Dual antiplatelet therapy, with aspirin and a thienopyridine, is the accepted treatment after percutaneous coronary intervention (PCI). No clear evidence exists regarding the ideal dosage of aspirin. Recent guidelines recommend higher-dose aspirin because of the possible decrease in stent thrombosis. The purpose of this study was to test the hypothesis that high-dose aspirin of 325 mg decreases death and myocardial infarction (MI) compared to a lower dose of 81 mg in patients undergoing PCI.
An observational cohort study of 1,840 consecutive patients who underwent PCI was conducted. Patients who did not survive to discharge were excluded. The primary endpoint was a composite of all-cause mortality and MI at 1 year.
Nine-hundred and thirty patients (50.5%) were discharged on 325 mg of aspirin and 910 (49.5%) were discharged of 81 mg. The risk of all-cause mortality or MI was not significantly different between patients: low-dose 5.49% (50/910) vs. high-dose 4.19% (39/930); adjusted odds ratio [OR], 1.16; 95% confidence interval [CI], 0.73-1.85). In a multivariable analysis, the Charlson comorbidity score (OR, 1.37; 95% CI, 1.18-1.58) and urgent PCI (OR, 1.75; 95% CI, 1.03-3.00) were associated with increased death or MI. Among patients with drug-eluting stents, the use of low-dose aspirin did not predispose them to death or MI (adjusted OR, 1.12, 95% CI, 0.53-2.34).
In this large contemporary analysis of PCI patients, no differences in death or MI were observed at 1 year between patients discharged on low-dose aspirin 81 mg compared to patients on a higher dose.
We assessed the safety and effectiveness of the sirolimus-eluting stent (SES) in treating single de novo long lesions in small native coronary arteries compared to an identical bare metal stent (BMS).
The SES was previously demonstrated to reduce restenosis significantly. However, patients with long lesions in small vessels have not been well studied and may define a group at very high risk.
The Canadian Study of the Sirolimus-Eluting Stent in the Treatment of Patients With Long De Novo Lesions in Small Native Coronary Arteries (C-SIRIUS) was a multicenter, randomized, double-blind trial comparing SES versus identical BMS. The primary end point was in-stent minimal lumen diameter (MLD) at eight months. Secondary end points included angiographic restenosis at 8 months, target lesion revascularization (TLR), and major adverse cardiac events (MACE) at 270 days.
A total of 100 patients were enrolled at eight Canadian sites. The in-stent MLD at eight months was 2.46 +/- 0.37 mm in the SES compared with 1.49 +/- 0.75 mm in the BMS (a 65% increase, p
Comment In: J Am Coll Cardiol. 2004 Mar 17;43(6):1116-715028376
The randomized BASKET-PROVE study showed no significant differences between sirolimus-eluting stents (SES), everolimus-eluting stents (EES), and bare-metal stents (BMS) with respect to the primary end point, rates of death from cardiac causes, or myocardial infarction (MI) at 2 years of follow-up, in patients requiring stenting of a large coronary artery. Clinical risk factors may affect clinical outcomes after percutaneous coronary interventions. We present a retrospective analysis of the BASKET-PROVE data addressing the question as to whether the optimal type of stent can be predicted based on a cumulative clinical risk score.
A total of 2,314 patients (mean age 66 years) who underwent coronary angioplasty and implantation of =1 stents that were =3.0 mm in diameter were randomly assigned to receive SES, EES, or BMS. A cumulative clinical risk score was derived using a Cox model that included age, gender, cardiovascular risk factors (hypercholesterolemia, hypertension, family history of cardiovascular disease, diabetes, smoking), presence of =2 comorbidities (stroke, peripheral artery disease, chronic kidney disease, chronic rheumatic disease), a history of MI or coronary revascularization, and clinical presentation (stable angina, unstable angina, ST-segment elevation MI).
An aggregate drug-eluting stent (DES) group (n = 1,549) comprising 775 patients receiving SES and 774 patients receiving EES was compared to 765 patients receiving BMS. Rates of death from cardiac causes or nonfatal MI at 2 years of follow-up were significantly increased in patients who were in the high tertile of risk stratification for the clinical risk score compared to those who were in the aggregate low-mid tertiles. In patients with a high clinical risk score, rates of death from cardiac causes or nonfatal MI were lower in patients receiving DES (2.4 per 100 person-years, 95% CI 1.6-3.6) compared with BMS (5.5 per 100 person-years, 95% CI 3.7-8.2, hazard ratio 0.45, 95% CI 0.26-0.80, P = .007). However, they were not significantly different between receivers of DES and BMS in patients in the low-mid risk tertiles.
This exploratory analysis suggests that, in patients who require stenting of a large coronary artery, use of a clinical risk score may identify those patients for whom DES use may confer a clinical advantage over BMS, beyond lower restenosis rates.
Patients with ST elevation myocardial infarction have traditionally been hospitalized for five to seven days to monitor for serious complications such as heart failure, arrhythmias, reinfarction and death. The Zwolle primary percutaneous coronary intervention (PCI) index is an externally validated risk score that has been used to identify low-risk primary PCI patients who can safely be discharged from the hospital within 48 h to 72 h.
The Zwolle score was retrospectively applied to all ST elevation myocardial infarction patients treated with primary PCI between April 2004 and February 2006 at a large Canadian teaching hospital. The goal was to characterize length of stay (LOS) in low-risk patients and to identify variables that correlate with patients who were hospitalized longer than expected.
