. Successful treatment of a spontaneous right coronary artery dissection with a 4-mm diameter cutting balloon: a case report. Eur Heart J Case Rep 2019; 3:1-6. [PMID: 31912001 PMCID: PMC6939819 DOI: 10.1093/ehjcr/ytz212] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 09/17/2019] [Accepted: 11/07/2019] [Indexed: 11/12/2022]
Abstract
Background Guidelines recommend conservative management for a spontaneous coronary artery dissection (SCAD) in the absence of ongoing ischaemia, haemodynamic instability, or left main dissection. Conventional percutaneous coronary intervention methods for SCAD are associated with an unfavourable prognosis due to difficulties wiring the lesion, dissection propagation, and potential ‘milking’ of the intramural haematoma along the vessel or into other vessels. These factors promote implantation of multiple stents which are often undersized, increasing the risk of in-stent restenosis significantly. There have been several case reports demonstrating the novel use of small diameter cutting balloons in the left anterior descending artery system. Here, we describe the successful use of a larger 4 mm cutting balloon to treat a spontaneous right coronary artery (RCA) dissection. Case summary A 53-year-old woman with troponin negative chest pain and was diagnosed with unstable angina due to ischaemic electrocardiographic features. Coronary angiography revealed a tight discrete lesion in the RCA. Intravascular imaging confirmed SCAD and a 4 mm cutting balloon was used to dissect the tunica intima to allow complete resorption of the intramural haematoma and resolution of symptoms. Discussion This case demonstrates the safe use of a larger 4 mm cutting balloon to treat an RCA SCAD, resulting in complete resolution of the haematoma.
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Affiliation(s)
- Harish Sharma
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, B15 2TH Edgbaston, Birmingham, UK
| | - Vincenzo Vetrugno
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, B15 2TH Edgbaston, Birmingham, UK.,Department of Cardiovascular and Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of the Sacred Heart, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Sohail Q Khan
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, B15 2TH Edgbaston, Birmingham, UK
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18
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Townend JN, Nadir A, George S, Khan SQ. VAD and CHIPS please. Int J Cardiol 2019; 293:105-106. [PMID: 31324397 DOI: 10.1016/j.ijcard.2019.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 11/29/2022]
Affiliation(s)
- J N Townend
- Dept of Cardiology, Queen Elizabeth Hospital, Birmingham B15 2TH, United Kingdom.
| | - A Nadir
- Dept of Cardiology, Queen Elizabeth Hospital, Birmingham B15 2TH, United Kingdom
| | - S George
- Dept of Cardiology, Queen Elizabeth Hospital, Birmingham B15 2TH, United Kingdom
| | - S Q Khan
- Dept of Cardiology, Queen Elizabeth Hospital, Birmingham B15 2TH, United Kingdom
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Lehru D, Mortimer N, Doshi SN, Zaphiriou A, George S, Khan SQ, Ludman PF, Townend JN, Nadir MA. P6150Clinical outcomes and downstream investigations following computed tomographic coronary angiography (CTCA) performed for evaluation of ambulatory patients with chest pain of recent onset. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
National Institute of Clinical Excellence guideline (NICE, CG95) recommends CTCA as a 1st line diagnostic test for evaluation of ambulatory patients with suspected stable angina based on its high sensitivity and low cost. This has led to increasing demand for CTCA across the National Health Service (NHS) in order to comply with the NICE recommendation.
Purpose
We studied the utility and effectiveness of CTCA in the evaluation of ambulatory patients with suspected stable angina attending rapid access chest pain clinic (RACPC) in a large tertiary hospital in the UK.
Methods
The study included consecutive patients attending RACPC over a pre-specified period of 6-months who were suspected of having stable angina and hence, referred for CTCA. The data were collected on demographics, CTCA results including incidental finding and downstream investigations. All patients had a minimum of 12-months follow up for clinical outcomes.
Results
A total of 170 patients were referred for CTCA (mean age = 56.8 years, male = 53.5%) out of the 388 consecutive patients who were reviewed in the RACPC during the 6-month period. CTCA was non-diagnostic in 48/170 (28.2%) cases (Breathing artefact 35%, Severe Coronary Calcification 31%, Elevated heart rate/Ectopy 30%) while 63/170 (37.1%) of patients had incidental extra-cardiac findings. Amongst patients with incidental findings, 17/63 (27.0%) underwent further investigations. A total of 54/170 (31.7%) of patients were recommended to have downstream cardiac investigations such as a stress test (DSE/MRI/MPS) (23/170, 15.8%) while 31/170 (18.2%) were referred for invasive coronary angiography. Revascularisation procedures (PCI n=7.6%, CABG n=4.7%) were required in 21/170 (12.4%) patients. Based on 2017 NHS tariffs, overall average cost-per-patient with the initial CTCA approach was £122.11 excluding downstream investigations and £548.43 including the cost of downstream cardiac investigations.
Incidental Findings after CTCA
Conclusions
Our study suggests that a CTCA based approach is associated with non-diagnostic information in at least 1:4 patients and incidental extracardiac findings in 1:3 patients. Further downstream cardiac investigations are required in around 1:3 patients after a CTCA carried out for evaluation suspected stable angina. The NICE recommendation is based on the low initial cost of CTCA and high sensitivity, however, taking in to account the additional cost of downstream investigations, the average cost per patient of this approach is significantly (4.5 times) higher.
