Abstract: The elderly diabetic patients are increasingly referred for percutaneous coronary interventions during acute coronary syndromes. A nonegligible proportion of this population includes the in stent restenosis as a possible cause of ischemic syndrome. This population accounts an higher risk of ischemic, bleeding and vascular complications affecting the periprocedural management, the length of hospital stay and also the prognosis. The improvement of strategies concerning site of access choice, antithrombotic drug and timing of interventional treatment have significantly reduced the incidence of complications. This paper reports the case of a 76 years-old diabetic female with a high bleeding risk, referred to our hospital because of NSTEMI complicated by pulmonary edema during hypertensive emergency. The patient had a simultaneous in stent restenosis both in left descending coronary artery and left renal artery, undergoing percutaneous transradial treatment during bivalirudin infusion. The clinical, technical, pharmacological and prognostic implications are discussed.
Abstract: It remains undefined if transradial coronary angiography from a right or left radial arterial approach differs in real-world practice. To address this issue, we performed a subanalysis of the PREVAIL study. The PREVAIL study was a prospective, multicenter, observational survey of unselected consecutive patients undergoing invasive cardiovascular procedures over a 1-month observation period, specifically aimed at assessing the outcomes of radial approach in the contemporary real world. The choice of arterial approach was left to the discretion of the operator. Prespecified end points of this subanalysis were procedural characteristics. Of 1,052 patients consecutively enrolled, 509 patients underwent transradial catheterization, 304 with a right radial and 205 with a left radial approach. Procedural success rates were similar between the 2 groups. Compared to the left radial group, the right radial group had longer procedure duration (46 ± 29 vs 33 ± 24 minutes, p <0.0001) and fluoroscopy time (765 ± 787 vs 533 ± 502, p <0.0001). At multivariate analysis, including a parsimonious propensity score for the choice of left radial approach, duration of procedure (beta coefficient 11.38, p <0.001) and total dose-area product (beta coefficient 11.38, p <0.001) were independently associated with the choice of the left radial artery approach. The operator's proficiency in right/left radial approach did not influence study results. In conclusion, right and left radial approaches are feasible and effective to perform percutaneous procedures. In the contemporary real world, however, the left radial route is associated with shorter procedures and lower radiologic exposure than the right radial approach, independently of an operator's proficiency.
Abstract: OBJECTIVES: The purpose of this study was to assess whether transradial access for ST-segment elevation acute coronary syndrome undergoing early invasive treatment is associated with better outcome compared with conventional transfemoral access. BACKGROUND: In patients with acute coronary syndrome, bleeding is a significant predictor of worse outcome. Access site complications represent a significant source of bleeding for those patients undergoing revascularization, especially when femoral access is used. METHODS: The RIFLE-STEACS (Radial Versus Femoral Randomized Investigation in ST-Elevation Acute Coronary Syndrome) was a multicenter, randomized, parallel-group study. Between January 2009 and July 2011, 1,001 acute ST-segment elevation acute coronary syndrome patients undergoing primary/rescue percutaneous coronary intervention were randomized to the radial (500) or femoral (501) approach at 4 high-volume centers. The primary endpoint was the 30-day rate of net adverse clinical events (NACEs), defined as a composite of cardiac death, stroke, myocardial infarction, target lesion revascularization, and bleeding). Individual components of NACEs and length of hospital stay were secondary endpoints. RESULTS: The primary endpoint of 30-day NACEs occurred in 68 patients (13.6%) in the radial arm and 105 patients (21.0%) in the femoral arm (p = 0.003). In particular, compared with femoral, radial access was associated with significantly lower rates of cardiac mortality (5.2% vs. 9.2%, p = 0.020), bleeding (7.8% vs. 12.2%, p = 0.026), and shorter hospital stay (5 days first to third quartile range, 4 to 7 days] vs. 6 [range, 5 to 8 days]; p = 0.03). CONCLUSIONS: Radial access in patients with ST-segment elevation acute coronary syndrome is associated with significant clinical benefits, in terms of both lower morbidity and cardiac mortality. Thus, it should become the recommended approach in these patients, provided adequate operator and center expertise is present. (Radial Versus Femoral Investigation in ST Elevation Acute Coronary Syndrome [RIFLE-STEACS]; NCT01420614).
