Anjan Gupta

Prospective randomized study of N-acetylcysteine, fenoldopam, and saline for prevention of radiocontrast-induced nephropathy

The objective of this study was to compare the efficacy of N‐acetylcysteine (NAC), fenoldopam, and saline in preventing radiocontrast‐induced nephropathy (RCIN) in high‐risk patients undergoing cardiovascular procedures. We prospectively enrolled 123 patients who were scheduled for cardiovascular procedures and had a baseline creatinine > 1.6 mg/dl or creatinine clearance of < 60 ml/min. Patients were randomly assigned to receive either saline (0.45% normal saline at 1 cc/kg) for 12 hr before and 12 hr after the procedure, or fenoldopam (0.1 μg/kg/min) plus saline for 4 hr prior and 4 hr after the procedure, or NAC orally (600 mg) plus saline every 12 hr for 24 hr prior and 24 hr after the procedure. All the patients received low‐osmolality nonionic contrast. RCIN was defined as an increase in creatinine level > 0.5 mg/dl after 48 hr. The incidence of RCIN was 17.7% in the NAC group, 15.3% in the saline group, and 15.7% in the fenoldopam group (P = 0.919). Of the 20 patients who developed RCIN, 2 required dialysis. Serum creatinine decreased after 48 hr (vs. baseline) in 38% patients in the NAC group, 18% in the fenoldopam group, and 15% in the saline group. In patients with chronic renal insufficiency, NAC or fenoldopam offered no additional benefit over hydration with saline in preventing RCIN. Cathet Cardiovasc Intervent 2002;57:279–283.

In-hospital switching between adenosine diphosphate receptor inhibitors in patients with acute myocardial infarction treated with percutaneous coronary intervention: Insights into contemporary practice from the TRANSLATE-ACS study:

Aims: While randomized clinical trials have compared clopidogrel with higher potency adenosine diphosphate (ADP) receptor inhibitors among patients with acute myocardial infarction, little is known about the frequency, effectiveness and safety of switching between ADP receptor inhibitors in routine clinical practice. Methods and results: We studied 11,999 myocardial infarction patients treated with percutaneous coronary intervention at 230 hospitals from April 2010 to October 2012 in the TRANSLATE-ACS study. Multivariable Cox regression was used to compare six-month post-discharge risks of major adverse cardiovascular events (MACE: death, myocardial infarction, stroke, or unplanned revascularization) and Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO)-defined bleeding between in-hospital ADP receptor inhibitor switching versus continuation of the initially selected therapy. Among 8715 patients treated initially with clopidogrel, 994 (11.4%) were switched to prasugrel or ticagrelor; switching occurred primarily after percutaneous coronary intervention (60.9%) and at the time of hospital discharge (26.7%). Among 3284 patients treated initially with prasugrel or ticagrelor, 448 (13.6%) were switched to clopidogrel; 48.2% of switches occurred after percutaneous coronary intervention and 48.0% at hospital discharge. Switching to prasugrel or ticagrelor was not associated with increased bleeding when compared with continuation on clopidogrel (2.7% vs. 3.3%, adjusted hazard ratio 0.96, 95% confidence interval 0.64–1.42, p=0.82). Switching from prasugrel or ticagrelor to clopidogrel was not associated with increased MACE (8.9% vs. 7.7%, adjusted hazard ratio 1.06, 95% confidence interval 0.75–1.49, p=0.76) when compared with continuation on the higher potency agent. Conclusions: In-hospital ADP receptor inhibitor switching occurs in more than one in 10 myocardial infarction patients in contemporary practice. In this observational study, ADP receptor inhibitor switching does not appear to be significantly associated with increased hazard of MACE or bleeding.

Carotid stenting in patients older than 65 years with inoperable carotid artery disease: a single-center experience

Carotid angioplasty and stenting to treat extracranial carotid stenosis is an alternative (as yet not widely accepted) to high‐risk surgery, but its safety and efficacy are little known, especially in elderly patients. We reviewed our 3‐year experience of treating 100 elderly patients (> 65 years old) considered to be inoperable (76 men, 24 women, mean age 76 ± 10 years, mean follow‐up 18 ± 9.2 months) and present two case histories. Most (85%) were symptomatic (transient ischemic attacks in 60, stroke in 25); 80 had concomitant coronary artery disease (severe in 30 [defined by > 70% stenosis in two or more epicardial coronary arteries or the left main coronary artery]) and 25 had severe left ventricular dysfunction (ejection fraction ≤ 20%). The procedure was technically successful in all patients; there was one major stroke and no patient died. Postprocedure, 15% had minor complications: reversible neurological deficit (5%), pulmonary edema (3%), prolonged hypotension (3%), vascular access complications (3%), and neck hematoma (1%). Over 90% of patients were discharged home within 24 hr. Cathet. Cardiovasc. Intervent. 50:1–8, 2000.

