Agustín Albarrán

Effect of Early Metoprolol on Infarct Size in ST-Segment–Elevation Myocardial Infarction Patients Undergoing Primary Percutaneous Coronary Intervention The Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction (METOCARD-CNIC) Trial

Background —The effect of β-blockers on infarct size when used in conjunction with primary percutaneous coronary intervention (PCI) is unknown. We hypothesize that metoprolol reduces infarct size when administered early (intravenously [i.v.] before reperfusion). Methods and Results —Patients with Killip-class ≤II anterior ST-segment elevation myocardial infarction (STEMI) undergoing PCI within 6 hours of symptoms onset were randomized to receive i.v. metoprolol (n=131) or not (control, n=139) pre-reperfusion. All patients without contraindications received oral metoprolol within 24 hours. The pre-defined primary endpoint was infarct size on magnetic resonance imaging (MRI) performed 5-7 days after STEMI. MRI was performed in 220 patients (81%). Mean (±SD) infarct size by MRI was smaller after i.v. metoprolol compared to control (25.6±15.3 vs. 32.0±22.2 grams; adjusted difference, -6.52; 95% confidence interval [CI], -11.39 to -1.78; P=0.012). In patients with pre-PCI TIMI flow grade 0/1, the adjusted treatment difference in infarct size was -8.02; 95% CI, -13.01 to -3.02; P=0.0029. Infarct size estimated by peak and area under the curve creatine-kinase release was measured in all study population and was significantly reduced by i.v. metoprolol. Left ventricular ejection fraction was higher in the i.v. metoprolol group (adjusted difference 2.67%; 95% CI, 0.09% to 5.21%; P=0.045). The composite of death, malignant ventricular arrhythmia, cardiogenic shock, atrioventricular block and reinfarction at 24 hours in the i.v. metoprolol and control groups respectively was 7.1% vs. 12.3%, p=0.21. Conclusions —In patients with anterior Killip-class ≤II STEMI undergoing primary PCI, early i.v. metoprolol before reperfusion reduced infarct size and increased LVEF with no excess of adverse events during the first 24 hours after STEMI. Clinical Trial Registration Information —ClinicalTrials.gov. Identifier: [NCT01311700][1] & EUDRACT Number 2010-019939-35. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT01311700&atom=%2Fcirculationaha%2Fearly%2F2013%2F09%2F03%2FCIRCULATIONAHA.113.003653.atomBackground— The effect of &bgr;-blockers on infarct size when used in conjunction with primary percutaneous coronary intervention is unknown. We hypothesize that metoprolol reduces infarct size when administered early (intravenously before reperfusion). Methods and Results— Patients with Killip class II or less anterior ST-segment–elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention within 6 hours of symptoms onset were randomized to receive intravenous metoprolol (n=131) or not (control, n=139) before reperfusion. All patients without contraindications received oral metoprolol within 24 hours. The predefined primary end point was infarct size on magnetic resonance imaging performed 5 to 7 days after STEMI. Magnetic resonance imaging was performed in 220 patients (81%). Mean±SD infarct size by magnetic resonance imaging was smaller after intravenous metoprolol compared with control (25.6±15.3 versus 32.0±22.2 g; adjusted difference, −6.52; 95% confidence interval, −11.39 to −1.78; P=0.012). In patients with pre–percutaneous coronary intervention Thrombolysis in Myocardial Infarction grade 0 to 1 flow, the adjusted treatment difference in infarct size was −8.13 (95% confidence interval, −13.10 to −3.16; P=0.0024). Infarct size estimated by peak and area under the curve creatine kinase release was measured in all study populations and was significantly reduced by intravenous metoprolol. Left ventricular ejection fraction was higher in the intravenous metoprolol group (adjusted difference, 2.67%; 95% confidence interval, 0.09–5.21; P=0.045). The composite of death, malignant ventricular arrhythmia, cardiogenic shock, atrioventricular block, and reinfarction at 24 hours in the intravenous metoprolol and control groups was 7.1% and 12.3%, respectively (P=0.21). Conclusions— In patients with anterior Killip class II or less ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention, early intravenous metoprolol before reperfusion reduced infarct size and increased left ventricular ejection fraction with no excess of adverse events during the first 24 hours after STEMI. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT01311700. EUDRACT number: 2010-019939-35.

