Kishore J Harjai

Impact of angina class on inhibition of platelet aggregation following clopidogrel loading in patients undergoing coronary intervention: Do we need more aggressive dosing regimens in unstable angina?

Pretreatment with thienopyridines has been shown to improve clinical outcomes in patients undergoing percutaneous coronary intervention (PCI). We determine the impact of angina class on inhibition of platelet aggregation (IPA) following clopidogrel loading. Seventy‐two patients (mean age, 64 ± 11 years; 76% male) were pretreated with 450 mg of clopidogrel at least 3 hr prior to PCI. All patients received ASA 325 mg prior to the procedure. Patients were classified into two groups according to angina class: group 1 = stable angina or Braunwald class 1 unstable angina (UA; n = 33); group 2 = Braunwald class 2 or 3 UA (n = 39). IPA was measured prior to PCI, with the Ichor point‐of‐care platelet analyzer (Helena Laboratories, Beaumont, TX), using 20 μM of ADP. Group 2 patients were more likely to have prior MI (54% vs. 27%; P = 0.023), prior CABG (33% vs. 5%; P = 0.046), and received IV heparin (64% vs. 27%; P = 0.0018). Mean IPA was significantly lower in group 2 compared to group 1 (19% ± 22% vs. 32% ± 22%; P = 0.004). In multivariate analysis, higher angina class was independently associated with lower IPA (P = 0.018). Patients with UA undergoing PCI have a lower IPA following clopidogrel loading with 450 mg. This may indicate the possibility of clopidogrel resistance in such patients. Cathet Cardiovasc Intervent 2003;59:21–25.

Comparison of outcomes of diabetic and nondiabetic patients undergoing primary angioplasty for acute myocardial infarction.

We sought to determine whether diabetes mellitus independently conferred poor prognosis in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). In 3,742 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI) studies with the intention of undergoing primary PCI, we compared in-hospital mortality, 6-month mortality, and 6-month major adverse cardiovascular events (MACEs), i.e., composite of death, reinfarction, or ischemic target vessel revascularization (TVR), between diabetics (n = 626, 17%) and nondiabetics (n = 3,116, 83%). We evaluated the independent impact of diabetes on outcomes after adjustment for baseline clinical and angiographic differences. Diabetics had worse baseline clinical characteristics, longer pain onset-to-hospital arrival time, and longer door-to-balloon time. They had more multivessel coronary disease and lower left ventricular ejection fractions, but better baseline Thrombolysis In Myocardial Infarction (TIMI) flow. Diabetics underwent primary PCI less often (88% vs 91%, p = 0.01). During the index hospitalization, diabetics were more likely to die (4.6% vs 2.6%, p = 0.005). During 6-month follow-up, diabetics had higher incidences of death (8.1% vs 4.2%, p <0.0001) and MACEs (18% vs 14%, p = 0.036). In multivariate analysis, diabetes was independently associated with 6-month mortality (hazard ratio 1.53, 95% confidence interval 1.03 to 2.26, p = 0.03), but not with in-hospital mortality or 6-month MACEs. We conclude that diabetics with AMI have less favorable baseline characteristics and are less likely to undergo primary PCI than nondiabetics. Despite excellent angiographic results, diabetics had significantly worse 6-month mortality.

The incidence, predictors, and outcomes of early reinfarction after primary angioplasty for acute myocardial infarction.

OBJECTIVES We sought to identify the incidence, predictors, and clinical consequences of one-month reinfarction (RE-MI) in patients undergoing primary percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). BACKGROUND One-month reinfarction after AMI significantly increases long-term mortality; however, little is known about the incidence and predictors of RE-MI in patients undergoing primary angioplasty. METHODS We analyzed data from 3,646 patients who underwent primary PCI in the Primary Angioplasty in Acute Myocardial Infarction (PAMI) studies. We studied the incidence, correlates, and clinical outcomes of 30-day RE-MI. RESULTS Reinfarction within one month of index hospitalization occurred in 77 (2.1%) of patients. In multivariate analysis, admission Killip class >1 (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.09 to 3.76), left ventricular ejection fraction <50% (OR 2.49, 95% CI 1.30 to 4.74), final coronary stenosis >30% (OR 2.57, 95% CI 1.28 to 5.15), and presence of coronary dissection (OR 2.40, 95% CI 1.36 to 4.24) and thrombus (OR 2.36, 95% CI 1.23 to 4.53) on the final angiogram were independent correlates of RE-MI. One-month reinfarction was independently associated with death (OR 7.14, 95% CI 3.28 to 15.5) and ischemic target vessel revascularization (I-TVR) (OR 15.0, 95% CI 8.68 to 26.0) at six months. CONCLUSIONS We conclude that, although early RE-MI is uncommon in patients treated by primary PCI, it is a significant independent predictor of death and I-TVR at six months. Admission Killip class >1 and left ventricular systolic dysfunction were associated with higher incidence of RE-MI. Our results suggest that optimal revascularization during primary PCI may decrease RE-MI rates.

