PPCI involving coronary artery aneurysms (CAAs) is challenging because of difficulties in “wiring” the distal part of the lesion, the presence of extensive thrombus burden, and increased risk of ...distal embolization and no reflow (1). ...CAA is a risk factor for stent thrombosis after stenting for acute coronary syndromes (2). ...PPCI-treated patients with STEMI caused by CAA show unacceptable rates of early stent thrombosis causing recurrent MIs. All event rates are calculated as Kaplan-Meier estimates.BARC = bleeding academic research consortium; CL = culprit lesion; EF = ejection fraction; MI = myocardial infarction; RCA = right coronary artery. Patients With Aneurysm as CL (n = 32) Patients Without Aneurysm as CL (n = 2,280) p Value Age, yrs 65.85 ± 11.61 62.94 ± 12.52 0.17 Male 26 (81.3) 1,773 (77.8) 0.637 Diabetes mellitus 7 (21.9) 374 (16.7) 0.441 Previous MI 8 (25.8) 256 (11.4) 0.013 CL = RCA 16 (50.0) 739 (32.4) 0.035 EF at discharge, % 48.28 ± 6.63 48.56 ± 9.40 0.884 Bleeding BARC 3,5 1 (3.2) 17 (0.8) 0.13 30-day event rates Death/MI 5 (15.6) 169 (7.7) 0.091 Death 1 (3.1) 131 (6.0) 0.515 Cardiac death 1 (3.1) 105 (4.7) 0.682 New MI 4 (12.7) 50 (2.3) <0.001...
Ischemia/reperfusion injury adversely affects the final infarct size (IS) after primary percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). ...Few studies have evaluated the role of remote ischemic conditioning (RIC) in reducing ischemia/reperfusion injury. However, the results of these studies were not consistent, and an overview of overall effectiveness of this technique in patients with STEMI is lacking. We conducted this meta-analysis to evaluate the available evidence in literature regarding the application of RIC in patients with STEMI who underwent primary PCI. The authors included randomized trials that studied RIC in patients with STEMI who underwent primary PCI versus no conditioning (standard of care). Final analysis included 8 trials with a total of 1,083 patients. Compared with standard of care alone, RIC was associated with reduced IS assessed by biomarker release (standardized mean difference = −0.23, 95% confidence interval CI −0.37 to −0.09; p = 0.001), better rates of ST-segment resolution (54% vs 30%; relative risk RR 1.78; 95% CI 1.35 to 2.34; p <0.001), reduced major adverse cardiac and cerebrovascular events (11% vs 20%; RR 0.57; 95% CI 0.39 to 0.83; p = 0.003), and nonsignificant reduction in IS assessed by cardiac imaging (standardized mean difference = −0.15; 95% CI −1.03 to −0.14; p = 0.36). There was no difference in postprocedural Thrombolysis In Myocardial Infarction-III flow between RIC and standard of care groups (86% vs 87%; RR 0.99; 95% CI 0.94 to 1.05; p = 0.81). In conclusion, remote ischemic conditioning may improve cardiovascular outcomes in patients with STEMI who underwent primary PCI evidenced by reduced biomarkers release, major adverse cardiac and cerebrovascular events, and better ST-segment resolution.
The management of noninfarct-related arteries in patients with ST-elevation myocardial infarction (STEMI) and multivessel coronary disease (MVD) is still debated. We evaluated the prognostic impact ...of staged complete revascularization with percutaneous coronary intervention (PCI) in STEMI patients with MVD admitted to our hospital from 2005 to 2013. Patients undergoing staged complete revascularization (n = 300) were compared with 1:1 propensity score–matched patients with culprit lesion–only treatment (n = 300). We considered a composite primary end point of all-cause death, myocardial infarction, and urgent PCI. Secondary end points included components of the primary, cardiovascular death, any PCI excluding staged PCI. We also performed an analysis including only patients surviving at least 5 days. The median follow-up was 553 days. The primary end point occurred in 10.3% of patients in the staged complete revascularization group and in 16.3% of patients in the culprit lesion–only group (hazard ratio 0.61, 95% CI 0.38 to 0.95, p = 0.031). Although this difference was no longer significant when considering only the survivors at day 5, all-cause and cardiovascular mortalities were still reduced in the staged complete revascularization group. Complete revascularization was associated with a better outcome (hazard ratio 0.35, 95% CI 0.17 to 0.63, p = 0.005) if performed within 30 days of STEMI. In conclusion, compared with culprit lesion–only revascularization, in STEMI patients with MVD undergoing primary PCI, an approach of staged complete revascularization was associated with a better outcome.
