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Risk of thrombosis during coronary angioplasty with low osmolality contrast media

Studies in vitro have suggested that nonionic low osmolar contrast agents produce an increase in thrombogenicity. To determine the incidence of thrombi related to the use of nonionic low osmolar contrast media during coronary angioplasty, a double-blind randomized study was performed in 100 patients. Medication before angioplasty included oral aspirin (250 mg/day) in all cases. At the beginning of the procedure, aspirin (250 mg) and heparin (10,000 U) were intravenously administered. During the procedure patients were randomly assigned to receive either an ionic low osmolar contrast agent ioxaglate (n = 50), or a nonionic low osmolar contrast media iohexol (n = 50). The presence of thrombus was evaluated on the angiogram and on the guidewire immediately after its retrieval from the patients. Clinical, angiographic and procedural variables were similar in the 2 randomized groups. Angiographic evidence of thrombus was observed in 1 patient (2%) assigned to ioxaglate and in 11 patients (22%) assigned to iohexol (p less than 0.005). One patient (2%) from the ioxaglate group and 6 patients (12%) from the iohexol group showed thrombotic residues on the guidewire (p = not significant). Three patients had acute myocardial infarction, 1 patient (2%) receiving ioxaglate and 2 patients (4%) iohexol (p = not significant). There were no deaths. Thus, compared with an ionic low osmolar contrast media ioxaglate, the nonionic low osmolar contrast agent iohexol increases the incidence of thrombus during coronary angioplasty.

Guías de práctica clínica de la Sociedad Española de Cardiología en cardiología intervencionista: angioplastia coronaria y otras técnicas

La cardiologia intervencionista ha experimentado en los ultimos anos un gran crecimiento. En esta guia de actuacion clinica se revisa la evidencia cientifica existente y su implicacion en la utilidad de las diferentes tecnicas en distintos contextos clinicos y anatomicos. La revision incluye los apartados: 1. Coronariografia. 2. Angioplastia con balon. 3. Stent coronario. 4. Otras tecnicas intervencionistas: aterectomia direccional, aterectomia rotacional, cateter de extraccion transluminal, balon de corte, laser intracoronario y transmiocardico e irradiacion intracoronaria. 5. Inhibidores de los receptores de la GP IIb/IIIa. 6. Nuevas tecnicas diagnosticas: ecografia intracoronaria, angioscopia, Doppler coronario y guia de presion. El grado de consenso de las fuentes consultadas y de los expertos son expresados utilizando la clasificacion en clases I, IIa, IIb y III, utilizada en las guias del American College of Cardiology/American Heart Association.

Early dysfunction and long-term improvement in endothelium-dependent vasodilation in the infarct-related artery after thrombolysis☆

OBJECTIVES This study assessed the degree of endothelial dysfunction in post-acute myocardial infarction (AMI) and its subsequent status in the infarct-related artery (IRA) in patients treated with thrombolysis. BACKGROUND Coronary flow reserve alterations in the IRA after thrombolysis have been described, but the endothelium-dependent vasomotion has not been investigated, to date. METHODS Endothelial function in patients after thrombolysis was assessed by infusion of acetylcholine (ACh) at increasing doses in the IRA. Diameter changes in the distal segments were evaluated using quantitative coronary angiography. Patients with coronary atherosclerosis constituted the control group. Clinical variables, electrocardiography and biochemical markers were used to determine the timing of reperfusion and the extent of the infarct. Patients in the AMI group were re-evaluated one year later. RESULTS In the initial assessment, 16 patients showed a vasoconstriction response to ACh in the IRA compared to the control group (-20 +/- 21% vs. 4 +/- 4%; p < 0.01). Significant correlations between the degree of vasoconstriction and maximum value of the creatine kinase-MB fraction and number of new Q waves were observed. Of the 12 patients re-evaluated, 4 had complete occlusion of the IRA. In the remaining eight patients with patent artery, an improvement in response to ACh was observed relative to the initial study (+3 +/- 11%, vs. -19 +/- 15%, p < 0.05). CONCLUSIONS In patients with AMI treated with thrombolysis, severe endothelial dysfunction in the IRA is observed early. In patients who retain patency of the IRA, the endothelial dysfunction improves during the follow-up and suggests a component of stunned endothelium in the first few days post-AMI.

