Rodney De Palma

A rapid protocol for the prevention of contrast-induced renal dysfunction: the RAPPID study

OBJECTIVES This study was designed to test a rapid protocol of intravenous acetylcysteine for prevention of radiocontrast-induced nephropathy (RCIN). BACKGROUND Oral acetylcysteine (NAC) may provide better prophylaxis against RCIN than intravenous (i.v.) hydration alone. Current protocols preclude prophylaxis of same-day or emergency patients owing to the need for prolonged pretreatment. METHODS We prospectively randomized 80 patients with stable renal dysfunction undergoing cardiac catheterization/intervention to a rapid protocol of i.v. NAC (150 mg/kg in 500 ml N/saline over 30 min immediately before contrast followed by 50 mg/kg in 500 ml N/saline over 4 h, n = 41, 67 +/- 10 years, 90% men) or i.v. hydration (1 ml/kg/h N/saline for 12 h pre- and post-contrast, n = 39, 71 +/- 8.8 years, 85% men). RESULTS Radiocontrast-induced nephropathy occurred in 2 of the 41 patients in the NAC group (5%) and in 8 of the 39 patients in the hydration group (21%; p = 0.045; relative risk: 0.28; 95% confidence interval 0.08 to 0.98). In the NAC group, mean serum creatinine fell from 1.85 +/- 0.59 to 1.77 +/- 0.73 and 1.79 +/- 0.73 mg/dl 48 h and four days post-contrast (p = 0.02 and 0.023 vs. baseline, respectively). In the hydration group, serum creatinine increased from 1.75 +/- 0.41 to 1.81 +/- 0.6 48 h and 1.80 +/- 0.50 mg/dl four days post-contrast (p = 0.99 and 0.23, respectively). NAC infusion was ceased after the bolus in three patients (7%) due to flushing, itching, or a transient rash. CONCLUSIONS Administration of i.v. NAC should be considered in all patients at risk of RCIN before contrast exposure when time constraints preclude adequate oral prophylaxis, provided the patient is able to tolerate this degree of volume loading.

Safety and feasibility of hospital discharge 2 days following primary percutaneous intervention for ST-segment elevation myocardial infarction

Aim Primary percutaneous coronary intervention (PPCI) produces more effective coronary reperfusion and allows immediate risk stratification compared with fibrinolysis. We investigated the safety and feasibility of very early discharge at 2 days following PPCI in selected low-risk cases. Methods This was a prospective observational cohort study of 2779 patients who underwent PPCI between 2004 and 2011. Patients meeting the following criteria were deemed suitable for very early discharge; TIMI III flow, left ventricle (LF) ejection fraction >40%, and rhythmic and haemodynamic stability out to 48 h. Higher-risk patients who did not fulfil these criteria were discharged later according to physician preference. All patients were offered outpatient review by a multidisciplinary team. Endpoints included 30 day readmission rates and major adverse cardiac events (MACE) out to a median of 2.8 years (IQR range: 1.3–4.4 years). Results 1309 (49.3%) PPCI patients met very early discharge criteria, of whom 1117 (85.3%) were actually discharged at 2 days. 620 (23.4%) were discharged at 3 days, and 916 (34.5%) >3 days after admission (median 5, IQR: 4–8) days). Patients discharged at 2 days were younger, and had lower rates of diabetes, renal dysfunction, multivessel coronary artery disease, previous myocardial infarction, and previous coronary artery bypass surgery, compared with patients discharged later. 30-day readmission rates for non-MACE events were 4.8%, 4.9% and 4.6% for patients discharged 2 days, 3 days and >3 days after admission, respectively. MACE rates were lowest in patients discharged at 2 days (9.6%, 95% CI 4.7% to 16.6%) compared with patients discharged at 3 days (12.3% 95% CI 6.0% to 19.2%) and >3 days (28.6% 95% CI 22.9% to 34.7%, p<0.0001) after admission. Conclusions Our data suggest that discharge of low-risk patients 2 days after successful PPCI is feasible and safe. Over 40% of all patients with ST-elevation myocardial infarction may be suitable for early discharge with important implications for healthcare costs.

