Seung Woon Rha

Sirolimus- Versus Paclitaxel-Eluting Stents for the Treatment of Coronary Bifurcations: Results From the COBIS (Coronary Bifurcation Stenting) Registry

OBJECTIVESnWe aimed to compare the long-term clinical outcomes of patients treated with sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) for coronary bifurcation lesions.nnnBACKGROUNDnThere are limited data regarding comparisons of SES and PES for the treatment of bifurcation lesions.nnnMETHODSnPatients who received percutaneous coronary intervention for non-left main bifurcation lesions were enrolled from 16 centers in Korea between January 2004 and June 2006. We compared major adverse cardiac events (MACE [cardiac death, myocardial infarction, or target lesion revascularization]) between the SES and PES groups in patients overall and in 407 patient pairs generated by propensity-score matching.nnnRESULTSnWe evaluated 1,033 patients with bifurcation lesions treated with SES and 562 patients treated with PES. The median follow-up duration was 22 months. Treatment with SES was associated with a lower incidence of MACE (hazard ratio [HR]: 0.53, 95% confidence interval [CI]: 0.32 to 0.89, p < 0.01) and target lesion revascularization (HR: 0.55, 95% CI: 0.31 to 0.97, p = 0.02), but not of cardiac death (HR: 2.77, 95% CI: 0.40 to 18.99, p = 0.62) and cardiac death or myocardial infarction (HR: 0.97, 95% CI: 0.38 to 2.49, p = 0.94). After propensity-score matching, patients with SES still had fewer MACE and target lesion revascularization incidences than did patients with PES (HR: 0.52, 95% CI: 0.30 to 0.91, p = 0.02, and HR: 0.48, 95% CI: 0.25 to 0.91, p = 0.02, respectively). There was no significant difference in the occurrences of stent thrombosis between the groups (0.7% vs. 0.7%, p = 0.94).nnnCONCLUSIONSnIn patients with bifurcation lesions, the use of SES resulted in better long-term outcomes than did the use of PES, primarily by decreasing the rate of repeat revascularization. (Coronary Bifurcation Stenting Registry in South Korea [COBIS]; NCT00851526).

Differential prognostic impact of treatment strategy among patients with left main versus non-left main bifurcation lesions undergoing percutaneous coronary intervention: results from the COBIS (Coronary Bifurcation Stenting) Registry II.

OBJECTIVESnThe authors sought to investigate whether the impact of treatment strategies on clinical outcomes differed between patients with left main (LM) bifurcation lesions and those with non-LM bifurcation lesions.nnnBACKGROUNDnFew studies have considered anatomic location when comparing 1- and 2-stent strategies for bifurcation lesions.nnnMETHODSnWe compared the prognostic impact of treatment strategies on clinical outcomes in 2,044 patients with non-LM bifurcation lesions and 853 with LM bifurcation lesions. The primary outcome was target lesion failure (TLF) defined as a composite of cardiac death, myocardial infarction (MI), and target lesion revascularization.nnnRESULTSnThe 2-stent strategy was used more frequently in the LM bifurcation group than in the non-LM bifurcation group (40.3% vs. 20.8%, p < 0.01). During a median follow-up of 36 months, the 2-stent strategy was not associated with a higher incidence of cardiac death (hazard ratio [HR]: 1.24; 95% confidence interval [CI]: 0.72 to 2.14; pxa0= 0.44), cardiac death or MI (HR: 1.12; 95% CI: 0.58 to 2.19; pxa0=xa00.73), or TLF (HR: 1.39; 95% CI: 0.99 to 1.94; pxa0= 0.06) in the non-LM bifurcation group. In contrast, in patients with LM bifurcation lesions, the 2-stent strategy was associated with a higher incidence of cardiac death (HR: 2.43; 95% CI: 1.05 to 5.59; pxa0= 0.04), cardiac death or MI (HR: 2.09; 95% CI: 1.08 to 4.04; pxa0= 0.03), as well as TLF (HR: 2.38; 95% CI: 1.60 to 3.55; p < 0.01). Significant interactions were present between treatment strategies and bifurcation lesion locations for TLF (pxa0= 0.01).nnnCONCLUSIONSnThe 1-stent strategy, if possible, should initially be considered the preferred approach for the treatment of coronary bifurcation lesions, especially LM bifurcation lesions. (Korean Coronary Bifurcation Stenting [COBIS] Registry II; NCT01642992).

