Alejandro Diego Nieto

Post-Treatment Platelet Reactivity Predicts Long-Term Adverse Events Better Than the Response to Clopidogrel in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

Introduction and objectives Poor response to antiplatelet therapy has been associated with adverse long-term outcomes. The objective of this study is to assess the relationship between response to clopidogrel and post-treatment platelet reactivity (PPR) and 1-year major adverse cardiovascular events (MACE) in patients with non-ST segment elevation acute coronary syndrome (NSTEACS). Methods Patients with NSTEACS undergoing early coronary angiography were enrolled in this prospective, observational study. The VerifyNow® analyzer was used to measure clopidogrel response and PPR immediately before coronary angiography. Results Of the 179 patients included (97 percutaneous coronary intervention, 21 coronary artery bypass graft), 161 (90%) completed 1-year follow-up and 18 (11%) incurred MACE: 10 deaths, 6 myocardial infarctions, 2 strokes, 5 revascularizations. Lower response to clopidogrel (31±21% vs. 43±21%; P=.049) and higher PPR (204±60 vs. 155±67 platelet reaction units [PRU]; p=.006) were significantly associated with MACE occurrence. Multivariate analysis confirmed PPR (OR per 10-unit increase, 1.12, 95% CI, 1.01-1.24; P=.020) as an independent predictor of MACE. A PPR cut-off value of 175 PRU was associated with an adjusted OR for 1-year MACE occurrence of 3.9 (95% CI, 1.2-15.4; P=.024). Conclusions PPR predicts adverse long-term outcomes better than response to clopidogrel in patients with NSTEACS. Patients with PPR values above 175 PRU were identified as being at higher risk for adverse long-term events.

Procedural, Functional and Prognostic Outcomes Following Recanalization of Coronary Chronic Total Occlusions. Results of the Iberian Registry

INTRODUCTION AND OBJECTIVES There is current controversy regarding the benefits of percutaneous recanalization (PCI) of chronic total coronary occlusions (CTO). Our aim was to determine acute and follow-up outcomes in our setting. METHODS Two-year prospective registry of consecutive patients undergoing PCI of CTO in 24 centers. RESULTS A total of 1000 PCIs of CTO were performed in 952 patients. Most were symptomatic (81.5%), with chronic ischemic heart disease (59.2%). Previous recanalization attempts had been made in 15%. The mean SYNTAX score was 19.5 ± 10.6 and J-score was > 2 in 17.3%. A retrograde procedure was performed in 92 patients (9.2%). The success rate was 74.9% and was higher in patients without previous attempts (82.2% vs 75.2%; P = .001), those with a J-score ≤ 2 (80.5% vs 69.5%; P = .002), and in intravascular ultrasound-guided PCI (89.9% vs 76.2%, P = .001), which was an independent predictor of success. In contrast, severe calcification, length > 20mm, and blunt proximal cap were independent predictors of failed recanalization. The rate of procedural complications was 7.1%, including perforation (3%), myocardial infarction (1.3%), and death (0.5%). At 1-year of follow-up, 88.2% of successfully revascularized patients showed clinical improvement (vs 34.8%, P < .001), which was associated with lower mortality. At 1-year of follow-up, the mortality rate was 1.5%. CONCLUSIONS Compared with other national registries, patients in the Iberian registry undergoing PCI of a CTO showed similar complexity, success rate, and complications. Successful recanalization was strongly associated with functional improvement, which was related to lower mortality.

TCT-137 Influence of non-culprit lesions management on outcomes in patients over 75 years old with ST elevated myocardial infarction. Results from the ESTROFA MI+75 nation-wide registry

