Jian Sheng Zhang

Clinical benefits of adjunctive tirofiban therapy in patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

BackgroundThere is continued debate as to whether a combined reperfusion regimen with platelet glycoprotein IIb/IIIa inhibitor – tirofiban provides additional benefit in optimal myocardial reperfusion for patients with acute ST-segment elevation myocardial infarction (STEMI). This study was conducted to investigate the clinical benefits of adjunctive tirofiban therapy combined with primary percutaneous coronary intervention (PCI) in patients with STEMI. MethodsOne hundred and seventy-two consecutive patients with STEMI presented within 12 h of symptoms were randomly allocated to primary PCI combined with early (upstream group, n=57) or late administration of tirofiban (downstream group, n=57) or primary PCI treatment alone (control group, n=58). Clinical characteristics, angiographic findings, and in-hospital outcomes were compared between groups, as well as left ventricular ejection fraction (LVEF) and major adverse cardiac events (MACE, including death, reinfarction and target vessel revascularization) at 30-day and 6-month clinical follow-up. ResultsDespite comparable baseline clinical features among three groups, angiographic and procedural characteristics and outcomes differed significantly between patients receiving tirofiban treatment and controls, with respect to preprocedural (upstream: 28.1%, downstream: 7.0%, control: 5.2%, P<0.001) and postprocedural thrombolysis in myocardial infarction (TIMI) grade 3 flow of infarct-related artery (98.2, 94.7, 86.2%, P=0.03), TIMI myocardial perfusion grade 3 (75.4, 70.2, 53.4%, P=0.03), corrected TIMI frame count (20.4±5.0, 23.1±5.3, 32.2±6.7, P<0.001), resolution of the sum of ST-segment elevation (6.16±1.21, 6.02±1.09, 4.53±2.65 mm, P<0.001), peak value of creatine kinase-MB (218.0±72.5, 224.2±69.4, 255.3±77.0 ng/ml, P=0.02) and troponin I (76.0±21.5, 79.8±18.7, 86.4±11.0 ng/ml, P=0.007), and average hospital stay (10.6±5.4, 12.6±4.7, 14.5±6.5 days, P=0.001). The MACE rate at 30 days (3.5, 5.3, 15.5%, P=0.04) was reduced and LVEF (0.51±0.07, 0.50±0.07, 0.47±0.08, P=0.008) was higher in upstream and downstream groups than in controls. At 6-month follow-up, the MACE rate was not significantly different among groups (7.0, 8.8, 17.2%, P=0.17), but LVEF in upstream and downstream groups was significantly improved (0.59±0.06, 0.57±0.07, 0.54±0.07, P<0.001). Subgroup analysis demonstrated a statistically significant difference between upstream and downstream groups in preprocedural TIMI grade 3 flow (P=0.003) and postprocedural corrected TIMI frame count (P=0.007), which resulted in a shortened hospital stay (P=0.04), reduction of MACE rate at 30-day and 6-month follow-up by 34 and 20%, respectively. Multivariate logistic analysis revealed that age more than 65 years [odds ratio (OR)=3.42, P<0.01], tirofiban therapy (OR=0.56, P<0.05) and LVEF less than 0.5 during hospitalization (OR=2.56, P<0.01) were major independent predictors of MACE at 6-month clinical follow-up. No significant difference in hemorrhagic complications among three groups was noted (upstream: 10.5%, downstream: 12.3%, control: 6.9%, P=0.61). ConclusionThis prospective study indicates that adjunctive tirofiban therapy for patients with STEMI who undergo primary PCI can significantly improve reperfusion level in the infarct area, clinical outcomes at 30-day and 6-month follow-up, especially with upstream tirofiban therapy, and is safe.

