Rutger L. Anthonio

Cardiac death and reinfarction after 1 year in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS): a 1-year follow-up study

BACKGROUNDnPercutaneous coronary intervention (PCI) for ST-elevation myocardial infarction can be complicated by spontaneous or angioplasty-induced embolisation of atherothrombotic material. Distal blockage induces microvascular obstruction and can result in less than optimum reperfusion of viable myocardium. The Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) found that thrombus aspiration resulted in improved myocardial reperfusion compared with conventional PCI, but whether this benefit improves clinical outcome is unknown. We aimed to investigate whether the early efficacy of thrombus aspiration seen in TAPAS translated into clinical benefit after 1 year.nnnMETHODSnPatients with ST-elevation myocardial infarction enrolled at the University Medical Centre Groningen were randomly assigned in a 1:1 ratio to either thrombus aspiration or conventional treatment, before undergoing initial coronary angiography. Exclusion criteria were rescue PCI after thrombolysis and known existence of a concomitant disease with life expectancy less than 6 months. Of the 1071 patients enrolled between January, 2005, and December, 2006, vital status at or beyond 1 year after randomisation was available for 1060 (99%). The primary endpoint was cardiac death or non-fatal reinfarction after 1 year, and analysis was by intention to treat. The TAPAS trial is registered with Current Controlled Trials number ISRCTN16716833.nnnFINDINGSnCardiac death at 1 year was 3.6% (19 of 535 patients) in the thrombus aspiration group and 6.7% (36 of 536) in the conventional PCI group (hazard ratio [HR] 1.93; 95% CI 1.11-3.37; p=0.020). 1-year cardiac death or non-fatal reinfarction occurred in 5.6% (30 of 535) of patients in the thrombus aspiration group and 9.9% (53 of 536) of patients in the conventional PCI group (HR 1.81; 95% CI 1.16-2.84; p=0.009).nnnINTERPRETATIONnCompared with conventional PCI, thrombus aspiration before stenting of the infarcted artery seems to improve the 1-year clinical outcome after PCI for ST-elevation myocardial infarction.

Effects of Aspirin on Angiotensin-Converting Enzyme Inhibition and Left Ventricular Dilation One Year After Acute Myocardial Infarction

There are conflicting reports on the interaction of aspirin with angiotensin-converting enzyme inhibitors in heart failure and systemic hypertension. A post hoc analysis of the Captopril and Thrombolysis Study (CATS) study was conducted. At randomization, 94 patients (31.5%) took aspirin. In patients who took aspirin, the cumulative alpha-hydroxy butyrate dehydrogenase release was 1,151 +/- 132 IU/L in patients randomized to captopril compared with 1,401 +/- 136 IU/L in patients randomized to placebo (difference -250 +/- 189 [95% confidence interval (CI) -620 to 120]). This difference was comparable to the difference in patients who did not use aspirin (-199 +/- 147 [95% CI -488 to 897]). One year after acute myocardial infarction, an increase in left ventricular end-diastolic volume index of 2.2 +/- 3.0 ml/m2 in captopril-treated and 1.9 +/- 2.9 ml/m2 in placebo-treated patients was observed in patients who took aspirin (difference 0.4 +/- 4.2 [95% CI -8.2 to 8.9]). This difference was also comparable to the difference in patients who did not take aspirin (2.2 +/- 3.8 [95% CI -5.2 to 9.7]). One year after acute myocardial infarction, patients who did take aspirin had a mean change in LV end-diastolic volume index of 2.1 +/- 2.1 ml/m2 compared with 8.4 +/- 1.9 ml/m2 in patients who did not use aspirin (p = 0.02). Thus, aspirin does not attenuate the acute and long-term effects of angiotensin-converting enzyme inhibition after acute myocardial infarction, but independently reduces LV dilation after myocardial infarction.