Mild chronic kidney disease is an independent predictor of long-term mortality after emergency angiography and primary percutaneous intervention in patients with ST-elevation myocardial infarction

Objective Moderate renal impairment (RI) with a glomerular filtration rate (GFR) <60 ml/min/1.73 m2 is known to predict survival. The authors investigated whether mild RI with an estimated GFR of 60–89 ml/min/1.73 m2 independently predicts survival in a contemporary population with ST segment elevation myocardial infarction (STEMI). Design This is a single-centre, observational, retrospective cohort study. Patients 601 patients with STEMI who underwent emergency catheter laboratory admission met the inclusion criteria for this study. Methods Estimated glomerular filtration rate (eGFR) was obtained by the Modified Diet in Renal Disease equation, and preprocedure renal function was subdivided into chronic kidney disease stages. Univariate and multivariate Cox regression analyses were performed to assess which of 17 patient or procedural variables were independent risk factors for death. Results Longitudinal data were collated for 576 patients (96.3%). Median follow-up time was 2.6 years. 30-day and long-term death rates were 5.7% and 12.5%, respectively. Following multivariable analysis, mild RI with an eGFR of 60–89 ml/min/1.73 m2 was a strong independent predictor of death, compared with an eGFR ≥90 ml/min/1.73 m2 (HR 2.79, 95% CI 1.98 to 3.92, p<0.001), and increasing chronic kidney disease stage was a strong predictor of death after both 30 days and long-term follow-up. An eGFR of 60–89 ml/min/1.73 m2 had a greater independent effect on short- and long-term mortality than the presence of diabetes mellitus (HR 2.0, 95% CI 1.2 to 3.33). Conclusion Mild RI (eGFR=60–89 ml/min/1.73 m2) on admission is strongly predictive of short- and long-term mortality in patients with STEMI admitted to the catheter laboratory. A redefined threshold of clinically significant impairment is now required (GFR<90 ml/min/1.73 m2).

Drug eluting balloons for de novo coronary lesions - a systematic review and meta-analysis.

BackgroundThe role of drug-eluting balloons (DEB) is unclear. Increasing evidence has shown a benefit for the treatment of in-stent restenosis. Its effect on de novo coronary lesions is more controversial. Several smaller randomized trials found conflicting results.MethodsThis is a systematic review and meta-analysis of randomized controlled trials (RCT) evaluating the effect of local Paclitaxel delivery/drug eluting balloons (DEB) (+/− bare metal stent) compared to current standard therapy (stenting) to treat de novo coronary lesions. Data sources for RCT were identified through a literature search from 2005 through 28 December 2012. The main endpoints of interest were target lesion revascularization (TLR), major adverse cardiac events (MACE), binary in-segment restenosis, stent thrombosis (ST), myocardial infarction (MI), late lumen loss (LLL) and mortality. A random effects model was used to calculate the pooled relative risks (RR) with 95% confidence intervals.ResultsEight studies (11 subgroups) and a total of 1,706 patients were included in this analysis. Follow-up duration ranged from 6 to 12 months. Overall, DEB showed similar results to the comparator treatment. The relative risk (RR) for MACE was 0.95 (0.64 to 1.39); P = 0.776, for mortality it was 0.79 (0.30 to 2.11), P = 0.644, for stent thrombosis it was 1.45 (0.42 to 5.01), P = 0.560, for MI it was 1.26 (0.49 to 3.21), P = 0.629, for TLR it was 1.09 (0.71 to 1.68); P = 0.700 and for binary in-stent restenosis it was 0.96 (0.48 to 1.93), P = 0.918. Compared to bare metal stents (BMS), DEB showed a lower LLL (− 0.26 mm (−0.51 to 0.01)) and a trend towards a lower MACE risk (RR 0.66 (0.43 to 1.02)).ConclusionOverall, drug-eluting balloons (+/− bare metal stent) are not superior to current standard therapies (BMS or drug eluting stent (DES)) in treating de novo coronary lesions. However, the performance of DEB seems to lie in between DES and BMS with a trend towards superiority over BMS alone. Therefore, DEB may be considered in patients with contraindications for DES. The heterogeneity between the included studies is a limitation of this meta-analysis; different drug-eluting balloons have been used.

Mortality after myocardial infarction in patients with diabetes mellitus

See article on page 1577

Delays in angiography may cost lives.