Acknowledgement/Funding
None
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Affiliation(s)
- D Lehru
- University Hospital Birmingham, Birmingham, United Kingdom
| | - N Mortimer
- University Hospital Birmingham, Birmingham, United Kingdom
| | - S N Doshi
- University Hospital Birmingham, Birmingham, United Kingdom
| | - A Zaphiriou
- University Hospital Birmingham, Birmingham, United Kingdom
| | - S George
- University Hospital Birmingham, Birmingham, United Kingdom
| | - S Q Khan
- University Hospital Birmingham, Birmingham, United Kingdom
| | - P F Ludman
- University Hospital Birmingham, Birmingham, United Kingdom
| | - J N Townend
- University Hospital Birmingham, Birmingham, United Kingdom
| | - M A Nadir
- University Hospital Birmingham, Birmingham, United Kingdom
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Cherukat J, Mechery A, Sandhu K, Khan SQ. P4574Anticoagulation and antiplatelet therapy in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI): Real world data. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p4574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Cherukat
- University of Birmingham, Birmingham, United Kingdom
| | - A Mechery
- University Hospital Birmingham, Cardiology, Birmingham, United Kingdom
| | - K Sandhu
- University Hospital Birmingham, Cardiology, Birmingham, United Kingdom
| | - S Q Khan
- University Hospital Birmingham, Cardiology, Birmingham, United Kingdom
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Khan SQ. TCTAP C-204 The Value of Intravascular Ultrasound in Aiding a Difficult Myocardial Infarction. J Am Coll Cardiol 2018. [DOI: 10.1016/j.jacc.2018.03.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Khan SQ. TCTAP C-228 Intraluminal Narrowing in Acute Coronary Syndrome - The Value of Intracoronary Imaging to Aid Diagnosis. J Am Coll Cardiol 2016. [DOI: 10.1016/j.jacc.2016.03.444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Mechery A, Jordan PJ, Doshi SN, Khan SQ. Retrieval of a stuck Rotablator burr ("Kokeshi phenomenon") and successful percutaneous coronary intervention. J Cardiol Cases 2015; 13:90-92. [PMID: 30546615 DOI: 10.1016/j.jccase.2015.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Revised: 09/06/2015] [Accepted: 10/28/2015] [Indexed: 11/25/2022] Open
Abstract
We report the case of a 74-year-old man having angioplasty following admission with a troponin positive acute coronary syndrome. Due to heavy coronary artery calcification, rotablation was used. The procedure was complicated by a stuck burr ("Kokeshi phenomenon"). We employed a novel method to safely remove the burr and complete the procedure. <Learning objective: Various methods have been described for the retrieval of an entrapped Rotablator burr; we show in this case that deep engagement of guiding catheter and manual traction is a safe and effective method for retrieval.>.
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Affiliation(s)
- Anthony Mechery
- Department of Interventional Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Paul J Jordan
- Department of Interventional Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Sagar N Doshi
- Department of Interventional Cardiology, University Hospitals Birmingham, Birmingham, UK
| | - Sohail Q Khan
- Department of Interventional Cardiology, University Hospitals Birmingham, Birmingham, UK
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Abstract
The transradial approach for coronary catheterisation has gained rising popularity owing to its fewer access site complications compared with the transfemoral approach. A rare but recognisable complication of the procedure is radial artery pseudoaneurysm (PSA). We report a case of radial PSA occurring 2 h following percutaneous coronary intervention in an 85-year-old woman, which was successfully treated by ultrasound-guided thrombin injection. This non-surgical technique has recently gained rising popularity as a relatively novel modality of managing radial PSA.
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Affiliation(s)
- Mohamed Osama Mohamed
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, UK
| | - Mohsin Saif
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, UK
| | - John N Townend
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, UK
| | - Sohail Q Khan
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, Birmingham, West Midlands, UK
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Khan SQ. TCTAP C-048 Treatment Options in an Ostial LAD Lesion. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.03.320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Khan SQ. TCTAP C-153 Intracoronary Imaging to Guide PCI. J Am Coll Cardiol 2015. [DOI: 10.1016/j.jacc.2015.03.433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Noroozian N, Bashir A, Bradlow W, Khan SQ. Mechanical mitral valve thrombosis in rheumatic valve disease. BMJ Case Rep 2014; 2014:bcr-2013-201918. [PMID: 24574523 DOI: 10.1136/bcr-2013-201918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Neda Noroozian
- Department of Cardiology, University Hospital Birmingham, Birmingham, West Midlands, UK
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Affiliation(s)
- Ahmed Bashir
- Department of Cardiology, Queen Elizabeth Hospital, Birmingham, UK
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Dhillon OS, Narayan HK, Khan SQ, Kelly D, Quinn PA, Squire IB, Davies JE, Ng LL. Pre-discharge risk stratification in unselected STEMI: Is there a role for ST2 or its natural ligand IL-33 when compared with contemporary risk markers? Int J Cardiol 2013; 167:2182-8. [DOI: 10.1016/j.ijcard.2012.05.073] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2011] [Revised: 05/09/2012] [Accepted: 05/27/2012] [Indexed: 12/22/2022]
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Freixa X, Almasood AS, Khan SQ, Mackie K, Osten M, Ing D, Overgaard CB, Horlick EM, Seidelin PH, Džavík V. Choice of stent and outcomes after treatment of drug-eluting stent restenosis in highly complex lesions. Catheter Cardiovasc Interv 2012; 81:E16-22. [DOI: 10.1002/ccd.24291] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2011] [Accepted: 12/10/2011] [Indexed: 11/08/2022]
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Freixa X, Almasood AS, Khan SQ, Wainstein R, Osherov A, Mackie K, Seidelin PH, Džavík V. Decreased risk of stent fracture-related restenosis between paclitaxel-eluting stents and sirolimus eluting stents: Results of long-term follow-up. Catheter Cardiovasc Interv 2011; 79:559-65. [DOI: 10.1002/ccd.23031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2010] [Accepted: 01/29/2011] [Indexed: 11/12/2022]
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Almasood AS, Freixa X, Khan SQ, Seidelin PH, Džavík V. Stent fracture after everolimus-eluting stent implantation. Cardiol Res Pract 2011; 2011:320983. [PMID: 21559260 PMCID: PMC3087897 DOI: 10.4061/2011/320983] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Accepted: 02/06/2011] [Indexed: 11/20/2022] Open
Abstract
Compared with bare-metal stents, drug-eluting stents (DES) have greatly reduced the risk of in-stent restenosis (ISR) by inhibiting neointimal growth. Nevertheless, DES are still prone to device failure, which may lead to cardiac events. Recently, stent fracture (SF) has emerged as a potential mechanism of DES failure that is associated with ISR. Stent fracture is strongly related to stent type, and prior reports suggest that deployment of sirolimus eluting stents (SES) may be associated with a higher risk of SF compared to other DES. Everolimus eluting stents (EESs) represent a new generation of DES with promising results. The occurrence of SF with EES has not been well established. The present paper describes two cases of EES fracture associated with ISR.
