Michał Hawranek

Thrombus aspiration followed by direct stenting: a novel strategy of primary percutaneous coronary intervention in ST-segment elevation myocardial infarction. Results of the Polish-Italian-Hungarian RAndomized ThrombEctomy Trial (PIHRATE Trial).

BACKGROUND Previous studies with thrombectomy showed different results, mainly due to use of thrombectomy as an additional device not instead of balloon predilatation. The aim of the present study was to assess impact of aspiration thrombectomy followed by direct stenting. METHODS Patients with ST elevation myocardial infarction (STEMI) <6 hours from pain onset and occluded infarct-related artery in baseline angiography were randomized into aspiration thrombectomy followed by direct stenting (TS, n = 100) or standard balloon predilatation followed by stent implantation (n = 96). The primary end point of the study was the electrocardiographic ST-segment elevation resolution >70% (STR > 70%) 60 minutes after primary angioplasty (percutaneous coronary intervention [PCI]). Secondary end points included angiographic myocardial blush grade (MBG) after PCI, combination of STR > 70% immediately after PCI and MBG grade 3 (optimal myocardial reperfusion), Thrombolysis In Myocardial Infarction flow after PCI, angiographic complications, and in-hospital major adverse cardiac events. RESULTS Aspiration thrombectomy success rate was 91% (crossing of the lesion with thrombus reduction and flow restoration). There was no significant difference in STR ≥ 70% after 60 minutes (53.7% vs 35.1%, P = .29). STR > 70% immediately after PCI (41% vs 26%, P < .05), MBG grade 3 (76% vs 58%, P < .03), and optimal myocardial reperfusion (35.1% vs 11.8%, P < .001) were more frequent in TS. There was no difference in between the groups in 6-month mortality (4% vs 3.1%, P = .74) and reinfarction rate (1% vs 3.1%, P = .29). CONCLUSIONS Aspiration thrombectomy and direct stenting is safe and effective in STEMI patients with early presentation (<6 hours). The angiographic parameters of microcirculation reperfusion and ECG ST-segment resolution directly after PCI were significantly better in thrombectomy group despite the lack of the difference in ST-segment resolution 60 minutes after PCI.

Comparison of Five-Year Outcomes of Patients With and Without Chronic Total Occlusion of Noninfarct Coronary Artery After Primary Coronary Intervention for ST-Segment Elevation Acute Myocardial Infarction

The aim of the present study was to evaluate the effect of concurrent chronic total occlusion (CTO) in a noninfarct-related artery (IRA) on the long-term prognosis in patients with ST-segment elevation myocardial infarction and multivessel coronary disease. Of 1,658 consecutive patients with ST-segment elevation myocardial infarction, 666 with multivessel coronary disease who underwent percutaneous coronary intervention from 1999 to 2004 were included in the present analysis. The patients were divided into 2 groups: no CTO and CTO. The first group included 462 patients without CTO (69%) and the second group included 204 patients with CTO in a non-IRA (31%). The in-hospital mortality rate was 6.3% and 21.1% (p < 0.0001) and the 5-year mortality rate was 22.5% and 40.2% (p < 0.0001) for the no-CTO and CTO patients, respectively. Multivariate analysis revealed that after correction for baseline differences CTO in a non-IRA was a strong, independent predictor of 5-year mortality in patients undergoing percutaneous coronary intervention (hazard ratio 1.85; 95% confidence interval 1.35 to 2.53; p = 0.0001). In conclusion, the presence of CTO in a non-IRA in patients with ST-segment elevation myocardial infarction and multivessel coronary disease is a strong and independent risk factor for greater 5-year mortality.

Reperfusion by primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction within 12 to 24 hours of the onset of symptoms (from a prospective national observational study [PL-ACS]).