Stent liberador de fármacos en lesiones de tronco coronario izquierdo en pacientes no candidatos a revascularización quirúrgica

Introduccion y objetivos. La cirugia es el tratamiento de eleccion de la estenosis del tronco. Los stents convencionales no son una alternativa debido a la reestenosis e incidencia de muerte subita. Los stents liberadores de farmacos, al disminuir la reestenosis, pueden ser una terapia valida. El objetivo del estudio es describir los resultados del stent con liberacion de farmacos en pacientes con lesion en tronco no candidatos a tratamiento quirurgico. Pacientes y metodo. Se analizo la evolucion de una serie de pacientes consecutivos no candidatos a cirugia a los que se implanto un stent liberador de farmacos entre mayo de 2002 y abril de 2004 por lesion en el tronco. Se analizaron los resultados intrahospitalarios y a largo plazo. Se realizo un seguimiento angiografico y con ultrasonidos intracoronarios. Resultados. Se estudio a 42 pacientes, con una edad de 70,1 ± 10,5 anos, 25 (59,5%) varones, y 14 (33%) diabeticos; 7 (16,7%) tenian tronco protegido. El motivo de imposibilidad de cirugia fue por malos vasos en 19 (45,2%) casos, cirugia previa en 9 (21,4%), edad en 6 (14,3%), angioplastia primaria en 5 (11,4%) y otras causas en 3 (7,2%) pacientes. Cuatro (9,5%) pacientes fallecieron antes del alta; a 3 de ellos se les practico una angioplastia primaria, y no hubo necesidad de nueva revascularizacion. La mediana de seguimiento fue de 288 dias (media, 315 ± 241). Otros 4 (9,5%) fallecieron despues del alta, en los dias 5, 24, 34 y 115. Se repitio la angioplastia en un caso y en otro se practico un trasplante. Conclusiones. Los stents liberadores de farmacos representan una alternativa para los pacientes con lesiones en el tronco que no son candidatos a cirugia. Se deberian hacer estudios aleatorizados con seguimiento a largo plazo para valorar su validez en pacientes elegibles para cirugia.

Comparative Tolerability of Contrast Media Used for Coronary Interventions

Radiographic contrast media (CM) are necessary to provide x-ray absorption of the bloodstream; all other observed effects need to be regarded as adverse. Four types of CM are currently used in diagnostic and interventional cardiology: ionic high-osmolar CM (HOCM), either ionic or non-ionic low-osmolar CM (LOCM), and non-ionic iso-osmolar CM (IOCM). Focusing on the potential cardiovascular effects caused by the CM, there is a clear difference between HOCM and the LOCM or IOCM. HOCM have a poorer profile due to a higher incidence of hypotension and electrophysiological effects. To prevent contrast-induced nephropathy, HOCM should be avoided and patients should receive the minimal dose of LOCM or IOCM with intravenous hydration before and after the procedure. Clinical hyperthyroidism has been detected after CM use, but the condition appears, ultimately, to be self-limited and to occur mainly in elderly patients. When assessing the need for a CM in terms of improved patient safety, preventing serious complications should be the major factor determining the choice. CM should not be selected on the basis of minor adverse effects since these are, ultimately, of low clinical relevance. Thrombotic events, in contrast, carry a high clinical relevance and we consider that these should be the main issue governing current choice. Ionic LOCM appear to have better profile than other CM with respect to interaction with platelet function and coagulation. In relation to thrombotic events in randomised clinical studies, ionic CM have been associated, mainly, with favourable and some neutral results compared with non-ionic agents. Only one trial indicated a more pronounced antithrombotic effect of the non-ionic IOCM relative to the ionic LOCM. The antithrombotic advantages of ionic over non-ionic LOCM are, in part, balanced by a greater frequency of minor adverse effects such as nausea, vomiting or cutaneous rashes. A matter of concern is the delayed adverse effects observed with non-ionic IOCM. However, severe and life-threatening reactions are exceptional and there are probably no significant differences between IOCM and LOCM whether ionic or non-ionic. However, in patients with known allergies, non-ionic CM are to be recommended. On the basis of the available pre-clinical and clinical data, the ionic LOCM or the non-ionic IOCM are the agents to be recommended in percutaneous coronary interventions because of their antithrombotic advantages over non-ionic LOCM.

