Adriano Caixeta

Prediction of Coronary Risk by SYNTAX and Derived Scores Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery

The introduction of the SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) score has prompted a renewed interest for angiographic risk stratification in patients undergoing percutaneous coronary intervention. Syntax score is based on qualitative and quantitative characterization of coronary artery disease by including 11 angiographic variables that take into consideration lesion location and characteristics. Thus far, this score has been shown to be an effective tool to risk-stratify patients with complex coronary artery disease undergoing percutaneous coronary intervention in the landmark SYNTAX trial, as well as in other clinical settings. This review provides an overview of its current applications, including its integration with other nonangiographic clinical scores, and explores future applications of the SYNTAX and derived scores.

SYNTAX score and the risk of stent thrombosis after percutaneous coronary intervention in patients with non‐ST‐segment elevation acute coronary syndromes: An ACUITY trial substudy

We sought to investigate the relationship between the SYNTAX score (SS) and stent thrombosis (ST) in patients with non‐ST‐segment elevation acute coronary syndromes (NSTE‐ACS) undergoing percutaneous coronary intervention (PCI).

Effect of Baseline Thrombocytopenia on Ischemic Outcomes in Patients With Acute Coronary Syndromes Who Undergo Percutaneous Coronary Intervention.

BACKGROUND Acquired thrombocytopenia (TP) has been associated with short- and long-term adverse outcomes after percutaneous coronary intervention (PCI), but the role of baseline TP is less well defined. We sought to evaluate the effect of TP on long-term adverse outcomes in patients with acute coronary syndromes (ACS) who undergo PCI. METHODS Data from 10,603 patients who underwent PCI for non-ST-elevation ACS or ST-elevation myocardial infarction were pooled from 2 large-scale randomized trials, Acute Catheterization and Urgent Intervention Triage Strategy (ACUITY) and Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction (HORIZONS-AMI). Patients were stratified according to baseline platelet counts. Those with platelet counts <150,000/mm(3) were considered to have normal platelet counts. Adverse event rates were compared between groups with and without multivariable adjustment. RESULTS Baseline TP was present in 607 (5.7%) patients. The unadjusted 1-year rates of death (6.7% vs 3.6%; P < 0.0001), occurrence of major adverse cardiac event (MACE) (20.8% vs 15.6%; P = 0.0002), and target lesion revascularization (TLR; 9.4% vs 7.2%; P = 0.01) were significantly higher in patients with baseline TP compared with patients with normal platelet counts. By multivariable analysis, the presence of TP at baseline was an independent predictor of 1-year death (hazard ratio [HR], 1.74; 95% confidence interval [CI], 1.12-2.69; P = 0.01), ischemic TLR (HR, 1.37; 95% CI, 1.04-1.81; P = 0.03), and MACE (HR, 1.39; 95% CI, 1.09-1.79; P = 0.009). CONCLUSIONS The presence of baseline TP in the setting of ACS patients who undergo PCI was strongly predictive of death, ischemic TLR, and MACE at 1 year. Baseline TP might be a useful baseline clinical parameter to estimate future ischemic risk after PCI.

Predictors of in-hospital mortality in patients with ST-segment elevation myocardial infarction undergoing pharmacoinvasive treatment

OBJECTIVES: To identify predictors of in-hospital mortality in patients with acute myocardial infarction undergoing pharmacoinvasive treatment. METHODS: This was an observational, prospective study that included 398 patients admitted to a tertiary center for percutaneous coronary intervention within 3 to 24 hours after thrombolysis with tenecteplase. ClinicalTrials.gov: NCT01791764 RESULTS: The overall in-hospital mortality rate was 5.8%. Compared with patients who survived, patients who died were more likely to be older, have higher rates of diabetes and chronic renal failure, have a lower left ventricular ejection fraction, and demonstrate more evidence of heart failure (Killip class III or IV). Patients who died had significantly lower rates of successful thrombolysis (39% vs. 68%; p = 0.005) and final myocardial blush grade 3 (13.0% vs. 61.9%; p<0.0001). Based on the multivariate analysis, the Global Registry of Acute Coronary Events score (odds ratio 1.05, 95% confidence interval (CI) 1.02-1.09; p = 0.001), left ventricular ejection fraction (odds ratio 0.9, 95% CI 0.89-0.97; p = 0.001), and final myocardial blush grade of 0-2 (odds ratio 8.85, 95% CI 1.34-58.57; p = 0.02) were independent predictors of mortality. CONCLUSIONS: In this prospective study that evaluated patients with ST-segment elevation myocardial infarction treated by a pharmacoinvasive strategy, the in-hospital mortality rate was 5.8%. The Global Registry of Acute Coronary Events score, left ventricular ejection fraction, and myocardial blush were independent predictors of mortality in this high-risk group of acute coronary syndrome patients.

