P3589New generation stents for primary percutaneous coronary intervention in patients with acute myocardial infarction: evidence from an individual patient data network meta-analysis of randomized clinical

Background

Drug-eluting stents have shown their superiority in primary percutaneous intervention in patients with ST-segment elevation myocardial infarction (STEMI). No specific stent type has fully proven its superiority over others.

Purpose

We sought to compare the safety and efficacy of coronary artery stents in STEMI patients undergoing primary PCI through comprehensive network meta-analysis (NMA).

Methods

We performed an individual patient data (IPD) NMA of dedicated randomized trials in STEMI patients treated with coronary stents. The primary endpoint of interest was the composite outcome of cardiac death, any myocardial infarction (MI) or target lesion revascularization (TLR). Secondary outcomes were the individual component of the primary endpoint and definite or probable stent thrombosis. Outcomes were analyzed at the longest available follow-up. The primary analysis was performed using a one-stage random-effects meta-analysis.

Results

IPD from 15 randomized trials in STEMI patients were obtained including a total of 10,979 patients. Six different stent types were studied including bare metal stents (BMS), durable-polymer paclitaxel-eluting stents (DP-PES), durable-polymer sirolimus-eluting stents (DP-SES), durable-polymer zotarolimus-eluting stents (DP-ZES), durable-polymer everolimus-eluting stents (DP-EES) and biodegradable-polymer biolimus-eluting stent (BP-BES).

Mean patient age was 60.7±11.9 years; 22.7% were female and 16.1% were diabetic. Median symptom onset to balloon time was 210 min.

At a median follow-up of 3 years (interquartile range 2–4.9 years), patients treated with second-generation (DP-EES and BP-BES) or first-generation DES (DP-PES, DP-SES and DP-ZES) had significantly lower risk of the primary endpoint than patients treated with BMS (BMS vs. second-generation DES; HR 0.69, 95% CI 0.57–0.82, BMS vs. first-generation DES; HR 0.70, 95% CI 0.61–0.80). The differences were driven by the significant reduction of TLR associated with first- and second-generation DES compared with BMS. A trend towards lower risk of MI with second-generation DES compared with BMS or first-generation DES was observed (BMS vs. second-generation DES; HR 0.79, 95% CI 0.58–1.06, first- vs. second-generation DES; HR 0.75, 95% CI 0.54–1.03). Second-generation DES was associated with a significantly lower risk of definite or probable stent thrombosis compared with BMS (HR 0.62, 95% 0.40–0.97) and first-generation DES (HR 0.55, 95% CI 0.34–0.91). DP-EES and BP-BES had a similar risk of the primary endpoint, individual components of the primary endpoint, and definite or probable stent thrombosis.

Conclusions

In this larger-scale IPD NMA in STEMI patients, second-generation DES were superior to BMS with respect to long-term efficacy and safety outcomes. Second-generation DES were associated with a significant reduction of stent thrombosis compared with BMS and first-generation DES. Similar long-term outcomes were observed between DP-EES and BP-BES.

Acknowledgement/Funding

This study was funded by Biosensors International

Increased cytokine response after toll-like receptor stimulation in patients with stable coronary artery disease

OBJECTIVE

Atherosclerosis is associated with increased levels of plasma cytokines and expression of Toll-like receptors (TLRs). Yet, little is known about the potential use of TLR ligand induced cytokine release as a biomarker of coronary artery disease (CAD). In this study, we investigated whether TLR ligand induced cytokine release is associated with atherosclerotic disease severity and its predictive value for future cardiovascular events.

METHODS

Blood samples were obtained from 260 patients with stable angina and 15 healthy controls. Cytokine levels of TNFα, IL-8 and IL-6 were measured after 2 h of whole blood stimulation with 10 ng/ml lipopolysaccharide (LPS, TLR4 ligand) and P3C 500 ng/ml (TLR2 ligand). In a subgroup, dose-response curves were created using additional LPS concentrations.

RESULTS

LPS induced whole blood release of TNFα and IL-6, but not IL-8, was significantly higher in patients compared to healthy controls. Among CAD patients, TLR responses did hardly differ when associated with the presence of traditional risk factors and atherosclerotic disease severity (number of diseased vessels and coronary stenosis degree). Patients with secondary events during follow-up showed a trend towards an increased TLR response. Furthermore, positive associations were found between CRP levels and TLR-induced TNFα (CRP<2: 2055 pg/ml; CRP>2: 2364 pg/ml) and IL-6 production (CRP<2: 1742 pg/ml; CRP>2: 2250 pg/ml).

CONCLUSION

In conclusion, TLR-induced whole blood cytokine release in patients with stable angina indicates the presence of coronary atherosclerosis but does not reflect its severity.