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Affiliation(s)
- Ali S Almasood
- Interventional Cardiology Program, Division of Cardiology, Peter Munk Cardiac Centre, University Health Network, University of Toronto, 6-246 EN, Toronto General Hospital, 200 Elizabeth Street, Toronto, ON, Canada M5G 2C4
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Khawaja MZ, Rajani R, Cook A, Khavandi A, Moynagh A, Chowdhary S, Spence MS, Brown S, Khan SQ, Walker N, Trivedi U, Hutchinson N, De Belder AJ, Moat N, Blackman DJ, Levy RD, Manoharan G, Roberts D, Khogali SS, Crean P, Brecker SJ, Baumbach A, Mullen M, Laborde JC, Hildick-Smith D. Permanent pacemaker insertion after CoreValve transcatheter aortic valve implantation: incidence and contributing factors (the UK CoreValve Collaborative). Circulation 2011; 123:951-60. [PMID: 21339482 DOI: 10.1161/circulationaha.109.927152] [Citation(s) in RCA: 251] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Permanent pacemaker (PPM) requirement is a recognized complication of transcatheter aortic valve implantation. We assessed the UK incidence of permanent pacing within 30 days of CoreValve implantation and formulated an anatomic and electrophysiological model. METHODS AND RESULTS Data from 270 patients at 10 centers in the United Kingdom were examined. Twenty-five patients (8%) had preexisting PPMs; 2 patients had incomplete data. The remaining 243 were 81.3±6.7 years of age; 50.6% were male. QRS duration increased from 105±23 to 135±29 milliseconds (P<0.01). Left bundle-branch block incidence was 13% at baseline and 61% after the procedure (P<0.001). Eighty-one patients (33.3%) required a PPM within 30 days. Rates of pacing according to preexisting ECG abnormalities were as follows: right bundle-branch block, 65.2%; left bundle-branch block, 43.75%; normal QRS, 27.6%. Among patients who required PPM implantation, the median time to insertion was 4.0 days (interquartile range, 2.0 to 7.75 days). Multivariable analysis revealed that periprocedural atrioventricular block (odds ratio, 6.29; 95% confidence interval, 3.55 to 11.15), balloon predilatation (odds ratio, 2.68; 95% confidence interval, 2.00 to 3.47), use of the larger (29 mm) CoreValve prosthesis (odds ratio, 2.50; 95% confidence interval, 1.22 to 5.11), interventricular septum diameter (odds ratio, 1.18; 95% confidence interval, 1.10 to 3.06), and prolonged QRS duration (odds ratio, 3.45; 95% confidence interval, 1.61 to 7.40) were independently associated with the need for PPM. CONCLUSION One third of patients undergoing a CoreValve transcatheter aortic valve implantation procedure require a PPM within 30 days. Periprocedural atrioventricular block, balloon predilatation, use of the larger CoreValve prosthesis, increased interventricular septum diameter and prolonged QRS duration were associated with the need for PPM.
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Affiliation(s)
- M Z Khawaja
- UK CoreValve Collaborative, Sussex Cardiac Centre, Brighton & Sussex University Hospital Trust, Eastern Road, Brighton, East Sussex, BN2 5BE, UK
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Kelly D, Squire IB, Khan SQ, Dhillon O, Narayan H, Ng KH, Quinn P, Davies JE, Ng LL. Usefulness of plasma tissue inhibitors of metalloproteinases as markers of prognosis after acute myocardial infarction. Am J Cardiol 2010; 106:477-82. [PMID: 20691304 DOI: 10.1016/j.amjcard.2010.03.060] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 03/25/2010] [Accepted: 03/25/2010] [Indexed: 01/30/2023]
Abstract
Alterations in the balance of matrix metalloproteinase to tissue inhibitor of metalloproteinase (TIMP) are seen after acute myocardial infarction (AMI) and are associated with adverse left ventricular remodeling and prognosis in this setting. We aimed to investigate the association between TIMP levels and the occurrence of major adverse cardiac events (MACEs) after AMI. We measured plasma TIMP-1, -2, and -4 levels in 1,313 patients presenting with AMI. Subjects were followed over a median period of 520 days for the occurrence of MACEs. Clinical risk was assessed using the Global Registry of Acute Coronary Events (GRACE) score. All TIMP levels correlated with patient age and inversely with estimated glomerular filtration rate (all p values <0.001). Levels were higher in women versus men (p <0.001) and in subjects with a history of diabetes (TIMP-1, p <0.001; TIMP-2, p = 0.002; TIMP-4, p <0.001) or hypertension (TIMP-1, p = 0.031; TIMP-2, p <0.001; TIMP-4, p <0.001). TIMP-1 and TIMP-4 were higher in subjects with previous MI or angina (p <0.001). TIMP levels increased incrementally with quartiles of GRACE score (p <0.001). All TIMPs showed univariate association with the occurrence of MACEs (p <0.001). Areas under the receiver operator characteristic curve for prediction of MACE at 1 year were 0.61 for TIMP-1, 0.57 for TIMP-2, and 0.64 for TIMP-4. Combination of TIMPs with GRACE risk score revealed a greater area under the curve than GRACE score alone (0.72 vs 0.69, p = 0.0015). On multivariable Cox proportional hazards analysis, GRACE score (p <0.001) and plasma TIMPs (log TIMP-1, p = 0.017; log TIMP-2, p <0.001; log TIMP-4, p = 0.011) independently predicted MACEs. Using Kaplan-Meier analysis, the risk of MACEs increased incrementally with the number of TIMPs above their respective median (p <0.001 for all comparisons, log-rank test). In conclusion, higher plasma TIMP-1, -2, and -4 after AMI are associated with MACEs and provide additional prognostic information to that obtained from GRACE clinical risk scores alone.
