Predictors and clinical implication of high-sensitivity cardiac troponin-I elevation following diagnostic cardiac catheterisations

Objectives

Although diagnostic coronary angiography (CAG) is performed worldwide, procedure-related myocardial necrosis (PMN) following diagnostic catheter-based procedures has not been well investigated. The aim of this study was to determine clinical and procedural factors associated with PMN, using a high-sensitivity cardiac troponin I (hs-cTnI) assay, and to investigate the clinical implications of PMN.

Methods

Among 697 patients undergoing elective CAG and pre- and post-procedural hs-cTnI (pre-TnI, post-TnI, respectively) measurements, a total of 538 patients (124 female) were evaluated, with 2.2% lost during follow-up. Minor PMN was defined as post-TnI above the sex-specific upper reference limit (URL), with a 20% increase from the pre-TnI level. Major PMN was defined as post-TnI above 5x the URL. Clinical and procedural factors predicting PMN and the association between PMN and major adverse cardiac events (MACE) following CAG were examined.

Results

PMN of any type was detected in 178 patients (33.0%), while major PMN was observed in 32 patients (5.9%). Female sex, estimated glomerular filtration rate, procedural time, left ventricular end-diastolic pressure (LVEDP) and fractional flow reserve measurement independently predicted any PMN; whereas, only LVEDP and log-transformed N-terminal pro-brain natriuretic peptide independently predicted major PMN. The incidence of MACE was significantly associated with major PMN. Cox proportional-hazards models revealed that major PMN, pre-TnI, and the absence of statin use were independently associated with MACE.

Conclusions

Diagnostic cardiac catheteriation may highlight cardiomyocyte susceptibility to stress in patients with or without CAD. CAG-related major myocardial injury might be associated with future adverse cardiac events independently of the presence or absence of functional stenosis.

Percutaneous PFO closure for cryptogenic stroke in the setting of a systematic cardiac and neurological screening and a standardised follow-up protocol

Background

There are no uniform workup and follow-up (FU) protocols for patients presenting with cryptogenic embolism (CE) who undergo percutaneous closure of a patent foramen ovale (PFO).

Methods

We prospectively performed a systematic cardiac and neurological FU protocol in all patients who underwent percutaneous PFO closure in order to assess the incidence of subsequent cardiac and neurological adverse events. All patients received dual antiplatelet therapy for 6 months and were systematically included in a 12-month standardised FU protocol including: clinical evaluation—transthoracic and transoesophageal echocardiography, 24-hour Holter monitoring and/or 1-week R-test, and transcranial Doppler. Late FU (>12 months) was performed by reviewing medical records.

Results

Over a 10-year period, 221 consecutive patients underwent PFO closure for CE and 217 of them (98%) completed the 12-month FU. Ischaemic event recurrence at 12-month and late FU (mean time 69±35 months, median time 65 months, Q1:38 months, Q3:98 months) was observed in 6 (2.8%) and 3 patients (1.4%), respectively. The initial diagnosis of CE was reconsidered in 17 cases (7.8%), as the clinical and paraclinical FU exams showed possible alternative aetiologies for the initial event: 13 patients (6.0%) presented at least 1 episode of atrial fibrillation, while in 4 cases (1.8%) a non-ischaemic origin of the initial symptoms was identified.

Conclusions

Alternative diagnoses explaining the initial symptoms are rarely detected with an in-depth screening for alternative diagnoses before PFO closure. Despite extensive screening, atrial fibrillation is the most frequently observed alternative aetiology for cryptogenic stroke.

Percutaneous balloon aortic valvuloplasty in the era of transcatheter aortic valve implantation: a narrative review

The role of percutaneous balloon aortic valvuloplasty (BAV) in the management of severe symptomatic aortic stenosis has come under the spotlight following the development of the transcatheter aortic valve implantation (TAVI) technique. Previous indications for BAV were limited to symptom palliation and as a bridge to definitive therapy for patients undergoing conventional surgical aortic valve replacement (AVR). In the TAVI era, BAV may also be undertaken to assess the ‘therapeutic response’ of a reduction in aortic gradient in borderline patients often with multiple comorbidities, to assess symptomatic improvement prior to consideration of definitive TAVI intervention. This narrative review aims to update the reader on the current indications and practical techniques involved in undertaking a BAV procedure. In addition, a summary of the haemodynamic and clinical outcomes, as well as the frequently encountered procedural complications is presented for BAV procedures conducted during both the pre-TAVI and post-TAVI era.

