Fen Wei Wang

Distal Myocardial Protection During Percutaneous Coronary Intervention With an Intracoronary β-Blocker

Background Experimental studies have demonstrated that intravenous &bgr;‐blocker administration before coronary artery occlusion significantly reduces myocardial injury. Clinical studies have shown that intracoronary (IC) propranolol administration before percutaneous coronary intervention (PCI) delays myocardial ischemia. The present study tested the hypothesis that IC propranolol treatment protects ischemic myocardium from myocardial damage and reduces the incidence of myocardial infarction (MI) and short‐term adverse outcomes after PCI. Methods and Results Patients undergoing PCI (n=150) were randomly assigned in a double‐blind fashion to receive IC propranolol (n=75) or placebo (n=75). Study drug was delivered before first balloon inflation via an intracoronary catheter with the tip distal to the coronary lesion. Biochemical markers were evaluated through the first 24 hours and clinical outcomes to 30 days. Evidence of MI with creatine kinase‐MB elevation after PCI was seen in 36% of placebo and 17% of propranolol patients (P=0.01). Troponin T elevation was seen in 33% of placebo and 13% of propranolol patients (P=0.005). At 30 days, the composite end point of death, postprocedural MI, non‐Q‐wave MI after PCI hospitalization, or urgent target‐lesion revascularization occurred in 40% of placebo versus 18% of propranolol patients (hazard ratio 2.14, 95% CI 1.24 to 3.71, P=0.004). Conclusions IC administration of propranolol protects the myocardium during PCI, significantly reducing the incidence of MI and improving short‐term clinical outcomes. (Circulation. 2003;107:2914‐2919.)

Outcomes After Carotid Artery Stenting and Endarterectomy in the Medicare Population

Background and Purpose— Carotid artery stenting (CAS) is an alternative to carotid endarterectomy (CEA) for stroke prevention. The value of this therapy relative to CEA remains uncertain. Methods— In 10 958 Medicare patients aged 66 years or older between 2004 and 2006, we analyzed in-hospital, 1-year stroke, myocardial infarction, and death rate outcomes and the effects of potential confounding variables. Results— CAS patients (87% were asymptomatic) had a higher baseline risk profile, including having a higher percentage of coronary and peripheral arterial disease, heart failure, and renal failure. In-hospital stroke rate (1.9% CAS versus 1.4% CEA; P=0.14) and mortality (CAS 0.9% versus 0.6% CEA; P=0.20) were similar. By 1 year, CAS patients had similar stroke rates (5.3% CAS versus 4.1% CEA; P=0.12) but higher all-cause mortality rates (9.9% CAS versus 6.1% CEA; P<0.001). Using Cox multivariable models, there was a similar stroke risk (hazard ratio, 1.28; 95% CI, 0.90–1.79) but CAS patients had a significantly higher mortality (HR, 1.32; 95% CI, 1.02–1.71). Sensitivity analyses suggested that unmeasured confounders could be responsible for the mortality difference. In multivariable analysis, stroke risk was highest in the patients symptomatic at the time of revascularization. Conclusions— CAS patients had a similar stroke risk but an increased mortality rate at 1 year compared with CEA patients, possibly related to the higher baseline risk profile in the CAS patient group.

Prolonged High-Pressure is Required for Optimal Stent Deployment as Assessed by Optical Coherence Tomography

Optimizing stent deployment is important for both acute‐ and long‐term outcomes. High‐pressure balloon inflation is the standard for coronary stent implantation. However, there is no standardized inflation protocol. We hypothesized that prolonged high‐pressure balloon inflation until stabilization of inflation pressure is superior to a rapid inflation/deflation sequence for both stent expansion and strut apposition.

Impact of left atrial volume in prediction of outcome after cardiac resynchronization therapy

UNLABELLED Left atrial volume index (LAVI) as a predictor of mortality has not been well investigated in patients with cardiac resynchronization therapy (CRT). The purpose of this study is to evaluate the impact of LAVI in predicting mortality in CRT patients. METHODS We studied 100 consecutive patients who received CRT (male 73, age 69.9 ± 9.6 years). The follow-up duration of all echocardiographic measurements was 14.4 ± 10.5 months after CRT. LAVI was measured from apical views on two-dimensional echocardiography by bi-plane rule. A decrease of left ventricular end systolic volume ≥ 15% after CRT was defined as a positive response to CRT. RESULTS The mean LAVI at baseline was 59.9 ± 22.7 ml/m(2). LAVI in patients who died (78.2 ± 27.5 ml/m(2)) was significantly greater than those who survived (55.9 ± 19.5 ml/m(2), p<0.0001) during follow-up of 17 ± 10.6 months. The area under ROC curve (AUC) for LAVI predicting death was 0.77 (p=0.0001). The cutoff point for LAVI predicting death was LAVI>59.4 ml/m(2). LAVI>59.4 ml/m(2) was related to mortality by Cox proportional univariate regression [hazard ratio (HR)=5.15, 95% CI=1.48-17.93, p=0.01]. After adjustment for the variables with significant difference by univariate regression, LAVI>59.4 ml/m(2) was continuously related to mortality by multivariate regression (HR=4.56, 95% CI, 1.30-15.97, p=0.02). LAVI>59.4 ml/m(2) was associated with a near 5-fold increase in mortality during follow-up of 17 ± 10.6 months. CONCLUSION Patients who have LAVI>59.4 ml/m(2) continue to have increased mortality despite CRT.

