Isabel Calvo

Routine invasive strategy within 24 hours of thrombolysis versus ischaemia-guided conservative approach for acute myocardial infarction with ST-segment elevation (GRACIA-1): a randomised controlled trial

BACKGROUND In patients with ST-segment elevated myocardial infarction (STEMI), early post-thrombolysis routine angioplasty has been discouraged because of its association with high incidence of events. The GRACIA-1 trial was designed to reassess the benefits of an early post-thrombolysis interventional approach in the era of stents and new antiplatelet agents. METHODS 500 patients with thrombolysed STEMI (with recombinant tissue plasminogen activator) were randomly assigned to angiography and intervention if indicated within 24 h of thrombolysis, or to an ischaemia-guided conservative approach. The primary endpoint was the combined rate of death, reinfarction, or revascularisation at 12 months. Analysis was by intention to treat. FINDINGS Invasive treatment included stenting of the culprit artery in 80% (199 of 248) patients, bypass surgery in six (2%), non-culprit artery stenting in three, and no intervention in 40 (16%). Predischarge revascularisation was needed in 51 of 252 patients in the conservative group. By comparison with patients receiving conservative treatment, by 1 year, patients in the invasive group had lower frequency of primary endpoint (23 [9%] vs 51 [21%], risk ratio 0.44 [95% CI 0.28-0.70], p=0.0008), and they tended to have reduced rate of death or reinfarction (7% vs 12%, 0.59 [0.33-1.05], p=0.07). Index time in hospital was shorter in the invasive group, with no differences in major bleeding or vascular complications. At 30 days both groups had a similar incidence of cardiac events. In-hospital incidence of revascularisation induced by spontaneous recurrence of ischaemia was higher in patients in the conservative group than in those in the invasive group. INTERPRETATION In patients with STEMI, early post-thrombolysis catheterisation and appropriate intervention is safe and might be preferable to a conservative strategy since it reduces the need for unplanned in-hospital revascularisation, and improves 1-year clinical outcome.

¿Mejora el uso de abciximab intracoronario el resultado del intervencionismo percutáneo? Estudio prospectivo y aleatorizado

Introduccion y objetivos La utilidad del abciximab en el intervencionismo coronario percutaneo se ha demostrado plenamente. Sin embargo, se desconoce si la administracion intracoronaria del bolo inicial puede aportar ventajas. Igualmente, podria haber dudas acerca de su seguridad. Metodos Estudio en un solo centro, prospectivo y aleatorizado, en el que se incluyo a todos los pacientes en los que se realizo un intervencionismo coronario percutaneo con abciximab. Se aleatorizo a los pacientes para recibir un bolo de abciximab (ABX) intracoronario o intravenoso. Se analizaron la incidencia de MACE (muerte, reinfarto y necesidad de revascularizacion) como variable principal y las complicaciones hemorragicas y las concentraciones de troponina I como variables secundarias. Resultados Se incluyo a 137 pacientes (72 con ABX intracoronario y 65 con ABX intravenoso). Las caracteristicas clinicas y los hallazgos angiograficos fueron similares en ambos grupos. Todos recibieron stents . No hubo diferencias en el tipo de stent utilizado (recubierto activo del 47,2 frente al 50,8%), la longitud total del stent y el flujo TIMI final (3 frente a 2,97). Los resultados del intervencionismo coronario percutaneo fueron similares: se realizo con exito en el 98,5% de los pacientes del grupo ABX intracoronario y en el 99% del grupo ABX intravenoso. No se detectaron complicaciones derivadas de la via de administracion. En el grupo ABX intravenoso se observo una elevacion significativa posprocedimiento de la troponina I. En el seguimiento clinico al ano no se hallaron diferencias significativas en la incidencia de MACE (el 8,5% en el grupo ABX intracoronario frente al 6,2% en el grupo ABX intravenoso). Conclusiones La administracion intracoronaria del bolo de abciximab no parece menos segura que la intravenosa y es, al menos, igualmente eficaz. Se observo un menor grado de dano miocardico posprocedimiento en el grupo ABX intracoronario.