nos: 137 201 TCT-137 Influence of non-culprit lesions management on outcomes in patients over 75 years old with ST elevated myocardial infarction. Results from the ESTROFA MI+75 nation-wide registry Jose M. de la Torre Hernandez, Joan Antoni Gomez Hospital, Salvatore Brugaletta, jose antonio baz, Armando Perez de Prado, Ramon Lopez Palop, Ana Belen Cid Alvarez, Tamara Garcia Camarero, Alejandro Diego Nieto, Federico Gimeno, Jose Antonio Fernandez Diaz, Juan Sanchis Fores, Fernando Alfonso, Roberto Blanco, Javier Botas, Javier Navarro Cuartero, Jose Moreu Burgos, Francisco Bosa, Jose Miguel Vegas, Jaime Elizaga, Antonio Luis Arrebola Moreno, Joseantonio Linares Vicente, Felipe Hernandez, Neus Salvatella Giralt, Marta Monteagudo, Alfredo Gomez Jaume, Xavier Carrillo, Roberto Martin-Reyes, Fernando Lozano, Jose Rumoroso, leire andraka, Antonio J. Dominguez Hospital Universitario Marques de Valdecilla, Santander, Spain; HU Bellvitge, Barcelona, Spain; Hospital Clinic, Barcelona, Spain; Unknown, Vigo, Spain; Fundación Investigación Sanitaria en León, Leon, Spain; Hospital San Juan, Alicante, Spain; HCU Santiago de Compostela, Santiago de compostela, Spain; H M de Valdecilla; Hospital Universitario de Salamanca, Pozuelo de Alarcon, Spain; Hospital de Valladolid; Hosp. Puerta de Hierro, Madrid, Spain; Hospital Clinico De Valencia, Valencia, Spain; Hospital Universitario de la Princesa, Madrid, Spain; Hospital de Cruces, Etxebarri, Spain; Fundacion Hospital Alcorcon, Alcorcon, Spain; Hospital de Albacete; Complejo Hospitalario de Toledo, Toledo, Spain; Hospital Universitario de Canarias, Santa Cruz de Tenerife, Spain; Oviedo, Spain; H.U. Gregorio Maranon, Madrid, Spain; H.U. Virgen de las Nieves, Granada, Spain; Lozano Blesa Hospital, Zaragoza, Spain; Hospital 12 de Octubre, Madrid, Spain; Clinical Cardiologist, Barcelona, Spain; Hospital Dr Peset; HU Son Espases, Palma de Mallorca, Spain; Hospital Germans Trias i Pujol; Hospital Universitario Fundacion Jimenez Diaz, MADRID, Spain; Madrid, Spain; Hospital Galdakao-Usansolo, Galdakao, Spain; hospital de basurto, Bilbao, Spain; Hospital Virgen de la Victoria de Malaga BACKGROUND Presence of multivessel disease and non-culprit lesions is not infrequent in patients undergoing primary angioplasty. However in patients over 75 years old the prognostic implications of angiographically significant non-culprit lesions management is not well known. METHODS A subanalysis of the nation-wide database of primary angioplasty in the elderly (ESTROFA MI+75) with 3,576 patients included in 31 centers. Angiographically significant non-culprit lesion was defined as any stenosis > 50% with reference vessel diameter > 2 mm. RESULTS In 2,155 (60.2%) patients angiographically significant nonculprit lesions were observed. In 891 patients (41.3%) complete revascularization was attempted, in 475 cases within the primary angioplasty procedure and in 416 in a staged procedure during admission. Finally, at discharge 1,264 (58.7%) patients had incomplete revascularization. A multivariant analysis was conducted with all clinical, angiographic and procedural variables in order to establish predictors of 2 years outcomes. Incomplete revascularization resulted independent predictor of cardiac death, infarction and revascularization (HR 1.39; 95% CI 1.02-1.63: p1⁄40.034), but PCI of non-culprit lesions in the same procedure of primary angioplasty was independent predictor of stent thrombosis (HR 2.55; 95% CI 1.10-5.92: p1⁄40.029). CONCLUSION Presence of significant non-culprit lesions is common in patients over 75 years undergoing primary angioplasty. Complete revascularization is attempted in less than half of cases. Incomplete revascularization is predictor of 2 years outcomes but complete revascularization in the primary PCI procedure is associated with steht thrombosis suggesting the recommendation of a staged approach. CATEGORIES CORONARY: Acute Myocardial Infarction TCT-138 Multivessel versus culprit-only percutaneous coronary intervention in ST-segment elevation myocardial infarction: analysis of a 8 yearall-comers registry Ana Belen Cid Alvarez, Carlos Galvao Braga, Alfredo Redondo Dieguez, Ramiro Trillo, Diego Lopez Otero, Raymundo Ocaranza-Sanchez, Belen Alvarez Alvarez, Kieran Docherty, Jose Ramon González-Juanatey HCU Santiago de Compostela, Santiago de compostela, Spain; Cleveland Clinic Foundation Weston Fl; Christus Health; Hospital Clinico Universitario de Santiago, Santiago de Compostela, Spain; Unknown, Santiago De Composte, Spain; Unknown, Spain, Spain; Au;tman Hospital; Golden Jubilee National Hospital; Philippine Heart Center BACKGROUND The optimal treatment of patients with multivessel coronary artery disease and ST-segment elevation acute myocardial infarction (STEMI) who undergo primary percutaneous coronary intervention (PCI) is controversial. The aim of this study was to access the prognostic impact of multivessel PCI versus culprit vessel-only PCI in real-world patients with