Prognostic factors of in-hospital mortality in all comers with ST elevation myocardial infarction undergoing primary percutaneous coronary intervention

BACKGROUND

The prognostic factors of in-hospital mortality in all comers and unselected patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) have not been well established.

OBJECTIVE

To identify the predictive factors of in-hospital mortality in patients with STEMI undergoing primary PCI in a tertiary heart centre.

METHODS

Between January 2008 and December 2011, all patients with STEMI undergoing primary PCI were retrospectively included in this study. Baseline characteristics and angiographic data were reviewed and recorded. The study endpoint was all-cause in-hospital mortality.

RESULTS

Of the 541 patients included in the study, 63 (11.6%) died during hospitalisation. Cardiogenic shock at admission was recorded in 301 patients (55.6%) and 424 patients (78%) had multivessel disease. Median door-to-device time was 65 min. After adjustment for baseline variables, the factors associated with in-hospital mortality included age >60 years (OR 2.98, 95% CI 1.17 to 7.05; p=0.01), left ventricular ejection fraction <40% (OR 2.53, 95% CI 1.20 to 5.36; p=0.02), and final TIMI flow grade 0/1 (OR 20.55, 95% CI 3.49 to 120.94; p=0.001).

CONCLUSIONS

Age, left ventricular function and final TIMI flow are significant predictors of adverse outcomes in unselected patients with STEMI undergoing primary PCI.

Heart rate never lies: interventional cardiologist and Braude's quote revised

Background

Interventional cardiologists may be immune to stress, allowing them to perform complex percutaneous interventions under pressure.

Objectives

To assess heart rate (HR) variations as a surrogate marker of stress of interventional cardiologists during percutaneous cardiac procedures and in every-day life.

Design

This is a single-centre observational study including a total of six male interventional cardiologists performing coronary interventions and pacemaker implantations. Participants were asked to record their HR with the Apple Watch Device during procedures, every-day life and control activities such as outpatient consultations, sport, marital conflicts and sexual intercourse.

Results

Average daily HR was 88±17 bpm. During work days, HR increased significantly during procedures (90±17 bpm) compared with days outside the cathlab (87±17 bpm, p=0.02). The average HR was higher during a regular week working (88±16 bpm) compared with weekends off (84±18 bpm, p=0.002). Complex cardiac procedures were associated with higher HR up to 122 bpm. Peak HR were higher during physical exertion. Of note, participants complained of hypersexuality and mania after night shifts.

Conclusions

Work and especially percutaneous cardiac procedures increase HR independently of physical exertion suggesting that interventional cardiologists experience mental stress and emotions.

Optical coherence tomography versus intravascular ultrasound to evaluate stent implantation in patients with calcific coronary artery disease

AIMS

Stent underexpansion and malapposition are associated with adverse outcomes following percutaneous coronary intervention, but detection and treatment can be challenging in the presence of extensive coronary artery calcification. Frequency domain optical coherence tomography (FD-OCT) is a novel intravascular imaging technique with greater spatial resolution than intravascular ultrasound (IVUS) but its role in the presence of extensive coronary calcification remains unclear. We sought to determine the utility of FD-OCT compared to IVUS imaging to guide percutaneous coronary intervention in patients with severe calcific coronary artery disease.

METHODS

18 matched IVUS and FD-OCT examinations were evaluated following coronary stent implantation in 12 patients (10 male; mean age 70±7 years) undergoing rotational atherectomy for symptomatic calcific coronary artery disease.

RESULTS

In-stent luminal areas were smaller (minimum in-stent area 6.77±2.18 vs 7.19±2.62 mm(2), p<0.05), while reference lumen dimensions were similar with FD-OCT compared with IVUS. Stent malapposition was detected in all patients by FD-OCT and in 10 patients by IVUS. The extent of stent malapposition detected was greater (20% vs 6%, p<0.001) with FD-OCT compared to IVUS. Postdilation increased the in-stent luminal area (minimum in-stent area: 8.15±1.90 vs 7.30±1.62 mm(2), p<0.05) and reduced the extent of stent malapposition (19% vs 34%, p<0.005) when assessed by FD-OCT, but not IVUS.

