Angelo S. Bongo

Prognostic value of left ventricular mass in uncomplicated acute myocardial infarction and one-vessel coronary artery disease

This study assesses the relative prognostic value of increased left ventricular (LV) mass compared with residual ischemic myocardium and angiographic characteristics of the diseased vessel in 76 patients with uncomplicated acute myocardial infarction associated with 1-vessel coronary artery disease (CAD). All patients underwent symptom-limited treadmill exercise testing, resting and dipyridamole echocardiography and coronary angiography before discharge, and were followed-up for 32 +/- 6 months. LV measurements were obtained in diastole according to the Penn convention. Measurements of LV mass were divided by body surface area to obtain LV mass index. A cut-off value of 135 g/m2 body surface area for men and 112 g/m2 for women was prospectively selected. The individual effects of clinical, stress testing and angiographic variables were evaluated by using the Cox regression model. Echocardiographic LV mass index was increased in 43 patients and normal in 33. There was no intergroup difference with respect to baseline clinical and angiographic variables, ejection fraction and prevalence of stress-induced ischemia. During follow-up there were 23 cardiac events in the 43 patients with increased LV mass index and only 5 in the 33 with normal LV mass index (p < 0.001). No patient died or had nonfatal reinfarction among patients with normal LV mass. Cox survival analysis identified an increased LV mass index as the only independent predictor of cardiac events (chi-square = 7.9; p < 0.005; RR = 5.4). Thus, these data suggest that LV mass is an important independent risk factor in patients with uncomplicated acute myocardial infarction associated with 1-vessel CAD.

High dose dipyridamole echocardiography early after uncomplicated acute myocardial infarction: Correlation with exercise testing and coronary angiography

The feasibility, safety and usefulness of dipyridamole echocardiography (two-dimensional echocardiography and 12 lead electrocardiographic monitoring during dipyridamole infusion, up to 0.84 mg/kg over 10 min) were evaluated in 94 asymptomatic patients 8 to 10 days after uncomplicated acute myocardial infarction. The results were compared with those of symptom-limited treadmill exercise testing and correlated with coronary angiography. Two mechanical patterns of positivity of dipyridamole echocardiography could be identified: 1) a new wall motion abnormality confined to the infarct zone or to the adjacent segments (24 patients), and 2) transient remote asynergy (33 patients). The success rate in recording adequate images during dipyridamole infusion was 100%. Interobserver agreement concerning diagnosis occurred in 89 (93%) of 94 patients. Dipyridamole echocardiography was well tolerated; no complication was observed during or after the test. Seventy-three patients underwent coronary angiography within 6 weeks after acute myocardial infarction. Transient remote asynergy on echocardiography was present in 27 of 40 patients with multivessel disease and in none of 33 patients without multivessel disease. Results of treadmill exercise testing were positive in 28 patients with multivessel disease and 8 patients without multivessel disease. Thus, the sensitivity of dipyridamole-induced transient remote asynergy was 68% compared with 52% for treadmill testing (p less than 0.05); specificity was 100% and 72%, respectively (p less than 0.005). The overall accuracy of dipyridamole echocardiography (81%) was higher than that of dipyridamole stress electrocardiography (63%) or exercise electrocardiography (60%) (p less than 0.02). It is concluded that dipyridamole echocardiography is a useful, feasible and inexpensive nonexercise-dependent test for detecting the extent of coronary artery disease early after acute myocardial infarction.

Silent versus symptomatic dipyridamole-induced ischemia after myocardial infarction: clinical and prognostic significance.