Abstract: Site of access vascular complications is infrequent after transradial interventions. We report the case of a 66-year-old man referred to our hospital because of right forearm swelling, oedema and pain with functional forearm disability, 1 year after a transradial primary percutaneous coronary intervention (PCI). The diagnostic and procedural issues are discussed. This is the first description of a successful and well-tolerated radial arteriovenous fistula (AVF) treatment by means of percutaneous antegrade approach with the use of a short introducer and a biocompatible covered stent.
Abstract: Coronary artery ectasia (CAE) is frequently considered an incidental finding during coronary angiography, however, several reports have shown an association with myocardial ischemia and infarction. When acute myocardial infarction (AMI) occurs in cases of CAE, current reperfusion therapies, due to the large arterial size and the massive intracoronary thrombus, when used alone are limited in preventing the development of distal embolization and 'no reflow phenomenon.' In this article, we described the case of a multiple sclerosis (MS) patient with diffuse CAE and ST elevation AMI, treated by coronary dethrombosis multistrategy (mechanical and pharmacologic) during a transradial primary angioplasty. The higher thrombotic burden in MS with CAE was analyzed and possible common pathophysiologic pathways were discovered in the imbalance between proteolytic activities of metalloproteinases and endogenous tissue inhibitor, with subsequent increased proteolysis leading to a risk for coronary plaque rupture. The one-year clinical and angiographic follow-up with coronary computed tomography (CT) angiography, together with long-term antiplatelet therapy, was also evaluated.
Abstract: Cardiovascular disease is a leading cause of morbidity and mortality in end-stage renal disease (ESRD) patients on maintenance hemodialysis (HD). Neither traditional nor emerging risk factors for cardiovascular disease can explain completely this excess of morbidity and mortality and the role and timing of primary prevention strategies in this population has not been clarified. The aim of this study was to assess if an aggressive pharmacological preventive treatment may reduce the myocardial ischemic burden and then improve the cardiovascular outcome In ESRD patients.
Abstract: Most of the studies assessing transradial approach for coronary angiography (CA) have been performed through right radial approach (RRA). Our aim was to evaluate the safety and efficacy of left radial approach (LRA) compared with RRA for coronary procedures.
Abstract: As data on the use of the latest-generation drugeluting stents (DES) in bifurcation interventions are lacking, we realized a multicenter registry to assess the procedural and clinical results obtained in patients with unselected bifurcated lesions treated with the novel zotarolimus-eluting Resolute stent (ZRS).
Abstract: Transradial percutaneous coronary procedures may be effectively performed through the right radial approach (RRA) or the left radial approach (LRA), but data on radiation dose absorbed by operators comparing the two approaches are lacking. The aim of the present study was to evaluate radiation dose absorbed by operators during coronary procedures through the RRA and LRA.
Abstract: The best timing for coronary angiography (immediate vs early) in patients with acute non-ST-elevation myocardial infarction (NSTEMI) is controversial.
Abstract: In chronic diseases the adherence and persistence to therapeutic treatments are often lower than guidelines said. This leads to a worse therapeutic effect of the treatments and to a misuse in healthcare costs. Our study evaluates the impact of a pharmacoutilization analysis model, derived from the administrative database of the Local Health Unit Roma B. In particularly we calculate some indicators of adherence, persistence, occasional treatment and switch in patients on statins secondary prevention treatment (patients discharged from Hospital with Acute Myocardial Infarction diagnosis). The model that we developed would be successfully used in the cost-effective analysis of other drugs.