CONCLUSIONS

Acute stent malapposition occurs frequently in patients with calcific coronary disease undergoing rotational atherectomy and stent implantation. In the presence of extensive coronary artery calcification, FD-OCT affords enhanced stent visualisation and detection of malapposition, facilitating improved postdilation stent apposition and minimal luminal areas.

TRIAL REGISTRATION NUMBER

NCT02065102.

Physiology-guided myocardial revascularisation in complex multivessel coronary artery disease: beyond the 2014 ESC/EACTS guidelines on myocardial revascularisation

For patients with multivessel coronary artery disease there are two options for revascularisation: Percutaneous coronary intervention (PCI) or Coronary Artery Bypass Graft Surgery (CABG). In daily clinical practice, a heart team consisting of an interventional cardiologist and a cardiothoracic surgeon decide on the most appropriate mode of revascularization. The current European guidelines on myocardial revascularisation include updated recommendations for patients with multivessel coronary artery disease. In patients with stable angina, three-vessel disease and a SYNTAX score of 23–32 or >32 a class I level of evidence A recommendation for CABG was issued as compared to PCI which received a class III recommendation. Although the authors of this viewpoint greatly appreciate the efforts of the guideline committee, we believe that it was an oversight not to include recommendations on physiology-guided PCI in multivessel disease (MVD). In this viewpoint, it is argued that physiology-guided revascularization using current-generation drug-eluting stents is a reasonable alternative for complex multivessel disease.

Optical coherence tomography for serial in vivo imaging of aortic plaque in the rabbit: a preliminary experience

Background

In this pilot feasibility study, we aimed to establish a reproducible means of performing serial optical coherence tomography (OCT) procedures in the abdominal aorta of the cholesterol-fed rabbit.

Methods

Eight cholesterol-fed New Zealand White rabbits were assigned to abdominal aortic balloon injury at baseline (n=6) or as controls (n=2). Three of the balloon injured rabbits received statins from weeks 6 to 12 post balloon injury. OCT of the abdominal aorta in each rabbit was performed at baseline±week 6±week 12 via alternate vascular access points (left or right femoral artery or left carotid artery). OCT sequences were analysed to derive an indexed plaque volume and other OCT measures of plaque complexity, and results were compared between groups. Histopathological correlations with OCT images were made following terminal procedures.

Results

Of the 16 OCT procedures in these rabbits (6 at baseline, 4 at 6 weeks, 6 at 12 weeks), excellent and analysable images were obtained on 15 occasions (94%). Inability to obtain adequate arterial access for the OCT catheter was the major experimental limitation encountered in the early part of our experience. Balloon injured rabbits developed larger volume and more complex plaque than non-balloon injured rabbits on all OCT indices measured (eg, both mean plaque volume and lumen stenosis were approximately double in the balloon injured group, p<0.0001). A significant correlation between 12 week measures of plaque area by OCT and histology was demonstrated (Pearson correlation coefficient: 0.992, p<0.0001).

Conclusions

Our preliminary experience suggests that serial OCT of the abdominal aorta in the New Zealand White rabbit is feasible and a potentially promising means of performing serial studies of aortic atherosclerosis.

Cardiovascular disease in HIV patients: from bench to bedside and backwards

HIV patients are exposed to a higher risk of adverse cardiovascular events, due to complex interactions between traditional risk factors and HIV infection itself in terms of ongoing endothelial dysfunctional immune activation/inflammation and increased risk of thrombosis. On the other hand, long-span antiretroviral therapy administration still raises questions on its long-term safety in an era in which life expectancy is becoming longer and longer while treatment of non-HIV-related serious events is increasingly raising concern. In this article, we will critically analyse the current knowledge of pathological and clinical aspects pertaining to the increased risk of cardiovascular events associated with HIV.

Validity of a PCI Bleeding Risk Score in patient subsets stratified for body mass index

Objective

An accurate tool with good discriminative for bleeding would be useful to clinicians for improved management of all their patients. Bleeding risk models have been published but not externally validated in independent clinical data set. We chose the National Cardiovascular Data Registry (NCDR) percutaneous coronary intervention (PCI) score to validate within a large, multisite community data set. The aim of the study was validation of this Bleeding Risk Score (BRS) tool among a subgroup of patients based on body mass index.

Methods

This is a large-scale retrospective analysis of a current registry utilising data from a 37-hospital health system. The central repository of patients with coronary heart disease undergoing PCI between 1 June 2009 and 30 June 2012 was utilised to validate the NCDR PCI BRS among 4693 patients. The primary end point was major bleeding. Validation analysis calculating the receiver operating characteristic curve was performed.