Does Intracoronary Abciximab Improve the Outcome of Percutaneous Coronary Interventions? A Randomized Controlled Trial

INTRODUCTION AND OBJECTIVES It has been clearly demonstrated that abciximab is useful in percutaneous coronary interventions. However, it is not known if intracoronary administration of the initial abciximab bolus improves outcome. Moreover, there may be safety concerns. METHODS The study was a single-center prospective randomized trial that included all patients undergoing coronary angioplasty involving the use of abciximab. Patients were randomized to either intracoronary or intravenous administration of the abciximab bolus. The primary endpoint was the incidence of major adverse cardiac events (i.e., death, myocardial infarction, or the need for revascularization); secondary endpoints were hemorrhagic complications and the troponin-I level. RESULTS The study included 137 patients; 72 received an intracoronary abciximab bolus and 65, an intravenous bolus. Clinical characteristics and baseline angiographic findings were similar in the two groups. All patients underwent coronary stent implantation. No difference was observed between the intracoronary bolus group and the intravenous bolus group in type of stent used (drug eluting stent 47.2% vs 50.8%, respectively), total stent length, or final TIMI flow grade (3 vs 2.97, respectively). The intervention success rates were also similar (98.5% vs. 99%, respectively). No complication associated with the administration route was reported. However, the level of the myocardial injury marker troponin I increased significantly in the intravenous bolus group. Clinical follow-up at 1 year did not reveal any difference in the incidence of major adverse cardiac events: 8.5% in the intracoronary bolus group versus 6.2% in the intravenous bolus group. CONCLUSIONS Intracoronary administration of an abciximab bolus did not appear to be less safe or effective than intravenous administration. Less post-procedural myocardial damage was observed in the intracoronary bolus group.

Implications of the ''Watermelon Seeding'' Phenomenon During Coronary Interventions for In-Stent Restenosis

The occurrence of balloon slippage (“watermelon seeding”; WMS) during treatment of patients with in‐stent restenosis (ISR) has been described, but predisposing factors and the potential implications of this phenomenon remain unknown. In the Restenosis Intrastent: Balloon Angioplasty vs. Elective Stenting (RIBS) randomized study, 450 patients with ISR were included. Of these, 42 patients (9%) presented WMS during the procedure. WMS was detected in 26 patients (12%) in the balloon arm and 16 (7%) in the stent arm (P = 0.11). In the stent arm, WMS was only noticed during balloon predilation, never during stent implantation. As compared with 408 patients without WMS, patients with WMS had more severe (TIMI flow 1; 21% vs. 8%; P = 0.01) and diffuse (length > 15 mm: 45% vs. 28%; P = 0.02) ISR lesions. Patients with WMS required more balloon inflations, longer total inflation time, had more frequent crossover to stenting or ended the procedure with residual dissections, and eventually obtained poorer acute results (minimal lumen diameter, 2.35 ± 0.5 vs. 2.53 ± 0.5 mm; P = 0.03). In addition, at 6‐month follow‐up, patients with WMS had a smaller minimal lumen diameter (1.26 ± 0.7 vs. 1.61 ± 0.7 mm; P = 0.007) and a higher restenosis rate (56% vs. 37%; P = 0.017). On logistic regression analysis, the WMS phenomenon emerged as an independent predictor of recurrent restenosis (adjusted RR = 2.1; 95% CI = 1.1–4.1; P = 0.04). The WMS phenomenon may complicate treatment of patients with ISR. Long and severe lesions appear to predispose to this technical problem that never occurs during stent deployment. In patients with ISR, WMS is associated with cumbersome procedures and poorer acute and long‐term angiographic results.

Uso amplio de stenting coronario directo. Estudio DISCO 2

Introduction and objectives. Direct coronary stenting yields immediate long-term clinical results similar to those obtained with balloon predilation, with the advantage of lower costs and procedural times. Until now, direct stenting has been attempted only for selected lesions, so that the potential scope of its use in everyday practice remains unknown. The DISCO 2 trial was designed to identify the number and type of lesions that could be safely treated by direct stenting. Patients and method. 1,269 lesions (886 patients) were treated consecutively in 7 different hospitals. Direct stenting was attempted in all cases, except for total chronic occlusions, severe tortuosity or calcification of the vessel, lesions in the sinus ostium, or bifurcated lesions and vessel diameter 65 years and type B2 or C lesion. After 6 months of follow-up the total incidence of major adverse cardiovascular events in patients treated with direct stenting was 6.2%, with a target lesion revascularization rate of 4.45%. Conclusions. In a mostly nonselected sample of coronary lesions, direct stenting was as safe as stenting with predilation. More than half of all elective stenting procedures can be attempted safely without balloon predilation. Greater need for predilation was associated with tortuosity, nonproximal right coronary artery location, older

