Antonios Ziakas

Safety of dental extractions during uninterrupted single or dual antiplatelet treatment.

Optimal dental management in patients on long-term antiplatelet treatment is not clearly defined. Antiplatelet discontinuation increases the risk of thrombotic complications, whereas uninterrupted antiplatelet therapy, which is the currently recommended approach, is assumed to increase the bleeding hazard after dental procedures. We sought to prospectively compare the risk of immediate and late postextraction bleeding in patients receiving uninterrupted single or dual antiplatelet therapy. We recruited 643 consecutive patients referred for dental extractions. In total 111 (17.3%) were on clinically indicated antiplatelet therapy: aspirin (n = 42), clopidogrel (n = 36), and aspirin and clopidogrel (n = 33). Controls (n = 532, 82.7%) were not on antiplatelet treatment. Immediate and late bleeding complications were recorded. Compared to controls the risk of prolonged immediate bleeding was higher in patients on dual antiplatelet therapy (relative risk [RR] 177.3, 95% confidence interval [CI] 43.5 to 722, p <0.001) but not in patients on aspirin alone (RR = 6.3, 95% CI 0.6 to 68.4, p = 0.2) or clopidogrel alone (RR = 7.4, 95% CI 0.7 to 79.5, p = 0.18); however, all immediate bleeding complications in all treatment groups were successfully managed with local hemostatic measures. No patient developed any late hemorrhage. In conclusion, dental extractions may be safely performed in patients receiving single or dual antiplatelet therapy when appropriate local hemostatic measures are taken, thus averting thrombotic risk of temporary antiplatelet discontinuation.

Left Ventricular Outflow Tract Obstruction as a Risk Factor for Sudden Cardiac Death in Hypertrophic Cardiomyopathy

The effect of left ventricular outflow tract obstruction (LVOTO) at rest on the incidence of sudden death (SD) in patients with hypertrophic cardiomyopathy is rather conflicting. The aim of this study was the evaluation of LVOTO at rest as a new potential risk factor for SD in hypertrophic cardiomyopathy. A total of 166 patients (112 men, 51.8 +/- 15.6 years) were studied; 50 patients (30.1%) had peak instantaneous LVOTO gradients of > or = 30 mm Hg at rest. During the follow-up period (median 32.4 months, range 1 to 209), 13 patients either died suddenly, or had cardiac arrest, documented sustained ventricular tachycardia, or implantable cardioverter defibrillator discharge. The cumulative event-free survival rate was 92% in patients with LVOTO, and 92% in patients without obstruction (p = NS). LVOTO at rest was associated with a particularly low positive predictive value for SD (8%), although a high negative predictive value (92%) was recorded. Patients having syncope or presenting with a maximum wall thickness > or =3 cm in echocardiography were more sensitive to SD emergence because they had a 13.07 (95% confidence interval 4.00 to 46.95, p <0.0001) and a 10.07 (95% confidence interval 2.92 to 34.79, p = 0.003) greater relative risk, respectively. In conclusion, our cohort study results do not support LVOTO as an independent risk factor for SD in patients with hypertrophic cardiomyopathy.

