Abstract Objectives This study aimed to determine whether remote ischemic conditioning (RIC) initiated prior to primary percutaneous coronary intervention (PPCI) could reduce myocardial infarct (MI) ...size in patients presenting with ST-segment elevation myocardial infarction. Background RIC, using transient limb ischemia and reperfusion, can protect the heart against acute ischemia-reperfusion injury. Whether RIC can reduce MI size, assessed by cardiac magnetic resonance (CMR), is unknown. Methods We randomly assigned 197 ST-segment elevation myocardial infarction patients with TIMI (Thrombolysis In Myocardial Infarction) flow grade 0 to receive RIC (four 5-min cycles of upper arm cuff inflation/deflation) or control (uninflated cuff placed on upper arm for 40 min) protocols prior to PPCI. The primary study endpoint was MI size, measured by CMR in 83 subjects on days 3 to 6 after admission. Results RIC reduced MI size by 27%, when compared with the MI size of control subjects (18.0 ± 10% n = 40 vs. 24.5 ± 12.0% n = 43; p = 0.009). At 24 h, high-sensitivity troponin T was lower with RIC (2,296 ± 263 ng/l n = 89 vs. 2,736 ± 325 ng/l n = 84; p = 0.037). RIC also reduced the extent of myocardial edema measured by T2 -mapping CMR (28.5 ± 9.0% vs. 35.1 ± 10.0%; p = 0.003) and lowered mean T2 values (68.7 ± 5.8 ms vs. 73.1 ± 6.1 ms; p = 0.001), precluding the use of CMR edema imaging to correctly estimate the area at risk. Using CMR-independent coronary angiography jeopardy scores to estimate the area at risk, RIC, when compared with the control protocol, was found to significantly improve the myocardial salvage index (0.42 ± 0.29 vs. 0.28 ± 0.29; p = 0.03). Conclusions This randomized study demonstrated that in ST-segment elevation myocardial infarction patients treated by PPCI, RIC, initiated prior to PPCI, reduced MI size, increased myocardial salvage, and reduced myocardial edema.
The optimal antiaggregant therapy after coronary stenting in patients receiving oral anticoagulants (OACs) is currently debated. MEDLINE and Cochrane Library were searched for studies reporting ...outcomes of patients who underwent PCI and who were on triple therapy (TT) or dual-antiplatelet therapy (DAPT) with aspirin and clopidogrel or dual therapy (DT) with OAC and clopidogrel. Major bleeding was the primary end point, whereas all-cause death, myocardial infarction (MI), stent thrombosis, and stroke were secondary ones. Results were reported for all studies and separately for those deriving from randomized controlled trials or multivariate analysis. In 9 studies, 1,317 patients were treated with DAPT and 1,547 with TT. DAPT offered a significant reduction of major bleeding at 1 year for overall studies and for the subset of observational works providing adjusted data (odds ratio OR 0.51, 95% confidence interval CI 0.39 to 0.68, I2 60% and OR 0.36, 95% CI 0.28 to 0.46) compared to TT. No increased risk of major adverse cardiac events (MACE: death, MI, stroke, and stent thrombosis) was reported (OR 0.71, 95% CI 0.46 to 1.08), although not deriving from randomized controlled trials or multivariate analysis. Six studies tested OAC and clopidogrel (1,263 patients) versus OAC, aspirin, and clopidogrel (3,055 patients) with a significant reduction of bleeding (OR 0.79, 95% CI 0.64 to 0.98), without affecting rates of death, MI, stroke, and stent thrombosis (OR 0.90, 95% CI 0.69 to 1.23) also when including clinical data from randomized controlled trials or multivariate analysis. In conclusion, compared to TT, both aspirin and clopidogrel and clopidogrel and OAC reduce bleeding. No difference in major adverse cardiac events is present for clopidogrel and OAC, whereas only low-grade evidence is present for aspirin and clopidogrel.