Results

There were 143 (3%) major bleeds. Mean BRS was 14.7 (range 3–42). Incidence of bleeding by risk category: low (0.5%), intermediate (1.7%) and high risk (7.6%). Tool accuracy was poor to fair (area-under-the curve (AUC) 0.78 heparin, 0.65 bivalirudin). Overall accuracy was 0.71 (CI 0.66 to 0.76). Accuracy did not improve when confined to just the intermediate risk group (AUC 0.58; CI 0.55 to 0.67). Tool accuracy was the lowest among the low BMI group (AUC 0.62) though they are at increased risk of bleeding following PCI.

Conclusions

Bleeding risk tools have low predictive value even among subgroups of patients at higher risk. Adjustment for anticoagulation use resulted in poor discrimination because bivalirudin differentially biases outcomes toward no bleeding. The current state of bleeding risk tools provide little support for diagnostic utility in regards to major bleeding and therefore have limited clinical applicability.

Fractional flow reserve versus angiography for guiding percutaneous coronary intervention: a meta-analysis

Objectives

The purpose of this study was to investigate whether fractional flow reserve (FFR) should be performed for patients with coronary artery disease (CAD) to guide the percutaneous coronary intervention (PCI) strategy.

Background

PCI is the most effective method to improve the outcomes of CAD. However, the proper usage of PCI has not been achieved in clinical practice.

Methods

A meta-analysis was performed on angiography-guided PCI and FFR-guided PCI strategies. Prospective and retrospective studies were included when research subjects were patients with CAD undergoing PCI. The primary endpoint was the rate of major adverse cardiac events (MACE) or major adverse cardiac and cerebrovascular events (MACCE). Secondary endpoints included death, myocardial infarction (MI), repeat revascularisation and death or MI.

Results

Four prospective and three retrospective studies involving 49 517 patients were included. Absolute risks of MACE/MACCE, death, MI, revascularisation and death or MI for angiography-guided PCI and FFR-guided PCI were 34.8% vs 22.5%, 15.3% vs 7.6%, 8.1% vs 4.2%, 20.4% vs 14.8%, and 21.9% vs 11.8%, respectively. The meta-analysis demonstrated that FFR-guided PCI was associated with lower MACE/MACCE (OR: 1.71, 95% CI 1.31 to 2.23), death (OR: 1.64, 95% CI 1.37 to 1.96), MI (OR: 2.05, 95% CI 1.61 to 2.60), repeat revascularisation (OR: 1.25, 95% CI 1.09 to 1.44), and death or MI (OR: 1.84, 95% CI 1.58 to 2.15) than angiography-guided PCI strategy.

Conclusions

This meta-analysis supports current guidelines advising the FFR-guided PCI strategy for CAD. PCI should only be performed when haemodynamic significance is found.

C-arm rotation as a method for reducing peak skin dose in interventional cardiology

PURPOSE

Prolonged interventional cardiology (IC) procedures may result in radiation-induced skin injury, a potentially preventable cause of patient morbidity. Rotating the C-arm during an IC procedure may reduce this risk, although the methods by which the technique can be practically applied remains unexplored. A previous study demonstrated that C-arm rotation often increases peak skin dose (PSD) in interventional radiology procedures. The purpose of this study was to determine whether C-arm rotation reduces the PSD in IC procedures and, if so, under what circumstances.

MATERIALS AND METHODS

Simulations were performed using a numerical ray-tracing algorithm to analyse the effect of C-arm rotation on PSD across a range of patient sizes, C-arm configurations and procedure types. Specific data from modern fluoroscopes and patient dimensions were used as inputs to the simulations.

RESULTS

In many cases, modest C-arm rotation angles completely eliminated overlap between X-ray field sites on the skin. When overlap remained, PSD increases were generally small. One exception was craniocaudal rotation, which tended to increase PSD. C-arm rotation was most effective for large patients and small X-ray field sizes. Small patients may not benefit from C-arm rotation as a procedural modification. The use of a prophylactic method where the C-arm was rotated between small opposing oblique angles was effective in reducing PSD.

CONCLUSIONS

With the exception of rotation to steep craniocaudal angles, rotating the C-arm reduces PSD in IC procedures when used as either a procedural modification or a prophylactic strategy. Tight collimation increases the benefit of C-arm rotation.