Objectives This study sought to evaluate whether remote ischemic post-conditioning (RIPC) could reduce enzymatic infarct size in patients with anterior ST-segment elevation myocardial infarction ...undergoing primary percutaneous coronary intervention (pPCI). Background Myocardial reperfusion injury may attenuate the benefit of pPCI. In animal models, RIPC mitigates myocardial reperfusion injury. Methods One hundred patients with anterior ST-segment elevation myocardial infarction and occluded left anterior descending artery were randomized to pPCI + RIPC (n = 50) or conventional pPCI (n = 50). RIPC consisted of 3 cycles of 5 min/5 min ischemia/reperfusion by cuff inflation/deflation of the lower limb. The primary endpoint was infarct size assessed by the area under the curve of creatinine kinase-myocardial band release (CK-MB). Secondary endpoints included the following: infarct size assessed by cardiac magnetic resonance delayed enhancement volume; T2 -weighted edema volume; ST-segment resolution >50%; TIMI (Thrombolysis In Myocardial Infarction) frame count; and myocardial blush grading. Results Four patients (2 RIPC, 2 controls) were excluded due to missing samples of CK-MB. A total of 96 patients were analyzed; median area under the curve CK-MB was 8,814 (interquartile range IQR: 5,567 to 11,325) arbitrary units in the RIPC group and 10,065 (IQR: 7,465 to 14,004) arbitrary units in control subjects (relative reduction: 20%, 95% confidence interval: 0.2% to 28.7%; p = 0.043). Seventy-seven patients underwent a cardiac magnetic resonance scan 3 to 5 days after randomization, and 66 patients repeated a second scan after 4 months. T2-weighted edema volume was 37 ± 16 cc in RIPC patients and 47 ± 22 cc in control subjects (p = 0.049). ST-segment resolution >50% was 66% in RIPC and 37% in control subjects (p = 0.015). We observed no significant differences in TIMI frame count, myocardial blush grading, and delayed enhancement volume. Conclusions In patients with anterior ST-segment elevation myocardial infarction, RIPC at the time of pPCI reduced enzymatic infarct size and was also associated with an improvement of T2 -weighted edema volume and ST-segment resolution >50%. (Remote Postconditioning in Patients With Acute Myocardial Infarction Treated by Primary Percutaneous Coronary Intervention PCI RemPostCon; NCT00865722 )
The residual burden of coronary artery disease after percutaneous coronary intervention (PCI) has been associated with worse ischemic outcome. However, data are conflicting in elderly patients. The ...aim of our study was to verify the incremental value of the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (rSS) over clinical variables and baseline SYNTAX score (bSS) in predicting 1-year mortality or cardiovascular events.
A post hoc analysis of data collected in the Elderly-ACS 2 multicenter randomized trial was performed. We included 630 patients aged > 75 years with multivessel coronary disease undergoing PCI for acute coronary syndrome (ACS). The primary outcome was a composite of death, recurrent myocardial infarction, and stroke at 1-year follow up. Change in c-statistic and standardized net benefit were used to evaluate the incremental value of the rSS.
Event rates were significantly higher in patients with incomplete revascularization (rSS > 8). When the rSS was included in a core Cox regression model containing age, previous myocardial infarction, and ACS type, the hazard ratio for patients with score values > 8 was 2.47 (95% confidence interval, 1.51-4.06). However, the core model with rSS did not increase the c-statistic compared with the core model with the bSS (from 0.69 to 0.70) and gave little incremental value in the standardized net benefit.
In elderly patients with ACS with multivessel disease undergoing PCI, incomplete revascularization was associated with worse outcome at 1-year follow-up. However, there was no clear incremental value of the rSS in the prediction of 1-year adverse outcome compared with a model including clinical variables and bSS.
Le fardeau résiduel de la coronaropathie après une intervention coronarienne percutanée (ICP) a été associé à de moins bons résultats sur le plan ischémique. Les données recueillies chez les patients âgés sont toutefois contradictoires. Cette étude avait donc pour objectif de valider la valeur ajoutée du score SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) résiduel (SSr) par rapport aux paramètres cliniques et au score SYNTAX initial (SSi) pour prédire la mortalité à 1 an et les manifestations cardiovasculaires.
Une analyse a posteriori des données de l’étude multicentrique avec répartition aléatoire Elderly-ACS 2 a été effectuée. Pour ce faire, 630 patients âgés de plus de 75 ans, atteints d’une coronaropathie multitronculaire et ayant subi une ICP pour traiter un syndrome coronarien aigu (SCA) ont été retenus. Le critère d’évaluation principal était composé du décès, de l’infarctus du myocarde récurrent et de l’accident vasculaire cérébral (AVC) au moment du suivi à 1 an. La variation de la statistique C et le bénéfice net normalisé ont servi à évaluer la valeur ajoutée du SSr.
Les manifestations étaient significativement plus fréquentes chez les patients dont la revascularisation était incomplète (SSr > 8). Lorsque le SSr a été pris en compte dans un modèle de régression de Cox de base ayant pour facteurs l’âge, les antécédents d’infarctus du myocarde et le type de SCA, le rapport des risques instantanés pour les patients ayant un score > 8 était de 2,47 (intervalle de confiance à 95 % : 1,51-4,06). L’intégration du SSr dans le modèle de base n’a toutefois pas donné lieu à une statistique C plus élevée que celle du SSi (0,70 vs 0,69) et conférait peu de valeur ajoutée sur le plan du bénéfice net normalisé.
Chez les patients âgés présentant un SCA et une atteinte multitronculaire, et subissant une ICP, la revascularisation incomplète a été associée à de moins bons résultats au moment du suivi à 1 an. Le SSr n’a toutefois pas été clairement associé à une valeur ajoutée pour prédire une issue défavorable à 1 an comparativement à un modèle reposant sur des paramètres cliniques et le SSi.
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