A. Al-Fiadh

Contemporary outcomes in women undergoing percutaneous coronary intervention for acute coronary syndromes

BACKGROUND Uncertainty remains as to whether females benefit as much as males from percutaneous coronary intervention (PCI) in the setting of an acute coronary syndrome (ACS). METHODS We compared 802 women with 2151 men presenting with ACS, undergoing PCI from April 2004 to October 2006 from the Melbourne Interventional Group registry. Clinical characteristics, in-hospital, 30-day and 1-year outcomes were compared. RESULTS Women were older (69.6 ± 11.6 vs. 62.17 ± 12.3 years, p<0.001), and had more diabetes (27.1% vs. 19.6%, p<0.001) and hypertension (70.3% vs. 53.9%, p<0.001) than men. Women were less likely to present with ST-elevation myocardial infarction (30.5% vs. 37.9%, p<0.001). Bleeding (3.6% vs. 0.8%, p<0.001) was higher among women. Thirty-day mortality (4.7 vs. 2.4%, p<0.001) and MACE (10.1 vs. 6.4%, p<0.001) were higher in women. Gender was an independent predictor of overall MACE at 30 days (OR 1.45, 95% CI 1.04-2.02, p=0.03) but not death. At 12 months, there were no significant differences in mortality (6.4% vs. 4.8%, p=0.09), myocardial infarction (5.5% vs. 5.0%, p=0.64), target vessel revascularization (7.9% vs. 7.0%, p=0.42) and MACE (16.3% vs. 14%, p=0.13) between women and men. CONCLUSIONS There is an early hazard amongst women undergoing PCI for ACS, but not at 12 months. These data suggest that gender should not affect the decision to offer PCI but further gender specific studies are warranted.

Retinal microvascular structure and function in patients with risk factors of atherosclerosis and coronary artery disease

OBJECTIVE Retinal microvascular signs are markers of cardiovascular disease risk. There are limited data, on relationships between retinal microvascular signs and retinal microvascular endothelial function. We sought to determine the relationship of retinal vascular signs with retinal microvascular endothelial function in patients with or at high risk of coronary artery disease. METHODS Participants with atherosclerosis risk factors and coronary disease (n=258; mean age 57±11 years) were recruited to have static and dynamic retinal vascular assessment. Retinal arteriolar dilatation in response to flicker light (FI-RAD) was measured using the Digital Vessel Analyser and expressed as percentage increase over baseline diameter. Static retinal photographs were acquired utilising a digital fundus camera for measurement of central retinal artery and vein equivalent (CRAE and CRVE), arteriovenous nicking (AVN) and focal arteriolar narrowing (FAN). RESULTS Intra-class correlation coefficient was 0.82 for flicker-light induced retinal arteriolar dilatation. There were modest associations in retinal vascular measurements between eyes. For each 10 μm decrease in retinal arteriolar diameter, the absolute increase in FI-RAD was 0.28% (95% CI 0.11, 0.45; p=0.002) independent of age, gender and atherosclerosis risk factors. AVN and FAN were associated with attenuated FI-RAD (β=-0.67%; 95% CI -1.20, -0.15; p=0.012) and (β=-0.83%; 95% CI -1.44, -0.23; p=0.007) respectively after adjustment for age and gender. CONCLUSION Assessment of retinal microvascular endothelial function is reproducible and correlated with retinal microvascular structure and signs, independent of atherosclerosis risk factors. Assessment of retinal vascular structure and function may provide insights into atherosclerotic disease.

Are Retinal Microvascular Caliber Changes Associated with Severity of Coronary Artery Disease in Symptomatic Cardiac Patients

Objectives: Recent population‐based studies have shown that retinal vascular caliber may predict the risk of clinical coronary artery disease (CAD) events. Whether this association is related to macro‐ or microvascular mechanisms remains unknown. We investigated the relationship of retinal vascular caliber with severity and extent of CAD in symptomatic cardiac patients.

Long-term prognostic significance of periprocedural myonecrosis in patients with stable coronary artery disease undergoing elective percutaneous coronary intervention

The clinical significance of myonecrosis, measured by cardiac troponin, in the context of percutaneous coronary intervention (PCI) is a matter of ongoing debate. The lack of substantial scientific evidence in this domain is apparent from the ever-changing definitions of periprocedural myocardial infarction and the uncertainty regarding its prognostic relevance.Myonecrosis due to PCI is common and occurs in up to 40% of cases, depending on the definition and biomarker used5. In the Third Universal Definition of Myocardial Infarction (MI), the cutoff cardiac troponin level to diagnose myonecrosis increased from 3 to 5 times the upper reference limit (URL). In contrast to previous definitions, troponin elevation needs to be associated with clinical, electrocardiographic, angiographic or cardiac imagingrelated evidence of ischaemia to be classified as a periprocedural MI, or type 4a MI. However, the occurrence of post-PCI chest pain without troponin elevation and troponin elevation without chest pain, angiographic complications or other signs of ischaemia is well documented. The Society of Cardiovascular Angiography and Interventions (SCAI) has proposed an alternative definition of “clinically significant myocardial infarction” requiring troponin levels of ≥70x upper limit of normal (ULN) or ≥35x ULN with electrocardiographic evidence of infarction.