Endovascular intervention of aortoiliac occlusive disease in high‐risk patients using the kissing stents technique: Long‐term results

Endovascular intervention deploying a kissing stents (KS) technique has been used as an alternative to surgical intervention in treating symptomatic aortoiliac occlusive disease. However, the long‐term results on high‐risk patients are unknown. We retrospectively analyzed data on high‐risk patients who underwent endovascular intervention using the KS technique at our institution. Fifty high‐risk patients aged 62 ± 6.4 years with severe aortoiliac stenosis underwent stent‐supported angioplasty using the KS technique. Thirty percent of the patients had total occlusion of the distal aorta and/or the iliac arteries. Twelve patients received thrombolytics prior to stenting. The procedure was successful in all 50 patients. There was a 4% acute complication rate (distal embolization). However, there were no vascular complications, myocardial infarction, or perioperative death. Primary patency during follow‐up of 20 ± 12.3 months was 92%, while secondary patency rate was 100%. Amputation‐free survival was 100%. Ninety‐two percent remained free of lifestyle‐limiting claudication.Catheter Cardiovasc Interv 2003;60:320–326.© 2003 Wiley‐Liss, Inc.

Combined use of Impella device and intra-aortic balloon pump to improve survival in a patient in profound cardiogenic shock post cardiac arrest.

Patients who suffer cardiogenic shock after cardiac arrest have a very poor prognosis. Left ventricular assist devices have proven to be useful in these patients to improve survival. Recently introduced percutaneous assist devices are easier to use and can be inserted quickly in the catheterization laboratory. We describe a case where intra‐aortic balloon pump by itself was not enough to provide hemodynamic support in a patient with cardiogenic shock after cardiac arrest. The Impella Recover® LP 2.5 system (ABIOMED, Inc., Danvers, MA) was successfully used along with the balloon pump for hemodynamic support and resulted in dramatic improvement of the patients condition.

Identifying False-positive ST-elevation Myocardial Infarction in Emergency Department Patients

BACKGROUND In a push to treat ST-elevation myocardial infarction (STEMI) patients with primary percutaneous coronary intervention (PCI) within 90 min of door-to-balloon time, emergency cardiac catheterization laboratory activation protocols bypass routine clinical assessments, raising the possibility of more frequent catheterizations in patients with no culprit coronary lesion. OBJECTIVE To determine the incidence, predictors, and prognosis of false-positive STEMI. METHODS We followed a prospective cohort of patients diagnosed with STEMI by usual criteria receiving emergency cardiac catheterization with intention of primary PCI between January 2005 and December 2007 at a tertiary care center. False-positive STEMI was defined as absence of a clear culprit lesion on coronary angiography. RESULTS Of 489 patients who received emergency cardiac catheterization indicated for STEMI, 54 (11.0%, 95% confidence interval [CI] 8.3-13.8) had no culprit lesion on coronary angiography. Independent predictors of false-positive STEMI were absence of chest pain (odds ratio [OR] 18.2, 95% CI 3.7-90.1), no reciprocal ST-segment changes (OR 11.8, 95% CI 5.14-27.3), fewer than three cardiovascular risk factors (OR 9.79, 95% CI 4.0-23.8), and symptom duration longer than 6h (OR 9.2, 95% CI 3.6-23.7); all p<0.001. Using predictors, we modeled a risk score that achieved 88% (95% CI 81-94%) accuracy in identifying patients with negative coronary angiography. Among the false-positive STEMI patients, 48.1% had other serious diagnoses related to their electrocardiographic findings. CONCLUSION When the diagnosis of STEMI is in doubt, clinicians may use predictors to quickly reassess the likelihood of an alternative diagnosis.

Comparison of safety and efficacy of bivalirudin versus unfractionated heparin in percutaneous peripheral intervention: a single-center experience.

OBJECTIVES The aim of this study was to determine the efficacy and safety of bivalirudin versus low-dose unfractionated heparin (UFH) in percutaneous peripheral intervention (PPI). BACKGROUND Anticoagulation strategies used in PPI are based primarily on studies of percutaneous coronary intervention where higher doses of heparin are used usually in combination with a glycoprotein IIb/IIIa inhibitor. There are no studies comparing bivalirudin alone versus low-dose heparin in PPI. METHODS Consecutive patients who underwent PPI at our institution were treated with either bivalirudin or low-dose UFH. Patients were assessed prospectively during index hospital stay for procedural success and bleeding complications. Of 236 patients, 111 were dosed with UFH at 50 U/kg (goal activated clotting time of 180 to 240 s), and 125 were dosed with bivalirudin at 0.75-mg/kg/h bolus followed by a 1.75-mg/kg infusion. Procedural success was defined as <20% post-procedure residual stenosis with no flow-limiting dissections or intravascular thrombus formation and major bleeding as intracranial or retroperitoneal hemorrhage or a fall in hemoglobin >or=5 g/dl. Anticoagulation cost analysis was conducted. RESULTS Procedural success and major bleeding rates were similar with bivalirudin versus heparin (98% vs. 99% and 2.4% vs. 0.9%, respectively). There were no differences in minor bleeding, time to ambulation, and length of hospital stay. The hospital cost for bivalirudin was

Contemporary clinical outcomes of primary percutaneous coronary intervention in elderly versus younger patients presenting with acute ST-segment elevation myocardial infarction.

547 and <

Comparing long‐term outcomes between drug‐eluting and bare‐metal stents in the treatment of cardiac allograft vasculopathy

1.22 for heparin (10,000 U). Two activated clotting time levels cost

Impact of 24‐hr in‐hospital interventional cardiology team on timeliness of reperfusion for ST‐segment elevation myocardial infarction

4.00. CONCLUSIONS Low-dose UFH is as effective and safe as bivalirudin when used as an anticoagulation strategy in patients undergoing PPI, and low-dose UFH is less costly than bivalirudin. Larger randomized studies are required to further evaluate these findings.