Biolimus-eluting stent with biodegradable polymer improves clinical outcomes in patients with acute myocardial infarction

OBJECTIVE

To investigate clinical outcomes of coronary intervention using a biolimus-eluting stent (BES) compared with a sirolimus-eluting stent (SES) in patients with acute myocardial infarction (AMI) in the Limus Eluted from A Durable versus ERodable Stent (LEADERS) coating trial at the final 5-year follow-up.

METHODS

The LEADERS trial is a multicentre all-comer study, where patients (n=1707) were randomised to percutaneous intervention with either BES containing biodegradable polymer or SES containing durable polymer. Out of 1707 patients enrolled in this trial, 573 patients had percutaneous coronary intervention for AMI (BES=280, SES=293) and were included in the current analysis. Patient-oriented composite endpoint (POCE, including all death, all myocardial infarction (MI) and all revascularisations), major adverse cardiac events (MACE, including cardiac death, MI and clinically indicated target vessel revascularisation) and stent thrombosis were assessed at 5-year follow-up.

RESULTS

The baseline clinical, angiographic and procedural characteristics were well matched between BES and SES groups. In all patients with AMI, coronary intervention with a BES, compared with SES, significantly reduced POCE (28.9% vs 42.3%; relative risk (RR) 0.61, 95% CI 0.47 to 0.82, p=0.001) at 5-year follow-up. There was also a reduction in MACE rate in the BES group (18.2% vs 25.9%; RR 0.67, 95% CI 0.47 to 0.95, p=0.025); however, there was no difference in cardiac death and stent thrombosis. In patients with ST-elevation MI (STEMI), coronary intervention with BES significantly reduced POCE (24.4% vs 39.3%; RR 0.55, 95% CI 0.36 to 0.85, p=0.006), MACE (12.6% vs 25.0%; RR 0.47, 95% CI 0.26 to 0.83, p=0.008) and cardiac death (3.0% vs 11.4%; RR 0.25, 95% CI 0.08 to 0.75, p=0.007), along with a trend towards reduction in definite stent thrombosis (3.7% vs 8.6%; RR 0.41, 95% CI 0.15 to 1.18, p=0.088), compared with SES.

CONCLUSIONS

BES, compared with SES, significantly improved safety and efficacy outcomes in patients with AMI, especially those with STEMI, at 5-year follow-up.

TRIAL REGISTRATION NUMBER

NCT 00389220.

First-generation versus second-generation drug-eluting stents in current clinical practice: updated evidence from a comprehensive meta-analysis of randomised clinical trials comprising 31 379 patients

Background

First-generation drug-eluting stents (DES) have become the most widely used devices worldwide for management of coronary artery disease. As remote follow-up data were becoming available, concerns emerged in regard to their long-term safety. Second-generation DES were designed to overcome safety issues, but the results of randomised clinical trials remain conflicting.

Methods

We compared the safety and efficacy of first-generation versus second-generation Food and Drug Administration approved DES; the following devices were included: first-generation sirolimus-eluting stent (SES) and paclitaxel-eluting stents (PES); second-generation everolimus-eluting stent (EES), zotarolimus-eluting stent Endeavor and ZES-Resolute (ZES-R). Prespecified safety end points comprised ≤1 and >1 year: overall and cardiac mortality, myocardial infarction (MI), definite/definite or probable ST; efficacy end points were target lesion revascularisation and target vessel revascularisation. Composite end points were analysed as well.

Results

33 randomised controlled trials involving 31 379 patients with stable coronary artery disease or acute coronary syndrome undergoing DES implantation were retrieved. No differences in mortality among devices were found. In the overall class comparison, second-generation DES were associated with a 22% reduction of odds of MI at short-term OR 0.77 (95% CI 0.68 to 0.89) p=0.0002; EES reduced the odds of definite-probable ST compared with PES: OR 0.33 (95% CI 0.15 to 0.73) p=0.006; First-generation SES along with second-generation EES and ZES-R showed similar efficacy in decreasing the odds of repeat revascularisation.

Conclusions

Second-generation EES and ZES-R offer similar levels of efficacy compared with first-generation SES, but are more effective than PES; however, only second-generation EES significantly reduced the incidence of MI and ST, and therefore should be perceived as the safest DES to date.

