Antonio Dellavalle

Plasma Activity and Insertion/Deletion Polymorphism of Angiotensin I–Converting Enzyme A Major Risk Factor and a Marker of Risk for Coronary Stent Restenosis

BACKGROUND Tissue proliferation is almost invariably observed in recurrent lesions within stents, and ACE, a factor of smooth muscle cell proliferation, may play an important role. Plasma ACE level is largely controlled by the insertion/deletion (I/D) polymorphism of the enzyme gene. The association among restenosis within coronary stents, plasma ACE level, and the I/D polymorphism is analyzed in the present prospective study. METHODS AND RESULTS One hundred seventy-six consecutive patients with successful, high-pressure, elective stenting of de novo lesions in the native coronary vessels were considered. At follow-up angiography, recurrence was observed in 35 patients (19.9%). Baseline clinical and demographic variables, plasma glucose and serum fibrinogen levels, lipid profile, descriptive and quantitative angiographic data, and procedural variables were not significantly different in patients with and without restenosis; mean plasma ACE levels (+/-SEM) were 40.8+/-3.5 and 20.7+/-1.0 U/L, respectively (P<.0001). Diameter stenosis percentage and minimum luminal diameter at 6 months showed statistically significant correlation with plasma ACE level (r=.352 and -.387, respectively P<.001). Twenty-one of 62 patients (33.9%) with D/D genotype, 13 of 80 (16.3%) with I/D genotype, and 1 of 34 (2.9%) with I/I genotype showed recurrence; the restenosis rate for each genotype is consistent with a codominant expression of the allele D. CONCLUSIONS In a selected cohort of patients, both the D/D genotype of the ACE gene, and high plasma activity of the enzyme are significantly associated with in-stent restenosis. Continued study with clinically different subsets of patients and various stent designs is warranted.

Plasma Lipoprotein(a) Is Not a Predictor for Restenosis After Elective High-Pressure Coronary Stenting

BACKGROUND Lipoprotein(a) is a risk factor for coronary artery disease. Although it has been implicated in restenosis after balloon angioplasty, its role in restenosis within coronary stents is unknown. The aim of the study was to assess the role of plasma lipoprotein(a) as a predictor for restenosis after elective coronary stenting. METHODS AND RESULTS Elective, high-pressure stenting of de novo lesions in native coronary arteries with Palmaz-Schatz stents was performed in 325 consecutive patients. Clinical, angiographic, and biochemical data were analyzed prospectively. Angiographic follow-up was performed at 6 months. Lipoprotein(a) levels were compared in patients with and without restenosis. Angiographic follow-up was obtained in 312 patients (96%); recurrence was observed in 67 patients (21.5%). No clinical or biochemical variable was associated with restenosis. Lipoprotein(a) level was 37.81+/-49. 01 mg/dL (median, 22 mg/dL; range, 3 to 262 mg/dL) in restenotic patients and 36.95+/-40.65 mg/dL (median, 22 mg/dL; range, 0 to 244 mg/dL) in nonrestenotic patients (P=NS). The correlations between percent diameter stenosis, minimum luminal diameter, and late loss at follow-up angiography and basal lipoprotein(a) plasma level after logarithmic transformation were 0.006, 0.002, and 0.0017, respectively. Multiple stents were associated with a higher incidence of restenosis (P=0.006), but biochemical data in these patients were similar to those treated with single stents. CONCLUSIONS The basal plasma level of lipoprotein(a) measured before the procedure is not a predictor for restenosis after elective high-pressure coronary stenting.

Vascular Access Complications after Cardiac Catheterisation: A Nurse-Led Quality Assurance Program

Background: Vascular access complications may be a cause of discomfort, prolonged hospital stay, and impaired outcomes in patients undergoing cardiac catheterisation. Aims: To assess vascular access complication in our patients with/without the use of closure devices as a first local benchmark for subsequent quality improvement. Methods: A nurse-led single-centre prospective survey of all vascular access complications in consecutive patients submitted to cardiac catheterisation during 4 months. Results: The radial and femoral access were used in 78 (14%) and 470 (83%), respectively, of 564 procedures, and a closure device was used in 136 of the latter. A haemathoma (any size) was isolated and uneventful in 9.6% of cases. More severe complications (haemoglobin loss > 2 g, need for blood transfusion or vascular repair) occurred in 1.2% of cases, namely: in none of the procedures with radial access, and in 0.4% and 2.4% of femoral diagnostic and interventional coronary procedures, respectively. During complicated (n = 40) vs uncomplicated (n = 172) transfemoral interventions, the activated coagulation time was 309 ± 83 vs 271 ± 71 s (p = 0.004), but the use of closure devices was similar. Conclusion: Severe vascular access complications in our patients were fewer than in most reports, and virtually absent in radial procedures. Vigorous anticoagulation was associated with increased complications in our patients, but closure devices were not. A new policy including both the use of the radial access whenever possible, and a less aggressive anticoagulation regimen during transfemoral interventions will be tested.

Coronary stenting after unsuccessful emergency angioplasty in acute myocardial infarction: results in a series of consecutive patients.