Effects of prior beta-blocker therapy on clinical outcomes after primary coronary angioplasty for acute myocardial infarction

Abstract We hypothesized that pretreatment with β blockers may improve clinical outcomes after primary angioplasty for acute myocardial infarction. We pooled clinical, angiographic, and outcomes data on 2,537 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI), PAMI-2, and Stent PAMI trials. We classified patients into a β group (n = 1,132) if they received β-blocker therapy before primary angioplasty or a no-β group (n = 1,405) if they did not. We evaluated procedural complications and in-hospital and 1-year outcomes (death and major adverse cardiac events [death, reinfarction, target vessel revascularization, or stroke]) between groups. Beta patients were younger, had higher systolic blood pressure and heart rate, and were more likely to be in Killip class I at admission. They had lower left ventricular ejection fraction, greater door-to-balloon time, greater likelihood of having a left anterior descending artery culprit lesion, but a similar incidence of Thrombolysis In Myocardial Infarction 3 flow after angioplasty (92.6% vs 92.7%, p = 0.91). The β group had less procedural complications (23% vs 34%, p

Percutaneous coronary interventions in octogenarians. glycoprotein IIb/IIIa receptor inhibitors' safety profile.

OBJECTIVES This study was designed to evaluate the safety profile of glycoprotein IIb/IIIa receptor inhibitors (GPI) in octogenarians undergoing percutaneous coronary intervention (PCI). BACKGROUND Patients > or =80 years old constitute the fastest growing segment of the U.S. population and have a high prevalence of coronary artery disease. Few data exist regarding the use of GPI during PCI in octogenarians, as these patients have been excluded from randomized clinical trials of GPI. METHODS Consecutive patients > or =80 years old undergoing PCI between January 1998 and June 2001 were evaluated for clinical outcomes and bleeding complications. RESULTS One thousand three hundred and ninety two of 14,308 patients (9.7%) undergoing PCI were > or =80 years old. Of these, 459 of 1,392 (33%) of the patients were treated with GPI. Octogenarians treated with GPI were more likely to present with acute coronary syndrome or infarction, receive stents, require an intra-aortic balloon pump, or undergo multi-vessel PCI. Glycoprotein receptor inhibitor use was associated with a higher rate of bleeding, but the transfusion rate was similar to that in patients who did not receive GPI (9.8% vs. 8.6%, p = NS). No cases of intracranial hemorrhage were observed. By multivariate analysis, GPI treatment was associated with longer hospitalization but did not independently predict the need for transfusion or affect mortality. CONCLUSIONS Octogenarians have a high incidence of bleeding and need for transfusion after PCI. Although the use of GPI was associated with more access and non-access site bleeding and longer hospital stay, GPI treatment does not significantly increase the risk of transfusion or intracranial hemorrhage in this non-randomized cohort.

Frequency, determinants, and clinical implications of residual intracoronary thrombus following primary angioplasty for acute myocardial infarction

The presence of intracoronary thrombus after percutaneous coronary intervention (PCI) worsens clinical outcomes. We performed this study to assess the incidence of intracoronary thrombus after primary angioplasty for acute myocardial infarction (AMI) and the clinical impact of nonocclusive thrombus. In 2,148 patients enrolled in the Primary Angioplasty in Myocardial Infarction (PAMI)-2, Stent PAMI, and PAMI No-Surgery-On-Site trials, we compared clinical and angiographic characteristics of 131 patients (6%) who had angiographically visible thrombus after PCI with those who did not (n = 2,017). In the subset of 2,115 patients with post-PCI Thrombolysis In Myocardial Infarction (TIMI) 2 or 3 flow, we assessed the impact of post-PCI thrombus (n = 110) on in-hospital, 1-month, and 1-year outcomes (reinfarction, ischemic target vessel revascularization [I-TVR], death, and major adverse cardiovascular events [MACEs] [i.e., death, reinfarction, or I-TVR]). Lack of stent use, presence of thrombus before PCI, and no history of PCI were independent correlates of post-PCI thrombus. Patients with nonocclusive thrombus after PCI had more reinfarctions during the index hospitalization (5.5% vs 2.0%, p = 0.03) and at 1 month (6.8% vs 2.3%, p = 0.01) and had nonsignificantly higher I-TVR (during hospitalization 5.5% vs 2.8%, p = 0.13; at 1 month 5.9% vs 3.4%, p = 0.17), but similar mortality and MACE rates as those without post-PCI thrombus. In multivariate analysis, post-PCI thrombus was not a significant predictor of in-hospital or 1-month reinfarction. At 1 year, clinical outcomes were similar between patient groups (reinfarction 8.3% vs 4.7%, p = 0.14; I-TVR 12.5% vs 12.1%, p = 0.91; death 5.9% vs 5.0%, p = 0.68; and MACEs 21% vs 18%, p = 0.54). We conclude that residual intracoronary thrombus after primary angioplasty is relatively uncommon. In patients who achieve TIMI 2 or 3 flow after PCI, intracoronary thrombus is associated with worse cardiovascular outcomes. However, differences in outcomes between patients with and without residual thombus are related to baseline clinical differences rather than thrombus per se.