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Affiliation(s)
- Dominic Kelly
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
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Dhillon OS, Khan SQ, Narayan HK, Ng KH, Struck J, Quinn PA, Morgenthaler NG, Squire IB, Davies JE, Bergmann A, Ng LL. Prognostic Value of Mid-Regional Pro-Adrenomedullin Levels Taken on Admission and Discharge in Non–ST-Elevation Myocardial Infarction. J Am Coll Cardiol 2010; 56:125-33. [DOI: 10.1016/j.jacc.2010.01.060] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2009] [Revised: 01/07/2010] [Accepted: 01/18/2010] [Indexed: 11/28/2022]
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Dhillon OS, Khan SQ, Narayan NH, Ng KH, Struck J, Quinn PA, Morgenthaler NG, Squire IB, Dvaies JE, Bergmann A, Ng LL. 043 Admission MR-PROANP levels are superior to grace score and NT-PROBNP for risk stratification in non ST-elevation acute coronary syndromes: Abstract 43 Table 1. Heart 2010. [DOI: 10.1136/hrt.2010.195958.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kelly D, Khan SQ, Dhillon O, Quinn P, Struck J, Squire IB, Davies JE, Ng LL. Procalcitonin as a prognostic marker in patients with acute myocardial infarction. Biomarkers 2010; 15:325-31. [DOI: 10.3109/13547501003675084] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Khan SQ, Ng K, Dhillon O, Kelly D, Quinn P, Squire IB, Davies JE, Ng LL. Growth differentiation factor-15 as a prognostic marker in patients with acute myocardial infarction. Eur Heart J 2009; 30:1057-65. [PMID: 19168526 DOI: 10.1093/eurheartj/ehn600] [Citation(s) in RCA: 157] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS Our aim was to assess the long-term prognostic value of growth differentiation factor-15 (GDF-15) in patients post-acute myocardial infarction (AMI). Growth differentiation factor-15 is a member of the transforming growth factor beta family. Growth differentiation factor-15 is expressed in the myocardium and upregulated due to 'stress' and has been shown to have antiapoptotic actions. Its role in the cardiovascular system however is not well defined. We were interested to see if GDF-15 could provide long-term prognostic value in post-AMI patients. We compared GDF-15 with N-terminal pro-B-type natriuretic peptide (NT-proBNP). METHODS AND RESULTS We recruited 1142 consecutive post-AMI patients [820 men, median (range) age 67 (24-97) years] in a prospective study with a follow-up period of 505 (range 1-2837) days. Growth differentiation factor-15 levels increased with increasing Killip class (P < 0.001) and were correlated with NT-proBNP (r = 0.47, P < 0.001). Using a multivariable Cox proportional hazards model, log GDF-15 (HR 1.77), log NT-proBNP (HR 2.06), age (HR 1.03) Killip class above 1, (HR 1.62), use of beta-blockers (HR 0.54) and past history of MI (HR 1.44) were significant independent predictors of death or heart failure (HF). Predictors of death were log NT-proBNP, log GDF-15, age, eGFR, past history of MI, use of beta-blockers, and use of ACE inhibitors or angiotensin receptor blockers. The C-statistic for GDF-15 for predicting death or HF at 1 year was 0.73 (95% CI: 0.70-0.76, P < 0.001) and was 0.76 (95% CI: 0.70-0.80, P < 0.001) for NT-proBNP. Combining these markers yielded an AUC of 0.81 (95% CI: 0.77-0.85), which exceeded that of GDF-15 (P < 0.001) and NT-proBNP (P = 0.004) alone. The Kaplan-Meier analysis revealed that those patients with above median GDF-15 and NT-proBNP had the highest event rate for death and HF (log rank 50.22, P < 0.001). CONCLUSION Growth differentiation factor-15 is a new marker for predicting death and HF in post-AMI patients. GDF-15 provides prognostic information over and above clinical factors and the established biomarker NT-proBNP. Combined levels of GDF-15 with NT-proBNP can identify a high-risk group of patients.
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Affiliation(s)
- Sohail Q Khan
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK.
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Kelly D, Khan SQ, Thompson M, Cockerill G, Ng LL, Samani N, Squire IB. Plasma tissue inhibitor of metalloproteinase-1 and matrix metalloproteinase-9: novel indicators of left ventricular remodelling and prognosis after acute myocardial infarction. Eur Heart J 2008; 29:2116-24. [PMID: 18614523 DOI: 10.1093/eurheartj/ehn315] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Matrix metalloproteinase (MMP) activity is central to the development of left ventricular (LV) remodelling and dysfunction after acute myocardial infarction (AMI). We assessed the relationships with LV structure and function and outcome, of tissue inhibitors of metalloproteinase-1 (TIMP-1) and MMP-9, and compared with N-terminal pro-B-type natriuretic peptide (NTproBNP). METHODS AND RESULTS We studied 404 patients with AMI. Primary outcome measures were the associations of TIMP-1, MMP-9, and NTproBNP with death or heart failure, and with LV dimensions, function and remodelling (ΔLVEDV, change in LV end-diastolic volume between discharge and follow-up). Cut-off concentrations for prediction of death or heart failure were identified from receiver operator characteristic (ROC) curves. In multivariable analysis, TIMP-1 and NTproBNP had predictive value for LV ejection fraction pre-discharge (TIMP-1 P = 0.023; N-BNP P = 0.007) and at follow-up (TIMP-1 P = 0.001; N-BNP P = 0.003). MMP-9, TIMP-1, and NTproBNP correlated directly with LV volumes. MMP-9 (P = 0.005) and TIMP-1 (P = 0.036), but not NTproBNP, correlated with ΔLVEDV. For the combined endpoint of death or heart failure the area under the ROC curve was 0.640 for MMP-9, 0.799 for NTproBNP and 0.811 for TIMP-1. Patients with TIMP-1 > 135 ng/mL (P < 0.001) or NTproBNP >1472 fmol/mL (P < 0.001) had increased risk of endpoint. Consideration of both NTproBNP and TIMP-1 further improved risk stratification. CONCLUSION TIMP-1 and MMP-9 correlate with echocardiographic parameters of LV dysfunction and remodelling after AMI and may identify patients at risk of subsequent LV remodelling and adverse prognosis.
