Alexis Matteau

Optimal Timing of Noncardiac Surgery After Stents

The planning of noncardiac surgery in patients with a history of coronary artery disease and previous percutaneous coronary intervention with stent implantation is a topic that elicits clinical concern and discussion. These patients face risks related to their underlying coronary heart disease, as well as potential problems related to the coronary stent or associated antiplatelet medications. Some surgical procedures that confer a significant risk of surgical bleeding may require consideration of interrupting dual antiplatelet therapy. This is particularly challenging within the first year after coronary stenting, for which there are only limited data to guide practice.1–5 Article see p 1355 In this issue of Circulation , Wijeysundera and colleagues6 examine cardiovascular outcomes during the 30 days after elective noncardiac surgery among patients who were previously treated with stents. Using province-wide data from Ontario, including 8116 patients undergoing surgical procedures from 2003 to 2009, they assessed the impact of various time intervals between stent and surgery on outcome. They included subjects undergoing orthopedic, vascular, and oncological surgical procedures. The authors concluded that the risk of the composite outcome of 30-day mortality, readmission for acute coronary syndrome, or repeat revascularization after bare metal stent (BMS) implantation was lowest at 46 to 180 days and, after drug-eluting stent (DES), was lowest more 180 days after the procedure. There are limitations to the data that were available for analysis that the authors acknowledge—no data are available on some key in-hospital outcomes such as perioperative bleeding, myocardial infarction, congestive heart failure, and stent thrombosis. The management of antiplatelet therapy around the time of surgery, and clinical factors such that might determine the urgency of surgery, could not be discriminated finely in this administrative database study. Adverse cardiac events after surgery were fairly infrequent (2.1% at 30 …

The safety and feasibility of immediately returning patients transferred for primary percutaneous coronary intervention with ST-elevation myocardial infarction

AIMS To describe the safety of immediate retransfer to community hospitals following primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS In a cohort of 246 consecutive patients transferred to a tertiary institution who all underwent primary or rescue PCI, 166 (67%) were immediately retransferred back. The retransfer occurred only if they were haemodynamically stable and had undergone an uncomplicated procedure. In-hospital adverse events were assessed in each referral hospital. Patients had a mean age of 59 years, presented an anterior MI in 39%, and 91% were in Killip class 1. In this cohort, 75% of patients underwent primary PCI and 25% received rescue PCI. A transradial approach was used in 74% of patients. During ambulance transport back to the referral hospital, no adverse events occurred. In-hospital outcomes were favourable, with low death (2.4%), reinfarction (3.6%) and stroke (1.2%) rates. TIMI major bleeding occurred in 1.8% (catheter-related in 0.6%). CONCLUSIONS In this carefully selected population of STEMI patients, immediate retransfer to the referral hospital following primary or rescue PCI is feasible in more than 2/3 of patients and associated with a low risk of major clinical adverse events.

Effectiveness of a change in reperfusion strategy to primary percutaneous coronary intervention in a nonselected population

BACKGROUND Randomized controlled trials have established the clinical superiority of primary percutaneous coronary intervention (PCI) over fibrinolysis for ST segment elevation myocardial infarction (STEMI) in selected populations. However, the clinical effectiveness of the primary PCI strategy with modern adjunctive antiplatelet therapy deserves further evaluation. OBJECTIVE To validate results from randomized controlled trials in a nonselected Canadian population. METHODS A retrospective study of 243 consecutive patients who presented with a STEMI at a single academic centre was performed. Baseline characteristics, treatment strategies and in-hospital outcomes of patients treated in 2004 to 2005 (n=129) were compared with those of patients treated in 1999 to 2000 (n=114). Logistic regression was used to adjust for imbalanced baseline characteristics. RESULTS Patients in the 2004 to 2005 cohort versus those in the 1999 to 2000 cohort were older and more likely to be hypertensive and to present in Killip class 2 to 4. All of the patients treated in 2004 to 2005 underwent a primary PCI strategy compared with 32.5% in the 1999 to 2000 cohort. The in-hospital incidence of death, reinfarction or stroke was reduced from 21.9% in 1999 to 2000, to 15.5% in 2004 to 2005 (adjusted OR 0.462; P=0.055), largely due to a reduction in reinfarction (10.5% to 3.1%, adjusted OR 0.275; P=0.041). In-hospital mortality and stroke rates did not change significantly. The median length of stay was reduced from eight to six days in the recent cohort (P=0.002). CONCLUSIONS In the present nonselected population, the change in reperfusion strategy from fibrinolysis to primary PCI in the treatment of STEMI reduced the length of hospitalization by two days and was associated with an adjusted 54% relative reduction in adverse in-hospital events, which was largely due to a significant reduction in reinfarction.