Impact of moderate or severe renal insufficiency on long-term outcomes in patients undergoing drug-eluting stent based coronary intervention

AIMS We sought to examine the impact of moderate or severe renal insufficiency (RI) on long-term clinical outcomes after successful percutaneous coronary intervention (PCI) with drug-eluting stent implantation. METHODS All-cause mortality and major adverse cardiac events were prospectively determined for 1174 patients after successful PCI with drug-eluting stent implantation. Based on estimated creatinine clearance (CrCl) levels, long-term outcomes were compared between patients with CrCl<60 ml/min (RI group; n=460) and those with CrCl> or =60 ml/min (control group; n=714). Hazard ratio for mortality and myocardial infarction was further evaluated for patients with severe (CrCl<30 ml/min), moderate (CrCl 30-59 ml/min), mild RI (CrCl 60-89 ml/min) and normal renal function (CrCl> or =90 ml/min). RESULTS Patients in RI group were older, lower body weight and hemoglobin, more female gender, and less cigarette smokers than those in control group. During follow-up (averaged 19.2 months) after successful PCI, all-cause death (8.3% vs. 1.5%, P<0.001), cardiac death (5.7% vs. 1.1%, P<0.001) and occurrence of non-fatal myocardial infarction (2.2% vs. 0.4%, P=0.005) were significantly higher, but rate of target vessel revascularization (TVR) was lower (5.7% vs. 9.6%, P=0.017) in RI group than in control group. Multivariate analysis revealed that CrCl<60 ml/min, diabetes, left ventricular ejection fraction <0.50 and anemia were independent risk factors for mortality and non-fatal myocardial infarction. Compared with patients with normal renal function, hazard ratio for a composite of mortality and myocardial infarction was 1.079 (P=0.907), 5.067 (P=0.007) and 8.828 (P=0.002) in patents with mild, moderate and severe RI, respectively. CONCLUSIONS Irrespective of whether drug-eluting stent implantation reduces TVR, the presence of moderate or severe RI is still associated with unfavorable long-term outcomes.

The utility of a 5-in-6 double catheter technique in treating complex coronary lesions via transradial approach: the DOCA-TRI study

AIMS To evaluate the efficacy and safety of a 5-in-6 double catheter (DC) technique during transradial complex PCI compared to a conventional buddy-wire or balloon-anchoring approach. METHODS AND RESULTS One hundred and eighty-seven patients who failed in stent or balloon delivery after successful wiring of the target vessel were prospectively randomised to further treatment with a 5-in-6 DC technique (DC group, n=94) or by a conventional buddy-wire or balloon-anchoring approach (control group, n=93). Baseline clinical and lesion features were comparable between the two groups. The primary endpoint of technical success was significantly higher in the DC than in the control group (97.9% and 39.8%, p<0.001). Fifty-six patients (60.2%) in the control group with failure of the buddy-wire or balloon-anchoring approach achieved successful PCI with bailout use of a DC technique. Procedural x-ray time (58.2±23.1 min vs. 94.9±18.6 min, p<0.001), patient dose-area product (23,970±8,555 cGy.cm2 vs. 44,475±10,573 cGy.cm2, p<0.001) and contrast consumption (177±33 ml vs. 271±70 ml, p<0.001) were significantly reduced in the DC group. One-year major adverse cardiac event-free survival did not differ between the two groups (89.4% vs. 84.9%, p=0.36). CONCLUSIONS The use of a 5-in-6 DC technique, especially as a bailout strategy, is a more effective back-up support of the guiding system, subsequently facilitating the success of transradial PCI for complex coronary lesions, than a conventional buddy-wire or balloon-anchoring approach.

One-Year Clinical Outcome of Interventionalist- Versus Patient-Transfer Strategies for Primary Percutaneous Coronary Intervention in Patients With Acute ST-Segment Elevation Myocardial Infarction Results From the REVERSE-STEMI Study