Pregnancy-associated spontaneous coronary artery dissection: insights from a case series of 13 patients.

Aims We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes. Methods and results Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient. Conclusion In these 13 cases of P-SCAD, clinical presentation commonly included acute myocardial infarction and cardiogenic shock. Multivessel dissections and involvement of the left coronary artery and left main coronary artery were highly prevalent. Clinicians must be aware of angiographic appearances of P-SCAD for prompt diagnosis and management in these high-risk patients.

Usefulness of the SYNTAX Score to Predict Acute Kidney Injury After Percutaneous Coronary Intervention (from the Acute Catheterization and Urgent Intervention Triage Strategy Trial)

The synergy between percutaneous coronary intervention (PCI) with Taxus and cardiac surgery (SYNTAX) score (SS) has prognostic utility for ischemic outcomes in patients undergoing PCI. Acute kidney injury (AKI) after PCI has been demonstrated to be associated with adverse outcomes. However, the relation between the SS and AKI after PCI has yet to be fully investigated. We therefore sought to study this relation in the formal angiographic substudy of the large Acute Catheterization and Urgent Intervention Triage Strategy trial. We stratified 2,268 patients who underwent PCI for non-ST-segment elevation acute coronary syndromes by postprocedural AKI status and by SS tertiles (SS<7, 7 to 12, and >12). We also assessed rates of in-hospital, 30-day, and 1-year adverse outcomes. A total of 226 patients (10%) developed AKI, and rates in the highest Acute Catheterization and Urgent Intervention Triage Strategy SS tertile (>12) were significantly greater than those in the intermediate (7 to 12) and lowest tertiles (<7; 13% vs 8.9% vs 7.7%, respectively, p=0.002). By multivariable analysis, the SS was independently associated with AKI (odds ratio per 10 SS points 1.22, 95% confidence interval 1.04 to 1.43, p=0.02. Rates of major adverse cardiovascular events and net adverse clinical events increased significantly by SS tertile and were more common in patients who developed AKI. Patients who developed AKI experienced higher in-hospital, 30-day, and 1-year rates of mortality. In this large study, the SS was independently associated with AKI after PCI for non-ST-segment elevation acute coronary syndromes, and patients who developed AKI experienced worse short-term and long-term outcomes.

P2Y12 receptor inhibition with prasugrel and ticagrelor in STEMI patients after fibrinolytic therapy: Analysis from the SAMPA randomized trial☆

BACKGROUND A pharmacodynamic comparison between ticagrelor and prasugrel after fibrinolytic therapy has not yet been performed. METHODS In the single-center SAMPA trial, 50 consecutive STEMI patients previously treated with clopidogrel and undergoing a pharmacoinvasive strategy were randomized to either a ticagrelor (n=25) 180mg loading dose followed by 90mg bid, or a prasugrel (n=25) 60mg loading dose followed by 10mg/day, initiated after fibrinolytic therapy but before angiography. Platelet reactivity was assessed with the VerifyNow P2Y12 assay at 0, 2, 6, and 24h after randomization. RESULTS Mean times from fibrinolysis to prasugrel or ticagrelor administration were 11.1±6.9 and 13.3±6.3h, respectively (p=0.24). The values of PRU decreased significantly from baseline to 2h (all p<0.001) and from 2h to 6h (all p<0.001) in both groups. There was no difference in PRU values between 6h and 24h. The mean PRU values at 0, 2, 6, and 24h were 234.9, 127.8, 45.4, and 48.0 in the prasugrel group and 233.1, 135.1, 67.7, and 56.9 in the ticagrelor group, respectively. PRU values did not significantly differ between groups at any time period of the study. CONCLUSIONS In patients with STEMI treated with fibrinolytic therapy, platelet inhibition after clopidogrel is suboptimal and can be further increased with more potent agents. Ticagrelor and prasugrel demonstrated a similar extent of P2Y12 receptor inhibition within 24h, although maximal platelet inhibition after these potent agents was not achieved for 6h.