The Importance of Investigating the Internal Thoracic Artery Before Coronary Artery Surgery in Leriche's Syndrome

Frequently, both peripheral and coronary artery disease are present in the same patient. In patients with abdominal aortic occlusion (i.e., Leriches syndrome) or femoroiliac occlusion, collateral circulation to the lower extremities can originate in branches of the abdominal aorta or even in the internal thoracic artery (depending on the level of the occlusion). It is important to identify the origin of this circulation during diagnostic procedures, especially in patients who may need to undergo coronary revascularization surgery since, in cases where the majority of the collateral circulation originates in the internal thoracic artery, using the artery as a coronary graft could lead to acute ischemia of the lower extremities. We present three patients with Leriches syndrome in whom the internal thoracic artery was the origin of the collateral circulation to the ipsilateral femoral artery.

Importancia del sondaje de la arteria mamaria antes de cirugía coronaria en el síndrome de Leriche

La enfermedad arterial periferica y la enfermedad coronaria frecuentemente coexisten en un mismo paciente. En los pacientes con oclusion de la aorta abdominal (syndrome de Leriche) o del eje femoroiliaco, la circulacion colateral a extremidades inferiores puede originarse en ramas de la aorta abdominal o incluso en la arteria mamaria interna (en funcion del grado de la oclusion). Es importante filiar, durante el procedimiento diagnostico, el origen de esta circulacion, especialmente en los pacientes que pueden necesitar revascularizacion coronaria quirurgica, ya que en los casos con circulacion colateral procedente en su mayoria de la arteria mamaria interna, su uso como injerto coronario puede ocasionar isquemia aguda en las extremidades inferiores. Presentamos los casos de 3 pacientes con sindrome de Leriche y circulacion colateral desde las arterias mamarias a las femorales homolaterales.

Stent coronario Wiktor por indicación electiva con régimen de antiagregación. Estudio WINE

Introduccion y objetivos La trombosis subaguda y las complicaciones vasculares y hemorragicas secundarias a los intensos regimenes de anticoagulacion seguidos hasta ahora tras la implantacion del stent intracoronario son los principales problemas del uso de este dispositivo. Estudiamos la incidencia de complicaciones relacionadas con el implante de un stent de Wiktor de forma electiva, en pacientes tratados con antiagregantes plaquetarios exclusivamente, asi como la incidencia de reestenosis clinica y angiografica a los 6 meses. Pacientes y metodos El estudio WINE es un estudio prospectivo, observacional y multicentrico en el que se incluyeron 368 pacientes (380 lesiones) de 11 hospitales espanoles. Todos los pacientes fueron tratados con aspirina (125-325 mg/dia) y ticlopidina (250 mg/12 h durante cuatro semanas). Tras el periodo de hospitalizacion se realizo un control clinico al final del primer mes y un control clinico y angiografico a los 6 meses. Resultados Fueron excluidos 27 pacientes despues del procedimiento (por no lograrse el implante en 5, por resultado inadecuado en 15 o por indicarse regimen de anticoagulacion en 7). En los 341 pacientes con resultado adecuado, el 88% de los stents fueron implantados sobre lesiones de novo y el 12% sobre lesiones de reestenosis. El mayor porcentaje de lesiones eran tipo B del American College of Cardiology- American Heart Association, con un 39,1% de lesiones tipo B2 y un 8,5% tipo C. Se produjo oclusion subaguda de 2 stents (0,6%); 7 pacientes (2,1%) presentaron complicaciones vasculares secundarias a la puncion arterial y no existieron complicaciones hemorragicas mayores con necesidad de transfusion. La reestenosis angiografica a los 6 meses fue del 19,8%. Conclusiones Cuando el resultado angiografico de la implantacion electiva del stent Wiktor es optimo, la terapia con aspirina y ticlopidina exclusivamente se acompana de un indice muy bajo de oclusion trombotica, de complicaciones hemorragicas y vasculares y de reestenosis clinica y angiografica a los 6 meses.