Shmuel Fuchs

Incidence, predictors, and prognostic implications of bleeding and blood transfusion following percutaneous coronary interventions

Bleeding related to percutaneous coronary intervention (PCI) occurs relatively frequently. We retrospectively investigated the incidence, predictors, and prognostic impact of periprocedural bleeding and transfusion in 10,974 patients who underwent PCI. Bleeding definitions were based on Thrombolysis In Myocardial Infarction (TIMI) criteria: (1) major bleeding (n = 588; 5.4%): if patients had a hemorrhagic stroke or if hematocrit decreased >15 points or by 10 to 15 points with clinical bleeding; (2) minor bleeding (n = 1,394; 12.7%): if hematocrit decreased <10 points with clinical bleeding or by 10 to 15 points without clinical bleeding; and (3) no bleeding (n = 8,992; 81.9%): if hematocrit decreased <10 points without clinical bleeding. Patients with major bleeding were older than patients with minor or no bleeding (67.8 +/- 11 vs 65.9 +/- 11 vs 63.6 +/- 11 years, respectively; p <0.001) and more often experienced intraprocedural complications, such as emergency use of an intra-aortic balloon pump (13.6% vs 6.5% vs 2.3%, respectively; p <0.001). Multivariate logistic regression analysis identified the use of an intra-aortic balloon pump (odds ratio [OR] 3.0, p <0.0001), procedural hypotension (OR 2.9, p <0.001), and age >80 years (OR 1.9 compared with age <50 years, p = 0.001) as the strongest predictors for major bleeding. Patients who had major bleeding had higher in-hospital and 1-year mortality compared with patients with minor or no bleeding. Bleeding was an independent predictor of in-hospital death. Thus, periprocedural major bleeding occurs relatively frequently and is associated with adverse outcomes. Patients >80 years of age who experience intraprocedural complications are at particularly high risk.

Comparison of the Predictive Value of Four Different Risk Scores for Outcomes of Patients With ST-Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Accurate risk stratification has an important role in the management of patients with acute coronary syndromes. Even in patients with ST-elevation acute myocardial infarction (STEMI), for whom early therapeutic options are well defined, risk stratification has an impact on early and late therapeutic decision making. We aimed to compare the prognostic value of 4 risk scores used to evaluate patients with STEMI. We conducted a prospective registry of all patients treated with primary percutaneous coronary intervention for STEMI from January 2001 to June 2006. Excluded were patients with cardiogenic shock. A total of 855 consecutive patients were included in the analysis (age 60.5 +/- 13 years, 19% women, 28% with diabetes, and 48% with anterior wall myocardial infarction). For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Controlled Abciximab and Device Investigation to Lower Late Angioplasty complications (CADILLAC), Primary Angioplasty in Myocardial Infarction (PAMI), and Global Registry for Acute Coronary Events (GRACE) risk scores were calculated using specific clinical variables and angiographic characteristics. Thirty-day and 1-year clinical outcomes were assessed. The predictive accuracy of the 4 risk scores was evaluated using the area under the curve or C statistic method. The CADILLAC, TIMI, and PAMI risk scores all had relatively high predictive accuracy for 30-day and 1-year mortality (C statistic range 0.72 to 0.82), with slight superiority of the CADILLAC score. These 3 risk scores also performed well for prediction of reinfarction at 30 days (C statistic range 0.6 to 0.7). The GRACE score did not perform as well and had low predictive accuracy for mortality (C statistic 0.47). In conclusion, risk stratification of patients with STEMI undergoing primary percutaneous coronary intervention using the CADILLAC, TIMI, or PAMI risk scores provide important prognostic information and enables accurate identification of high-risk patients.