Data were collected on 255 patients. The mean LOS was 7.2+/-7.7 days (median 5.0 days [interquartile range 3.5 days]). A total of 179 patients (70%) had a Zwolle score of 3 or lower, identifying them as low risk. There was one death in the low-risk group (0.6% 30-day mortality) and 15 deaths in the higher-risk group (19.7% 30-day mortality), validating the Zwolle score in the population. A contraindication to early discharge was identified in 34 of the low-risk patients. Among the 144 remaining low-risk patients, the mean LOS was 5.1+/-3.3 days (median 4.0 days [interquartile range 3.0 days]). Only 8% were discharged within 48 h and only 28% within 72 h. It was determined that fewer patients were discharged on weekends and Wednesdays (when medical residents were away for teaching) than on other weekdays. LOS was longer among patients who were discharged on warfarin (7.6 days versus 4.6 days, P=0.006), and among patients who were transferred back to their presenting hospital rather than being discharged directly from the hospital where PCI was performed (5.6 days versus 4.0 days, P
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Three schemes of treatment were used in the management of 230 patients with acute myocardial infarction: immediate thrombolysis (group 1, n=71), immediate thrombolysis followed by angioplasty in 12 hours-7 days depending of the clinical picture of the disease (group 2, n=65), primary angioplasty not later than 12 hours after onset of pain (group 3, n=94). Clopidogrel was given to all patients at least in 2 hours before primary angioplasty and no less than in 6 hours in combined reperfusion. Composite end point (total number of lethal outcomes and nonfatal reinfarctions) was significantly higher in group 1 (14.1%) compared with groups 2 (3.0%) and 3 (3.2%). Invasive intervention improved results of treatment after both effective and ineffective preceding thrombolytic therapy. Thus efficacy of combined reperfusion therapy is not inferior to primary angioplasty if interval between thrombolysis and invasive intervention varies between 12 hours and 7 days and angioplasty is carried out at the background of antiaggregant therapy with clopidogrel and aspirin.
Practice patterns for percutaneous coronary interventions (PCIs) may differ between Canada and the United States. Few data are available comparing PCI outcomes between the two countries in the era of coronary stenting and adjunctive glycoprotein IIb/IIIa inhibition.
In the Enhanced Suppression of the Platelet IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) trial, 2064 patients were randomly assigned to receive eptifibatide or placebo during nonurgent PCI. The 30-day and one-year rates of death, myocardial infarction (MI) and target vessel revascularization (TVR) were compared between Canadian and American patients enrolled in the ESPRIT trial.
There were 1531 American patients and 533 Canadian patients enrolled. Americans were older and heavier, and had a higher incidence of cardiac risk factors than Canadians (P
Diabetes is associated with increased risk of major adverse cardiac events (MACEs) after percutaneous coronary intervention. The purpose of this substudy of the SORT OUT IV trial was to compare clinical outcomes in patients with and without diabetes mellitus treated with everolimus-eluting stents (EESs) or sirolimus-eluting stents (SESs). In total 2,774 patients (390 with diabetes, 14.1%) were randomized to stent implantation with EESs (n = 1,390, diabetes in 14.0%) or SESs (n = 1,384, diabetes in 14.2%). Randomization was stratified by presence/absence of diabetes. The primary end point was MACEs, a composite of cardiac death, myocardial infarction, definite stent thrombosis, or target vessel revascularization within 18 months. MACEs were higher in diabetic than in nondiabetic patients (13.1% vs 6.4%, hazard ratio [HR] 2.08, 95% confidence interval [CI] 1.51 to 2.86). In diabetic patients, MACEs were seen in 10.3% of those treated with EESs and in 15.8% of those treated with SESs (HR 0.63, 95% CI 0.36 to 1.11). In nondiabetic patients, MACEs occurred in 6.6% of EES-treated and in 6.3% SES-treated patients (HR 1.06, 95% CI 0.77 to 1.46). In diabetics, cardiac death occurred in 3.1% of EES-treated and in 4.6% of SES-treated patients (HR 0.67, 95% CI 0.24 to 1.89), myocardial infarction occurred in 0.5% of EES-treated and in 3.6% of SES-treated patients (HR 0.14, 95% CI 0.02 to 1.16), and clinically driven target lesion revascularization was needed in 3.1% of EES-treated and in 7.7% of SES-treated patients (HR 0.40, 95% CI 0.15 to 1.02). No interaction between diabetes status and type of drug-eluting stent was found for the end points. In conclusion, patients with diabetes have higher MACE rates than nondiabetics. No significant differences in safety or efficacy outcomes after EES or SES implantation were present in nondiabetic or diabetic patients.
This study was performed to assess the lipid burden of culprit lesions in non-ST-segment elevation myocardial infarction (non-STEMI) and unstable angina (UA).
A recent intracoronary near-infrared spectroscopy (NIRS) study showed 85% of STEMI culprit lesions have a maximum lipid core burden index in 4-mm (maxLCBI(4mm))?=?400. Whether culprit lesions in non-STEMI and UA are characterized by a similarly large lipid burden is unknown.
We studied 81 non-STEMI and UA patients undergoing culprit vessel NIRS imaging before stenting. Culprit segments were compared to all nonoverlapping 10-mm nonculprit segments for maxLCBI(4mm). Culprit segments in non-STEMI and UA were compared for the frequency of maxLCBI(4mm) =?400.
Among 81 patients (53.1% non-STEMI, 46.9% UA), non-STEMI culprit segments had a 3.4-fold greater maxLCBI(4mm) than nonculprits (448?±?229 vs 132?±?154, P?
Comment In: Catheter Cardiovasc Interv. 2015 Nov 15;86(6):1022-326541802