Non-ST-elevation acute coronary syndromes (NSTEACS) represent a growing challenge to cardiologists. While ST-elevation infarction (STEMI) has been attracting the focus of acute cardiovascular healthcare systems owing to the proliferation of 24-hour regional primary percutaneous coronary interventions (PCI) services, NSTEACS management has lagged behind. More numerous,1 and with a higher cumulative mortality than STEMI,2 this spectrum of conditions is threatening to be the “elephant in the room” of acute coronary syndromes. Access to diagnostic coronary angiography and, if necessary, revascularisation within 72 hours of presentation is a class 1A indication in North American and European guidelines for those with high or intermediate risk features for poor clinical outcome. This strong recommendation is based on contemporary randomised trials, including meta-analyses3 4 comparing a systematic invasive strategy against a default conservative medical strategy with intervention only in the event of refractory ischaemia. Cost-effectiveness analyses also indicate that targeting those at highest risk is of economic value.5 6 Early invasive strategies (<24 hours) remain an area for further investigation and debate but evidence is rapidly accumulating that this has clinical benefit. Nevertheless, despite the wealth of data to inform us, there has been difficulty in translating guidance into practice. The Global Registry of Acute Coronary Events (GRACE) gives us insight into this disconnection. It is the largest database of contemporary management with over 100 000 patient records collected over the last decade. By involving 30 countries across four continents it is a truly international cohort with enviable external validity. It has the highest c-statistic of any clinical risk score to date with predictive outcomes to 6 months from the index presentation. Swanson et al , in the February issue of Heart , have analysed the data from the patients in the GRACE registry.7 The investigators found that a staggering 43% …

Predictors of clinical outcome in transfemoral TAVI: Circumferential iliofemoral calcifications and manufacturer-derived recommendations

Objective: This study aimed to investigate the predictive value of circumferential iliofemoral calcifications and current manufacturer recommendations, which are not evidence-based, in transfemoral (TF) transcatheter aortic valve implantation (TAVI) Methods: A patient cohort with a broad range of iliofemoral anatomies undergoing TF TAVI (n=132) were retrospectively divided as “suitable” (n=76, 58%) and “unsuitable” (n=56, 42%) candidates according to current recommendations. Iliofemoral angiography and reconstructed mul- tislice CT (MSCT) images were used for access screening in the majority of patients. Results: Vessel properties were significantly worse in the “unsuitable group.” The sheath-to-iliofemoral artery ratio (SIFAR) and calcium score were 1.35±0.2 and 1.7±0.8 in the unsuitable group, compared to 1.0±0.12 (p<0.0001) and 1.0±0.7 (p=0.0001) in the “suitable” patients. Major vascular complications (MVCs) occurred more frequently in the “unsuitable” group (10.7% vs. 2.6%, p=0.07) and were predicted by SIFAR [OR: 64, 95% CI: 1.4-2971, p=0.03] and circumferential iliofemoral calcifications [OR: 6, 95% CI: 1.2-26, p=0.025]. In the multivariate analysis, circumferential calcifications [HR: 3.6, 95% CI: 1-13.2, p=0.043] but not major vascular complications (MVCs) or manufacturer recommendations were associated with increased mortality. Conclusion: According to our results, manufacturer recommendations are safe but overly conservative. Circumferential iliofemoral calcifications may provide independent prognostic information in patients undergoing TAVI.

An Unusual Cause of Electrocardiographic ST Elevation- Can the Japanese Fishing Industry Help Us?

A 76-year-old previously well woman presented after an unwitnessed collapse. She had no coronary disease risk factors. Physical examination result was unremarkable and she appeared well. Her ECG showed ST-segment elevation (V2-6/II/III and aVF) (Figure 1), and her troponin T level was 2.87 mg/L (normal limit 0.04 mg/L). Bedside transthoracic echocardiography showed akinesia of all mid and apical left ventricular segments (Figure 2). Invasive coronary angiography demonstrated no disease but apical ballooning on left-sided ventriculography (Figure 3).

Selection and timing for invasive therapy in non-ST-segment-elevation acute coronary syndrome

While outcomes for ST-segment-elevation myocardial infarction has significantly decreased over the last years, patients presenting with non-ST-segment-elevation acute coronary syndromes (NSTEACS) still have a rather high mortality. Longer term mortality over 4 years is about double the mortality after a ST-segment-elevation myocardial infarction. The reason for the poorer prognosis is unclear but is very likely to be partially explained by the generally older age of NSTEACS patients. The optimal therapy for NSTEACS is less well defined. In this review, the authors specifically discuss the role of coronary angiography, how to decide which patient should undergo this procedure and whether there is an optimal time point. The review provides an up-to-date discussion about the best treatment strategies for NSTEACS.