A Comparison of 2 Thrombus Aspiration Devices With Histopathological Analysis of Retrieved Material in Patients Presenting With ST-Segment Elevation Myocardial Infarction

OBJECTIVESnThe objective of this study was to compare 2 manual thrombus aspiration catheters in unselected patients with ST-segment elevation myocardial infarction.nnnBACKGROUNDnDistal embolization is common during percutaneous coronary intervention in ST-segment elevation myocardial infarction and can induce impaired myocardial perfusion. Several aspiration thrombectomy devices have been introduced to prevent distal embolization, however, with conflicting clinical results. Currently, it is unclear to what extent this variance in outcome can be explained by device-related factors, such as internal lumen size.nnnMETHODSnWe performed a prospective cohort study in which patients undergoing primary percutaneous coronary intervention were treated with a large-internal-lumen catheter (Diver, Invatec, Roncadelle, Italy). Outcomes were compared with a matched population of the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) trial, in which patients were treated with a medium-sized catheter (Export, Medtronic, Minneapolis, Minnesota). A histopathological analysis was performed of retrieved material.nnnRESULTSnA total of 160 patients, treated with the Diver (n = 80) or Export (n = 80) aspiration catheter, were enrolled. Effective thrombus aspiration was seen in 70.3% of the patients treated with the Diver catheter versus 81.8% with the Export catheter (p = 0.10) No significant difference was found in myocardial blush grade or electrocardiographic outcome between the 2 devices. Size distribution of retrieved thrombotic particles was similar per device. Erythrocyte-rich thrombi were found in 34.8% of the cases and were predominately seen in patients with low initial Thrombolysis In Myocardial Infarction flow grade (p = 0.008).nnnCONCLUSIONSnA larger internal lumen diameter does not result in retrieval of larger thrombotic particles, nor in improved angiographic or electrocardiographic outcomes.

β-Adrenoceptor density in chronic infarcted myocardium: a subtype specific decrease of β1-adrenoceptor density

Abstract β-adrenoceptor density is altered in different cardiac diseases. In heart failure β-adrenoceptor density is down regulated but in acute myocardial ischemia β-adrenoceptor density is up regulated. In hearts with myocardial infarction total β-adrenoceptor density is decreased shortly after myocardial infarction. Aims and methods: To investigate whether total β-adrenoceptor number is altered in the chronic phase after myocardial infarction, and to identify the specificity of alteration, we studied male Wistar rats ( n =18) which underwent a ligation of the left coronary artery or a sham operation. Twelve weeks after coronary ligation, rats were sacrificed and hearts were excised, perfused to obtain blood-free myocardium and frozen in liquid nitrogen. Infarcted myocardium was identified visually and separated from non-infarcted myocardium. Total β-adrenoceptor number was calculated in fmol (−)-[ 125 I]iodocyanopindolol specifically bound/mg protein and the relative amount of β 1 - and β 2 -adrenoceptor density was measured by inhibition of (−)-[ 125 I] iodocyanopindolol binding with CGP 20712 A. Results: Total β-adrenoceptor number in infarcted myocardium was significantly decreased (25.7±1.4 vs. 24.9±2.2 vs. 20.1±3.2 fmol/mg protein ( P =0.03) resp. Sham vs. Non-infarcted vs. Infarcted myocardium), due to a decrease of only β 1 -adrenoceptor density (14.7±0.61 vs. 12.7±1.09 vs. 4.84±0.96 fmol/mg protein ( P =0.004) resp.), whereas the β 2 -adrenoceptor density and the dissociation constant ( K d ) were not significantly decreased. Conclusion: In the infarcted myocardium total β-adrenoceptor density is decreased due to a decreased β 1 -adrenoceptor density at 12 weeks after myocardial infarction.

The Feasibility and Safety of Routine Thrombus Aspiration in Patients With Non-ST-Elevation Myocardial Infarction

To investigate the feasibility and safety of manual thrombus aspiration in patients undergoing percutaneous coronary intervention (PCI) for non‐ST‐elevation myocardial infarction (NSTEMI).