STEMI and multivessel disease. METHODS This was a retrospective cohort study of 1499 patients with STEMI diagnosis who underwent primary-PCI between January 2008 and December 2015. We performed a propensity score-matched analysis to draw up two groups of 225 patients paired according to whether or not they had undergone multivessel PCI or culprit vesselonly PCI. RESULTS During follow-up (median 2.36 years), after propensity score matching, patients who underwent multivessel PCI had lower rates of mortality (7.6% versus 11.6%, log rank p1⁄40.022), unplanned repeated revascularization (9.4% versus 14.7%, log rank p1⁄40.010) and MACE (29.7% versus 33.8%, log rank p1⁄40.016). These patients had also a trend to lower incidence of myocardial infarction (8.0% vs. 4.9%, log rank p1⁄40.093). CONCLUSION In real-world patients presenting with STEMI and multivessel coronary artery disease, multivessel PCI strategy was associated with lower rates of mortality, unplanned repeated revascularization and MACE. CATEGORIES CORONARY: Acute Myocardial Infarction TCT-139 A randomized trial of complete versus culprit-only revascularization during primary percutaneous coronary intervention in diabetic patients with acute ST elevation myocardial infarction and multi vessel disease Mohamed Hamza, Islam Elgendy Ain Shams University, Cairo, Egypt; University of Florida, Gainesville, Florida, United States BACKGROUND Recent randomized trials and meta-analyses demonstrated that a complete revascularization of significant non culprit lesions in patients with ST elevation myocardial infarction (STEMI) is J O U R N A L O F T H E A M E R I C A N C O L L E G E O F C A R D I O L O G Y , V O L . 6 8 , N O . 1 8 , S U P P L B , 2 0 1 6 B57 superior to a culprit only revascularization approach in reducing major adverse cardiac events (MACE), however the proportion of diabetic patients was low in these trials. METHODS One hundred diabetic patients with acute STEMI with at least one non-culprit lesion were randomized to either complete revascularization (n1⁄450) or culprit-only treatment (n1⁄450). Complete revascularization was performed either at the time of primary percutaneous coronary intervention (PCI) or within 72 hours during hospitalization. The primary endpoint was the composite of all-cause mortality, recurrent MI, and ischemia-driven revascularization at 6 months. RESULTS A complete revascularization approach was significantly associated with a reduction in the primary outcome (6% versus 24%, p1⁄40.01), primarily due to reduction in ischemia driven revascularization in the complete revascularization group (2% versus 12%; p 1⁄4 0.047). There was no significant reduction in death or MI (2% vs. 8%; p 1⁄4 0.17) and (2% vs. 4%; p 1⁄4 0.56) respectively, or in the safety endpoints of major or minor bleeding, contrast-induced nephropathy, or stroke between the groups. CONCLUSION In diabetic patients with multi-vessel coronary artery disease undergoing PPCI, complete revascularization is associated with significantly reduced risk of adverse cardiovascular events, as compared with culprit vessel only PCI. CATEGORIES CORONARY: Acute Myocardial Infarction TCT-140 Explore trial (additional early CTO PCI in STEMI patients with a concurrent CTO) and SYNTAX score. What are lessons learned? Ivo van Dongen, Joelle Elias, Loes Hoebers, Dagmar Ouweneel, Bimmer Claessen, Jose Henriques Academic Medical Center University of Amsterdam, Amsterdam, Netherlands; Academic Medical Centre (AMC) University of Amsterdam, Amsterdam, Netherlands; Academic Medical Center, Amsterdam, Netherlands; Academic Medical Center, Amsterdam, Netherlands; Academic Medical Center University of Amsterdam, Amsterdam, Netherlands; Academic Medical Center University of Amsterdam, Amsterdam, Netherlands BACKGROUND The EXPLORE trial studied the impact on Left Ventricular Function (LVF) of additional early PCI of a concurrent chronic total occlusion in post STEMI patients, compared to no early PCI. No difference was observed between both arms. However, previous observational data consistently showed an improvement in LVF after elective CTO-PCI. Explorative subanalyses may yet reveal which patients may benefit from an early PCI CTO approach. The SYNTAX score enables high level quantification of the extent of coronary artery disease. We therefore analyzed the value of SYNTAX score on LV MRI data in the EXPLORE trial. METHODS Corelab adjudicated (Cardialysis) syntax score calculations were divided in tertiles. Cardiac MRI at baseline and 4 months were also analyzed by a corelab. In patients with paired MRI (baseline and 4 months), delta ejection fraction, enddiastolic volume, culprit scar, CTO scar and total scar were related to the SYNTAX score tertiles. RESULTS The Syntax tertiles for the entire study population were: Low <25, Intermediate 25-32.5 and High >32.5. In the group of patients with MRI at 4 months the median (IQR) total scar was 4.8 (2.8 – 7.7) for the low, 5.7 (3.4 – 9.5) for

