Giovanni Falsini

Elevations in troponin I after percutaneous coronary interventions are associated with abnormal tissue-level perfusion in high-risk patients with non-ST-segment-elevation acute coronary syndromes.

Background—In the setting of non–ST-segment–elevation (NSTE) acute coronary syndromes (ACS), the pathophysiological mechanisms underlying post–percutaneous coronary intervention (PCI) cardiac troponin I (cTnI) elevation remain unclear. Methods and Results—We evaluated the relationship between troponin elevation and tissue-level perfusion using the TIMI flow grade, corrected TIMI frame count, TIMI myocardial perfusion grade (TMPG), and myocardial contrast enhancement by intracoronary myocardial contrast echocardiography (MCE) before and immediately after PCI performed within 24 to 48 hours of hospital admission in 42 high-risk (angina at rest, unequivocal ST-segment depression, and cTnI elevation) patients with NSTE-ACS. All patients were treated with glycoprotein IIb/IIIa inhibitors (27 with tirofiban and 15 with abciximab) and had successful PCI. Fourteen patients had a postprocedural cTnI elevation, whereas 28 did not. TMPG 0/1 after PCI was observed more frequently in patients with postprocedural cTnI elevation (43% versus 7%; P<0.02). cTnI levels were higher among patients with TMPG 0/1 versus patients with TMPG 2/3 (5.3±2.7 versus 1.5±1.3 ng/mL; P<0.0001). Patients with postprocedural cTnI elevation also presented a significantly lower number of perfused segments at MCE (59% versus 81%; P=0.02) as well as a lower MCE score index (0.65±0.38 versus 0.89±0.21; P<0.02). Conclusions—Postprocedural cTnI elevation in high-risk patients with NSTE-ACS is associated with an abnormal tissue-level perfusion.

Early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome: comparison with younger patients regarding 30 day and long term outcome

Objectives: To evaluate an early invasive strategy in elderly patients with non-ST elevation acute coronary syndrome (ACS). Methods: All consecutive patients admitted with a diagnosis of non-ST elevation ACS from June 2002 to February 2004 were enrolled in this registry. Clinical outcome was assessed at 30 days and in long term follow up. Results: An early invasive strategy was followed for 439 patients, of whom 159 (36%) were elderly and had a higher clinical risk profile and greater extent of coronary artery disease (CAD) than the younger patients. Coronary revascularisation was conducted in 133 (83%) elderly patients and 239 (85%) younger patients (not significant). At a mean (SD) follow up time of 10.7 (5.2) months overall mortality, cardiac death, and death plus myocardial infarction were significantly higher among elderly patients than among younger patients (9.4% v 2.1%, p < 0.001; 6.8% v 1.8%, p < 0.01; 11.3% v 5%, p  =  0.02, respectively). The significant difference in cardiac death between the two groups was related more to elderly patients being treated by coronary artery bypass grafting (19.3% v 4.9%, p  =  0.05) than by percutaneous coronary intervention (PCI) (2.9% v 1.1%, p  =  0.3). Cox regression analysis showed age, serum creatinine >115 μmol/l, no previous history of CAD, left ventricular ejection fraction > 45%, and the absence of diabetes to be independent predictors of the occurrence of major adverse cardiac events. Conclusions: In unselected elderly patients presenting with non-ST elevation ACS an early invasive strategy is feasible and leads to coronary revascularisation in the majority of cases, resulting in encouraging immediate and long term clinical results, particularly among PCI treated patients.

Late acute thrombosis after implantation of sirolimus-eluting stent to treat in-stent restenosis.

Drug‐eluting stents (DES) have significantly reduced the incidence of in‐stent restenosis (ISR) compared to bare metal stents (BMS). However, recent randomized trials comparing DES with BMS reported few cases of late DES thrombosis. We report the case of late sirolimus‐eluting stent thrombosis occurring 22 months after its elective implantation in a restenotic BMS and soon after the interruption of combined anti‐platelet therapy with aspirin and Clopidogrel.

Transfer for primary angioplasty in elderly patients with acute myocardial infarction

Introduction: The aim of this study was the evaluation of an immediate transfer for primary angioplasty (PPCI) in elderly (age ≥ 75 years) patients with ST elevation acute myocardial infarction (STEMI). Methods and materials: All elderly patients with STEMI admitted for PPCI from June 2002 to October 2005, were enrolled. Major Adverse Cardiac Events (MACE) were collected at 6 months. Results: 133 patients (group 1) were admitted directly and 154 patients (group 2) were transferred from peripheral hospitals. Ischemia time was 248±146min in group 1 and 276±169min in group two (P<0.001); door-to-balloon time was 60±30 min in group 1 and 90±45 min in group two (P<0.0001). At 6 months cardiac death occurred in 15 (11%) and 16 (10%) patients in group 1 and 2 respectively (P=NS), MI in 3(2%) and 2(1%) respectively (P=NS), clinically driven target lesion revascularization in 6(4%) and 5(3%) respectively, for an overall event-free survival rate of 82% in group 1 and 83% in group 2 (P=NS). Logistic regression analysis showed age (OR: 1.04.1; 95% CI: 1.0–1.2; P=0.049) Killip class ≥2 (OR: 4.6; 95% CI: 1.3–16.4; P=0.01) to be the only independent predictors of 6-month cardiac mortality. Conclusion: Systematic transfer of elderly STEMI patients for PPCI, with a door-to-balloon time <1 h, leads to clinical results similar to those achievable in patients who present directly in hospital with cath.-lab. facilities.

Shifting from pharmacological to systematic mechanical reperfusion therapy for acute myocardial infarction via a cooperating network: impact on reperfusion rate and in-hospital mortality.

Background Primary percutaneous transluminal coronary angioplasty is the preferred reperfusion strategy for acute ST-elevation myocardial infarction in selected settings. Limited data are available about the clinical impact of the implementation of a systematic primary angioplasty infarct reperfusion program in the real world. Methods and Results We organized a comprehensive district network allowing the coordinated and timely transfer of patients with acute ST-elevation myocardial infarction to the hub hospital with catheterization facilities in order to expand the use of mechanical reperfusion. Implementation of the network resulted in increased numbers of patients receiving reperfusion therapies (from 57.5% to 74.1%; P < 0.001). In addition, the proportion of elderly individuals (those aged ≥ 75 years) who received a reperfusion therapy significantly increased (from 25.7% to 66.3%; P < 0.001). Accordingly, the proportion of patients not receiving reperfusion therapy dropped from 42.5% to 25.9%. Primary percutaneous transluminal coronary angioplasty usage increased from 24.5% to 73.1% (P < 0.001). As a consequence, in-hospital mortality decreased from 13.5% before establishment of the network to 6.0% (P = 0.016), and major adverse cardiac events decreased from 17.5% to 7.8% (P = 0.005). Conclusions Implementation of a systematic primary angioplasty infarct reperfusion program improves reperfusion rate and reduces in-hospital mortality and total major adverse cardiovascular events.