Association of Beta-Blocker Therapy at Discharge With Clinical Outcomes in Patients With ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

OBJECTIVESnThis study sought to investigate the association of beta-blocker therapy at discharge with clinical outcomes in patients with ST-segment elevation myocardial infarction (STEMI) after primary percutaneous coronary intervention (PCI).nnnBACKGROUNDnLimited data are available on the efficacy of beta-blocker therapy for secondary prevention in STEMI patients.nnnMETHODSnBetween November 1, 2005 and September 30, 2010, 20,344 patients were enrolled in nationwide, prospective, multicenter registries. Among these, we studied STEMI patients undergoing primary PCI who were discharged alive (n = 8,510). We classified patients into the beta-blocker group (n = 6,873) and no-beta-blocker group (n = 1,637) according to the use of beta-blockers at discharge. Propensity-score matching analysis was also performed in 1,325 patient triplets. The primary outcome was all-cause death.nnnRESULTSnThe median follow-up duration was 367 days (interquartile range: 157 to 440 days). All-cause death occurred in 146 patients (2.1%) of the beta-blocker group versus 59 patients (3.6%) of the no-beta-blocker group (p < 0.001). After 2:1 propensity-score matching, beta-blocker therapy was associated with a lower incidence of all-cause death (2.8% vs. 4.1%, adjusted hazard ratio: 0.46, 95% confidence interval: 0.27 to 0.78, p = 0.004). The association with better outcome of beta-blocker therapy in terms of all-cause death was consistent across various subgroups, including patients with relatively low-risk profiles such as ejection fraction >40% or single-vessel disease.nnnCONCLUSIONSnBeta-blocker therapy at discharge was associated with improved survival in STEMI patients treated with primary PCI. Our results support the current American College of Cardiology/American Heart Association guidelines, which recommend long-term beta-blocker therapy in all patients with STEMI regardless of reperfusion therapy or risk profile.

Different Impact of Diabetes Mellitus on In-Hospital and 1-Year Mortality in Patients with Acute Myocardial Infarction Who Underwent Successful Percutaneous Coronary Intervention: Results from the Korean Acute Myocardial Infarction Registry

Background/Aims The aim of this study was to evaluate the impact of diabetes mellitus (DM) on in-hospital and 1-year mortality in patients who suffered acute myocardial infarction (AMI) and underwent successful percutaneous coronary intervention (PCI). Methods Among 5,074 consecutive patients from the Korea AMI Registry with successful revascularization between November 2005 and June 2007, 1,412 patients had a history of DM. Results The DM group had a higher mean age prevalence of history of hypertension, dyslipidemia, ischemic heart disease, high Killip class, and diagnoses as non-ST elevation MI than the non-DM group. Left ventricular ejection fraction (LVEF) and creatinine clearance were lower in the DM group, which also had a significantly higher incidence of in-hospital and 1-year mortality of hospital survivors (4.6% vs. 2.8%, p = 0.002; 5.0% vs. 2.5%, p < 0.001). A multivariate analysis revealed that independent predictors of in-hospital mortality were Killip class IV or III at admission, use of angiotensin converting enzyme inhibitors or angiotensin-II receptor blockers, LVEF, creatinine clearance, and a diagnosis of ST-elevated MI but not DM. However, a multivariate Cox regression analysis showed that DM was an independent predictor of 1-year mortality (hazard ratio, 1.504; 95% confidence interval, 1.032 to 2.191). Conclusions DM has a higher association with 1-year mortality than in-hospital mortality in patients with AMI who underwent successful PCI. Therefore, even when patients with AMI and DM undergo successful PCI, they may require further intensive treatment and continuous attention.

Comparing Two-Stent Strategies for Bifurcation Coronary Lesions: Which Vessel Should be Stented First, the Main Vessel or the Side Branch?

This study compared two-stent strategies for treatment of bifurcation lesions by stenting order, main across side first (A-family) vs side branch first (S-family). The study population was patients from 16 centers in Korea who underwent drug eluting stent implantation with two-stent strategy (A-family:109, S-family:140 patients). The endpoints were cardiac death, myocardial infarction (MI), stent thrombosis (ST), and target lesion revascularization (TLR) during 3 years. During 440.8 person-years (median 20.2 months), there was 1 cardiac death, 4 MIs (including 2 STs), and 12 TLRs. Cumulative incidence of cardiac death, MI and ST was lower in A-family (0% in A-family vs 4.9% in S-family, P = 0.045). However, TLR rates were not different between the two groups (7.1% vs 6.2%, P = 0.682). Final kissing inflation (FKI) was a predictor of the hard-endpoint (hazard ratio 0.061; 95% CI 0.007-0.547, P = 0.013), but was not a predictor of TLR. The incidence of hard-endpoint of S-family with FKI was comparable to A-family, whereas S-family without FKI showed the poorest prognosis (1.1% vs 15.9%, retrospectively; P = 0.011). In conclusion, A-family seems preferable to S-family if both approaches are feasible. When two-stent strategy is used, every effort should be made to perform FKI, especially in S-family.