Recent advances in antithrombotic therapy after acute coronary syndrome

Acute coronary syndrome is a broad category of coronary heart disease that ranges from unstable angina to ST elevation myocardial infarction (MI). Its initial evaluation relies heavily on rapid triage according to the electrocardiogram and cardiac biomarkers. The cornerstone of treatment for ST

APPROPRIATENESS OF CORONARY ARTERY BYPASS GRAFTING BASED ON FRACTIONAL FLOW RESERVE LESIONS ASSESSMENT

Background: Fractional Flow Reserve (FFR) is currently validated as an important tool in the hemodynamic evaluation of coronary stenosis. Some studies reported that Coronary Artery Bypass Graft (CABG) on lesions with normal FFR arteries might result in early graft patency compromise. However, the

Impact of Paclitaxel-Eluting Balloons Compared to Second-Generation Drug-Eluting Stents for of In-Stent Restenosis in a Primarily Acute Coronary Syndrome Population

Background The place of drug-eluting balloons (DEB) in the treatment of in-stent restenosis (ISR) is not well-defined, particularly in a population of all-comers with acute coronary syndromes (ACS). Objective Compare the clinical outcomes of DEB with second-generation drug-eluting stents (DES) for the treatment of ISR in a real-world population with a high proportion of ACS. Methods A retrospective analysis of consecutive patients with ISR treated with a DEB compared to patients treated with a second-generation DES was performed. The primary endpoint was a composite of major adverse cardiovascular events (MACE: all-cause death, non-fatal myocardial infarction, and target lesion revascularization). Comparisons were performed using Cox proportional hazards multivariate adjustment and Kaplan-Meier analysis with log-rank. Results The cohort included 91 patients treated with a DEB and 89 patients treated with a DES (74% ACS). Median follow-up was 26 months. MACE occurred in 33 patients (36%) in the DEB group, compared to 17 patients (19%) in the DES group (p log-rank = 0.02). After multivariate adjustment, there was no significant difference between the groups (HR for DEB = 1.45 [95%CI: 0.75-2.83]; p = 0.27). Mortality rates at 1 year were 11% with DEB, and 3% with DES (p = 0.04; adjusted HR = 2.85 [95%CI: 0.98-8.32]; p = 0.06). Conclusion In a population with a high proportion of ACS, a non-significant numerical signal towards increased rates of MACE with DEB compared to second-generation DES for the treatment of ISR was observed, mainly driven by a higher mortality rate. An adequately-powered randomized controlled trial is necessary to confirm these findings.

COMPARISON OF TRIPLE ANTITHROMBOTIC THERAPY TO TICAGRELOR-BASED DUAL ANTIPLATELET THERAPY FOR LEFT VENTRICLE DYSFUNCTION FOLLOWING STEMI USING NATURAL RANDOMIZATION: A RETROSPECTIVE PILOT STUDY

Background: Antithrombotic management of STEMI patients with apical dysfunction is controversial. Clopidogrel-based triple antithrombotic therapy (TATT) may be associated with increased bleeding, while ticagrelor-based dual antiplatelet therapy (DAPT) may not adequately protect against cardio-

Maximal expected benefits from lowering cholesterol in primary prevention for a high-risk population

Abstract Aims: The objective of this study was to estimate the maximal clinical benefit that could be reasonably expected from a cholesterol-lowering intervention. Materials and methods: We used a hypothetical population at high risk of cardiovascular disease events from three risk assessment models including the Framingham risk function, the Score Canada and the Pooled Cohort Risk Assessment Equations. Our source population were all 55-year-old smoking men with diabetes, hypertension and low HDL. From this population, we identified two different subpopulations named “high” and “low”, referring to their cholesterol levels which were set at 8.60 and 4.14 mmol/L respectively. Both subpopulations were identified for each risk assessment model in order to estimate the maximal impact of lowering cholesterol on cardiovascular disease events. Results: Our extrapolations estimated that the maximal theoretical efficacy of a cholesterol-lowering intervention corresponds to a risk ratio ranging between 0.46 and 0.66 over a 10-year period. The number of events prevented during this period were between 21 and 29 per 100 patients which corresponds to a number needed to treat varying from 3.47 to 4.76. Conclusions: Our estimation showed the maximal clinical benefit that could be reasonably expected by an intervention that would lower total cholesterol in high-risk patients.

719 Incidence, predictors and long-term clinical outcomes of coronary perforation in the modern era

CONCLUSIONS: In fibrinolytic-treated STEMI patients undergoing a routine early invasive approach or receiving standard care, radial PCI was chosen in younger, less ill patients and was associated with a lower rate of bleeding compared to patients undergoing femoral PCI. The independent association between radial access and lower rates of major bleeding remained significant after adjusting for potential confounding variables.