Ischemic hepatitis: Clinical and laboratory observations of 34 patients

Ischemic hepatitis, a relatively infrequent disorder occurring in 0.16% to 0.50% of patients admitted to medical intensive care units, often follows episodes of hypotension or acute heart failure. Investigating the clinical characteristics of patients with ischemic hepatitis may add to our understanding of the pathogenesis and significance of this syndrome. We therefore conducted a retrospective analysis of 34 patients to examine the possible contribution of the various baseline characteristics to the severity of the hepatic damage. In all patients liver disease was unexpected and in some, liver dysfunction dominated the clinical picture. All patients had high serum glutamic pyruvic transaminase (SGPT) and lactic dehydrogenase (LDH) levels (mean +/- SE, 2073 +/- 255 international units and 6085 +/- 748 international units, respectively). The mean SGPT/LDH ratio was 0.34. Most patients had coagulopathy with a prolonged prothrombin time (mean +/- SE, 5.86 +/- 1.37 international normalized ratio [INR]). The most common diagnosis on admission was respiratory distress secondary to various causes. Before the development of the hepatic dysfunction, respiratory failure and hypoxemia were observed in 68% of the patients, whereas hypotension was observed in only 38%. More than 90% of the patients had three or more associated comorbid conditions. The most frequent of these were left heart failure (88.2%), right heart failure (67.6%), chronic obstructive lung disease (58.8%), and chronic renal failure (55.9%). During the acute episode, more than 90% of the patients had transient deterioration of their renal functions. Hypoglycemia was noted in 11 patients (32.4%), and the glucose level was inversely correlated with the SGPT level (r = -0.43, p = 0.01). Stepwise multiple regression analysis showed that left heart failure, systolic blood pressure lower than 90 mm Hg, and female gender, together, accounted for 34% of the variance of the peak SGPT levels (p = 0.002). Fourteen (41.2%) patients died during the 3-month follow-up period, but none from the hepatic injury. None of the clinical or laboratory parameters measured predicted mortality. Clearly, ischemic hepatitis is associated with a high risk of death. The characteristic patients are those with multiple underlying systemic diseases and conditions, especially those with left heart failure. Liver function test results and levels of liver enzymes should be monitored in these patients, particularly when they are admitted for respiratory deterioration and episodes of hypotension.

Major bleeding complicating contemporary primary percutaneous coronary interventions-incidence, predictors, and prognostic implications.

BACKGROUND Major bleeding is one of the most frequent procedural-related complications of primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infraction (STEMI). We investigated the incidence, predictors, and prognostic impact of peri-procedural bleeding in a cohort of unselected patients undergoing contemporary primary PCI. METHODS A total of 831 consecutive patients who underwent primary PCI between 1/2001 and 6/2005 were studied. Major bleeding was defined as hemorrhagic stroke, hemoglobin (Hb) drop of >5 g%, or 3-5 g% with a need for blood transfusion. Clinical outcomes were evaluated at 30 days and 6 months. RESULTS Major bleeding occurred in 27 patients (3.5%). Those who experienced major bleeding were older (66+/-15 vs. 61+/-13, P=.02), more frequently female gender (48% vs. 27%, P=.0001), presented more often with cardiogenic shock (37% vs. 8%, P=.0001), and had higher CADILLAC score (7.8+/-4.5 vs. 5.1+/-4.0, P=.002) and activated clotting time (ACT) levels (284+/-63 vs. 248+/-57 s, P=.007). In multivariate analysis, significant predictors of major bleeding were female gender (OR 5.1, 95% CI 1.7-15.2, P=.004), ACT levels >250 s (OR 3.6, 95% CI 1.1-12.1, P=.04), and use of intra-aortic balloon pump (IABP) (OR 3.5, 95% CI 1.0-12.1, P=.047). Major bleeding was associated with increased 6-month mortality rates (37% vs. 10%, P=.0001), which remained significant after adjustment for baseline CADILLAC score (37% vs. 19.4%, P=.05). CONCLUSIONS Major bleeding complicating primary PCI is associated with increased 6-month mortality. Women and those who need IABP support are at particularly high risk. Tight monitoring of anticoagulation may reduce the risk of bleeding.

