Mandeep S. Sidhu

Classification and Atherosclerosis Distribution in Patients with Left Main Coronary Disease

OBJECTIVE The purpose of this investigation was to characterize clinical variables and angiographic distribution of coronary atherosclerosis to classify patients with de novo left main (LM) disease in a real-world population presenting for coronary angiography. BACKGROUND Limited quantitative and angiographic published data exist that provide detailed quantitative information to classify potential target population for elective LM percutaneous coronary intervention (PCI) and guide development of dedicated LM PCI platforms. METHODS Medical history and clinical presentation were prospectively collected on 177 consecutive patients with LM stenosis > or =50% by coronary angiography. Blinded quantitative coronary angiography (QCA) was performed on all LM stenoses to classify LM-A (ostial), LM-B (nonostial, non-bifurcation), and LM-C (bifurcation involvement). QCA was performed on the left anterior descending (LAD), left circumflex (LCx), and right coronary arteries (RCA) and branches (> or =2.5 mm) to identify lesions with > or =60% stenosis or occlusion. RESULTS No differences in baseline clinical history or presentation discriminated the distribution patterns of LM stenosis. QCA revealed 66% of LM stenoses were LM-C. Mean LM reference vessel diameter was 4.65 mm and average lesion length was 11.12 mm. Around 88.7% of patients had at least one lesion > or =60% in a major epicardial artery and 32.2% of patients had RCA chronic total occlusion. Right-to-left coronary collateralization was only identified in patients with obstructive stenosis in the LAD or LCx in addition to the LM stenosis. CONCLUSION Dedicated LM stent platforms may need to be developed to accommodate larger vessel size and bifurcation distributions. A majority of patients with LM stenosis will require adjunctive epicardial vessel PCI to achieve complete anatomic revascularization.

The evaluation of creatinine clearance, estimated glomerular filtration rate and serum creatinine in predicting contrast-induced acute kidney injury among patients undergoing percutaneous coronary intervention ☆,☆☆

PURPOSE The purpose of the study was to compare creatinine clearance (CrCl), estimated glomerular filtration rate (eGFR) and serum creatinine (SCr) in predicting contrast-induced acute kidney injury (CI-AKI), dialysis and death following percutaneous coronary intervention (PCI). METHODS AND MATERIALS Data were prospectively collected on 7759 consecutive patients within the Dartmouth Dynamic Registry undergoing PCI between January 1, 2000, and December 31, 2006. Renal function was measured at baseline and within 48 h after PCI using three methods: CrCl using the Cockcroft-Gault equation, eGFR using the abbreviated Modification of Diet in Renal Disease equation and SCr. We compared CrCl, eGFR and SCr in predicting CI-AKI, post-PCI dialysis-dependent renal failure and in-hospital mortality. Areas under the receiver operating characteristic curve (ROC) were calculated using logistic regression and tested for equality. RESULTS On univariable analysis, CrCl [ROC: 0.69; 95% confidence interval (CI): 0.67-0.72] predicted CI-AKI better than eGFR (ROC: 0.67; 95% CI: 0.64-0.70) (P=.013) and SCr (ROC: 0.64; 95% CI: 0.61-0.67) (P<.001). Creatinine clearance (ROC: 0.73; 95% CI: 0.69-0.77) and eGFR (ROC: 0.70; 95% CI: 0.65-0.74) outperformed SCr for predicting in-hospital mortality. On multivariable analysis, CrCl (ROC: 0.77; 95% CI: 0.75-0.80), SCr (ROC: 0.78; 95% CI: 0.76-0.80) and eGFR (ROC: 0.77; 95% CI: 0.75-0.80) predicted CI-AKI well. Creatinine clearance (ROC: 0.88; 95% CI: 0.85-0.90) and eGFR (ROC: 0.87; 95% CI: 0.85-0.90) were strong independent predictors of in-hospital mortality. CONCLUSIONS Creatinine clearance, eGFR and SCr predict CI-AKI equally well. Creatinine clearance and eGFR are strong independent predictors of in-hospital mortality.