Impact of bifurcation stent technique on clinical outcomes in patients with a Medina 0,0,1 coronary bifurcation lesion: results from the COBIS (COronary BIfurcation Stenting) II registry.

To compare the long‐term clinical outcomes of patients treated with 1‐ versus 2‐stent techniques for Medina 0,0,1 type bifurcation lesions. Background: Little is known about clinical outcomes and optimal treatment strategies for Medina 0,0,1 type bifurcation lesions

Predictors for Side Branch Failure During Provisional Strategy of Coronary Intervention for Bifurcation Lesions (from the Korean Bifurcation Registry).

The most favored strategy for bifurcation lesion is stenting main vessel with provisional side branch (SB) stenting. This study was performed to elucidate predictors for SB failure during this provisional strategy. The study population was patients from 16 centers in Korea who underwent drug-eluting stent implantation for bifurcation lesions with provisional strategy (1,219 patients and 1,236 lesions). On multivariate analysis, the independent predictors for SB jailing after main vessel stenting were SB calcification, large SB reference diameter, severe stenosis of SB, and not taking clopidogrel. Regarding SB compromise, however, the independent predictors were true bifurcation lesion and small SB reference diameter, whereas possible predictors were parent vessel thrombus and parent vessel total occlusion. In addition, SB predilation helps us to get favorable SB outcome. The diameter of SB ostium after main vessel stenting became similar between severe SB lesions treated with predilation and mild SB lesions not treated with predilation. In conclusion, SB calcification, less clopidogrel use, large SB reference diameter, and high SB diameter stenosis are independent predictors for SB jailing, and true bifurcation and small SB reference diameter are independent predictors for SB compromise after main vessel stenting.

Clinical influence of early follow-up glycosylated hemoglobin levels on cardiovascular outcomes in diabetic patients with ST-segment elevation myocardial infarction after coronary reperfusion

ObjectiveRecent studies have shown continuous control of diabetes is important for favorable outcomes in patients with ST-segment elevation myocardial infarction (STEMI). This study aimed to evaluate the clinical influence of postprocedural glycosylated hemoglobin A1c (HbA1c) levels on major adverse cardiac events (MACE) in diabetic patients with STEMI after coronary reperfusion. Patients and methodsA total of 303 patients with diabetes and STEMI undergoing a primary percutaneous coronary intervention were enrolled in this study. All eligible patients were divided into the following three groups on the basis of follow-up HbA1c (FU-HbA1c) levels, which were measured at a median of 85 days after the procedure: optimal, FU-HbA1c<7%; suboptimal, 7%⩽FU-HbA1c<9%; and poor, FU-HbA1c≥9%. We analyzed the 12-month cumulative MACE, defined as mortality, nonfatal myocardial infarction, and revascularization. In addition, we investigated FU-HbA1c levels as a predictor of MACE. ResultsThe incidence rates of MACE differed significantly between groups (6.4 vs. 13.6 vs. 19.6%; P=0.048). Moreover, the risk was increased in each successive group (hazard ratio: 1.00 vs. 2.19 vs. 3.68; P=0.046). Each 1% increase in the FU-HbA1c level posed a 26.6% relative increased risk of MACE (P=0.031). The optimal cutoff value for FU-HbA1c in predicting MACE was 7.45%. ConclusionThis study showed that higher levels of early FU-HbA1c after reperfusion in diabetic patients with STEMI were associated with increased 12-month MACE, suggesting continuous serum glucose level control even after reperfusion is important for a better outcome. FU-HbA1c seems to be a useful marker for predicting clinical outcome.

PHARMACOINVASIVE STRATEGY VERSUS PRIMARY PERCUTANEOUS CORONARY INTERVENTION IN PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION: A PROPENSITY SCORE MATCHED ANALYSIS

There is a paucity of data comparing pharmacoinvasive (PI) strategy versus primary percutaneous coronary intervention (PPCI) in real-world patients with ST-elevation myocardial infarction (STEMI).nnWe used the Korea Acute Myocardial Infarction Registry to identify STEMI patients receiving either PI

IMPACT OF IMMEDIATE INVASIVE STRATEGY IN PATIENTS WITH NON-ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION

Immediate invasive approach for acute myocardial infarction (MI) may permit treatment of the underlying plaque rupture as early as possible with subsequent reduction of death and recurrent MI. We sought to assess clinical impact of immediate invasive strategy for acute non-ST-segment elevation MI (