Uncontrolled complement activation is central to the occurrence of atypical hemolytic uremic syndrome (aHUS) and can result in thrombotic microangiopathies (TMAs).These terms encompass a group of ...heterogenic inherited or acquired diseases that recent research suggests may be triggered by the complement cascade. Pathogenetic triggers of complement activation include immunologic disorders, genetics, infections, systemic diseases, pregnancy, drug administration, metabolic diseases, transplantation, or triggers of mixed cause. Hallmarks of aHUS and other TMAs include increased vascular endothelium thromboresistance, leukocyte adhesion to damaged endothelium, complement consumption, coagulation abnormalities, and vascular shear stress, whereas common end points of these mechanisms include hemolytic anemia, thrombocytopenia with microvascular infarction, and predisposition for decreased kidney function and other organ involvement. The central role of the complement cascade as a disease trigger suggests a possible therapeutic target. Eculizumab, a first-in-class humanized monoclonal anti-C5 antibody that has been successful in the treatment of paroxysmal nocturnal hemoglobinuria, a disorder of complement-induced hemolytic anemia, received approval for the treatment of aHUS in the United States and Europe in late 2011. We review the treatment of aHUS and other TMAs, focusing on the role of eculizumab, including its pharmacology, mechanism of action, and approved dosing recommendations and health economic considerations. Finally, the potential for future indications for eculizumab use in other complement-driven diseases is discussed.
A systematic review and meta-analysis was performed to evaluate the effects of carvedilol versus metoprolol on the incidence of postoperative atrial fibrillation in patients undergoing coronary ...artery bypass grafting in randomized controlled trials. Ovid MEDLINE, PubMed, CENTRAL, and Excepta Medica (EMBASE) were searched up to March 2013 for suitable randomized controlled trials. Data were pooled using random-effects model for pairwise analyses. A total of 4 trials with 601 patients were included in this analysis. Pairwise analyses showed that compared with metoprolol, carvedilol significantly reduced the incidence of postoperative atrial fibrillation (odds ratio 0.50, 95% confidence interval 0.32 to 0.80). In conclusion, compared with metoprolol, carvedilol significantly reduces the incidence of postoperative atrial fibrillation in patients undergoing coronary artery bypass grafting.
Objective An increasing number of patients presenting for urgent coronary surgery have been exposed to clopidogrel, which constitutes a risk of bleeding and related events. Based on the wide ...variability in clopidogrel response and platelet function recovery after cessation, we evaluated the role of point-of-care platelet function testing to define the optimal time for off-pump coronary artery bypass graft (CABG) surgery in a case-control study. Methods Three equally matched groups (300 patients in total) undergoing isolated off-pump CABG for acute coronary syndrome were compared. Group A were treated with clopidogrel and prospectively underwent a strategy guided by platelet function testing. Outcomes were compared with 2 propensity score matched groups: group B underwent CABG after the currently recommended 5 days without clopidogrel; group C were never exposed to clopidogrel. Results Patients in group A had reduced postoperative bleeding compared with those in group B (523 ± 202 mL vs 851 ± 605 mL; P < .001) and a lower number of units packed red blood cells (PRBCs) transfused during the postoperative hospital stay (1.2 ± 1.6 units vs 1.9 ± 1.8 units; P = .004). Postoperative bleeding and the number of units of PRBCs transfused were similar in group A and group C. There was no difference in blood-derived products and platelet consumption, mortality, or the need for reoperation among the groups. Patients in group A waited 3.6 ± 1.7 days for surgery. The strategy used for group A saved 280 days of hospital stay in total. Conclusions The strategy guided by platelet function testing for off-pump CABG offers improved guidance for optimal timing of CABG in patients treated with clopidogrel. This strategy significantly reduces postoperative bleeding and blood consumption, and has a shorter waiting time for surgery than current clinical practice.