The effect of electrical neurostimulation on collateral perfusion during acute coronary occlusion

BackgroundElectrical neurostimulation can be used to treat patients with refractory angina, it reduces angina and ischemia. Previous data have suggested that electrical neurostimulation may alleviate myocardial ischaemia through increased collateral perfusion. We investigated the effect of electrical neurostimulation on functional collateral perfusion, assessed by distal coronary pressure measurement during acute coronary occlusion. We sought to study the effect of electrical neurostimulation on collateral perfusion.MethodsSixty patients with stable angina and significant coronary artery disease planned for elective percutaneous coronary intervention were split in two groups. In all patients two balloon inflations of 60 seconds were performed, the first for balloon dilatation of the lesion (first episode), the second for stent delivery (second episode). The Pw/Pa ratio (wedge pressure/aortic pressure) was measured during both ischaemic episodes. Group 1 received 5 minutes of active neurostimulation before plus 1 minute during the first episode, group 2 received 5 minutes of active neurostimulation before plus 1 minute during the second episode.ResultsIn group 1 the Pw/Pa ratio decreased by 10 ± 22% from 0.20 ± 0.09 to 0.19 ± 0.09 (p = 0.004) when electrical neurostimulation was deactivated. In group 2 the Pw/Pa ratio increased by 9 ± 15% from 0.22 ± 0.09 to 0.24 ± 0.10 (p = 0.001) when electrical neurostimulation was activated.ConclusionElectrical neurostimulation induces a significant improvement in the Pw/Pa ratio during acute coronary occlusion.

Beta-Blocker Titration Failure is Independent of Severity of Heart Failure

In the present study, predictors of complicated initiation of beta blockade in patients with idiopathic dilated cardiomyopathy was studied. We found that generally accepted measures of severity of heart failure are not predictable, whereas low systolic blood pressure (< or =120 mm Hg) was the strongest predictor for problematic (up)titration.

Left ventricular dilatation after myocardial infarction: ACE inhibitors, beta-blockers, or both?

Left ventricular (LV) dilatation after myocardial infarction (MI) is a major predictor of prognosis and identifies which patients will develop heart failure. Left ventricular dilatation or remodeling starts immediately after MI and progresses in the chronic phase of heart failure. Factors influencing remodeling, such as infarct size and neurohumoral activation, including the sympathetic and renin-angiotensin system, are discussed. Remodeling can be affected by reduction of infarct size and inhibition of neurohumoral activation. The effect of thrombolysis, beta-blockade, and angiotensin-converting enzyme (ACE) inhibition in the acute phase after MI and in the chronic phase of heart failure on remodeling are discussed. On the basis of beneficial effects of ACE inhibition and beta-blockade in acute MI and in chronic heart failure, a treatment strategy is proposed in which both ACE inhibition and beta-blockade are started early after MI. Depending on infarct size and ventricular function, continued treatment in the chronic phase of heart failure must be considered.

Incidence and angiographic predictors of collateral function in patients with stable coronary artery disease scheduled for percutaneous coronary intervention.

Objectives: To investigate the incidence and angiographic predictors of functional collateral perfusion in patients with stable coronary artery disease, scheduled for elective PCI. Background: Functional collateral perfusion is defined as a Pw/Pa ratio ≥0.24. Since this can only be measured intracoronary, it is important to investigate baseline clinical and angiographic predictors for functional collateral perfusion. Methods: Collateral perfusion was measured during balloon inflation, with the use of a pressure‐monitoring guide wire. Baseline clinical and angiographic characteristics were analyzed and collateral grading was done according to Rentrops classification for coronary angiograms. Results: Functional collateral perfusion was found in 40 of the 89 patients (45%). Angiographic signs of collaterals (Rentrop ≥ 1) were present in 15 of the 89 patients. Of the 40 patients with the functional collateral perfusion 11 patients (28%) had Rentrop ≥1; of the 49 patients without functional collaterals there were 4 patients with Rentrop ≥1 (8%) (P = 0.02). There were no significant differences in baseline clinical characteristics or in other angiographic characteristics. Conclusions: In patients with stable coronary artery disease scheduled for elective PCI, 45% have functional collaterals. Rentrops angiographic classification can be used to predict the presence or absence of functional collaterals, however with a rather modest positive and negative predictive value.

Life-threatening bilateral aorto-ostial coronary artery disease in an octogenarian

Aorto-ostial disease is difficult to approach percutaneously; therefore, a surgical option may be more desirable. We describe a case of an octogenarian in which the clinical arguments and technical approach have been summarised for a successful percutaneous therapeutic strategy. (Neth Heart J 2009;17:30-2.)