Drug-Eluting Stents in Patients With Left Main Coronary Lesions Who Are Not Candidates for Surgical Revascularization

INTRODUCTION AND OBJECTIVES Surgical revascularization is the treatment of choice in patients with left main coronary artery stenosis. Conventional stents are not a valid alternative because of the rate of restenosis and sudden cardiac death. Drug-eluting stents, which reduce the rate of restenosis, may represent an alternative to cardiac surgery. The objective of this study was to describe the results with drug-eluting stents in patients with left main coronary artery stenosis who were poor candidates for surgical revascularization. PATIENTS AND METHOD We prospectively followed a consecutive series of patients who were poor candidates for surgical revascularization and were treated with implantation of a drug-eluting stent in the left main coronary artery between May 2002 and April 2004. In-hospital and long-term results were analyzed. Follow-up included angiographic and intravascular ultrasound (IVUS) studies. RESULTS Forty-two patients (25 men, 59.5%) with a mean age of 70.1 (10.5) years were studied. Fourteen (33%) had diabetes, and 7 (16.7%) had a protected left main coronary artery. The reasons for ruling out surgery were poor distal vessels in 19 (45.2%), previous surgery in 9 (21.4%), age in 6 (14.3%), primary angioplasty in 5 (11.4%), and other reasons in 3 (7.2%). Four patients (9.5%) died before discharge, three of them after primary angioplasty. No in-hospital revascularization procedures were needed. Median follow-up time was 288 days; mean follow-up time was 315 (241) days. Another four patients died after discharge (9.5%) on days 5, 24, 34 and 115. Angioplasty was repeated in one patient, and another was referred for heart transplantation. CONCLUSIONS Drug-eluting stents represent a valid alternative in patients with left main coronary artery stenosis who are poor candidates for surgical revascularization. Randomized studies with a longer follow-up should be performed to evaluate their benefits in patients eligible for surgery.

Heart transplant recipient clinical profile improvement following mycophenolate mofetil late incorporation into the treatment schedule

Abstract:  Mycophenolate mofetil (MMF) has a better clinical profile than azathioprine in heart transplantation (HT). Forty‐five recipients (aged 53 ± 9 yr) were retrospectively evaluated (first year of follow‐up) post‐MMF introduction since its advent in 1997 (mean daily dose: 1.97 ± 0.2 g). MMF was used (mean post‐HT time: 40 ± 27 months) for: (i) renal insufficiency attenuation (group 1 = 20); (ii) steroid reduction because of osteoporosis (group 2 = 12); (iii) treatment of persistent cellular rejection (group 3 = 7) and vascular graft disease (VGD) (group 4 = 6). Mean changes (groups 1–2) were: creatinine 172 ± 59, 158 ± 51, 153 ± 57 μmol/L (at baseline, 6 and 12 months, respectively; p < 0.001). Cyclosporine daily dose: 219 ± 37, 166 ± 46, 176 ± 98 mg, respectively (p < 0.001). Cyclosporine blood concentration: 151 ± 40, 103 ± 41, 83 ± 34 ng/mL, respectively (p < 0.004). Prednisone daily dose: 8.3 ± 2, 5.2 ± 1, 4.1 ± 1 mg, respectively (p < 0.001). Cellular rejection (group 3) was successfully treated (86%) but the outcome of VGD did not improve after the switch (group 4). Our limited experience (with caution) confirms the reported benefits of MMF particularly attenuating renal insufficiency.