Long-term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: results from the METOCARD-CNIC trial (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction)

OBJECTIVES The goal of this trial was to study the long-term effects of intravenous (IV) metoprolol administration before reperfusion on left ventricular (LV) function and clinical events. BACKGROUND Early IV metoprolol during ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size when used in conjunction with primary percutaneous coronary intervention (pPCI). METHODS The METOCARD-CNIC (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction) trial recruited 270 patients with Killip class ≤II anterior STEMI presenting early after symptom onset (<6 h) and randomized them to pre-reperfusion IV metoprolol or control group. Long-term magnetic resonance imaging (MRI) was performed on 202 patients (101 per group) 6 months after STEMI. Patients had a minimal 12-month clinical follow-up. RESULTS Left ventricular ejection fraction (LVEF) at the 6 months MRI was higher after IV metoprolol (48.7 ± 9.9% vs. 45.0 ± 11.7% in control subjects; adjusted treatment effect 3.49%; 95% confidence interval [CI]: 0.44% to 6.55%; p = 0.025). The occurrence of severely depressed LVEF (≤35%) at 6 months was significantly lower in patients treated with IV metoprolol (11% vs. 27%, p = 0.006). The proportion of patients fulfilling Class I indications for an implantable cardioverter-defibrillator (ICD) was significantly lower in the IV metoprolol group (7% vs. 20%, p = 0.012). At a median follow-up of 2 years, occurrence of the pre-specified composite of death, heart failure admission, reinfarction, and malignant arrhythmias was 10.8% in the IV metoprolol group versus 18.3% in the control group, adjusted hazard ratio (HR): 0.55; 95% CI: 0.26 to 1.04; p = 0.065. Heart failure admission was significantly lower in the IV metoprolol group (HR: 0.32; 95% CI: 0.015 to 0.95; p = 0.046). CONCLUSIONS In patients with anterior Killip class ≤II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer heart failure admissions. (Effect of METOprolol in CARDioproteCtioN During an Acute Myocardial InfarCtion. The METOCARD-CNIC Trial; NCT01311700).

Long term benefit of early pre-reperfusion metoprolol administration in patients with acute myocardial infarction: results from the METOCARD-CNIC trial.

OBJECTIVES The goal of this trial was to study the long-term effects of intravenous (IV) metoprolol administration before reperfusion on left ventricular (LV) function and clinical events. BACKGROUND Early IV metoprolol during ST-segment elevation myocardial infarction (STEMI) has been shown to reduce infarct size when used in conjunction with primary percutaneous coronary intervention (pPCI). METHODS The METOCARD-CNIC (Effect of Metoprolol in Cardioprotection During an Acute Myocardial Infarction) trial recruited 270 patients with Killip class ≤II anterior STEMI presenting early after symptom onset (<6 h) and randomized them to pre-reperfusion IV metoprolol or control group. Long-term magnetic resonance imaging (MRI) was performed on 202 patients (101 per group) 6 months after STEMI. Patients had a minimal 12-month clinical follow-up. RESULTS Left ventricular ejection fraction (LVEF) at the 6 months MRI was higher after IV metoprolol (48.7 ± 9.9% vs. 45.0 ± 11.7% in control subjects; adjusted treatment effect 3.49%; 95% confidence interval [CI]: 0.44% to 6.55%; p = 0.025). The occurrence of severely depressed LVEF (≤35%) at 6 months was significantly lower in patients treated with IV metoprolol (11% vs. 27%, p = 0.006). The proportion of patients fulfilling Class I indications for an implantable cardioverter-defibrillator (ICD) was significantly lower in the IV metoprolol group (7% vs. 20%, p = 0.012). At a median follow-up of 2 years, occurrence of the pre-specified composite of death, heart failure admission, reinfarction, and malignant arrhythmias was 10.8% in the IV metoprolol group versus 18.3% in the control group, adjusted hazard ratio (HR): 0.55; 95% CI: 0.26 to 1.04; p = 0.065. Heart failure admission was significantly lower in the IV metoprolol group (HR: 0.32; 95% CI: 0.015 to 0.95; p = 0.046). CONCLUSIONS In patients with anterior Killip class ≤II STEMI undergoing pPCI, early IV metoprolol before reperfusion resulted in higher long-term LVEF, reduced incidence of severe LV systolic dysfunction and ICD indications, and fewer heart failure admissions. (Effect of METOprolol in CARDioproteCtioN During an Acute Myocardial InfarCtion. The METOCARD-CNIC Trial; NCT01311700).

Registro Español de Hemodinámica y Cardiología Intervencionista. XVI Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2006)