2016 Revision of the SCAI Position Statement on Public Reporting

The public reporting of institutional and individual operator results of percutaneous coronary interventions (PCIs) is intended to provide meaningful information to the public and enhance the delivery of superlative health care. By giving consumers specific outcome data [1], patients will be empowered to participate more fully in decisions concerning their medical care. The influence that public reports wield could increase if publicly reported information proves to be an accurate representation of “value” in health care delivery, and if third-party payers use this information to allocate reimbursement in a value-based system [2]. Despite these well-intended goals, there is uncertainty whether existing programs correctly identify highand low-performing PCI centers and operators. Moreover, there is emerging evidence that public reporting can deleteriously influence case selection by encouraging risk avoidance behaviors. Thus, potentially beneficial procedures might be withheld from high-risk patients who can derive the greatest benefit, because operators and facilities fear being labeled as outliers [3–8]. This position statement updates the prior Society for Cardiac Angiography and Interventions (SCAI) Policy on Public Reporting [1]. SCAI continues to endorse public reporting, provided the reports are not misleading, deliver meaningful information to consumers to help inform their choices, and facilitate quality improvement. Offering the public accurate and understandable metrics, including measures to assess the appropriateness of case selection, are essential to achieve this aim.

Stenting of anomalous left carotid artery using a radial artery approach.

A 90‐year‐old male presented with symptomatic severe stenosis of an anomalous left carotid artery originating from the brachicephalic trunk. A previous attempt at selective cannulation of the left carotid artery was unsuccessful using a transfemoral approach. We performed successful carotid artery angioplasty and stenting using a right radial artery approach. Catheter Cardiovasc Interv 2004;61:286–288.

Comparison of effectiveness of primary angioplasty for proximal versus distal right coronary artery culprit lesion during acute myocardial infarction.

From the cohort of 4,023 patients enrolled in the Primary Angioplasty for Myocardial Infarction (PAMI) trials, we pooled clinical, angiographic, and outcomes data on 1,521 patients with culprit lesions in the right coronary artery (RCA). We compared angiographic results, procedural complications, and in-hospital and 1-year clinical outcomes between patients with proximal RCA (n = 572) versus nonproximal RCA culprit lesions (n = 949). Patients with proximal RCA culprit lesions were older, had lower systolic blood pressure, greater diameter stenosis, and were less likely to have Thrombolysis In Myocardial Infarction (TIMI) 2 or 3 flow (19% vs 31%; p <0.0001) before percutaneous coronary intervention (PCI). After PCI, the incidence of TIMI 3 flow (94% vs 93%) was similar between groups. Patients with proximal RCA lesions were more likely to have bradyarrhythmias (30% vs 23%, p = 0.016) and require an intra-aortic balloon pump (IABP; 4.6% vs 2%, p = 0.034) during PCI. In-hospital complications, including mortality (2.3% vs 2.2%) and reinfarction (1.4% vs 1.1%), and the 1-year incidence of death, reinfarction, ischemia driven target vessel revascularization, and major adverse cardiovascular events were similar between groups. After adjustment for baseline differences, proximal RCA location of the culprit lesion was independently associated with greater IABP use (odds ratio 2.41, 95% confidence interval 1.04 to 5.58) but not with bradyarrhythmias during PCI. Thus, in patients with acute myocardial infarction referred for primary angioplasty, proximal RCA location of the culprit lesion is associated with excellent clinical outcomes that are similar to nonproximal RCA lesions.

Does Oral Beta-Blocker Therapy Improve Long-Term Survival in ST-Segment Elevation Myocardial Infarction With Preserved Systolic Function? A Meta-Analysis.

Background: The effect of oral beta-blocker therapy on long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) who are treated with primary percutaneous coronary intervention (PCI) and who have preserved left ventricular ejection fraction (LVEF) remains unclear. Methods: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies evaluating the effect of oral beta-blocker therapy in patients with STEMI who underwent primary PCI and who had preserved LVEF. The primary outcome was all-cause mortality. Randomized controlled trials and the observational studies that reported an adjusted hazard ratio (or hazard ratio in the propensity score-matched patients) with follow-up duration equal to or more than 6 months were included. Pooled hazard ratio with 95% confidence interval (CI) was calculated using a random effect model. Results: No randomized controlled trials met the inclusion criteria. Seven observational studies totaling 10 857 patients met the inclusion criteria. Follow-up duration ranged from 6 months to 5.2 years. Preserved LVEF was defined as 40% in 4 studies and 50% in 3 studies. Based on the pooled estimate, oral beta-blocker therapy was associated with a reduction in all-cause mortality (combined hazard ratio 0.79, 95% CI 0.65-0.97). Conclusion: This meta-analysis demonstrates that oral beta-blocker therapy is associated with decreased all-cause mortality in patients with STEMI who are treated with primary PCI and who have preserved LVEF. This supports the current American College of Cardiology Foundation/American Heart Association 2013 Guideline for the Management of STEMI.