Minor Myocardial Damage During Percutaneous Coronary Intervention Does Not Affect Long-Term Prognosis

INTRODUCTION AND OBJECTIVES To determine whether long-term prognosis is affected by myocardial damage taking place during percutaneous coronary intervention (PCI). METHODS The study included consecutive patients undergoing PCI. Those with elevated baseline cardiac marker levels were excluded. Cardiac markers were evaluated and an ECG was recorded before and 12 and 24 hours after PCI. Patients were divided into three groups after PCI according to their cardiac marker levels: no myocardial damage (i.e. normal troponin and creatine kinase MB fraction [CK-MB]), minor damage (elevated troponin with normal CK-MB), and myonecrosis (elevated troponin and CK-MB). The occurrence of death, myocardial infarction or repeat revascularization during follow-up was recorded. RESULTS Minor myocardial damage associated with PCI was observed in 127 (16.8%) of the 757 patients included in the study and myonecrosis, in 46 (6.1%). During a follow-up of 45+/-14 months, cardiac events occurred in 151 (19.1%) patients. Mortality during follow-up was significantly higher in patients with myonecrosis (13%) than in the other two groups (4.8% and 3.9%; log rank, 6.83; P=.032). No difference was observed in the rate of myocardial infarction or repeat revascularization during follow-up. CONCLUSIONS Minor myocardial damage during PCI had no effect on long-term prognosis. In contrast, myonecrosis was associated with increased mortality. Consequently, the CK-MB level should be measured after all PCIs because of its prognostic implications, and strategies for reducing the risk of myonecrosis developing should be implemented.

El daño miocárdico mínimo durante el intervencionismo coronario percutáneo no influye en el pronóstico a largo plazo

Introduccion y objetivos Evaluar el pronostico a largo plazo del dano miocardico producido durante el intervencionismo coronario percutaneo (ICP). Metodos Incluimos una serie de pacientes consecutivos a quienes se practico ICP, excluyendo a los que ya presentaban basalmente elevacion de marcadores cardiacos. El ECG y los marcadores de dano miocardico se evaluaron antes y a las 12 y 24 h tras el procedimiento. Segun el valor de dichos marcadores, se clasifico a los pacientes en tres grupos: ausencia de dano miocardico (troponina y CK-MB normal), dano miocardico minimo (elevacion del valor de troponina, con CK-MB normal) y mionecrosis (elevacion de troponina I y CK-MB). Muerte, infarto de miocardio y nueva revascularizacion fueron evaluados durante el seguimiento. Resultados De 757 pacientes incluidos, en 127 (16,8%) se detecto dano miocardico minimo asociado al procedimiento y en 46 (6,1%) mionecrosis. Durante un seguimiento de 45 ± 14 meses, 151 (19,1%) pacientes sufrieron eventos cardiacos. Los pacientes que presentaron mionecrosis tuvieron un significativo incremento de la mortalidad durante el seguimiento (13%) respecto a los otros dos grupos (el 4,8 y el 3,9%; log rank test, 6,83; p = 0,032). No se detectaron diferencias en la tasa de IAM o nueva revascularizacion en el seguimiento. Conclusiones El dano miocardico minimo durante el intervencionismo no influye en el pronostico a largo plazo. Por contra, la mionecrosis se asocia a un incremento de mortalidad. Este hecho implica la necesidad de determinar la CK-MB tras todo ICP debido a su implicacion pronostica y la aplicacion de estrategias que disminuyan la aparicion de mionecrosis.

Obstruction of aortocoronary bypass due to blunt chest trauma

We report the first case in the literature of acute myocardial infarction due to blunt chest trauma in a patient with saphenous vein aortocoronary bypass to the anterior descending coronary artery. Angiograms demonstrated two stumps - aortic and coronary - suggesting that the primary obstruction was at the graft level with subsequent anterior descending occlusion. A large left ventricular aneurysm developed. As his clinical situation was stable, early aneurysmectomy was not done, and the patient is asymptomatic 15 months after the trauma.