Se presentan los resultados del Registro de Actividad de la Seccion de Hemodinamica y Cardiologia Intervencionista de la Sociedad Espanola de Cardiologia del ano 2006. Se recogen los datos de 135 hospitales, de los cuales 125 realizan su actividad predominante en adultos y 10 atienden exclusivamente a pacientes pediatricos. Se realizaron 126.196 estudios diagnosticos, con 113.228 coronariografias, lo que representa un aumento del 7,6% respecto al ano 2005 y una tasa de 2.560 coronariografias/millon de habitantes. Se realizaron 57.041 procedimientos intervencionistas coronarios, con un incremento del 7,8% respecto al 2005 y una tasa de 1.293 intervenciones/millon de habitantes. Se implantaron 90.006 stents, de los cuales el 59,3% fueron farmacoactivos. Se llevaron a cabo 10.067 procedimientos de intervencionismo en el infarto agudo de miocardio, lo que supone un incremento del 20,6% respecto al ano anterior y representa el 17,6% del total de las intervenciones coronaries percutaneas. El intervencionismo no coronario mas frecuente se realiza en las cardiopatias congenitas del adulto, como el cierre de la comunicacion interauricular, que es el de mayor numero, 334 procedimientos. La valvuloplastia mitral, con 431 casos tratados, apenas presenta cambios respecto al anterior Registro, y su exito esta en el 93,6%. La via de acceso radial se usa cada vez mas y mantiene el aumento de anos anteriores. Es de destacar el alto grado de participacion de los diferentes centros en el actual Registro, que hace que sea un referente internacional de la actividad hemodinamica en nuestro pais.

Registro Español de Hemodinámica y Cardiología Intervencionista. XVII Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2007)

Se presentan los resultados del Registro de Actividad de la Seccion de Hemodinamica y Cardiologia Intervencionista de la Sociedad Espanola de Cardiologia del ano 2007. Se recogen los datos de 129 hospitales que realizan su actividad predominante en adultos; de esos centros, 74 realizan actividad publica y 55, privada. Se realizaron 136.231 estudios diagnosticos, con 122.260 coronariografias, lo que representa un aumento del 7,9% respecto al ano 2006 y una tasa de 2.725 coronariografias/ millon de habitantes. Los procedimientos intervencionistas coronarios practicados fueron 60.457, con un incremento del 6% respecto al 2006 y una tasa de 1.347 intervenciones/millon de habitantes. Se implantaron 94.966 stents, de los que el 57,7% fueron farmacoactivos. Se llevaron a cabo 11.322 procedimientos de intervencionismo en el infarto agudo de miocardio, lo que supone un incremento del 12,5% respecto al ano anterior y el 18,7% del total de intervenciones coronarias percutaneas. El intervencionismo no coronario mas frecuente se realiza en las cardiopatias congenitas del adulto; el cierre de la comunicacion interauricular es el de mayor numero, con 334 procedimientos. La valvuloplastia mitral, con 367 casos tratados y una tasa de exito del 90,7%, es el procedimiento percutaneo valvular mas realizado. Este ano han avanzado los procedimientos de implante de valvulas percutaneas, pues se ha implantado 18 valvulas entre pulmonares y aorticas. La via de acceso radial alcanza el 40% tanto en el diagnostico como en el intervencionismo. Es de destacar el alto grado de participacion de los diferentes centros en el actual Registro, que hace que sea un referente internacional de la actividad hemodinamica en nuestro pais.

Registro Español de Hemodinámica y Cardiología Intervencionista. XVIII Informe Oficial de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología (1990-2008)

Introduccion y objetivos La Seccion de Hemodinamica y Cardiologia Intervencionista presenta un informe anual con los datos del registro de actividad estatal. El actual corresponde al ano 2008. Esta informacion permite saber la distribucion nacional del intervencionismo cardiaco y ofrece datos para compararlo con el de otros paises. Metodos Los centros proporcionan sus datos de forma voluntaria. La informacion es analizada por la Junta directiva de la Seccion de Hemodinamica. Resultados Enviaron sus datos 131 hospitales (74 centros publicos y 57 privados) que realizan su actividad predominantemente en adultos. Se realizaron 136.458 estudios diagnosticos, con 123.031 coronariografias, sin apenas cambios respecto al ano anterior, con una tasa de 2.658 coronariografias por millon de habitantes. Los procedimientos intervencionistas coronarios aumentaron un 2,2% y llegaron a los 61.810, con una tasa de 1.334 intervenciones por millon de habitantes. Se implantaron 101.753 stents, de los cuales el 58,2% eran farmacoactivos. Se llevaron a cabo 12.079 procedimientos en el infarto agudo de miocardio, lo que supone un incremento del 6,7% respecto a 2007 y representa el 20,6% del total de intervenciones coronarias percutaneas. El intervencionismo mas frecuente en las cardiopatias congenitas del adulto es el cierre de la comunicacion interauricular (305 procedimientos). La valvuloplastia mitral (con 371 casos tratados y exito en el 96%) es el procedimiento valvular mas realizado. Se han implantado 151 valvulas aorticas percutaneas. Conclusiones El aumento mas importante en la actividad ha tenido lugar en relacion con el infarto agudo de miocardio con elevacion del segmento ST y el implante percutaneo de valvulas; los demas procedimientos tanto diagnosticos como terapeuticos aumentaron ligeramente.