Nineteen consecutive procedures of coronary stenting were attempted in 70 consecutive patients (27%) with evolving myocardial infarction due to threatened vessel reocclusion after primary (16 cases) or rescue (3 cases) angioplasty. Two patients were in cardiogenic shock. Stent delivery was successful in 18 patients, with a Thrombolysis in Myocardial infarction flow grade 3; residual diameter stenosis and minimum luminal diameter were 19% +/- 11% and 2.96 +/- 0.62 mm, respectively. After the procedure, heparin was continued for 4 days and 250 mg ticlopidine twice a day for 1 month. Acute stent occlusion occurred in one patient 1 hour after the procedure and was successfully treated with emergency repeat angioplasty. Subacute stent occlusion occurred 6 days after the procedure in one patient, with multivessel coronary disease and a suboptimal stent result. He had been referred for surgery, and emergent coronary artery bypass was performed. Coronary bypass surgery was performed in another patient before discharge because of severe multivessel disease. Persistent cardiogenic shock and new myocardial infarction in another location were the causes of death in two patients, 3 and 10 days after the procedure, respectively. Fifteen patients were discharged with a patient infarct vessel and without reinfarction or need for coronary bypass surgery. One patient had repeat angioplasty for intrastent restenosis at 3 months. The remaining 14 patients were free from new coronary events 4 +/- 2 months after the procedure. Although acute myocardial infarction is generally considered a contraindication to the use of coronary stents, stents may play a role in increasing the rates of successful infarct artery reperfusion.

Use of glycoprotein IIb/IIIa inhibitors in invasively-treated patients with non-ST elevation acute coronary syndrome.

Background In patients with non-ST elevation acute coronary syndrome (NST-ACS) that is treated invasively, glycoprotein (GP) IIb/IIIa inhibitors can be used either as upstream treatment in a coronary care unit or as downstream provisional treatment in selected patients who are undergoing percutaneous coronary intervention (PCI). The relative advantage of either strategy is unknown. The purpose of this study was to assess 30-day outcome of patients enrolled in a prospective NST-ACS registry and treated invasively with either of these two therapeutic strategies. Methods Patients treated invasively (coronary arteriography within 4 days of admission), in the prospective registry ROSAI-2, were divided into two groups according to the upstream use of GPIIb/IIIa inhibitors (n = 241), or not (n = 548). In the latter group, 76 (14%) patients received GPIIb/IIIa in association with a PCI procedure. Clinical and angiographic characteristics as well as in-hospital and 30-day outcome of these two groups of patients were compared. Results The two groups were similar with respect to age, sex, presence of hypertension, diabetes, number of PCI procedures. However, patients treated with upstream GPIIb/IIIa blockers had more frequently ST-segment depression (P = 0.002), a high TIMI risk score (P = 0.01) and were more frequently admitted to centres with Cath Lab facilities (P = 0.001). At 30-day follow-up, the composite of death, acute myocardial infarction and stroke, as well as major bleeding, was not significantly different between the two groups, although it occurred more frequently in patients who received upstream GPIIb/IIIa blockers (9.5% versus 5.7% and 1.7% versus 0.2%, respectively). By multivariate analysis, diabetes [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 1.2–4.09] and a diagnosis on admission of non-Q-wave myocardial infarction (OR = 2.0, 95% CI = 1.10–3.6) were independently related to outcome. No additional risk or benefit was related to upstream GPIIb/IIIa inhibitor treatment (OR = 1.5, 95% CI = 0.84–2.68). Conclusions Among invasively-treated patients with NST-ACS, upstream treatment with GPIIb/IIIa inhibitors was used in those with a higher clinical risk profile, whereas downstream treatment was reserved for a limited number of patients undergoing PCI. Thirty-day outcome was similar in the two groups, irrespective of the treatment strategy used.

PREVALENCE OF LATE POTENTIALS AFTER MYOCARDIAL INFARCTION TREATED WITH SYSTEMIC THROMBOLYSIS OR PRIMARY PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

The term cardiomyopathy was probably used for the first time in 1957, when W. Bridgen [1] described the diseases of the myocardium of “non-coronary ” etiology. Previously, a variable terminology had been used for these diseases, such as “myocardosis ” /“cardiac myopathy ”, “myocarditis ” etc.

Impact of angiographic coronary artery disease complexity on ischemic and bleeding risks and on the comparative effectiveness of zotarolimus-eluting vs. bare-metal stents in uncertain drug-eluting stent candidates

BACKGROUND The impact of coronary artery disease (CAD) extension/complexity on outcomes and on the comparative benefits/risks of zotarolimus-eluting stent (ZES) versus bare-metal stents (BMS) remains unclear in patients at high risk of bleeding or thrombosis or at low restenosis risk. METHODS We performed a post-hoc analysis of the ZEUS trial. The impact of coronary anatomic complexity measured by the SYNTAX score on the differences in outcomes following ZES and BMS was assessed at 1 year. RESULTS The mean SYNTAX score was 16.3 ± 13.1 with a median of 12 (IQR: 7 to 22). We stratified patients according to SYNTAX tertiles (0-8: n = 563; >8-19 n = 532; >19: n = 511), and observed that the higher the score, the correspondingly higher was the rate of the primary endpoint of major adverse cardiovascular events (MACE) and other ischemic events, but not bleeding after adjustment. The superior efficacy of ZES versus BMS for MACE was consistent across SYNTAX tertiles (tertile 1: HR 0.71, 95% CI 0.44-1.13; tertile 2: HR 0.71, 95% CI 0.46-1.09; tertile 3: HR 0.83, 95% CI 0.61-1.10) without significant heterogeneity (p for trend = 0.55). This between-groups difference mainly reflected a reduction in MI and TVR without effect on mortality. There was no significant interaction between the SYNTAX score and allocated stent type with respect to ischemic and bleeding endpoints. CONCLUSIONS The SYNTAX score was predictor of major adverse cardiovascular events but not bleeding and ZES provided superior efficacy and safety than BMS across the whole spectrum of CAD complexity. SYNTAX score may be routinely used for the assessment of the ischemic risk (but not bleeding) after PCI and should not guide the decision-making for DES versus BMS in patients undergoing PCI.