Two-year outcomes after percutaneous mitral valve repair with the MitraClip system: durability of the procedure and predictors of outcome

OBJECTIVE

Analyse 2-year outcomes after MitraClip therapy and identify predictors of outcome.

METHODS

Consecutive patients (n=74) undergoing MitraClip therapy were included in the MitraSWISS registry and followed prospectively.

RESULTS

A reduction of mitral regurgitation (MR) to ≤ mild was achieved in 32 (43%) patients and to moderate in 31 (42%) patients; 16/63 (25%) patients with initially successful treatment developed recurrent moderate to severe or severe MR during the first year and only 1 patient did so during the second year. At 2 years, moderate or less MR was more frequently present in patients with a transmitral mean gradient <3 mm Hg at baseline (73% vs 23%, p < 0.01) and in patients with a left atrial volume index (LAVI) <50 mL/m(2) at baseline (86% vs 52%, p=0.03). More than mild MR post MitraClip, N-terminal probrain natriuretic peptide ≥5000 ng/L at baseline, chronic obstructive pulmonary disease (COPD) and chronic kidney disease (CKD) were associated with reduced survival.

CONCLUSIONS

A mean transmitral gradient <3 mm Hg at baseline, an LAVI <50 mL/m(2), the absence of COPD and CKD, and reduction of MR to less than moderate were associated with favourable outcome. Given a suitable anatomy, such patients may be excellent candidates for MitraClip therapy. Between 1 and 2 years follow-up, clinical and echocardiographic outcomes were stable, suggesting favourable, long-term durability of the device.

Overaggressive stent expansion without intravascular imaging: impact on restenosis

OBJECTIVE

Aggressive stent expansion is required for optimal strut apposition, but risk of stent deformation, fracture and subsequent restenosis is potentially greater when performed without intravascular imaging guidance. We investigated how frequently stents are 'overexpanded' and whether this correlates with restenosis.

DESIGN AND SETTING

Single-centre prospective database study at a high-volume tertiary university hospital.

PATIENTS

243 patients undergoing single-vessel stenting for de novo stenosis in 277 lesions. Exclusion criteria were bifurcational, graft or left main disease and intravascular imaging use. All had ischaemia-driven repeat coronary angiography up to 48 months later. Degree of stent overexpansion was the difference between nominal and final stent size.

RESULTS

Stents were expanded above nominal in 99% of cases and above rated burst pressure in 52%. Stents were expanded >20% above nominal in 12% of cases. Stents overexpanded by >20% were smaller (2.87 vs 3.19 mm), longer (24 vs 19 mm) and more often drug-eluting (53% vs 27%). Angiographic restenosis was observed in 80 lesions (29%). There was no correlation between degree of overexpansion and per cent angiographic restenosis across the whole group (R(2)=-0.01; p=0.09), in those with stent overexpansion >20% (p=0.31) or small stents <3 mm (p=0.71). Indeed, in the group with stent overexpansion >25%, the greater the overexpansion, the less the per cent angiographic restenosis (p=0.02).

CONCLUSIONS

In this real-world population undergoing non-complex percutaneous coronary intervention without intravascular imaging, any tendency to overaggressive stent expansion did not predispose at all to restenosis.

Academic training in radiation safety awareness and practice among Iranian residents/fellows

OBJECTIVE

To determine the current state of radiation safety awareness and practice among Iranian radiology/cardiology residents.

METHODS

In this cross-sectional study, 725 Iranian cardiology/radiology fellows/residents (685 residents and 40 fellows) were studied. Radiation safety awareness and practice were assessed using a 13-item survey questionnaire. Based on academic trainings provided in their medical centres, the subjects were divided into two groups (trained vs untrained).

RESULTS

Trained residents/fellows had better performance compared with untrained ones regarding awareness of radiation dealing instructions, knowing safety experts of their centres (43.8% vs 20.1%, p<0.001) and their contact information (38.4% vs 11.4%, p<0.001), date of the last CBC (complete blood count) checking (15.1% vs 2.5%, p<0.001), use of lead glass (61.6% vs 41.8%, p=0.003), apron (94.5% vs 90%, p=0.016) and radiation shield (71.2% vs 46.2%, p<0.001).