TCT-120 Primary angioplasty for patients over 75 years old in cardiogenic shock: contemporary results and prognostic predictors from the ESTROFA MI+75 nationwide registry.

TCT-119 A New Risk Score to Predict Long-Term Cardiac Mortality in Patients with Acute Myocardial Infarction Complicated by Cardiogenic Shock and Treated with Primary Percutaneous Intervention Ruben Vergara, Renato Valenti, Angela Migliorini, Guido Parodl, Maria Grazia De gregorio, Maria Raffaella Aicale, Elena De Vito, Eleonora Gabrielli, David Antoniucci DivCardiology-Careggi Hospital, Florence, Italy; Careggi Hospital, Florence, Italy; careggi Hospital, Florence, Florence, Italy; Division of Cardiology Careggi Hospital; Division of Cardiology Careggi Hospital; Division of Cardiology Careggi Hospital; Division of Cardiology Careggi Hospital; Division of Cardiology Careggi Hospital; Careggi Hospital, Florence, Italy

Letter by de Miguel Castro et al regarding article, "cardiovascular death and nonfatal myocardial infarction in acute coronary syndrome patients receiving coronary stenting are predicted by residual platelet reactivity to ADP detected by a point-of-care assay: a 12-month follow-up".

To the Editor: We read with great interest the article by Marcucci et al in a recent issue of Circulation .1 The authors concluded that a residual platelet reactivity (RPR) cutoff value ≥240 reaction units identified patients with a significantly higher risk of cardiovascular death and nonfatal myocardial infarction. Considering the potential clinical implications of this attractive study, addressing some methodological issues would be appreciated. Although only patients with acute coronary syndrome were enrolled, the study population is somewhat heterogeneous because patients with ST-elevation myocardial infarction (STEMI), non-STEMI, and unstable angina were included. Patients with STEMI suffer from acute …“Cardiovascular Death and Nonfatal Myocardial Infarction in Acute Coronary Syndrome Patients Receiving Coronary Stenting Are Predicted by Residual Platelet Reactivity to ADP Detected by a Point-of-Care Assay: A 12-Month Follow-Up” To the Editor: We read with great interest the article by Marcucci et al in a recent issue of Circulation.1 The authors concluded that a residual platelet reactivity (RPR) cutoff value 240 reaction units identified patients with a significantly higher risk of cardiovascular death and nonfatal myocardial infarction. Considering the potential clinical implications of this attractive study, addressing some methodological issues would be appreciated. Although only patients with acute coronary syndrome were enrolled, the study population is somewhat heterogeneous because patients with ST-elevation myocardial infarction (STEMI), nonSTEMI, and unstable angina were included. Patients with STEMI suffer from acute thrombus formation leading to total coronary artery occlusion. Greater platelet reactivity should be expected in this clinical condition. In the present study,1 a similar proportion of patients with STEMI were found in the high-RPR (28.7%) and low-RPR (27.5%) groups. Did the authors analyze differences in RPR mean values between patients with STEMI and the rest of the study population? It would be interesting to know whether the proposed cutoff value might be influenced by potential differences in RPR in different clinical conditions. Geisler et al2 showed different posttreatment platelet reactivity and response to dual antiplatelet therapy between patients with stable angina and those with acute coronary syndrome, supporting the concept that “the more severe the clinical condition, the higher the platelet reactivity.” In the present study, RPR measurement was performed in some patients within 24 hours after 600 mg clopidogrel loading dose and in other patients (those who received glycoprotein IIb/IIIa inhibitors) 6 days after clopidogrel loading dose. Did the authors observe different RPR mean values between these 2 groups of patients? After intensive treatment, a delay in the measurement of platelet function to a subacute phase of the coronary event might influence platelet reactivity values. In a series of patients with non-STEMI and unstable angina,3 we identified a RPR cutoff value of 175 reaction units as a predictor of 1-year adverse cardiovascular events. This cutoff value differs from that proposed by Marcucci et al1 and other authors.4,5 Differences in the composition of the study population and antithrombotic therapies can explain the difference, as does the prolonged period (69 30 hour) of intensive treatment before the angiography in our study group. RPR is recognized as a better estimate for thrombotic risk than the inhibition of platelet aggregation, given that the latter does not take into account the absolute level of platelet reactivity. We absolutely agree with the authors that RPR is able to identify patients at higher risk of long-term adverse clinical events. Due to the limitations of available clinical studies and platelet function tests, proposed cutoff values should be applied with caution in different clinical conditions. Definitive data from large-scale clinical trials are needed to confirm these differences and to support a change in antiplatelet therapy based on the measurement of the platelet reactivity.