Facilitated percutaneous coronary intervention for ST-segment-elevation myocardial infarction (STEMI) is defined as the use of pharmacological substances before a planned immediate intervention, to ...improve coronary patency. We undertook a meta-analysis of randomised controlled trials (published and unpublished) to compare facilitated and primary percutaneous coronary intervention.
We identified 17 trials of patients with STEMI assigned to facilitated (n=2237) or primary (n=2267) percutaneous coronary intervention. We identified short-term outcomes (up to 42 days) of death, stroke, non-fatal reinfarction, urgent target vessel revascularisation, and major bleeding. Grade 3 flow rates for prethrombolysis and post-thrombolysis in myocardial infarction (TIMI) were also analysed.
The facilitated approach resulted in a greater than two-fold increase in the number of patients with initial TIMI grade 3 flow, compared with the primary approach (832 patients 37%
vs 342 15%, odds ratio 3·18, 95% CI 2·22–4·55); however, final rates did not differ (1706 89%
vs 1803 88%; 1·19, 0·86–1·64). Significantly more patients assigned to the facilitated approach than those assigned to the primary approach died (106 5%
vs 78 3%; 1·38, 1·01–1·87), had higher non-fatal reinfarction rates (74 3%
vs 41 2%; 1·71, 1·16–2·51), and had higher urgent target vessel revascularisation rates (66 4%
vs 21 1%; 2·39, 1·23–4·66); the increased rates of adverse events seen with the facilitated approach were mainly seen in thrombolytic-therapy-based regimens. Facilitated intervention was associated with higher rates of major bleeding than primary intervention (159 7%
vs 108 5%; 1·51, 1·10–2·08). Haemorrhagic stroke and total stroke rates were higher in thrombolytic-therapy-containing facilitated regimens than in primary intervention (haemorrhagic stroke 15 0·7%
vs two 0·1%, p=0·0014; total stroke 24 1·1%
vs six 0·3%, p=0·0008).
Facilitated percutaneous coronary intervention offers no benefit over primary percutaneous coronary intervention in STEMI treatment and should not be used outside the context of randomised controlled trials. Furthermore, facilitated interventions with thrombolytic-based regimens should be avoided.
Aims
We sought to investigate the impact of multivessel coronary artery disease (CAD) on reperfusion success and prognosis following primary percutaneous coronary intervention (PCI) in patients with ...acute myocardial infarction (AMI). The influence of multivessel disease on myocardial reperfusion and subsequent survival after primary PCI has not been studied.
Methods and results
In the CADILLAC trial, primary PCI was performed in 2082 patients of any age with AMI within 12 h of symptom onset. Myocardial perfusion post-PCI assessed by ST-segment recovery and myocardial blush and clinical outcomes were stratified by the extent of CAD. Single-, double-, and triple-vessel disease were present in 1066 (51.2%), 692 (33.2%), and 324 (15.6%) patients, respectively. Patients with multivessel disease compared with those with single-vessel disease undergoing primary PCI were significantly more likely to have absent ST-segment recovery (13.3 vs. 7.4%, P = 0.01), though the rates of post-procedural TIMI-3 flow (89.7 vs. 88.9%, P = 0.66) and grade 2 or 3 myocardial blush (51.2 vs. 51.5%, P = 0.91) in the infarct vessel were comparable. By 1 year, the cumulative incidence of death for patients with single-, double-, and triple-vessel disease was 3.2, 4.4, and 7.8%, respectively (P = 0.003), and the composite rate of major adverse cardiac events (MACE) was 14.8, 19.5, and 23.6%, respectively (P = 0.0006). By multivariable analysis, the presence of triple-vessel disease was the strongest predictor of 1-year death hazard ratio (HR) = 2.60, P = 0.009, death and re-infarction (HR = 1.88, P = 0.03), and MACE (HR = 1.80, P = 0.0009).
Conclusion
Patients with extensive CAD in vessels remote from the infarct-related artery have reduced reperfusion success and an adverse prognosis following primary PCI in AMI. Future studies regarding the optimal treatment of patients with multivessel disease and AMI are warranted.
Key Points
The risk of anaphylaxis from contrast allergy is very low, and there is little evidence to support the use of steroids for premedication.
Use of oral steroids prior to cardiac ...catheterization in diabetics is associated with more hyperglycemia and hypertension.
The long‐term consequences of steroid induced transient hyperglycemia is unknown.
Key Points
Heavily calcified coronary arteries may mask lesions.
There is no correlation between angiographic determination of stenosis severity 40–80% and intracoronary measurements of fractional ...flow reserve and Pd/Pa in heavily calcified lesions.
It is essential to perform additional intracoronary hemodynamic measurements or invasive imaging to determine the significance of calcified coronary lesions.
Since the beginning of 2020, the corona virus (COVID-19) pandemic redefined in many ways the practice of cardiology, research and cardiology conferences. Virtual conferences replaced most major ...in-person venues. The number of “elective” structural heart interventions declined and clinical research endured major setbacks in regards to academic and industry-sponsored clinical trials. In this review, we attempt to provide a broad overview of the field for general and interventional cardiologists with a specific interest in structural heart interventions.
•Sustained TAVR benefits in low and intermediate-risk.•TAVR effective for bicuspid aortic AV and cancer.•New TEER guidelines.•Sustained outcomes with MitraClip, PASCAL, TENDYNE.
Key Points
Cardiogenic shock mortality is extremely variable and likely is related to the heterogeneous population and hemodynamic differences in patients.
The National Cardiogenic Shock Initiative ...(NCSI) demonstrated that patients in SCAI shock class E had the worst prognosis, but mortality in all classes was better than expected, perhaps due to applying a vigorous treatment protocol.
Society for Cardiovascular Angiography and Interventions (SCAI) shock classification has now been validated in many studies and allows both clinicians and researchers to rapidly determine risk of mortality.
Alcohol septal ablation (ASA) is indicated for symptomatic hypertrophic cardiomyopathy (HC) patients. We sought to analyze the incidence of the 30-day readmission rate, predictors, causes of ...readmission, and incremental healthcare resource (cost and length of stay) utilization after ASA. Nationwide Readmission Database from 2010 January to 2015 September was queried to identify 30-day unplanned readmission after ASA for HC by using the International Classification of Disease, 9th Revision, Clinical Modification. Those readmitted were similar in terms of age and sex but had higher burden of co-morbidities compared with those not readmitted within 30-days. The 30-day unplanned readmission rate was 10.4% (511/4,932) after ASA. Readmissions lead to an additional mean hospitalization cost of 8,433 US dollars and mean of 4.9 days of length of stay. Predictors of 30-day unplanned readmission were liver disease (adjusted odds ratio aOR 2.62, 95% confidence interval CI 1.22 to 5.59), renal failure (aOR 2.30, 95%CI 1.52 to 3.50), previous myocardial infarction (aOR 1.97, 95%CI 1.16 to 3.33), previous pacemaker (aOR 1.50, 95%CI 1.09 to 2.08), atrial fibrillation (aOR 1.43, 95%CI 1.08 to 1.89), Medicaid (aOR 1.74, 95%CI 1.12 to 2.68), and weekend admission (aOR 1.75, 95%CI 1.12 to 2.75). Common reasons for readmissions were atrial fibrillation (12.6%), acute on chronic systolic heart failure (12.6%), paroxysmal ventricular tachycardia (6.4%), atrioventricular block (4.9%), and HC (3.0%). Unplanned readmissions after ASA occur in patients with higher burden of co-morbidities and are mainly caused by cardiac etiologies.
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