The prevalence and prognostic significance of silent myocardial ischemia were prospectively assessed in 217 patients (mean age 57 +/- 9 years, 83% male) recovering from a first uncomplicated acute myocardial infarction and undergoing a dipyridamole echocardiography test before hospital discharge. Clinical, angiographic, exercise electrocardiographic (ECG) and dipyridamole echocardiographic variables were also examined. Of the 217 patients, 89 had no echocardiographically proved dyssynergy after dipyridamole, whereas 128 had dipyridamole-induced wall motion abnormalities that were silent in 94 (Group I) and symptomatic in 34 (Group II). There was no intergroup difference with respect to dipyridamole time (i.e., the time from onset of the test to frank dyssynergy: 7 +/- 3 vs. 8 +/- 3 min; p = NS); prevalence of inferior myocardial infarction (69% vs. 71%; p = NS); ischemic ECG changes during the test (83% vs. 71%; p = NS); diabetes (8.5% vs. 6%; p = NS); ongoing medical therapy; multivessel disease (57% vs. 56%; p = NS); and baseline left ventricular ejection fraction (57 +/- 13% vs. 57 +/- 10%; p = NS). There was also no significant difference between Group I and Group II with respect to wall motion score index at peak dipyridamole effect (1.77 +/- 0.39 vs. 1.78 +/- 0.36; p = NS). Patients were followed up for 24 +/- 4 and 25 +/- 5 months, respectively (p = NS). Life table analysis revealed no difference in unstable angina, reinfarction and death between the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Dipyridamole echocardiography test. A new tool for detecting jeopardized myocardium after thrombolytic therapy.

BackgroundWe wished to assess whether dipyridamole echocardiography test (DET) can detect jeopardized myocardium after thrombolytic therapy. Methods and ResultsSeventy-six consecutive patients with a first acute myocardial infarction (AMI) were treated with 2 million IU urokinase i.v. within 4 hours of the onset of AMI and underwent high-dose (as much as 0.84 mg/kg over 10 minutes) DET 8–10 days after AMI. The results were correlated to the anatomy of the infarct-related vessel (IRV). In patients with positive DET, we evaluated the wall motion score index (WMSI; a semiquantitative integrated estimation of extent and severity of the stress-induced dyssynergy). WMSI was derived by summation of individual segment scores divided by the number of interpreted segments. In a 13-segment model, each segment was assigned a score ranging from 1 (normal) to 4 (dyskinetic). Fifty-three patients had positive results on DET. Of these, 42 had dipyridamoleinduced new wall motion abnormalities (WMAs) confined to the infarct zone or adjacent segments. In these patients, mean WMSI increased from 1.46 ± 0.26 (at resting conditions) to 1.73 ± 0.35 (at peak dipyridamole) (p < 0.01), whereas no significant change was detected in negative patients (1.6 ± 0.34 versus 1.57 ± 0.34, p = NS). Coronary angiography showed a patent IRV (TIMI grade 2 or 3) in 53 patients and no or minimal reperfusion (TIMI grade 0 or 1) in 23 patients. A patent IRV with critical residual stenosis was found in 35 of 42 patients with dipyridamole-induced WMAs in the infarct zone and in 18 of 34 patients without WMAs (p < 0.05). Among the 23 patients with occluded IRVs, nine had collateral flow to the distal vessel; six of these had a positive DET. Thus, the sensitivity and specificity for identifying a critically stenotic but patent IRV or the presence of a collateral-dependent zone were 66% and 93%, respectively. In a subset of nine patients with a positive DET in the infarct zone or adjacent segments, DET and a control coronary angiography were repeated 1-3 months after an angiographically successful (residual stenosis, 50% or less) coronary angioplasty in the IRV. The repeat DET was negative in eight patients (all with patent IRV at control angiography) and again positive in one patient, who showed restenosis at angiography. The WMSI at resting conditions was similar before and after angioplasty, whereas it differed significantly at peak dipyridamole (1.7 ± 0.2 versus 1.4 ± 0.2, p < 0.01). ConclusionsDET can identify the anatomy of the IRV, and dipyridamole-induced WMAs within the infarct zone detect regions with jeopardized myocardium that may benefit from intervention.

