Elias B. Hanna

Characteristics and in-hospital outcomes of patients with non-ST-segment elevation myocardial infarction and chronic kidney disease undergoing percutaneous coronary intervention.

OBJECTIVES This study sought to evaluate the characteristics, therapies, and outcomes of patients with chronic kidney disease (CKD) presenting with non-ST-segment elevation myocardial infarction (NSTEMI) and managed with percutaneous coronary intervention (PCI). This specific population has not been evaluated previously. BACKGROUND Among patients with acute coronary syndrome, the presence of renal dysfunction is associated with an increased risk of death and major bleeding. METHODS We examined data on 40,074 NSTEMI patients managed with PCI who were captured by the ACTION (Acute Coronary Treatment and Intervention Outcomes Network) registry. Patients were divided according to baseline renal function in 4 groups: no CKD and CKD stages 3, 4, and 5. RESULTS Overall, 31.1% (n = 12,045) of patients with NSTEMI undergoing PCI had CKD. Compared with patients with normal renal function, CKD patients managed with PCI had significantly more history of myocardial infarction, heart failure, and more 3-vessel coronary artery disease. They received fewer antithrombotic therapies but were treated more frequently with bivalirudin. In addition, they had significantly higher rates of in-hospital mortality and major bleeding. CKD stage 4 was associated with the highest risk of adverse events relative to no CKD. The multivariable adjusted odds ratios of in-hospital mortality for CKD stages 3, 4, and 5 relative to no CKD were 2.0, 2.8, and 2.6, respectively (global p value <0.0001), and the analogous adjusted odds ratios of major bleeding were 1.5, 2.8, and 1.8, respectively (global p value <0.0001). CONCLUSIONS CKD patients presenting with NSTEMI and managed with PCI have more comorbidities and receive guideline-recommended therapies less frequently than do patients without CKD. CKD is strongly associated with in-hospital mortality and bleeding in NSTEMI patients undergoing PCI.

ST-segment depression and T-wave inversion: Classification, differential diagnosis, and caveats

Heightened awareness of the characteristic patterns of ST-segment depression and T-wave inversion is paramount to quickly identifying life-threatening disorders. This paper reviews how to distinguish the various causes of these abnormalities. Knowing the characteristic patterns is critical for a timely diagnosis of life-threatening disorders.

The evolving role of glycoprotein IIb/IIIa inhibitors in the setting of percutaneous coronary intervention strategies to minimize bleeding risk and optimize outcomes.

The use of glycoprotein IIb/IIIa inhibitors (GPI) reduces ischemic events in patients undergoing percutaneous coronary intervention (PCI). However, the same properties that confer this benefit lead to an increased bleeding risk. Recent studies have shown a less robust net clinical benefit of GPI in the current era of routine thienopyridine and direct thrombin inhibitor use. To optimize the net clinical benefit of GPI, these agents need to be selectively used in patients most likely to benefit from their anti-ischemic effect, namely patients undergoing PCI for non-ST-segment elevation myocardial infarction, select patients undergoing primary PCI, and select patients undergoing PCI without appropriate pre-loading with a thienopyridine. Moreover, strategies to minimize bleeding should be applied in these patients and include shorter GPI infusions (in some patients), dose adjustments of heparin and GPI, careful access site management with more frequent use of the transradial approach, use of smaller sheaths, and identification of patients at high bleeding risk. This review provides an update of the current literature that supports these measures, an insight on the tailored use of GPI, and a potential direction for future research addressing combined antithrombotic therapies.

Periprocedural Myocardial Infarction: Review and Classification

Technical and pharmacologic advances have reduced the occurrence of large periprocedural myocardial infarction (PMI) after percutaneous coronary interventions (PCI), but PMI still occurs in 6% to 18% of the cases and is associated with impaired short‐ and long‐term survival. PMI might be due to side branch closure or flow‐limiting dissection, but is most often diagnosed after apparently uncomplicated PCI and is due to atheroembolization into the microcirculation. Various definitions of PMI are used in clinical trials, but a rise in creatine kinase‐MB greater than 3 to 8 times the upper limit of normal is consistently associated with worse prognosis, particularly as it reflects a more extensive and unstable atherosclerotic burden. On the other hand, data regarding the independent prognostic value of periprocedural troponin increase are conflicting. Some data suggest that PMI has a better prognosis than a spontaneously occurring myocardial infarction, and that its incidence is reduced with aggressive antiplatelet and statin therapy. Copyright

Drug eluting versus bare metal stents in cardiac allograft vasculopathy

Background: Cardiac allograft vasculopathy (CAV) is a distinct pathological condition characterized by diffuse and progressive arteriopathy and it is an important determinant of long‐term graft survival. Definitive CAV treatment is retransplantation but palliation with stenting might temporarily alleviate it. The benefit of drug eluting stents (DES) over bare metal stents (BMS) in the treatment of such lesions is debatable. We therefore sought to do a literature search to review the available evidence comparing DES to BMS. Methods: We conducted Pub Med, EMBASE, Cochrane database review, Web of Science search of studies comparing DES with BMS in CAV. Available studies were retrospective in nature with either direct comparison groups (n = 5) or historical controls (n = 1). The main outcomes analyzed were in stent restenosis (ISR) during follow‐up and clinical outcomes. Results: A total of 312 patients from six studies were included in the review (1995–2007). Most commonly used DES were sirolimus eluting stent. DES appeared to reduce the long‐term risk of ISR compared with BMS. Three of the five studies showed a statistically significant reduction in ISR at 12 months while the one study assessing ISR at 6 months showed no significant difference. Clinical endpoints such as death and major adverse cardiac events were not statistically different. Conclusion: DES appear to reduce the incidence of ISR in CAV as compared with BMS. Prospective randomized clinical trials are needed to determine the clinical benefit of DES beyond a reduction in ISR.