Circadian rhythm in sudden cardiac death : A retrospective study of 2,665 cases

Several studies have reported a circadian variation in sudden cardiac death. The aim of this study was to determine whether in northern Greece sudden cardiac death shows a circadian rhythm and/or a weekly and seasonal distribution. We studied 2,665 sudden deaths due to coronary heart disease from 13,832 sudden deaths that merited autopsy; 1,429 (53.6%) of them were due to acute myocardial infarction (AMI) and 1,236 (46.4%) to chronic ischemic heart disease (IHD). The time of death was determined on the basis of autopsy results and witness interviews. There was a circadian rhythm of sudden cardiac death (p<0.010), with a low incidence during the hours 04.00-08.00 (13.1%) and an increased incidence during 20.00-24.00 (19.8%) (p<0.05). Women did not show the same significant circadian variation. Time of occurrence of sudden cardiac death attributed either to AMI or to IHD showed a similar 24-hour distribution (lowest incidence during 04.00-08.00 hours, 12.8% and 13.5%, respectively, and higher during 20.00-24.00, 19.5% and 20.3%, respectively). Weekday distribution of sudden cardiac death showed a significant statistical variation (p<0.005) with the highest frequency on Monday (21.1%) and the lowest on Sunday (7.5%). The same distribution was observed in men, whereas in women the lower frequency was also on Sunday but the higher was on Tuesday. Sudden cardiac death was evenly distributed over the months of the year, with the highest incidence in summer (27.3%) and the lowest in autumn (22%). Sudden cardiac death shows a circadian rhythm and a significant variation during the week.

Radial versus femoral access for orally anticoagulated patients

Objectives: To prospectively compare the efficacy and procedural safety of the radial versus femoral route for cardiac catheterization during uninterrupted warfarin therapy. Background: The optimal treatment strategy for cardiac catheterization in patients receiving long‐term oral anticoagulation has not been defined. Increasing evidence suggests the feasibility and safety of catheterization without warfarin interruption. However, the relative safety and efficacy of the radial and femoral access in fully anticoagulated patients are unknown. Methods: Fifty‐six consecutive patients on chronic warfarin treatment with international normalized ratio (INR) between 1.8 and 3.5 were randomized to undergo coronary angiography, alone, or followed by percutaneous coronary intervention (PCI), via the femoral (n = 29) or radial route (n = 27). Procedural success, in‐hospital major adverse cardiac and cerebrovascular events, access‐site, and bleeding complications were recorded. Results: The two groups were well balanced with similar clinical characteristics at baseline. There were no significant differences in preprocedural antiplatelet therapy or in INR levels between the radial and femoral group (2.62 ± 0.7 vs. 2.48 ± 0.6, respectively, P = 0.63). Procedural success was achieved in all femoral patients, whereas one patient in the radial group (3.7%) required crossover to femoral access. Eight patients from the femoral and 10 patients from the radial group successfully underwent PCI. Access‐site complications occurred only in patients who underwent PCI: three (37.5%) in the femoral versus none in the radial group (P = 0.034). Conclusion: The radial access is as efficacious and safe as the femoral route for coronary angiography in fully anticoagulated patients, but is likely to result in fewer access‐site complications in patients who also undergo PCI.

Comparison of the Radial and the Femoral Approaches in Percutaneous Coronary Intervention for Acute Myocardial Infarction

In conclusion, in selected patients, the transradial approach performed by skilled operators is as safe and feasible as the transfemoral for PCI in the setting of AMI. The major clinical advantage of the radial approach is the absence of major vascular access complications.

In-Hospital and Long-Term Prognostic Value of Fibrinogen, CRP, and IL-6 Levels in Patients with Acute Myocardial Infarction Treated with Thrombolysis