Background— Traditional reperfusion options for patients with acute ST-segment elevation myocardial infarction (STEMI) presenting to non-primary percutaneous coronary intervention (PPCI)-capable hospitals generally include onsite fibrinolytics or emergency transfer for PPCI. A third option, involving interventionalist transfer, was examined in the REVERSE-STEMI study. Methods and Results— A total of 334 patients with acute STEMI who presented to 5 referral hospitals with angiographic facilities but without interventionalists qualified for PPCI were randomized to receive PPCI with either an interventionalist- (n=165) or a patient-transfer (n=169) strategy. The primary end point of door-to-balloon (D2B) time and secondary end points of left ventricular ejection fraction and major adverse cardiac events (MACE) at 1-year clinical follow-up were compared between the 2 groups. Compared with the patient-transfer strategy, the interventionalist-transfer strategy resulted in a significantly shortened D2B time (median, 92 minutes versus 141 minutes; P<0.0001), with more patients having first balloon angioplasty within 90 minutes (21.2% versus 7.7%, P<0.001). This treatment strategy also was associated with higher left ventricular ejection fraction (0.60±0.07 versus 0.57±0.09, P<0.001) and improved 1-year MACE-free survival (84.8% versus 74.6%, P=0.019). Multivariate Cox proportional hazards modeling revealed that the interventionalist-transfer strategy was an independent factor for reduced risk of composite MACE (hazard ratio, 0.63; 95% CI, 0.45 to 0.88; P=0.003). Conclusions— The interventionalist-transfer strategy for PPCI may be effective in improving the care of patients with STEMI presenting to a non-PPCI-capable hospital, particularly in a congested cosmopolitan region where patient transfers could be prolonged. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00713557.

Impact of angiographic and intravascular ultrasound features on clinical outcome after sirolimus-eluting stent implantation for de-novo lesions in nondiabetic and type 2 diabetic patients.

ObjectivesThis study aimed to evaluate the impact of angiographic and intravascular ultrasound (IVUS) features on clinical outcome in nondiabetic and type 2 diabetic patients after percutaneous coronary intervention (PCI) with sirolimus-eluting stent (SES) implantation. MethodsRepeat coronary angiography with IVUS imaging was performed after SES-based PCI for de-novo lesions in 128 diabetic and 327 nondiabetic patients (189 lesions and 504 lesions, respectively). The rate of major adverse cardiac events including cardiac death, non fatal myocardial infarction (MI), and target lesion revascularization during clinical follow-up was recorded. ResultsIn-stent and in-segment late loss, intimal hyperplasia volume, and percentage volumetric obstruction were similar, but stented external elastic membrane cross-sectional area and reference/stented segment ratio were lower in diabetic than in nondiabetic patients. Incomplete stent apposition (ISA) was less frequent, but occurrence of new coronary lesions was higher in diabetic than in nondiabetic patients. Despite similar target lesion revascularization, cumulative survival rates freedom from composite cardiac death and nonfatal MI or major adverse cardiac events were reduced in diabetic patients. Cox proportional hazards model identified diabetes, left ventricular ejection fraction, minimal stent CSA, maximal ISA area, atherosclerotic progression and lesion length as independent predictors of non fatal MI or mortality at follow-up. ConclusionIn diabetic patients, PCI with SES implantation neutralizes the excess risk of intimal hyperplasia and decreases occurrence of ISA, but could not modify the propensity of increased adverse clinical outcomes at follow-up.

Correlates and outcomes related to periprocedural myocardial injury during percutaneous coronary intervention for chronic total occlusion: Results from a prospective, single center PCI registry.

There is increasing interest in percutaneous coronary intervention (PCI) for chronic total occlusions (CTO). Periprocedural myocardial injury (PMI) post CTO PCI is not uncommon, but true incidence and implications of PMI are not well understood.

Periprocedural use of tirofiban in elective percutaneous coronary intervention for long coronary lesions in stable patients with overlapping drug-eluting stents--the PETITION study: a prospective, randomized, multicenter study.

Patients are at risk of developing periprocedural myonecrosis after percutaneous coronary intervention (PCI). We investigated whether the use of the platelet glycoprotein (GP) IIb/IIIa receptor inhibitor tirofiban could reduce periprocedural myocardial infarction (PMI) in patients with stable coronary artery disease undergoing elective PCI with overlapping stent implantation for long lesions.