Use of trellis thrombectomy system in acute aortofemoral graft occlusion

Acute aortofemoral graft occlusion is often effectively treated with endovascular therapy but a substantial proportion of patients experience failure or complications of this therapy, and most of them require definitive surgery for the underlying inflow, outflow, or graft disease. We describe a case of an aortofemoral graft occlusion that was successfully treated with the Trellis thrombectomy–thrombolysis system (Covidien, Dublin, Ireland). Subsequent stenting of the graft obviated the need for a definitive graft revision surgery. The Trellis system combines mechanical and local pharmacologic lysis of the thrombus, with more rapid and more effective thrombus dissolution and theoretically less risk of systemic dispersion of the thrombolytic agent and less bleeding.

Combined Radial-Pedal Access Strategy and Radial-Pedal Rendezvous in the Revascularization of Complex Total Occlusions of the Superficial Femoral Artery (the “No Femoral Access” Strategy)

Purpose: To describe the combined use of radial-pedal access for recanalization of complex superficial femoral artery (SFA) occlusions unsuitable for transfemoral recanalization. Technique: Patients are selected for this strategy if they have a long (≥10 cm) SFA occlusion with unfavorable aortoiliac anatomy, an absent ostial stump, or severely diseased and calcified distal reconstitution. Left radial artery and distal anterior or posterior tibial artery are accessed with 6-F and 4-F sheaths, respectively. The SFA lesion is crossed retrogradely with a 0.035-inch wire system. If retrograde crossing is not immediately successful, transradial subintimal tracking and radial-pedal subintimal rendezvous are used to allow retrograde reentry. Fifteen patients (mean age 62±5 years; 11 men) have been treated in this fashion, and frequently stented, through the tibiopedal access. Seven patients required radial-pedal rendezvous to facilitate retrograde reentry. Two patients underwent transradial iliac stenting during the same session, and 1 patient underwent transradial kissing angioplasty of the profunda. No major complication occurred in any patient. After the procedure, the pulse across the accessed tibial artery was palpable in all patients. Conclusion: In patients with long and complex SFA occlusion unsuitable for transfemoral recanalization, a radial-pedal strategy can overcome revascularization obstacles.

A New Era for Antiplatelet Therapy in Patients With Acute Coronary Syndrome

Platelet aggregation is one of the most important underlying mechanisms in acute coronary syndromes (ACS). Antiplatelet therapy is considered as a cornerstone therapy and is widely used in these patients. Clopidogrel is currently a class I indication in patients with ACS. However, different degrees of resistance to clopidogrel have been the subject of many recent studies that led to higher dosing regimens of clopidogrel. Failure of clopidogrel to provide consistent platelet aggregation inhibition in all patients made the emergence of new more reliable agents crucial. Prasugrel and ticagrelor are the 2 new antiplatelet agents that have recently been compared with clopidogrel in patients with ACS. This article reviews the current evidence that supports the use of each of those agents and provides clinicians with an objective summary supporting their use.

Characteristics and In-Hospital Outcomes of Patients With Non–ST-Segment Elevation Myocardial Infarction Undergoing an Invasive Strategy According to Hemoglobin Levels

The benefit of an invasive strategy in non-ST-segment elevation myocardial infarction (NSTEMI) was established from randomized trials that included few anemic patients. The aim of this study was to describe the characteristics, therapies, and mortality of patients with NSTEMIs who undergo an invasive strategy in relation to their admission hemoglobin levels. Data from 73,067 patients with NSTEMIs who underwent cardiac catheterization and who were captured by the Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines (ACTION-GWTG) were examined. Patients were divided into 3 hemoglobin groups on the basis of initial hemoglobin level: (1) <10 g/dl, (2) 10 to 12 g/dl, or (3) >12 g/dl. Patients with hemoglobin <10 g/dl had more co-morbidities and more 3-vessel coronary artery disease at catheterization compared with those with hemoglobin >12 g/dl (46.2% vs 33.9%, all p values <0.0001). They received fewer acute antithrombotic therapies, less often underwent revascularization (57.4% vs 74.1%), and had higher rates of red blood cell transfusion before catheterization (32.1% vs 0.3%, all p values <0.0001). After adjustment, in-hospital mortality was inversely associated with initial hemoglobin, with a 7% increase for each 1 g/dl decrease in hemoglobin lower than 15 g/dl (odds ratio 1.07, 95% confidence interval 1.02 to 1.11). In conclusion, in patients presenting with NSTEMIs and managed with an invasive strategy, a lower hemoglobin level is associated with more extensive coronary artery disease, less use of revascularization and evidence-based therapies, and increased mortality.

Combined reperfusion strategies in ST-segment elevation MI: Rationale and current role

Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for ST-elevation myocardial infarction (MI), but most patients do not arrive at a PCI facility within the recommended 90 minutes of first medical contact. If delay is expected, timely thrombolysis is recommended, followed by early transfer for PCI. The authors review the rationale behind three combined reperfusion strategies—facilitated PCI, pharmacoinvasive therapy, and rescue PCI—and data on their effectiveness. In geographic areas where percutaneous coronary intervention (PCI) is not immediately available, the best strategy may be to give thrombolysis immediately and then to transfer the patient to a PCI hospital.