The aim of the present study was to investigate whether reperfusion by primary percutaneous coronary intervention (PCI) improves 12-month survival in late presenters with ST-segment elevation myocardial infarction (STEMI). We analyzed 2,036 patients with STEMI presenting 12 to 24 hours from onset of symptoms, without cardiogenic shock or pulmonary edema and not reperfused by thrombolysis, of 23,517 patients with STEMI enrolled in the Polish Registry of Acute Coronary Syndromes from June 2005 to August 2006. An invasive approach was chosen in 910 (44.7%) of late presenters and 92% of them underwent reperfusion by PCI. Patients with an invasive approach had lower mortality after 12 months than patients with a conservative approach (9.3% vs 17.9%, p <0.0001). The benefit of an invasive approach was also observed after multivariate adjustment with a relative risk 0.73 for 12-month mortality (95% confidence interval 0.56 to 0.96) and in a subpopulation of patients selected by a propensity-score matching procedure with an adjusted relative risk 0.73 for 12-month mortality (0.58 to 0.99). In conclusion, almost 1/2 of late presenters with STEMI were considered eligible for reperfusion by primary PCI. These patients had a lower 12-month mortality rate than they would have had if they had been treated conservatively, which supports the idea of late reperfusion in STEMI. However, whether all late presenters with STEMI should be treated invasively remains unanswered. Nevertheless, until a randomized trial is undertaken, late presenters with STEMI could be considered for reperfusion by primary PCI.

Impact of chronic total occlusion artery on 12-month mortality in patients with non-ST-segment elevation myocardial infarction treated by percutaneous coronary intervention (From the PL-ACS Registry)

BACKGROUND Three-vessel coronary artery disease is associated with high mortality in patients with non-ST-segment elevation myocardial infarction (NSTEMI). The purpose of this study was to assess the impact on 12-month mortality of chronic total occlusion (CTO) in the non-infarct-related artery (non-IRA), as assessed by coronary angiography during percutaneous coronary intervention (PCI) for NSTEMI, of patients with 3-vessel disease. METHODS The study included all of the NSTEMI patients with 3-vessel disease by coronary angiogram who were treated by PCI and who were registered in the prospective Polish Registry of Acute Coronary Syndromes (PL-ACS) from July 2007 to November 2009. The patients with prior coronary artery bypass grafting and those with significant stenosis of the left main coronary artery were excluded. The 12-month mortality was obtained from a government database. RESULTS Of the 925 patients fulfilling the inclusion and exclusion criteria, 438 (47.4%) patients had 1 or more CTO of a major non-IRA coronary artery (+CTO), and 487 (52.6%) patients had 3-vessel disease without CTO (-CTO). The in-hospital mortality for the +CTO and -CTO patients was 5.3% and 2.1%, respectively (p=0.009), whilst the 12-month mortality was 21.1% and 11.9%, respectively (p=0.0001). After multivariate adjustment for differences in the baseline characteristics, the presence of CTO remained significantly associated with higher 12-month mortality (relative risk=1.42, 95%CI=1.01-2.00, p=0.047). CONCLUSIONS The presence of CTO in non-IRA in patients with NSTEMI and 3-vessel coronary disease predicts higher 12-month mortality.

Temporal Trends in the Treatment and Outcomes of Patients With Non-ST-Segment Elevation Myocardial Infarction in Poland from 2004–2010 (from the Polish Registry of Acute Coronary Syndromes)

The aim of this work was to analyze temporal trends in clinical presentation, treatment methods, and outcomes of patients in Poland with non-ST-segment elevation myocardial infarction (NSTEMI) from 2004 to 2010. A total of 90,153 patients with NSTEMI enrolled in the Polish Registry of Acute Coronary Syndromes (PL-ACS) from 2004 to 2010 were analyzed. The main outcome measure was all-cause mortality after 12 months, identified from official mortality records. The percentage of admissions for NSTEMI among all acute coronary syndromes increased from 24% in 2004 to 38% in 2010 (p < 0.0001). From 2004 to 2010, the percentage of invasive treatment for NSTEMI increased significantly, almost threefold, to 83% (p < 0.0001). The frequency of recurrent myocardial infarction and stroke during hospitalization decreased significantly over the years, while the frequency of major bleeding increased. Twelve-month mortality decreased significantly throughout the time period, from 19.1% to 14.5%, but was stable in patients treated invasively and slightly higher in the last years in patients treated noninvasively. The invasive treatment of NSTEMI (relative risk 0.62, 95% confidence interval 0.57 to 0.67, p < 0.0001), together with the pharmacotherapy recommended by the guidelines, had a significant impact on reducing 12-month mortality in a multifactor analysis. In conclusion, the distinct improvement in the short- and long-term prognoses of patients with NSTEMI may be in part the result of the popularization of invasive treatment and the optimization of pharmacotherapy.