Implementation and application of a continuous quality improvement (CQI) program for the cardiac catheterization laboratory: One institution's 10‐year experience

There is consensus that a continuous quality improvement (CQI) program is essential in optimizing patient outcomes in the cardiovascular catheterization laboratory. A CQI method was described in guidelines produced by the Society for Cardiovascular Angiography and Interventions (SCAI) in 1993 and 1997. However, little information is available in the medical literature to determine the implementation and application of this approach in a modern catheterization program. This presentation describes the lessons learned from one institutions 10 year CQI experience by using the SCAI blueprint.

Distal myocardial protection with intracoronary beta blocker when added to a Gp IIb/IIIa platelet receptor blocker during percutaneous coronary intervention improves clinical outcome†

Objective: The present study tested the hypothesis that intracoronary (IC) propranolol improves clinical outcomes with percutaneous coronary intervention (PCI) when used with background Gp IIb/IIIa receptor blockade. Background: We have previously shown that administration of a relatively large weight‐based IC dose of the beta blocker propranolol before PCI decreases the incidence of post‐PCI myocardial infarction (MI) and improves short‐ and long‐term outcome. It has previously been shown that administration of a Gp IIb/IIIa receptor blocker decreases post‐PCI MI and improves short‐ and long‐term clinical outcome. Methods: Patients undergoing PCI (n = 400) were randomized in a prospective double‐blind fashion to IC propranolol (n = 200) or placebo (n = 200) with eptifibatide administered to all the patients. Myocardial isoform of creatine kinase was measured during the first 24 hr and clinical outcomes at 30 days and 1 year. Results: MI after PCI was seen in 21.5% of placebo and 12.5% of propranolol patients (relative risk reduction 0.42; 95%CI 0.09, 0.63; P = 0.016). At 30 days, the composite end point of death, post‐procedural MI, urgent target lesion revascularization, or MI after index hospitalization occurred in 22.5% of placebo vs. 13.5% of propranolol patients (risk reduction 0.43; 95%CI 0.08, 0.65; P = 0.018). Similar results were observed at 1 year with adverse outcomes in 21.5% of propranolol and 32.5% of placebo patients (P = 0.01). Conclusion: IC propranolol administration with the background Gp IIb/IIIa receptor blockade significantly reduces the incidence of post‐PCI MI and improves the short‐ and long‐term clinical outcome when compared with a Gp IIb/IIIa blocker alone.

Survival advantage in Medicare patients receiving drug-eluting stents compared with bare metal stents: real or artefactual?

Concerns have been raised regarding late mortality, particularly from late stent thrombosis, from drug‐eluting stents (DES). Randomized clinical trials have shown that DES decrease restenosis but do not decrease mortality compared with bare metal stents (BMS). These studies utilized well‐defined clinical and angiographic subsets. In the “real world” drug‐eluting stents are used in a much broader crosssection of patients. We evaluated mortality in the first year after implantation of DES, specifically the sirolimus‐eluting stent (SES), Cypher vs. BMS in “real world” older patients using the Medicare claims database.

EFFICACY OF A STANDARDIZED PROLONGED HIGH–PRESSURE STENT DEPLOYMENT PROTOCOL COMPARED WITH A HIGH–PRESSURE RAPID INFLATION/DEFLATION SEQUENCE AS EVALUATED BY OPTICAL COHERENCE TOMOGRAPHY

Previous studies have demonstrated that high–pressure stent deployment reduces the incidence of stent thrombosis (ST) and probably decreases in–stent restenosis. However, there is no consensus as to the protocol for high–pressure inflation. In patients undergoing routine PCI and in an attempt

Distal myocardial protection with intracoronary propranolol during percutaneous coronary intervention is widely applicable

Background: Myocardial necrosis (Ml) after percutaneous coronary intervention (PCI) IS associated with an increased incidence of late adverse outcomes. Methods: We conducted a prospective randomized. placebo-controlled trial in 150 PCI patients to determine whether intracoronary (IC) propranolol ( 0.015mglkg) decreases post PCI MI and in which subgroups this effect occurs. Results: Post -PCI Ml &K-MB > upper limit of normal) developed in 17% of IC propranolol pts (13/75) and 36% of placebo pts ( 27175) (p=O.Ol). The figure shows that this effect is widely applicable including the subgroup receiving prophylactic GP llbillla inhibitors (28% of pts) and chronic oral pre-PCI betablockers (64%). Factors associated with decreased risk of MI were IC propranolol (OR: 0.40, Cl: 0.17-0.91, p= 0.03) and prophylactic GP Ilb/llla use (OR: 0.41, Cl: 0.14-I .08, p= 0.08). IC propranolol decreased MIS in GP llblllla pts ( O%vs. 41%) and pts on chronic beta blockers ( 16% vs. 35%).Factors associated with increased Ml were age > 60 years old and mechanical complications during PCI. IC propranolol decreased MI risk in older pts (19% vs. 46%) and in patients with mechanical complications (41% vs. 61%). Conclusion: These data are consistent with IC propranolol being a broadly effective cardioprotective agent during PCI. *ak*n --