Coronary Collateral Function Long After Drug-Eluting Stent Implantation Pascal Meier, Rainer Zbinden, Mario Togni, Peter Wenaweser, Stephan Windecker, Bernhard Meier, Christian Seiler A total of 120 ...patients with long-term stable coronary artery disease after bare-metal stent (BMS) or drug-eluting stent (DES) implantation were included in this study. Both the BMS and the DES groups comprised 60 patients matched for in-stent stenosis severity of the vessel undergoing collateral flow index (CFI) measurement at follow-up and for the duration of follow-up. The primary end point of the investigation was invasively determined coronary collateral function 6 months after stent implantation. Despite equal in-stent stenosis severity (46 ± 34% and 45 ± 36%) and equal follow-up duration (6.2 ± 10 months and 6.5 ± 5.4 months), CFI was diminished in the DES versus BMS group (0.154 ± 0.097 vs. 0.224 ± 0.142; p = 0.0049).
Objectives A history of percutaneous coronary intervention increases the risk of death and complications of coronary artery bypass grafting. This retrospective multicenter study evaluated the impact ...of continuative use of statin on postoperative outcomes when subsequent elective coronary artery bypass grafting is required after percutaneous coronary intervention. Methods Among 14,575 patients who underwent isolated first-time coronary artery bypass grafting between January 2000 and December 2010, 2501 who had previous percutaneous coronary intervention with stenting and fulfilled inclusion criteria were enrolled. Continuative statin therapy was used in 1528 patients and not used in 973 patients. Logistic multiple regression and propensity score analyses were used to assess the risk-adjusted impact of statin therapy on in-hospital mortality and major adverse cardiac events. The Cox proportional hazards model was constructed to assess the effect of continuative statin therapy on 24-month outcome. Results At multivariate analysis, age more than 70 years, 3-vessel or 2-vessel plus left main coronary disease, multivessel percutaneous coronary intervention, ejection fraction 0.40 or less, diabetes mellitus, and logistic European System for Cardiac Operative Risk Evaluation 5 or greater were independent predictors of hospital mortality and major adverse cardiac events. After propensity score matching, conditional logistic regression analysis demonstrated that continuative statin therapy before coronary artery bypass grafting reduced the risk for hospital and 2-year mortality (odds ratio OR, 0.27; 95% confidence interval CI, 0.12-0. 57; P = .004 and OR, 0.6; 95% CI, 0.36-0.96; P = .04, respectively) and major adverse cardiac events (OR, 0.31; 95% CI, 0.18-0.78; P = .003 and OR, 0.5; 95% CI, 0.34-0.76; P = .006, respectively). Conclusions Long-term statin treatment after percutaneous coronary intervention improves early and midterm outcome when surgical revascularization will be required.
The purpose of the present study was to examine the feasibility and efficacy of a program to acquire devices with adequate battery life from crematories and funeral homes for potential reutilization ...in underserved nations.
There exists a great health-care disparity between the industrialized world and underserved nations--specifically in the frequency of pacemaker implantation.
Flyers were mailed to all 1057 members of the Michigan Funeral Directors Association providing information to download a consent-for-explant form and request a postage-paid envelope from www.myheartyourheart.org in order to send explanted devices. Donated devices from funeral homes and crematories nationwide were also collected from World Medical Relief. Adequate battery life was defined as ≥75% or ≥4 years of estimated longevity.
A total of 3176 devices (65% pacemakers, 21% implantable cardioverter-defibrillators ICDs, 12% biventricular ICDs, and 3% biventricular pacemakers) were donated to the reutilization program. Five hundred fifty devices (21%; 95% confidence interval CI 19.4-22.6%) were found to have an acceptable battery life for reutilization. Among these devices, 313 were pacemakers (17.9%; 95% CI 16.1-19.8%), 118 were ICDs (17.9%; 95% CI 15.1-21.1%), 112 were biventricular ICDs (30.3%; 95% CI 25.6-35.2%), and 7 were biventricular pacemakers (17.3%; 95% CI 16.0-18.7%).
Approximately 21% of donated devices and 30% of donated biventricular ICDs possess an adequate battery life for potential reuse. Device donations from funeral homes and crematories appear to be a potential resource for device reutilization for those in need in underserved nations.
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