A Randomized Trial Comparing Dual Axis Rotational Versus Conventional Coronary Angiography in a Population with a High Prevalence of Coronary Artery Disease

OBJECTIVES To compare the safety, radiation dose, and contrast volume between dual axis rotational coronary angiography (DARCA) and conventional coronary angiography (CCA). BACKGROUND CCA is performed in multiple, predefined stationary views, at different angulations around the patient, for both the left and right coronary arteries. DARCA (AlluraXperSwing™, Philips, the Netherlands) involves a pre-set rotation of the C-arm around the patient and allows for the visualization of each coronary artery in different views, using a single automatic pump contrast injection. METHODS From November 2012 to February 2013, 201 patients were randomly assigned to either CCA (n = 100) or DARCA (n = 101). Exclusion criteria included acute coronary syndrome (ACS), prior PCI or CABG. CCAs were performed in 4 acquisition runs for the left coronary artery and 2 to 3 acquisition runs for the right coronary artery, whereas DARCAs were performed in a single run for each coronary artery. RESULTS Baseline demographics and clinical characteristics were similar for both groups. The overall prevalence of CAD was 77.6%. The DARCA group had a significant reduction in the amount of contrast, 60 ml (IQR: 52.5-71.5 ml) versus 76 ml (IQR: 68-87 ml), P < 0.0001; and radiation dose by Air Kerma, 269.5 mGy (IQR: 176-450.5) versus 542.1 mGy (IQR: 370.7-720.8), P < 0.0001. There were fewer patients requiring additional projections in the DARCA group: 54.0% versus 75.0%; P = 0.002. CONCLUSIONS In a population with a high prevalence of CAD, DARCA was safe and resulted in a significant decrease in contrast volume and radiation dose.

P2Y12 platelet receptors: importance in percutaneous coronary intervention

Apart from their role in hemostasis and thrombosis, platelets are involved in many other biological processes such as wound healing and angiogenesis. Percutaneous coronary intervention is a highly thrombogenic procedure inducing platelets and monocytes activation through endothelial trauma and contact activation by intravascular devices. Platelet P2Y12 receptor activation by adenosine diphosphate facilitates non-ADP agonist-mediated platelet aggregation, dense granule secretion, procoagulant activity, and the phosphorylation of several intraplatelet proteins, making it an ideal drug target. However, not all compounds that target the P2Y12 receptor have similar efficacy and safety profiles. Despite targeting the same receptor, the unique pharmacologic properties of each of these P2Y12 receptor-directed compounds can lead to very different clinical effects.

Increased hospitalizations for decompensated heart failure and acute myocardial infarction during mild winters: A seven-year experience in the public health system of the largest city in Latin America

Background In high-income temperate countries, the number of hospitalizations for heart failure (HF) and acute myocardial infarction (AMI) increases during the winter. This finding has not been fully investigated in low- and middle-income countries with tropical and subtropical climates. We investigated the seasonality of hospitalizations for HF and AMI in Sao Paulo (Brazil), the largest city in Latin America. Methods This was a retrospective study using data for 76,474 hospitalizations for HF and 54,561 hospitalizations for AMI obtained from public hospitals, from January 2008 to April 2015. The average number of hospitalizations for HF and AMI per month during winter was compared to each of the other seasons. The autoregressive integrated moving average (ARIMA) model was used to test the association between temperature and hospitalization rates. Findings The highest average number of hospital admissions for HF and AMI per month occurred during winter, with an increase of up to 30% for HF and 16% for AMI when compared to summer, the season with lowest figures for both diseases (respectively, HF: 996 vs. 767 per month, p<0.001; and AMI: 678 vs. 586 per month, p<0.001). Monthly average temperatures were moderately lower during winter than other seasons and they were not associated with hospitalizations for HF and AMI. Interpretation The winter season was associated with a greater number of hospitalizations for both HF and AMI. This increase was not associated with seasonal oscillations in temperature, which were modest. Our study suggests that the prevention of cardiovascular disease decompensation should be emphasized during winter even in low to middle-income countries with tropical and subtropical climates.