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Affiliation(s)
- Dominic Kelly
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK
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Khan SQ, Dhillon O, Kelly D, Squire IB, Struck J, Quinn P, Morgenthaler NG, Bergmann A, Davies JE, Ng LL. Plasma N-Terminal B-Type Natriuretic Peptide as an Indicator of Long-Term Survival After Acute Myocardial Infarction: Comparison With Plasma Midregional Pro-Atrial Natriuretic Peptide. J Am Coll Cardiol 2008; 51:1857-64. [DOI: 10.1016/j.jacc.2008.01.041] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2007] [Revised: 01/15/2008] [Accepted: 01/21/2008] [Indexed: 11/25/2022]
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Abstract
BACKGROUND The TIMI risk score is a well-validated scoring system used to predict mortality in patients following an ST-segment elevation myocardial infarction (STEMI). N-terminal pro-B-type natriuretic peptide (NTproBNP) has also been found to be useful in predicting mortality following STEMI. OBJECTIVE To investigate the utility of the TIMI score and NTproBNP levels at predicting risk of death in patients with acute myocardial infarction (AMI). METHODS 473 patients (352 men, mean (SD) age 63.7 (12.3) years) with AMI were studied. Blood was drawn within 24 hours after the onset of chest pain and the plasma concentration of NTproBNP was determined using an in-house non-competitive immunoassay. Patients' TIMI risk score was measured and patients stratified into low- (0 to 2), intermediate- (3-7) and high-risk (>8) groups. RESULTS Mortality was 8.9% and was related to higher TIMI risk scores (p = 0.029 for trend). Higher NTproBNP levels were also related to increased mortality (median (range) fmol/ml, survivors 700.2 (0.3-11485.3) vs dead 5781.3 (1.4-10835.9), p<0.001). In a multivariate binary logistic regression model, independent predictors of mortality were NTproBNP levels in the first 24 hours (odds ratio (OR) = 4.21, 95% CI 1.96 to 9.07, p<0.001) together with drug treatments. The receiver operating curve for NTproBNP in the first 24 hours yielded an area under the curve (AUC) of 0.79 (95% CI 0.70 to 0.88), p<0.001, for TIMI risk score the AUC was 0.67 (95% CI 0.58 to 0.76), p = 0.001. CONCLUSION In the first 24 hours following an AMI, NTproBNP is better than the TIMI risk score at predicting mortality. A simple NTproBNP blood test is more easily applicable and is more accurate than a clinical risk score.
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Affiliation(s)
- S Q Khan
- University of Leicester, Department of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, UK.
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Khan SQ, Dhillon O, Struck J, Quinn P, Morgenthaler NG, Squire IB, Davies JE, Bergmann A, Ng LL. C-terminal pro-endothelin-1 offers additional prognostic information in patients after acute myocardial infarction: Leicester Acute Myocardial Infarction Peptide (LAMP) Study. Am Heart J 2007; 154:736-42. [PMID: 17893002 DOI: 10.1016/j.ahj.2007.06.016] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2007] [Accepted: 06/17/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Endothelin-1 is elevated in heart failure (HF) and after acute myocardial infarction (AMI) and gives prognostic information on mortality. Another part of its precursor, C-terminal pro-endothelin-1 (CT-proET-1), is more stable in circulation and ex vivo. We investigated the cardiovascular prognostic value post-AMI of CT-proET-1 and compared it to N-terminal pro-B-type natriuretic peptide (NTproBNP), a marker of death and HF. METHODS We measured plasma CT-proET-1 and NTproBNP in 983 consecutive post-AMI patients (721 men, mean age 65.0 +/- [SD] 12.2 years), 3 to 5 days after chest pain onset. RESULTS There were 101 deaths and 49 readmissions with HF during follow-up (median 343, range 0-764 days). C-terminal pro-endothelin-1 was raised in patients with death or HF compared to survivors (median [range] [pmol/L], 119.0 [14.0-671.0] vs 73.0 [4.6-431.0], P < .0001). Using a Cox proportional hazards logistic model, log CT-proET-1 (HR 6.82) and log NTproBNP (HR 2.62) were significant independent predictors of death or HF (along with age, sex, history of AMI, and therapy with beta-blockers). The areas under the receiver operating curve for CT-proET-1, NTproBNP, and the logistic model with both markers were 0.76, 0.76, and 0.81 respectively. Findings were similar for death and HF as individual end points. CONCLUSION The endothelin system is known to be activated post AMI. C-terminal pro-endothelin-1 is a powerful predictor of adverse outcome, along with NTproBNP. CT-proET-1 may represent a clinically useful marker of prognosis after AMI.