Biodegradable versus durable polymer drug eluting stents in coronary artery disease: Insights from a meta-analysis of 5834 patients

Background Biodegradable polymer drug eluting stents (BP-DES) have been developed to overcome the limitations of first generation durable polymer DES (DP-DES) but the clinical results of different BP-DES are not consistent. We performed a meta-analysis to compare the outcomes of BP-DES and DP-DES in the treatment of coronary artery disease (CAD). Methods and results Online databases including MEDLINE were searched for studies comparing BP-DES and DP-DES for obstructive CAD that reported rates for overall mortality, myocardial infarction (MI), late stent thrombosis (LST), target lesion revascularization (TLR) and late lumen loss (LLL) with a follow-up of ≥6 months. Ten studies (5834 patients) with a 1-year median follow-up were included in the meta-analysis. When comparing patients treated with DP-DES and BP-DES those treated with BP-DES had lower LLL (in-stent: weighted mean difference (WMD) −0.10 mm, 95% CI = −0.17 to −0.03 mm, p = 0.004; in-segment: WMD −0.06 mm, 95% CI = −0.10 to −0.01 mm, p = 0.01) with lower TLR rates (OR 0.67, 95% CI = 0.47 to 0.98, p = 0.04). However, BP-DES did not improve mortality (OR 0.97, 95% CI = 0.73 to 1.29, p = 0.83), MI (OR 1.13, 95% CI = 0.87 to 1.46, p = 0.36) or LST rates (OR 0.64, 95% CI = 0.36 to 1.16, p = 0.14). A pre-specified subgroup analysis of Biolimus BP-DES confirmed significant LLL reduction without differences in other clinical endpoints. Meta-regression analysis demonstrated a strong significant inverse correlation between LLL and reference coronary diameter (p < 0.001). Conclusions Our present meta-analysis showed that BP-DES when compared with DP-DES significantly reduced LLL and TVR but without clear benefits on mortality, MI and LST rates. (Clinicaltrials.gov identifier: NCT01466634).

Meta‐analysis of bioabsorbable versus durable polymer drug‐eluting stents in 20,005 patients with coronary artery disease: An update

To perform an updated meta‐analysis comparing biodegradable polymer drug eluting stents (BP‐DES) and durable polymer drug eluting stents (DP‐DES).

Prognostic value of cystatin C in acute coronary syndromes: enhancer of atherosclerosis and promising therapeutic target.

Abstract Background: Cystatin C (CC) has been proposed to play a role in atherosclerosis. We aimed to review the prognostic value of CC serum/plasma levels in patients with acute coronary syndromes (ACS). Methods: Fifteen observational longitudinal studies were selected by Medline. Results: Increased CC over threshold values ranging from 0.93 to 1.3 mg/L were prognostic for death (hazard ratio; HR: 2.04–3.6) and for the occurrence of any fatal and non-fatal cardiovascular events (HR: 1.7–9.6) for patients with either ACS only or coronary heart disease and prevalent ACS. Only one study showed an increased risk for future myocardial infarction (MI) in patients with marker levels higher than 1.0 mg/L. Three studies reported the risk associated with a change of one unit of CC for long-term death (HR ranging from 1.9 to 6.3) and for the composite end point of 1 year MI and death (HR 2.15). Some studies showed the additional prognostic value contributed from CC measurements to other markers and to conventional risk scores. Conclusion: Despite low to moderate evidence, there is a general agreement on the significant prognostic value of CC in ACS that might encourage further research focused on risk assessment for patients with MI.

Drug eluting balloon versus drug eluting stent in percutaneous coronary interventions: Insights from a meta-analysis of 1462 patients

BACKGROUND Drug eluting balloons (DEB) have been developed to overcome the limitations of drug eluting stents (DES), but clinic results of various DEB studies are still not consistent. Thus, we performed a meta-analysis to compare outcomes of DEB and DES for the treatment of coronary artery disease (CAD). METHODS Medline/Web databases were searched for studies comparing DEB and DES for obstructive CAD, reporting late lumen loss (LLL) and rates for overall mortality, myocardial infarction (MI), stent thrombosis (ST) and target lesion revascularization (TLR). RESULTS 8 studies (1462 patients) were included in the meta-analysis. Compared with DES, DEB treated patients showed non-significantly higher LLL (weighted mean difference [WMD] 0.32, 95% confidence interval [CI] -0.15 to 0.78, P=0.18) and non-significantly higher rate of binary restenosis (odds ratio [OR] 1.40 [0.68-2.48], P=0.36). Mortality (OR 1.13[0.54-2.37], P=0.74), MI (OR 0.95, [0.50-1.80], P=0.87), ST (OR 1.12, [0.34-4.19], P=0.77) and TLR rates (OR 1.19[0.60-2.38], P=0.61) were similar between the 2 treatments. A pre-specified meta-regression analysis showed that LLL WMD and TLR OR were inversely correlated to the prevalence of diabetes (P<0.0001) and directly correlated to reference coronary diameters (P<0.001). CONCLUSIONS The present meta-analysis showed that compared to DES, DEB use resulted in similar clinical efficacy and safety. Thus DEB could be considered a reasonable alternative to DES for the treatment of CAD in selected clinical settings (Clinicaltrials.gov identifier: NCT01760200).