Outcomes of Diabetics Receiving Bare-Metal Stents Versus Drug-Eluting Stents

Objectives: We sought to determine if differences existed in in‐hospital outcomes, long‐term rates of target vessel revascularization (TVR), and/or long‐term mortality trends between patients with diabetes mellitus undergoing percutaneous coronary intervention (PCI) with either a drug‐eluting stent(s) (DES) or a bare metal stent(s) (BMS). Background: Short‐ and long‐term clinical outcomes of patients with diabetes mellitus undergoing PCI with DES versus BMS remain inconsistent between randomized‐controlled trials (RCTs) and observational studies. Methods: Data were collected prospectively on diabetics undergoing PCI with either DES or BMS from January 2000 to June 2008. Demographic information, medical histories, in‐hospital outcomes, and long‐term TVR and mortality trends were obtained for all patients. Results: A total of 1,319 patients were included in the study. Diabetics receiving DES had a significant reduction in index admission MACE compared to diabetics receiving BMS. Using multivariable adjustment, after a mean follow‐up of 2.5 years (maximum 5 years), diabetics who received DES had a 38% decreased risk of TVR compared to diabetics with BMS [HR 0.62 (95% CI: 0.43–0.90)]; diabetics with DES had an insignificant adjusted improvement in long‐term survival compared to diabetics with BMS [HR 0.72 (95% CI: 0.52–1.00)]. These long‐term survival and TVR rates were confirmed using propensity scoring. Conclusions: The use of DES when compared with BMS among diabetics undergoing PCI is associated with significant improvement in long‐term TVR, with an insignificant similar trend in all‐cause mortality. The long‐term results of this observational study are consistent with prior RCTs after adjusting for confounding variables.

Real World, Long-Term Outcomes Comparison Between Paclitaxel-Eluting and Sirolimus-Eluting Stent Platforms

We compare real-world, extended target vessel revascularization (TVR)-free survival following percutaneous coronary intervention (PCI) for patients receiving either sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) following an index drug-eluting stent (DES) supported procedure. We analyzed 2,363 consecutive patients having first DES-supported PCI at receiving PES (n = 1,012) or SES (n = 1,332) from April 2004 to July 2006. Baseline clinical and procedural characteristics and in-hospital outcomes were recorded during the time of the index procedure and extended clinical outcomes data were obtained thereafter. TVR and all cause mortality were identified during the study period. Adjusted Kaplan-Meier and Coxs proportional hazard survival methods were performed. TVR-free survival at 2.3 years was 91.3% for SES compared with 88.9% for PES (P = 0.06). Kaplan-Meier survival curves did not significantly differ (adjusted hazard ratio -1.39 [95% CI 0.99-1.97]) between the SES and PES patient cohorts. TVR was similar between the stent platforms at one (96.6% for SES [95% CI 95.3-97.6] vs. 95.7% for PES [95% CI 94.1-96.9]) and two (95.0%[95% CI 93.0-96.4] for SES vs. 93.7% for PES [95% CI 91.6-95.3]) years. Overall survival at 2 years was 96.2% for SES (95% CI 94.7-97.3) and 95.3% for PES (95% CI 93.7-96.5). SES and PES drug-eluting stent platforms have good and similar extended outcomes in this real world registry of unselected patients having PCI.

The impact of hematocrit drop on long-term survival after cardiac catheterization: Insights from the Dartmouth Dynamic Registry

Background: The long‐term prognostic implication of post‐procedural hematocrit drops in patients undergoing cardiac catheterization outside the clinical trial setting is not well defined. Methods: Data was prospectively collected from 12,661 patients undergoing diagnostic or interventional cardiac catheterization between July 1998 and July 2006. Patients were divided into three cohorts based upon the degree of hematocrit change: drop greater than 6, drop between 3 and 6, and drop less than 3. In‐hospital major adverse events, 30‐day mortality, and long‐term all‐cause mortality were recorded. Results: Patients with larger reductions in hematocrit were more likely to be older, female, and have a higher baseline hematocrit, present with acute myocardial infarction, develop cardiogenic shock, require emergent catheterization, develop retroperitoneal bleeds and large hematomas, receive transfusions, have longer index hospitalizations, develop subacute stent thrombosis, and have higher 30‐day and long‐term mortality. An increase in long‐term mortality was observed with progressive hematocrit drop. This finding is largely driven by early (30 day) mortality, as trends were no longer significant after rezeroing mortality. Hematocrit drop was not an independent risk factor for 30‐day mortality. Transfusion and low baseline hematocrit were identified as independent predictors of near and long‐term mortality. Conclusions: Periprocedural bleeding, defined by hematocrit drop, is associated with increased near‐term and long‐term mortality in patients undergoing diagnostic and therapeutic cardiac catheterization procedures. Long‐term mortality is largely driven by up front 30‐day mortality. Hematocrit drop was not an independent predictor for near‐term mortality. Transfusion and low baseline hematocrit were independent predictors for near and long‐term mortality.