Plasma fibrinogen, C-reactive protein (CRP), and interleukin-6 (IL-6) levels in patients with acute myocardial infarction (AMI) receiving thrombolysis have been related to prognosis. The aim of this study was to investigate the time course of plasma fibrinogen, CRP, and IL-6 levels during the in-hospital phase in patients with AMI receiving thrombolysis, and their relationship to in-hospital and prognosis after 12-months follow-up. In 40 patients presenting with AMI within 6 hours of symptom onset and treated with thrombolysis, plasma fibrinogen, CRP, and IL-6 levels were measured on admission and after 6, 12, 24, 48, and 72 hours; 7 days; and 6 months. Patients with other diseases that can alter fibrinogen, CRP, or IL-6 levels were excluded. Patients had a clinical follow-up at 6 and 12 months, and the following cardiac events were recorded: cardiac death, recurrent angina, recurrent AMI, and heart failure. Plasma fibrinogen concentrations decreased significantly (p<0.01 vs admission levels) at 12 hours (425 ±94 vs 322 ±132 mg/dL), started to increase at 24 hours, reached peak value at 72 hours (602 ±209 mg/dL), remained elevated at 7 days, and were back to admission levels at 6 months (375 ±79 mg/dL). CRP levels increased significantly at 12 hours (0.73 ±0.43 vs 0.23 ±0.11 mg/dL, p<0.01), reached peak value at 72 hours (7.66 ±3.28 mg/dL), decreased significantly on day 7 (2.32 ±1.17 mg/dL), and at 6 months were within normal limits (0.49 ±0.29 mg/dL). IL-6 levels increased significantly at 6 hours (14.03 ±8.13 vs 6.37 ±3.88 pg/mL, p<0.05), reached peak value at 24 hours (59.49 ±23.57 pg/mL), started to decrease at 48 hours, and at 6 months were within normal limits (2.25 ±1.24 pg/mL). During the in-hospital phase 33 patients had an uneventful course and 7 patients had complications (3 post-AMI angina; 4 heart failure). During the 12-month follow-up period 28 patients had an uneventful course, and 12 patients had complications (1 cardiac death, 5 recurrent angina, 2 recurrent AMI, and 4 heart failure). Regarding the in-hospital prognosis, fibrinogen, CRP, and IL-6 levels were significantly higher (p<0.05) in patients with complications from 48 to 72 hours, from 12 hours until day 7, and from 6 hours until day 7, respectively. During the 12-month follow-up period fibrinogen, CRP, and IL-6 levels were significantly higher in patients with complications (at 48, 24, and 24 hours, respectively) only in the subgroup of patients who had complications within the first 6 months following AMI. Multivariate analysis showed that CRP at 48 hours was the most important factor related to in-hospital prognosis (p=0.02), and ejection fraction followed by CRP at 24 hours (p=0.02) to 6-month prognosis (p=0.018). Fibrinogen, CRP, and IL-6 levels alter in patients with AMI receiving thrombolysis, and are related both to in-hospital and to 6-month follow-up prognosis.

Transulnar Compared With Transradial Artery Approach as a Default Strategy for Coronary Procedures A Randomized Trial The Transulnar or Transradial Instead of Coronary Transfemoral Angiographies Study (The AURA of ARTEMIS Study)

Background—The ulnar artery is rarely selected for coronary angiography or percutaneous coronary intervention despite the expanding use of the transradial approach. We aimed to establish noninferiority of a default transulnar relative to transradial approach in terms of feasibility and safety. Methods and Results—This was a prospective, randomized, multicenter, parallel-group study involving 902 patients at 5 sites eligible to undergo diagnostic coronary angiography and percutaneous coronary intervention. Patients were randomized in a 1:1 ratio to either transradial approach (reference intervention) or transulnar approach (experimental intervention) regardless of the Allen test results. The primary end point was a composite of cross-over to another arterial access, major adverse cardiovascular events, and major vascular events of the arm at 60 days. The study was prematurely terminated after the first interim analysis because of inferiority of the transulnar approach. Although the difference in the primary end point became inconclusive after adjustment for operator clustering (24.30%; 99.99% confidence interval [CI], −7.98% to 56.58%; P=0.03 at &agr;=0.0001), need for cross-over in the transulnar group remained inferior to transradial access site with a difference of 26.34% (95% CI, 11.96%–40.69%; P=0.004). Conclusions—As a result of higher cross-over rates, a first-line transulnar strategy was proven inferior to the transradial approach for coronary procedures. At present, the transulnar route should not be regarded as an acceptable alternative to the transradial access site. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT01364532.