ACS, myocardial bridging, Tako-tsubo syndrome and mitral regurgitation

Isolated systolic compression of the mid portion of the left anterior descending artery (LAD) by a bridge of overlying cardiac muscle is an infrequent but well-recognised angiographic anomaly that is often considered harmless. The long-term prognosis appears to be excellent, but occasional reports of patients with angina pectoris, myocardial infarction and sudden death indicate that this is not always true. The prevalence of the anomaly in the normal population is unknown, but the incidence is low and ischaemic events are rare. Tako-tsubo-like left ventricular dysfunction syndrome (TTS) is characterised by ischaemia, anterior ST-segment elevation, no significant coronary artery disease and reversible ampulla-like left ventricular ballooning in postmenopausal females after emotional or physical stress. Dynamic left ventricular outflow tract (LVOT) obstruction is a rare but potentially fatal complication of acute anterior wall infarction. We present a patient with an acute coronary syndrome (ACS) with ST-segment elevation in the anterior leads, transient TTS and transient LVOT obstruction with systolic anterior motion (SAM) of the mitral valve and severe mitral regurgitation. This is the first report of myocardial bridging associated with TTS, and the first report of TTS associated with dynamic LVOT obstruction with SAM and mitral regurgitation.

Randomized comparison of primary stenting and provisional balloon angioplasty guided by flow velocity measurement. Doppler Endpoints Balloon Angioplasty Trial Europe (DEBATE) II Study Group

BACKGROUND

Coronary stenting improves outcomes compared with balloon angioplasty, but it is costly and may have other disadvantages. Limiting stent use to patients with a suboptimal result after angioplasty (provisional angioplasty) may be as effective and less expensive.

METHODS AND RESULTS

To analyze the cost-effectiveness of provisional angioplasty, patients scheduled for single-vessel angioplasty were first randomized to receive primary stenting (97 patients) or balloon angioplasty guided by Doppler flow velocity and angiography (523 patients). Patients in the latter group were further randomized after optimization to either additional stenting or termination of the procedure to further investigate what is "optimal." An optimal result was defined as a flow reserve >2.5 and a diameter stenosis <36%. Bailout stenting was needed in 129 patients (25%) who were randomized to balloon angioplasty, and an optimal result was obtained in 184 of the 523 patients (35%). There was no significant difference in event-free survival at 1 year between primary stenting (86.6%) and provisional angioplasty (85.6%). Costs after 1 year were significantly higher for provisional angioplasty (EUR 6573 versus EUR 5885; P:=0.014). Results after the second randomization showed that stenting was also more effective after optimal balloon angioplasty (1-year event free survival, 93.5% versus 84.1%; P:=0. 066).

CONCLUSIONS

After 1 year of follow-up, provisional angioplasty was more expensive and without clinical benefit. The beneficial value of stenting is not limited to patients with a suboptimal result after balloon angioplasty.

Coronary stenting for failed angioplasty in acute myocardial infarction

Intracoronary stents were implanted in 15 patients after unsuccessful PTCA in the setting of acute myocardial infarction (AMI). The stented vessel was the left anterior descending (LAD) in 11 patients, the right coronary artery (RCA) in 3 patients, and a venous bypass graft to the LAD in a single patient. A total of 16 stents were implanted (15 Palmaz Schatz, Johnson and Johnson; and 1 Wiktor, Medtronic).

FOLLOW-UP

1 patient died 10 days after stent implantation as a result of renal failure and cardiogenic shock. Subacute thrombosis occurred in 2 patients, 5 and 15 days after stent implantation; both underwent successful emergency coronary artery bypass grafting (CABG). The remaining 12 patients were free from major ischemic events (death, AMI, and further revascularization) after a mean follow-up of 18.7 +/- 4.1 months. We conclude that the long-term results of intracoronary stenting in AMI after failed PTCA are favourable.

Experience with U-shaped catheters in angiography and angioplasty of the left coronary artery

We developed a U-shaped diagnostic and guiding catheter for left coronary angiography and angioplasty. Angiography with a 6 French (F) diagnostic U-shaped catheter was attempted in 101 patients (pts). Primary use in 82 pts; all successful. Secondary use after failure of 6 F left Judkins diagnostic catheters to intubate the left main coronary artery in 19 pts; 17 successful. An 8 F U-shaped guiding catheter was used for percutaneous transluminal coronary angioplasty (PTCA) of left coronary artery branches in 102 pts [left anterior descending (LAD), 48 pts; circumflex (CX), 54 pts]. Stable cannulation of the left coronary artery was achieved in 96 pts (94%), but PTCA was successful in 90 pts (88%). Primary use in 70 pts (LAD, 27 pts; CX, 43 pts). PTCA was successful in 60 pts. Secondary use after failure of left Judkins and Amplatz guiding catheters in 32 pts (LAD, 21 pts; CX, 11 pts). PTCA was successful in 30 pts. No complications were seen. In conclusion, U-shaped diagnostic and guiding catheters increased the success rate of 1) left coronary angiography after failure of left Judkins diagnostic catheters; and 2) PTCA of the left anterior descending and circumflex arteries after failure of left Judkins and Amplatz guiding catheters.

Antepartum determination of pre-ejection period of fetal cardiac cycle: its relation to newborn body weight

Simultaneous recordings of the fetal electrocardiogram and ultrasound Doppler-cardiogram were used for the determination of the pre-ejection period (PEP) of the fetal cardiac cycles. All 50 fetuses selected for the present study experienced uneventful perinatal lives despite maternal antepartum complications which required hospitalization. A significant positive correlation between the PEP and gestational age of the fetuses was again demonstrated. The PEP of the fetus measured within one week prior to delivery was also found to be significantly correlated with the newborn body weights at birth. Statistical analysis demonstrates that fetal body weight was more closely related to the physiologic lengthening of the PEP.