Spanish Cardiac Catheterization and Coronary Intervention Registry. 18th Official Report of the Spanish Society of Cardiology Working Group on Cardiac Catheterization and Interventional Cardiology (1990-2008)

INTRODUCTION AND OBJECTIVES Each year the Spanish Society of Cardiology Working Group on Cardiac Catheterization and Interventional Cardiology reports on the data contained in a national registry of procedures performed. The present report is for the year 2008. It contains information on the scope of interventional cardiology in Spain and provides data for use in comparisons with other countries. METHODS Hospitals provided data voluntarily. The information was analyzed by the steering committee of the Working Group. RESULTS Data were submitted by 131 hospitals (74 public and 57 private) that performed relevant procedures, mainly in adults. In total, 136,458 diagnostic procedures were carried out, of which 123,031 involved coronary angiography. Numbers were little changed from the previous year, with an overall rate of 2658 coronary angiograms per million population. The number of percutaneous coronary interventions increased by 2.2% to 61,810, with a rate of 1334 per million inhabitants. In addition, 101,753 stents were implanted, of which 58.2% were drug-eluting. The number of procedures carried out for acute myocardial infarction was 12,079, which makes up 20.6% of all percutaneous coronary interventions and is an increase of 6.7% relative to 2007. The most common intervention in adults with congenital heart disease was closure of an atrial septal defect, which was performed in 305 cases. The most common valve procedure was mitral valvuloplasty, which was performed in 371 cases with a success rate of 96%. Further, 151 aortic percutaneous valves were implanted. CONCLUSIONS The most significant increases in activity were in procedures for ST-segment elevation myocardial infarction and percutaneous valve implantation. The rates of all other diagnostic and therapeutic procedures changed only slightly.

Acute coronary embolism: angiographic diagnosis and treatment with primary angioplasty.

Acute coronary embolism is rarely diagnosed and it may explain why normal coronary arteries are found after or even before an acute coronary event in patients with thromboembolic risk factors. Emergency coronary angiography was performed in three patients with prior normal coronary arteries and an acute myocardial infarction, followed by primary angioplasty with low‐pressure balloon inflations plus stenting and combined antiaggregation with aspirin, clopidogrel, and abciximab to disrupt the thrombi and protect distal circulation from microemboli. Angiographic success was achieved in 100%, and 6‐month follow‐up has been uneventful on oral anticoagulation and antiaggregation. Cathet Cardiovasc Intervent 2002;55:491–494.

Study design for the “effect of METOprolol in CARDioproteCtioN during an acute myocardial InfarCtion” (METOCARD-CNIC): A randomized, controlled parallel-group, observer-blinded clinical trial of early pre-reperfusion metoprolol administration in ST-segment elevation myocardial infarction

BACKGROUND Infarct size predicts post-infarction mortality. Oral β-blockade within 24 hours of a ST-segment elevation acute myocardial infarction (STEMI) is a class-IA indication, however early intravenous (IV) β-blockers initiation is not encouraged. In recent magnetic resonance imaging (MRI)-based experimental studies, the β(1)-blocker metoprolol has been shown to reduce infarct size only when administered before coronary reperfusion. To date, there is not a single trial comparing the pre- vs. post-reperfusion β-blocker initiation in STEMI. OBJECTIVE The METOCARD-CNIC trial is testing whether the early initiation of IV metoprolol before primary percutaneous coronary intervention (pPCI) could reduce infarct size and improve outcomes when compared to oral post-pPCI metoprolol initiation. DESIGN The METOCARD-CNIC trial is a randomized parallel-group single-blind (to outcome evaluators) clinical effectiveness trial conducted in 5 Counties across Spain that will enroll 220 participants. Eligible are 18- to 80-year-old patients with anterior STEMI revascularized by pPCI ≤6 hours from symptom onset. Exclusion criteria are Killip-class ≥III, atrioventricular block or active treatment with β-blockers/bronchodilators. Primary end point is infarct size evaluated by MRI 5 to 7 days post-STEMI. Prespecified major secondary end points are salvage-index, left ventricular ejection fraction recovery (day 5-7 to 6 months), the composite of (death/malignant ventricular arrhythmias/reinfarction/admission due to heart failure), and myocardial perfusion. CONCLUSIONS The METOCARD-CNIC trial is testing the hypothesis that the early initiation of IV metoprolol pre-reperfusion reduces infarct size in comparison to initiation of oral metoprolol post-reperfusion. Given the implications of infarct size reduction in STEMI, if positive, this trial might evidence that a refined use of an approved inexpensive drug can improve outcomes of patients with STEMI.

Complicaciones del acceso femoral en el cateterismo cardíaco: impacto de la angiografía femoral sistemática previa y la hemostasia con tapón de colágeno VasoSeal-ES®

Introduccion y objetivos.Dado el uso generalizado del acceso femoral y del material hemostatico, se plantea realizar la angiografia femoral sistematica y la hemostasia con VasoSeal-ES