Prognostic significance of mean platelet volume in diabetic patients with ST-elevation myocardial infarction

PURPOSE Mean platelet volume (MPV) is a universally available parameter with routine blood counts. It has been linked to many cardiovascular risk factors. MPV is a marker of platelet size and activity and has been linked to poor prognosis following STEMI. There has been an increasing number of reports linking diabetes mellitus (DM) to platelet dysfunction. The aim of the study was to examine the association between admission MPV and clinical outcomes in patients with DM and STEMI undergoing primary percutaneous coronary intervention (PCI). The secondary objective of the study was to evaluate whether this index can be used to determine the long-term prognosis. METHODS A total of 1,557 patients with STEMI undergoing primary PCI were enrolled and divided into two groups depending on their diabetes mellitus status: Group 1 - patients with diabetes mellitus (N=539) and Group 2 - patients without diabetes mellitus (N=1018). RESULTS MPV and peak CK-MB concentration were higher in diabetic patients as compared to non-diabetic patients. In diabetic patients, MPV was positively correlated with admission Killip class and negatively correlated with time to death during follow-up, initial TIMI flow, final TIMI flow, and erythrocyte count. In non-diabetic patients, MPV was positively correlated with the number of diseased coronary arteries, admission Killip class, and negatively correlated with time to death during follow-up and initial TIMI flow. ROC analysis revealed high diagnostic value of MPV in predicting in-hospital and one-year mortality. MPV cut-off level was lower for diabetic patients compared to non-diabetic patients. CONCLUSIONS Diabetic patients had higher MPV than non-diabetic patients. Both in diabetic and non-diabetic patients MPV proved to have good prognostic value for in-hospital and late mortality. MPV cut-off value for predicting mortality was lower in diabetic patients. Mortality rate was the highest in the fourth quartiles of MPV in both study groups.

Effect of Glycemic Control on Response to Antiplatelet Therapy in Patients With Diabetes Mellitus and ST-Segment Elevation Myocardial Infarction

Impaired glycemic control (GC) is a troubling clinical condition with an unclear prognostic value that is frequent in diabetics, especially in the setting of acute coronary syndrome. Residual platelet reactivity can be also affected by GC. We evaluated the relation between response to dual antiplatelet therapy and GC in diabetics with STEMI treated with primary coronary angioplasty (PCI). Sixty diabetic patients were prospectively enrolled in the study. All patients were treated with clopidogrel and aspirin. Platelet reactivity (whole blood aggregation and phosphorylation of vasodilator-stimulated phosphoprotein, VASP) were assessed serially before and 24 hours, 7 days, and 30 days after the PCI. Blood glucose >8.5 mmol/L on admission was an independent predictor of a impaired clopidogrel response measured with platelet reactivity index (PRI) >50% on admission (OR 7.8, 95% CI 1.4-17.7, p<0.02) and 24 hours after PCI (OR 13.1, 95% CI 3.4-28.1, p<0.01). In conclusion, diabetic patients with STEMI and glycemia >8.5 mmol/L on admission is related to a poorer response to clopidogrel. There were no interaction between glycated hemoglobin level or glycemia on admission and platelet reactivity measured with collagen, arachidonic acid or thrombin receptor agonist peptide-induced aggregation. Further clinical studies of the role of GC in the efficacy of antiplatelet agents are warranted.