Preventing Restenosis after Implantation of Bare Stents with Oral Rapamycin: A Randomized Angiographic and Intravascular Ultrasound Study with a 5-Year Clinical Follow-Up

Objectives: To establish the efficacy of oral rapamycin at a dose of 2 mg for 1 month at reducing the 6-month restenosis rate after the implantation of bare metal stents. Methods: A prospective, 1:1 randomized, single-blind, placebo-controlled study was conducted in 108 consecutive patients assigned immediately after stent implantation to oral rapamycin (4 mg loading dose followed by 2 mg daily for 30 days) or a placebo. Results: Rapamycin was maintained in 98% of patients. Angiographic in-stent binary restenosis was 14.3% in the rapamycin group versus 32.1% in the placebo group, with a relative risk (RR) of 0.45 (95% CI 0.24–0.84, p = 0.015). The rapamycin blood concentration at 15 days correlated with binary restenosis (p = 0.044). The volume obstructions found by intravascular ultrasound for the rapamycin and the placebo groups were 18.1±10.7 and 27.1±15.7% (p = 0.002), respectively. Major adverse cardiac events at a 5-year follow-up were 31.5% for the rapamycin group and 50.0% for the placebo group (RR 0.63, 95% CI 0.39–1.01, p = 0.078). Conclusions: Oral rapamycin significantly reduces the incidence of restenosis at follow-up compared to a placebo.We believe these findings deserve further testing in larger trials.

Gas6 evaluation in patients with acute dyspnea due to suspected pulmonary embolism

BACKGROUND Gas6 protein is involved in pulmonary embolism (PE) and acute inflammation in animal models. METHODS We enrolled 82 consecutive patients with acute dyspnea and suspected PE (Geneva score with high (HCP) or low/intermediate clinical probability (LICP)+D-dimer >or=0.5microg/mL) and 29 age-matched healthy volunteers. According to clinical and instrumental evaluations the following diagnoses were obtained: heart failure (HF), pulmonary or systemic infection (I), PE, or no illness (N). Twenty-two patients were excluded due to oral anticoagulation (9), lack of CT angiography or pulmonary scintigraphy (6), plasma creatinine >or=3mg/dL (3), and pulmonary cancer (4). Plasma Gas6 was measured with a validated enzyme-linked immunoassay. Non-parametric tests and accuracy measures were calculated. RESULTS Out of 60 patients included, 8 were N, 12 HF, 11 I and 29 PE. Gas6 median value in the N group (20.4ng/mL, interquartile range 17.6-21.6) matched that of healthy volunteers, 19.1 (17.2-21.4). Median Gas6 values in HF, 26.4 (21.6-33.3) and I groups, 34.1 (30.0-38.7), were significantly higher than those in PE 18.2 (16.3-23.3) or N (Kruskal-Wallis test p<or=0.05) groups. Gas6 test improved PE diagnosis with an area under the curve of 0.80 and 0.91 (in all and LICP patients). A 24ng/mL threshold excluded PE in 33% of LICP patients without loosing any diagnosis. CONCLUSIONS The data link Gas6 protein to infection/inflammation, but not to PE, in humans. Gas6 assay was useful in PE diagnosis, improving D-dimer accuracy particularly in LICP patients, and limiting false positives.