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Khan SQ, Bhandari SS, Quinn P, Davies JE, Ng LL. Urotensin II is raised in acute myocardial infarction and low levels predict risk of adverse clinical outcome in humans. Int J Cardiol 2007; 117:323-8. [PMID: 16887216 DOI: 10.1016/j.ijcard.2006.05.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2006] [Revised: 05/16/2006] [Accepted: 05/18/2006] [Indexed: 11/17/2022]
Abstract
BACKGROUND UII is elevated in patients with heart failure; however its role in acute myocardial infarction (AMI) is unknown. We sought to compare levels of UII in patients with AMI to controls. We also compared UII to N terminal pro B type natriuretic peptide (NT-BNP) to evaluate whether levels of UII can be used to predict the risk of adverse clinical outcome (ACO). METHODS AND RESULTS 129 patients were studied with serial blood measurements and echocardiogram during their index admission. Plasma concentration of median UII was significantly elevated in AMI compared to controls (median 1.40 vs. 0.42 fmol/ml p<0.012). Over the median follow up of 102 days (range 0-189) there were 14 deaths and 14 readmissions with AMI or heart failure. Using a Cox proportional hazards model the only independent predictors of ACO were UII (OR 0.29, p=0.046) and NT-BNP (OR 4.78, p=0.012) between 73 and 96 h. The Kaplan-Meier survival curve revealed a significantly better clinical outcome in patients with UII above the median compared with UII below the median. CONCLUSIONS UII levels are raised in AMI and is an independent predictor of ACO. Patients with a poor outcome mount a lower UII response suggesting a possible cardioprotective role for this peptide.
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Affiliation(s)
- Sohail Q Khan
- University of Leicester, Department of Cardiovascular Sciences, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK.
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Khan SQ, Dhillon OS, O'Brien RJ, Struck J, Quinn PA, Morgenthaler NG, Squire IB, Davies JE, Bergmann A, Ng LL. C-terminal provasopressin (copeptin) as a novel and prognostic marker in acute myocardial infarction: Leicester Acute Myocardial Infarction Peptide (LAMP) study. Circulation 2007; 115:2103-10. [PMID: 17420344 DOI: 10.1161/circulationaha.106.685503] [Citation(s) in RCA: 277] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The role of the vasopressin system after acute myocardial infarction is unclear. Copeptin, the C-terminal part of the vasopressin prohormone, is secreted stoichiometrically with vasopressin. We compared the prognostic value of copeptin and an established marker, N-terminal pro-B-type natriuretic peptide (NTproBNP), after acute myocardial infarction. METHODS AND RESULTS In this prospective single-hospital study, we recruited 980 consecutive post-acute myocardial infarction patients (718 men, median [range] age 66 [24 to 95] years), with follow-up over 342 (range 0 to 764) days. Plasma copeptin was highest on admission (n=132, P<0.001, day 1 versus days 2 to 5) and reached a plateau at days 3 to 5. In the 980 patients, copeptin (measured at days 3 to 5) was elevated in patients who died (n=101) or were readmitted with heart failure (n=49) compared with survivors (median [range] 18.5 [0.6 to 441.0] versus 6.5 [0.3 to 267.0] pmol/L, P<0.0005). With logistic regression analysis, copeptin (odds ratio, 4.14, P<0.0005) and NTproBNP (odds ratio, 2.26, P<0.003) were significant independent predictors of death or heart failure at 60 days. The area under the receiver operating characteristic curves for copeptin (0.75) and NTproBNP (0.76) were similar. The logistic model with both markers yielded a larger area under the curve (0.84) than for NTproBNP (P<0.013) or copeptin (P<0.003) alone, respectively. Cox modeling predicted death or heart failure with both biomarkers (log copeptin [hazard ratio, 2.33], log NTproBNP [hazard ratio, 2.70]). In patients stratified by NTproBNP (above the median of approximately 900 pmol/L), copeptin above the median (approximately 7 pmol/L) was associated with poorer outcome (P<0.0005). Findings were similar for death and heart failure as individual end points. CONCLUSIONS The vasopressin system is activated after acute myocardial infarction. Copeptin may predict adverse outcome, especially in those with an elevated NTproBNP (more than approximately 900 pmol/L).
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Affiliation(s)
- Sohail Q Khan
- University of Leicester, Department of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester LE2 7LX, UK
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Khan SQ, O'Brien RJ, Struck J, Quinn P, Morgenthaler N, Squire I, Davies J, Bergmann A, Ng LL. Prognostic value of midregional pro-adrenomedullin in patients with acute myocardial infarction: the LAMP (Leicester Acute Myocardial Infarction Peptide) study. J Am Coll Cardiol 2007; 49:1525-32. [PMID: 17418290 DOI: 10.1016/j.jacc.2006.12.038] [Citation(s) in RCA: 124] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2006] [Revised: 11/28/2006] [Accepted: 12/05/2006] [Indexed: 12/20/2022]
Abstract
OBJECTIVES This study sought to assess the prognostic impact of midregional pro-adrenomedullin (MR-proADM) after an acute myocardial infarction (AMI). BACKGROUND Adrenomedullin (ADM) is elevated in heart failure (HF) and after AMI. Another part of its precursor, MR-proADM, is more stable in circulation and ex vivo. We investigated the cardiovascular prognostic value after AMI of MR-proADM and compared it with N-terminal pro-B-type natriuretic peptide (NTproBNP), a marker of death and HF. METHODS We measured plasma MR-proADM and NTproBNP in 983 consecutive post-AMI patients (721 men, mean age 65.0 +/- 12.2 years), 3 to 5 days after chest pain onset. RESULTS There were 101 deaths and 49 readmissions with HF during follow-up (median 342, range 0 to 764 days). The MR-proADM was increased in patients with death or HF compared with survivors (median 1.19 nmol/l, range 0.09 to 5.39 nmol/l, vs. 0.71 nmol/l, range 0.25 to 6.66 nmol/l, p < 0.0001). Using a multivariate binary logistic model, log MR-proADM (odds ratio 4.22) and log NTproBNP (odds ratio 3.20) were significant independent predictors of death or HF (with creatinine, age, gender, and history of AMI). The areas under the receiver-operating characteristic curve for MR-proADM, NTproBNP, and the logistic model with both markers were 0.77, 0.79, and 0.84 respectively. Cox models for the predictors of death or HF showed the same variables (including log MR-proADM, hazard ratio 3.63; log NTproBNP, hazard ratio 2.67). The MR-proADM provided further risk stratification in those patients who had NTproBNP levels above the median (p < 0.0001). Findings were similar for death and HF as individual end points. CONCLUSIONS The ADM system is activated after AMI. The MR-proADM is a powerful predictor of adverse outcome, especially in those with an elevated NTproBNP. The MR-proADM may represent a clinically useful marker of prognosis after AMI.