A comparison of the radial and the femoral approach in vein graft PCI. A retrospective study

BACKGROUND: Transradial PCI is a safe and effective method of percutaneous revascularization. However, there is limited data on the efficacy of the transradial approach for saphenous vein graft (SVG) PCI. METHODS: We studied 334 patients who underwent SVG PCI between January 2000 and December 2003, and compared the radial (132 patients) and the femoral (202 patients) approach. RESULTS: Mean EF (55.6±18.6% radial versus 58.1±16.8% femoral), lesion location (proximal, mid, distal: 22.6/50.6/26.7% versus 22.6/44.5/32.9% respectively) and lesion type (B1/B2/C: 3.4/4.1/92.5% versus 0.4/3.1/96.5%) were similar in both groups (P>0.05). Five patients had a failed radial attempt (3.8%) and were switched to the femoral approach. Mean fluoroscopy time (20.4±12.2 versus 18.4±10.2min), procedural time (60.0±27.2 versus 61.6±24.9 min) and the use of contrast (223±91 versus 234±91ml) IIB/IIIA inhibitors (27.2 versus 33.2%), and stenting (81.5 versus 81.3%) were similar in both groups, whereas 5 or 6 French sheaths were used more often in the radial group (83.4 versus 64.9%, P<0.01). Angiographic success (93.9 versus 92.9%), in hospital MACE (radial:5 MI (3.8%) versus femoral: 1 death (0.5%) and 7 MI (3.5%) and major vascular complications (0.7 versus 0.5%) were also similar. CONCLUSIONS: The radial approach in SVG PCI is as fast and successful as the femoral.

Total Cholesterol Content of Erythrocyte Membranes and Coronary Atherosclerosis: An Intravascular Ultrasound Pilot Study

Background: Increasing evidence suggests that erythrocytes may participate in atherogenesis. We sought to investigate the relationship between total cholesterol content in erythrocyte membranes (CEM) and coronary atheroma burden in patients with coronary artery disease (CAD). Methods: We prospectively enrolled 28 participants: 11 patients with angiographically significant CAD and 17 controls. Intravascular ultrasound (IVUS) and 3-dimensional reconstruction of coronary arteries was performed in the patient subgroup. Results: Cholesterol content of erythrocyte membranes was higher in patients compared to controls (P < .01). Cholesterol content of erythrocyte membranes correlated with total atheroma volume (r = .82, P < .01) and with percentage plaque area at the vessel site with minimal lumen area (r = .75, P < .05). On multivariate analysis, CEM was the only variable independently predicting total atheroma volume (P = .05). Conclusions: This pilot study is the first to demonstrate a significant relation between CEM and coronary atherosclerotic burden, suggesting a possible role of erythrocyte membrane—derived lipids in the expansion of atheromata. The results merit validation in larger studies.

A comparison of the radial and the femoral approaches in primary or rescue percutaneous coronary intervention for acute myocardial infarction in the elderly.

Background: Access site complications are reduced using radial percutaneous coronary intervention (PCI). There is concern that technical difficulties using this approach can delay achievement of reperfusion during primary or rescue PCI for acute myocardial infarction (AMI) especially in elderly patients. Methods and Results: We studied 155 patients (pts)⩾70 years who underwent primary or rescue PCI for AMI; radial (Group1; 87 pts) or femoral (Group2; 68 pts). Baseline characteristics, the amount of IIB/IIIA inhibitor, contrast and heparin used, and TIMI flow pre and post PCI were similar in both groups (P>0.05). Time from arrival in the catheterization laboratory to the first balloon inflation (Group 1: 44.0±21.5 versus Group 2 38.8±18.7 min) was also similar, but was significantly longer (61.2±11.1 min) compared to both groups in patients with a failed radial approach (7 pts, 8%). Angiographic success, and in‐hospital MACE were also similar in the two groups, but vascular access site complications were significantly higher in Group 2 (0 versus 2.9%, P<0.05). Conclusion: The use of the radial approach in elderly patients undergoing primary and rescue PCI, when successful, is safe and effective as the femoral approach, and leads to fewer vascular complications.