Abstract: OBJECTIVES:: To evaluate the efficacy of the new Cobalt-Chromium PRESILLION stent for the treatment of high-risk acute myocardial infarction (MI) patients. BACKGROUND:: Percutaneous coronary intervention (PCI) with stent represents the gold standard treatment for acute MI. METHODS AND RESULTS:: We enrolled patients with high-risk acute MI (either ST-segment elevation or non-ST-segment elevation MI, STEMI or NSTEMI, respectively) treated with PCI employing a new Cobalt-Chromium bare metal stent with closed cells design and limited balloon compliance. We considered high-risk features as one of the following: age >/=70 years, ejection fraction </=35%, glomerular filtration rate </= 60mL/min, diabetes mellitus, rescue PCI, or chronic atrial fibrillation or other conditions requiring long-term oral anticoagulation therapy. Primary outcome of the study was rate of major adverse cardiac events (MACE) defined as all-cause death, new MI, and target-vessel revascularization. A total of 129 consecutive patients were enrolled (69 +/- 11 years, 74% men): 71 patients (55%) with STEMI and 58 patients (45%) with NSTEMI. A total of 153 vessels (169 lesions and 179 stents) were treated. The device success rate was high (98.8%). In-hospital MACE rate was 5.4% mainly due to death associated with the acute MI. At 1-year follow-up the MACE rate was 17.3%, with 11% all-cause death (7.9% of cardiac origin), 0.6% of stent thrombosis and 4.6% target-vessel revascularization CONCLUSIONS: The use of the Cobalt-Chromium Presillion stent in patients with high-risk acute MI treated invasively appears to be safe and efficacious with optimal deliverability and good long-term outcomes and represents a good option in the treatment of these patients. (c) 2010 Wiley-Liss, Inc.
Abstract: Chronic use of aspirin and statins has been associated with reduced risk of subsequent myocardial infarction (MI). However, in patients with chronic kidney disease (CKD), the cardioprotective role of aspirin and statins seems to be reduced. To evaluate the impact of chronic aspirin and statin use on clinical presentation of acute MI according to renal function, the authors retrospectively analyzed 595 consecutive patients admitted to our hospital for acute MI. Renal function was normal in 404 patients and impaired in 191. Patients on therapy (113 patients) were less likely to have ST-segment elevation MI (STEMI) compared with patients not treated (36% vs 53%, respectively, P=.0002). These results have been confirmed in the population of patients with CKD (48% of STEMI in patients receiving chronic therapy and 67% in patients without therapy,P=.01). Multivariate analysis in the group of patients with CKD showed that use of aspirin or statins was an independent predictor of a decreased probability of STEMI (odds ratio, 0.5; 95% confidence interval, 0.2-1.0,P=.05). The authors' results suggest that in a community-based sample of patients with acute MI, chronic aspirin and statin therapy has a cardioprotective role that is evident also in patients with CKD.
Abstract: Stent thrombosis is a catastrophic occurrence burdened by a high mortality rate and a tendency to recur. We sought to evaluate the angiographic risk factors for recurrent stent thrombosis (rST) in a subpopulation of 91 Outcome of PCI for stent-ThrombosIs Multicenter STudy (OPTIMIST) patients who underwent quantitative angiographic evaluation by an independent core laboratory. The Academic Research Consortium criteria were used for rST adjudication. A multivariate Cox proportional hazards model was applied to estimate the hazard ratios and the corresponding 95% confidence intervals for the occurrence of Academic Research Consortium-defined, definite rST (primary end point), definite or probable rST (secondary end point), and definite or probable or possible rST (secondary end point). A total of 8 definite rST events occurred during a median follow-up of 244 days (range 165 to 396), of which 5 were early and 3 were late. In the multivariate model, a residual thrombus score of > or =3 (hazard ratio 6.5, 95% confidence interval 1.4 to 30.7, p = 0.017) and a larger postprocedural reference vessel diameter (hazard ratio 4.5, 95% confidence interval 1.5 to 13.3, p = 0.006) were significantly associated with the primary end point. When the same model was applied to the 15 definite and probable rST events, only a residual thrombus score of > or =3 (hazard ratio 7.8, 95% confidence interval 2.5 to 24.5, p <0.001) was significantly associated with rST. Finally, when possible rST events were included (18 patients), a residual thrombus score of > or =3 remained associated with the dependent variable (hazard ratio 6.1, 95% confidence interval 2.0 to 18.2, p = 0.001), along with a larger postprocedural reference vessel diameter. In conclusion, when performing percutaneous coronary intervention for stent thrombosis, the residual thrombus burden and larger reference vessel were potent risk factors for rST.