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Affiliation(s)
- Sohail Q Khan
- University of Leicester, Department of Cardiovascular Sciences, Leicester Royal Infirmary, Leicester, United Kingdom.
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Khan SQ, Kelly D, Quinn P, Davies JE, Ng LL. Myotrophin is a more powerful predictor of major adverse cardiac events following acute coronary syndrome than N-terminal pro-B-type natriuretic peptide. Clin Sci (Lond) 2007; 112:251-6. [PMID: 17014419 DOI: 10.1042/cs20060191] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Myotrophin is a 12 kDa protein initially isolated from hypertrophied hearts of spontaneously hypertensive rats and acts by modulating NF-kappaB (nuclear factor kappaB) activity. We have reported previously the presence of myotrophin in patients with human systolic heart failure; however, its role as a predictor of MACE (major adverse cardiac events) in patients with ACS (acute coronary syndrome) is unclear. In the present study, we sought to investigate this and compared myotrophin with NTproBNP (N-terminal pro-B-type natriuretic peptide), a marker of MACE. We studied 356 patients with ACS {276 men; mean age, 63.0+/-12.8 years; 80.6% STEMI [ST segment elevation MI (myocardial infarction)]; and 19.4% NSTEMI (non-STEMI)}. Blood measurement was made at 25-48 h after the onset of chest pain. The plasma concentration of myotrophin and NTproBNP was determined using in-house non-competitive immunoassays. Patients were followed-up for the combined end point of death, MI or need for urgent revascularization. Over the median follow-up period of 355 (range 0-645) days, there were 28 deaths, 27 non-fatal MIs and 73 patients required urgent revascularization. Myotrophin was raised in patients with MACE compared with survivors [510.7 (116.0-7445.6) fmol/ml compared with 371.5 (51.8-6990.4) fmol/ml respectively; P=0.001; values are medians (range)]. Using a Cox proportional hazards model, myotrophin {HR (hazard ratio), 1.64 [95% CI (confidence interval), 0.97-2.76]; P=0.05} and Killip class above 1 [HR, 1.52 (95% CI, 0.93-2.42); P=0.10] were the only independent predictors of MACE. A Kaplan-Meier survival curve revealed a significantly better clinical outcome in patients with myotrophin below the median compared with those with myotrophin above the median (log rank, 7.63; P=0.006). In conclusion, after an ACS, levels of myotrophin are more informative at predicting MACE than NTproBNP and may be useful to risk stratify patients.
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Affiliation(s)
- Sohail Q Khan
- Department of Cardiovascular Sciences, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, Leicester LE2 7LX, UK.
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Khan SQ, Kelly D, Quinn P, Davies JE, Ng LL. Myeloperoxidase aids prognostication together with N-terminal pro-B-type natriuretic peptide in high-risk patients with acute ST elevation myocardial infarction. Heart 2006; 93:826-31. [PMID: 17194712 PMCID: PMC1994475 DOI: 10.1136/hrt.2006.091041] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Inflammation plays a critical role in acute myocardial infarction (MI). One such inflammatory marker is myeloperoxidase (MPO). Its role as a predictor of death or MI in patients with ST segment elevation myocardial infarction (STEMI) is unclear. AIM To investigate the role of MPO as a predictor of death or MI in patients with STEMI and to compare it with N-terminal pro-B-type natriuretic peptide (NT-BNP). METHOD 384 post STEMI patients were studied. Patients were followed up for the combined end point of death or readmission with non-fatal MI. RESULTS There were 40 deaths and 37 readmissions with MI. Median MPO was raised in patients experiencing death or MI than in survivors (median (range), 50.6 (15.3-124.1) ng/ml vs 33.5 (6.6-400.2) ng/ml, p = 0.001). Using a Cox proportional hazards model, log median MPO (HR 6.91, 95% CI 1.79 to 26.73, p = 0.005) and log median NT-BNP (HR 4.21, 95% CI 1.53 to 11.58, p = 0.005) independently predicted death or non-fatal MI. MPO had predictive power in both below and above median NT-BNP levels (log rank 5.60, p = 0.020 and log rank 5.12, p = 0.024, respectively). The receiver-operating curve for median NT-BNP yielded an area under the curve (AUC) of 0.72 (95% CI 0.65 to 0.79, p<0.001); for median MPO, the AUC was 0.62 (95% CI 0.55 to 0.69, p = 0.001). The logistic model combining the two markers yielded an AUC of 0.76 (95% CI 0.69 to 0.82, p<0.001). CONCLUSION MPO and NT-BNP may be useful tools for risk stratification of all acute coronary syndromes, including patients with STEMI at higher risk.
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Affiliation(s)
- Sohail Q Khan
- Department of Cardiovascular Medicine, University of Leicester, Clinical Sciences Building, Leicester Royal Infirmary, Leicester, UK.