CONCLUSIONS

Awareness/practice of Iranian cardiology/radiology residents/fellows about radiation exposure safety issues is not acceptable currently. Those who received formal training courses at their academic centres about the safety measures had significantly better knowledge compared with those who did not. It is suggested that radiation safety training be offered at the beginning of residency/fellowship for residents/fellows in a comprehensive and uniform way throughout medical universities.

The impact of the coronary collateral circulation on outcomes in patients with acute coronary syndromes: results from the ACUITY trial

OBJECTIVE

We sought to assess the prognostic role of collaterals in a large population of patients presenting with an acute coronary syndrome (ACS).

METHODS

The coronary collateral circulation was assessed by an independent angiographic core laboratory using the Rentrop Score in patients enrolled in the randomised Acute Catheterization and Urgent Intervention Triage Strategy trial.

RESULTS

The cohort comprised 5412 patients with moderate to high risk ACS. A total of 858 patients (16.0%) had visible collaterals while 4554 patients (84.0%) had no collaterals. After multivariable adjustment, there were no differences in clinical outcomes at 1 year between the groups, including major adverse cardiac events (MACE) (HR 0.94 (95% CI 0.76 to 1.16), p=0.55), mortality (HR 1.03 (0.65 to 1.62), p=0.91), myocardial infarction (MI) (HR 1.07 (0.83 to 1.38), p=0.60) and unplanned target vessel revascularisation (TVR) (HR 0.95 (0.71 to 1.28), p=0.75). Similarly, in the subgroup of patients undergoing percutaneous coronary intervention (PCI), the adjusted HR for major adverse cardiac events was 1.1 (0.76 to 1.61), p=0.595; 0.81 (0.10 to 6.44), p=0.999 for mortality; and 0.86 (0.54 to 1.35), p=0.564 for MI. The risk of unplanned TVR was increased (HR 2.74 (1.48 to 5.10), p=0.004).

CONCLUSIONS

In contrast to other studies, this large core laboratory-based analysis does not confirm a beneficial role of visible coronary collateral vessels on clinical outcomes in patients with ACS; the presence of collaterals was even associated with increased mortality in the unadjusted analysis. Collaterals were associated with a higher risk of TVR in patients undergoing PCI, a finding that may not have been fully corrected given confounders and clinical differences between the groups.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00093158.

Incidence and predictors of restenosis after coronary stenting in 10 004 patients with surveillance angiography

OBJECTIVE

Systematic investigation of restenosis after percutaneous coronary intervention (PCI) with bare metal stents (BMS) or first or second generation drug eluting stents (DES) in large scale, broadly inclusive patient populations undergoing follow-up angiography represents a gap in our scientific knowledge. We investigated the incidence of angiographically proven restenosis and its predictors in patients undergoing PCI with stents.

METHODS

All patients undergoing successful implantation of coronary stents for de novo lesions from 1998 to 2009 and follow-up angiography at 6-8 months at two centres in Munich, Germany were eligible for inclusion. Patients with cardiogenic shock, dialysis dependent renal insufficiency or previous cardiac transplantation were excluded. Data were prospectively collected. The incidence of restenosis, defined as diameter stenosis ≥50% in the in-segment area at follow-up angiography, and its predictors were evaluated.

RESULTS

A total of 12 094 patients met inclusion criteria. Angiographic follow-up was available for 10 004 patients (77.5%) with 15 004 treated lesions. Binary restenosis was detected in 2643 (26.4%) patients. Use of first generation DES versus BMS (OR 0.35, 95% CI 0.31 to 0.39) and second generation DES versus first generation DES (OR 0.67, 95% CI 0.58 to 0.77) were independent predictors of lower rates of restenosis. At multivariate analysis, smaller vessel size (OR 1.59, 95% CI 1.52 to 1.68, for each 0.5 mm decrease), total stented length (OR 1.27, 95% CI 1.21 to 1.33, for each 10 mm increase), complex lesion morphology (OR 1.35, 95% 1.21 to 1.51), presence of diabetes mellitus (OR 1.32, 95% 1.19 to 1.46), and history of bypass surgery (OR 1.38, 95% CI 1.20 to 1.58) were independently associated with restenosis and were similar across the spectrum of stent devices.

CONCLUSIONS

In this large cohort of patients with angiographic surveillance we demonstrated the impact of device  development on antirestenotic efficacy, with sequentially improved efficacy from BMS to first generation DES to second generation DES. Predictors of restenosis were small vessel size, increased stented length, complex lesion morphology, diabetes mellitus, and prior bypass surgery.