Abstract: To assess: the reasons behind an operator choosing to perform radial artery catheterisation (RAC) as against femoral arterial catheterisation, and to explore why RAC may fail in the real world.
Abstract: Transradial access (RA) is associated with less complications and is preferred by patients. Vascular closure devices (VCDs) may improve discomfort and may reduce complications associated with transfemoral access. Aim was to evaluate complications and discomfort associated with percutaneous coronary procedures employing RA or VCDs.
Abstract: Left ventricular assist devices provide an important tool in the management of patients with severe left ventricular dysfunction undergoing percutaneous coronary intervention. We describe a case of successful high-risk percutaneous coronary intervention in an octogenarian patient assisted by the Impella Recover LP 5.0 l/min, assuring complete left ventricle support. In our experience this device, although requiring adequate manipulation to be positioned in the aortic valve, proved to be relatively easy to set up and hemodynamically useful for patients with left ventricular dysfunction and end-stage coronary atherosclerosis.
Abstract: Stent thrombosis is a severe complication associated with percutaneous coronary interventions (PCIs). The optimal treatment strategy of this complication is not well known, although emergency PCI in hospitals with 24h facilities for urgent coronary angiography is still considered the best solution. The present report describes four cases of subacute and late stent thrombosis treated with systemic thrombolysis due to the unavailability of the catheterization laboratory. All patients had a very short symptom-to-treatment time (median of 50 min) and were successfully treated with tenecteplase. The subsequent coronary angiography confirmed complete resolution of the thrombosis and the patients were discharged without further PCIs performed.
Abstract: Stent thrombosis (ST) is a major complication of percutaneous coronary interventions (PCIs). An invasive management by re-PCI is the commonly adopted treatment for ST, but data on outcome are limited.
Abstract: Stent thrombosis (ST) is a recognized complication limiting the clinical efficacy of percutaneous coronary interventions (PCI). Because of the increasing number of stent-based PCI, the absolute number of patients experiencing ST is expected to expand. Re-PCI is the commonly adopted treatment for patients with ST; however, the prognostic variables as well as the angiographic and clinical results have not been systematically assessed. Moreover, the possible benefit associated with the use of adjunctive devices (AD) with theoretical antiembolic property has not been systematically analyzed in this high-risk population.
Abstract: Myocardial bridging, a systolic compression of an intramyocardial segment of an epicardial coronary artery, may be an incidental finding during coronary angiography or autopsy. However, some investigators reported a variety of acute coronary syndromes associated with this condition. We describe the case of a relatively young male patient (43 years old) referred to our emergency department for cardiac arrest and subsequent evidence of significant myocardial bridging at coronary angiography. The patient has been treated with an implantable cardioverter-defibrillator to prevent possible subsequent arrhythmic events associated with the myocardial bridging.
Abstract: Antibody antioxidized low density lipoproteins (oxLDL) might play a role both in atherogenesis and in the pathogenesis of acute coronary syndromes.
Abstract: In a group of patients admitted for unstable angina, we investigated whether C-reactive protein (CRP) plasma levels remain elevated at discharge and whether persistent elevation is associated with recurrence of instability.