Outcomes of invasive treatment in very elderly Polish patients with non-ST-segment-elevation myocardial infarction from 2003–2009 (from the PL-ACS registry)

BACKGROUND Elderly patients with non-ST-segment elevation myocardial infarction (NSTEMI) are rarely included in randomized trials due to concomitant diseases. As a result, invasive treatment and aggressive pharmacotherapy are used less frequently in this group. The aim of the study was to analyze the impact of invasive treatment used for elderly patients (≥ 80 years) with NSTEMI from 2003-2009 and its impact on 24-month outcomes. METHODS We performed analysis of 13,707 elderly patients, out of 78,422 total NSTEMI patients, enrolled in the prospective, nationwide, Polish Registry of Acute Coronary Syndromes (PL-ACS) from 2003 to 2009. RESULTS The percentage of elderly NSTEMI population was 17.5%. Invasive treatment received 24% of them. In-hospital complications (stroke, reinfarction and death) were significantly less frequent in the invasive group, with the exception of major bleeding, which occurred almost three times more frequently (2.9% vs. 1.1%, p < 0.0001) in the invasive group. The 24-month mortality was lower (29.4% vs. 50.4%, p < 0.0001) in the invasive group and remained so after matching patients by the propensity score method (31.1% vs. 40.9%, p < 0.0001). From 2003 to 2009 the use of thienopyridines, beta-blockers and statins rose significantly. The frequency of invasive strategy increased significantly, from 10% in to over 50% in 2009. The frequency of major bleeding increased twofold, however a significant reduction in the 24-month mortality was observed over the years. CONCLUSIONS Elderly patients with NSTEMI benefit significantly from invasive strategies and modern pharmacotherapy recommended by treatment guidelines. Nevertheless, this approach is associated with an increased incidence of major bleeding.

Invasive and non-invasive fractional flow reserve index in validation of hemodynamic severity of intracoronary lesions.

This review discusses visual and functional evaluation of the hemodynamic significance of the degree of stenosis in coronary angiography, with respect to the indications for revascularization. The concept of the coronary flow reserve is defined, and the theoretical assumptions of the invasive measurement of the fractional flow reserve (FFR) are presented. In the following part, the publication describes the basic steps of numerical stimulations in terms of computational fluid dynamics (CFD) in calculating the fractional flow reserve based on computed tomography (CT) coronary angiography (FFRCT). The numerical FFRCT estimation in correlation with invasive measurements, as well as benefits deriving from FFRCT in the diagnosis of coronary artery disease, is presented in the example of the multicentre prospective DISCOVER-FLOW trial and the DeFACTO project. The CDF method enables to obtain hemodynamic significance of stenosis solely from the coronary anatomy vizualized by CT angiography. The calculation of FFRCT increases the diagnostic reliability of coronary flow reserve estimations. It contributes to the improvement in patients’ qualification for contrast coronarography. If the accuracy of FFRCT is confirmed in clinical practice, and the time required for computational processing is shortened, it may turn out that the algorithms of coronary heart disease diagnosis will be verified and it will be to a greater extent based on the CT results.

Prognostic implications of mean platelet volume on short- and long-term outcomes among patients with non-ST-segment elevation myocardial infarction treated with percutaneous coronary intervention: A single-center large observational study

Abstract Background: Mean platelet volume (MPV) is a simple and reliable indicator of platelet size that correlates with platelet activation and their ability to aggregate. We studied the predictive value of MPV in patients with non-ST-segment elevation myocardial infarction (NSTEMI) treated with percutaneous coronary intervention (PCI). Methods: We analyzed the consecutive records of 1001 patients who were hospitalized due to NSTEMI at our center. The primary end point was a composite end point that included the rates of all-cause death, non-fatal myocardial infarction, and acute coronary syndrome (ACS) driven revascularization at 12 months. The enrolled patients were stratified according to the quartile of the MPV level at admission. Results: Along with the increasing quartile of MPV, the 12-month composite end point increased significantly (p = 0.010), and this association remained significant after the risk-adjusted analyses (per 1 fL higher MPV; adjusted hazard ratio [HR] 1.13; 95% confidence interval [CI] 1.02–1.27; p = 0.026). In the multivariate analysis, the MPV was also an independent factor of all-cause mortality (per 1 fL increase; adjusted HR 1.34; 95% CI 1.12–1.61; p = 0.0014) and death or non-fatal myocardial infarction (per 1 fL increase; adjusted HR 1.16; 95% CI 1.03–1.31; p = 0.017). Conclusion: In patients with NSTEMI treated with PCI, a high MPV value was associated with a significantly increased incidence of long-term adverse events, particularly for all-cause mortality.