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Khan SQ, Kelly D, Quinn P, Davies JE, Ng LL. Cardiotrophin-1 Predicts Death or Heart Failure Following Acute Myocardial Infarction. J Card Fail 2006; 12:635-40. [PMID: 17045183 DOI: 10.1016/j.cardfail.2006.06.470] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2006] [Revised: 06/14/2006] [Accepted: 06/14/2006] [Indexed: 11/30/2022]
Abstract
BACKGROUND Cardiotrophin-1 (CT-1) is an important inflammatory cytokine; its presence has been documented in patients after acute myocardial infarction (AMI). However, its role as a predictor of death or heart failure is unclear. We sought to investigate this and compared it with N terminal pro-B-type natriuretic peptide (NT-proBNP), a marker of death or heart failure. METHODS AND RESULTS We studied 291 post-AMI patients. The plasma concentration of CT-1 and NT-proBNP was determined using in-house noncompetitive immunoassays and patients followed for death or heart failure. There were 27 deaths and 19 readmissions with heart failure. CT-1 was raised in patients with death or heart failure compared with survivors (median [range] fmol/mL, 0.9 [0.1-392.2] vs. 0.67 [0-453.3], P = .019). Using a multivariate binary logistic model CT-1 (OR 1.8, 95% CI: 1.1-3.2, P = .031) and NT-proBNP (OR 2.4, 95% CI: 1.1-5.2, P = .026) predicted death or heart failure independently of age, sex, previous AMI, serum creatinine, and Killip class. The receiver-operating curve for CT-1 yielded an area under the curve (AUC) of 0.62 (95% CI: 0.53-0.70, P = .017); for NT-proBNP the AUC was 0.77 (95% CI: 0.69-0.86, P < .001); the logistic model combining the 2 markers yielded an AUC of 0.84 (95% CI: 0.78-0.91, P < .001). CONCLUSION After an AMI, combined levels of CT-1 and NT-proBNP are more informative at predicting death or heart failure than either marker alone.
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Affiliation(s)
- Sohail Q Khan
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
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Sogo N, Wilkinson IB, MacCallum H, Khan SQ, Strachan FE, Newby DE, Megson IL, Webb DJ. A novel S-nitrosothiol (RIG200) causes prolonged relaxation in dorsal hand veins with damaged endothelium. Clin Pharmacol Ther 2000; 68:75-81. [PMID: 10945318 DOI: 10.1067/mcp.2000.107049] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Reduced nitric oxide bioavailability caused by endothelial dysfunction or damage is a contributory factor in the initiation and progression of a number of cardiovascular diseases. Delivery of exogenous nitric oxide is an attractive therapeutic option, but current agents lack selectivity for areas of endothelial damage. We tested the hypothesis that a novel nitric oxide donor drug, N-(S-nitroso-N-acetylpenicillamine)-2-amino-2-deoxy-1,3,4,6-tetra-O-acet yl-P-glucopyranose [RIG200], which has selective effects in endothelium-denuded isolated arteries in vitro, would exert similar effects in dorsal hand veins with experimentally damaged endothelium in vivo. METHODS Venodilator responses to sodium nitroprusside and RIG200 were compared in two groups of healthy volunteers (age range, 18 to 63 years; n = 7 for each group) in norepinephrine 70% maximum effective concentration (EC70) preconstricted hand veins with use of the Aellig technique. In this doubleblind study, subjects were randomly assigned to receive either sodium nitroprusside or RIG200 (infusions of 0.06 and 6 nmol/min into the hand vein) before and 2 days after 15 minutes of local venous irription with distilled water. Endothelial function was assessed in all subjects on both visits with use of the endothelium-dependent vasodilator acetylcholine (1 nmol/min). RESULTS Irrigation of hand veins with distilled water abolished endothelium-dependent dilatation in response to acetylcholine in both study groups (n = 14) but did not affect the amplitude or duration of responses to the conventional nitric oxide donor sodium nitroprusside (P = .87; n = 7). However, responses to RIG200 were significantly prolonged during the washout phase (30 minutes) in veins after water irrigation (P = .02; n = 7). CONCLUSION These studies confirm that RIG200 has prolonged effects in veins with damaged endothelium, a characteristic that might be exploited therapeutically to target nitric oxide delivery to damaged blood vessels.
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Affiliation(s)
- N Sogo
- Clinical Pharmacology Unit and Research Centre, University of Edinburgh, Western General Hospital, Scotland
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Fink KB, Andrews LJ, Butler WE, Ona VO, Li M, Bogdanov M, Endres M, Khan SQ, Namura S, Stieg PE, Beal MF, Moskowitz MA, Yuan J, Friedlander RM. Reduction of post-traumatic brain injury and free radical production by inhibition of the caspase-1 cascade. Neuroscience 2000; 94:1213-8. [PMID: 10625061 DOI: 10.1016/s0306-4522(99)00345-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Necrotic and apoptotic cell death both play a role mediating tissue injury following brain trauma. Caspase-1 (interleukin-1beta converting enzyme) is activated and oligonucleosomal DNA fragmentation is detected in traumatized brain tissue. Reduction of tissue injury and free radical production following brain trauma was achieved in a transgenic mouse expressing a dominant negative inhibitor of caspase-1 in the brain. Neuroprotection was also conferred by pharmacological inhibition of caspase-1 by intracerebroventricular administration of the selective inhibitor of caspase-1, acetyl-Tyr-Val-Ala-Asp-chloromethyl-ketone or the non-selective caspase inhibitor N-benzyloxycarbonyl-Val-Ala-Asp-fluoromethylketone. These results indicate that inhibition of caspase-1-like caspases reduces trauma-mediated brain tissue injury. In addition, we demonstrate an in vivo functional interaction between interleukin-1beta converting enyzme-like caspases and free radical production pathways, implicating free radical production as a downstream mediator of the caspase cell death cascade.
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Affiliation(s)
- K B Fink
- Stroke and Neurovascular Regulation, Massachusetts General Hospital, Harvard Medical School, Charlestown 02129, USA
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