Abstract: Activated mast cells are present in human coronary atheromas, as well as in the adventitia of patients with variant angina, and may play an important role in plaque rupture and coronary vasomotion. To assess whether or not activation of mast cells is a primary event, we measured serum levels of tryptase, a specific marker of mast cell activation, in 8 patients with unstable angina during a spontaneous ischemic episode (Group 1) and in 5 patients with variant angina (Group 2) during ergonovine-induced coronary spasm. Blood samples were collected as soon as possible after the onset of pain and ECG changes (0 min), and after 5, 15 and 60 min. Tryptase levels in Group 1 were 0.13 U/l (range 0.017-0.44) at the onset of pain and significantly raised to 0.75 U/l (range 0.05-2.49) at 5 min, decreasing to 0.076 U/l (range 0.018-0.16) at 15 min and to 0.085 U/l (range 0.01-0.25) at 60 min (p = 0.035). Conversely, tryptase levels in Group 2 were 0.09 U/l (range 0.07-0.13) at 0 min, 0.11 U/l (range 0.07-0.22) at 5 min, 0.10 U/l (range 0.07-0.18) at 15 min, 0.11 U/l (range 0.07-0.17) at 60 min (NS). In conclusion, tryptase levels raise during spontaneous ischemic episodes in unstable angina, but not after ergonovine-provoked ischemia in variant angina, suggesting that a primary, yet unknown stimulus, may activate mast cells during some ischemic episodes in unstable angina.
Abstract: In order to evaluate whether different clinical presentations of unstable angina are associated with a different degree or pattern of activation of the hemostatic, fibrinolytic and inflammatory systems, we measured plasma levels of thrombin-antithrombin III, plasmin-alpha2- antiplasmin complexes and C-reactive protein, as markers of activation of coagulation, fibrinolysis and inflammation respectively, in two groups of patients: 7 patients with de novo unstable angina (Group 1) and 7 patients with destabilizing unstable angina (Group 2). Blood samples were taken on admission for measuring levels of C-reactive protein and during ischemic episodes at the onset of ECG changes and pain (0 min) and after 5, 15 and 60 min in order to assess the peak values of thrombin-antithrombin III and plasmin-alpha2-antiplasmin during the episode. Thrombin-antithrombin III levels in Group 1 were 1.8 microgram/l (0.3-4.15) at 0 min and increased to 17 micrograms/l (2.8-60) after 5 to 15 min (p = 0.013); conversely thrombin-antithrombin III levels in Group 2 were 2.15 microgram/l (1.4-3.8) at 0 min and raised to 4 micrograms/l (2-43) after 5 to 15 min (NS). No significant differences in both groups were observed in plasmin-alpha2-antiplasmin levels (Group 1:650 micrograms/l, ranged 492-956, at 0 min vs 670 microgram/l, range 415-977, at peak; Group 2: 480 micrograms/l, range 274-955, at 0 min vs 502 micrograms/l, range 304-1027, at peak; NS). Inversely, C-reactive protein levels on admission were 4 mg/dl (range 2-27) in Group 1, and 1 mg/dl (range 0.6-4) in Group 2 (p = 0.006). In conclusion, patients with de novo unstable angina have significantly enhanced thrombin (but not plasmin) production during spontaneous ischemic episodes than patients with destabilizing unstable angina. Furthermore, patients with de novo unstable angina have enhanced acute phase responses than patients with destabilizing unstable angina. Our data suggest that different pathogenetic mechanisms may be responsible for acute ischemic episodes in unstable angina and may explain different response to antithrombotic therapy in unstable angina patients.
Abstract: The growing size of trials on primary and secondary prevention of acute coronary syndromes characterised by very broad inclusion criteria may seem logical to 'trialists', who reason that the the broader the inclusion criteria, the easier it is to recruit large numbers of patients in a short period of time and the more widely applicable are the results of the study. However, large trials with very broad inclusion criteria raise two grounds for concern for physicians. The first is that the broader the inclusion criteria for enrollment in a trial in order to prove a statistically significant benefit, the greater the heterogeneity of the study population which is likely to include both susceptible and non-susceptible patients to the tested treatment. The second is that this method of assessment rapidly increases the number of treatments that produce a statistically-significant improvement in prognosis within the same broad group of patients. On the contrary, the identification of potential responders to a specific treatment can provide a personalised form of medical care suited to the needs of each individual patient with an optimal cost-benefit ratio. This approach, however, represents a major challenge as it can only be based on the identification of homogeneous subgroups of patients with common risk factors for the development of acute coronary syndromes or of their recurrence. This challenge can only be overcome by a strong commitment in funding studies on the multiple causes of acute coronary syndromes.