Type-II Myocardial Infarction – Patient Characteristics, Management and Outcomes

Background Type-II MI is defined as myocardial infarction (MI) secondary to ischemia due to either increased oxygen demand or decreased supply. This categorization has been used for the last five years, yet, little is known about patient characteristics and clinical outcomes. In the current work we assessed the epidemiology, causes, management and outcomes of type II MI patients. Methods A comparative analysis was performed between patients with type-I and type-II MI who participated in two prospective national Acute Coronary Syndrome Israeli Surveys (ACSIS) performed in 2008 and 2010. Results The surveys included 2818 patients with acute MI of whom 127 (4.5%) had type-II MI. The main causes of type-II MI were anemia (31%), sepsis (24%), and arrhythmia (17%). Patients with type-II MI tended to be older (75.6±12 vs. 63.8±13, p<0.0001), female majority (43.3% vs. 22.3%, p<0.0001), had more frequently impaired functional level (45.7% vs. 17%, p<0.0001) and a higher GRACE risk score (150±32 vs. 110±35, p<0.0001). Patients with type-II MI were significantly less often referred for coronary interventions (36% vs. 89%, p<0.0001) and less frequently prescribed guideline-directed medical therapy. Mortality rates were substantially higher among patients with type-II MI both at thirty-day (13.6% vs. 4.9%, p<0.0001) and at one-year (23.9% vs. 8.6%, p<0.0001) follow-ups. Conclusions Patients with type-II compared to type-I MI have distinct demographics, increased prevalence of multiple comorbidities, a high-risk cardiovascular profile and an overall worse outcome. The complex medical condition of this cohort imposes a great therapeutic challenge and specific guidelines with recommended medical treatment and invasive strategies are warranted.

The risk of cardiac complications following noncardiac surgery in patients with drug eluting stents implanted at least six months before surgery.

Aims: Given the anecdotal reports and case series suggesting that drug‐eluting coronary stents [DES] may be still vulnerable to coronary thrombosis after six months, we sought to assess this risk in patients undergoing non‐cardiac surgery six months after stenting. Methods and Results: Linking the Rabin Medical Centre interventional cardiology database with its non‐cardiac surgical database, we identified 78 patients who underwent DES placement and subsequently [after six months] had noncardiac surgery [15‐vascular, 37‐ abdominal and genitourinary and 26‐others, excluding ophthalmic surgery]. Outcome measures included 30‐day rate of postoperative myocardial infarction (MI), DES‐related thrombosis, and cardiac mortality. Major adverse cardiac events [death and non‐fatal MI] occurred in 6 (7.7%) patients including 2 cardiac deaths (2.6%), 4 (5.1%) non‐fatal myocardial infarctions (MIs). Two patients (2.6%) sustained stent thrombosis [one patient had ‘definite’ and one ‘probable’ stent thrombosis]. All MIs [including stent thrombosis] occurred in the vascular and abdominal surgery group. Two of the MIs events occurred while the patients were on dual antiplatelet agents. In conclusions: Perioperative cardiac events during non cardiac surgery after six months of DES deployment still occur. These cardiac complications [not entirely prevented by continued dual antiplatelet agents] remain a matter of diagnostic and therapeutic challenge and concern.

Hematocrit Level as a Marker of Outcome in ST-Segment Elevation Myocardial Infarction

Anemia is a well-known predictor of a poor outcome in patients with ST-segment elevation myocardial infarction (STEMI). In contrast, data relating erythrocytosis to clinical outcomes in patients with STEMI are limited. Because erythrocytosis predisposes to a prothrombotic state, we hypothesized it would be associated with an increased risk of thrombotic complications in patients with STEMI undergoing primary percutaneous coronary intervention. We studied 1,042 consecutive patients with STEMI who underwent primary percutaneous coronary intervention and were a part of our primary percutaneous coronary intervention registry from 2001 to 2007. Patients with cardiogenic shock and late arrival were excluded. Patients were allocated into 3 groups according to their baseline hematocrit: anemia (<36% for women and <39% for men), normal, erythrocytosis (>46% for women and >47% for men). The clinical outcomes were assessed at 1, 6, and 12 months. The patients with anemia had the greatest clinical risk profile. Patients with erythrocytosis had a lower risk profile than the other 2 groups, except for greater rates of smoking. The mortality rates were greatest among the patients with anemia, followed by the patients with erythrocytosis, who in turn had greater short-term mortality than patients with normal hematocrit. Multivariate analysis, which included patients with erythrocytosis and those with normal hematocrit (excluding the patients with anemia), revealed that erythrocytosis was associated with an odds ratio of 4.3 (95% confidence interval 1.4 to 13, p = 0.01) for 1-month mortality. In conclusion, although not as strong a predictor of mortality as anemia, erythrocytosis might be associated with increased short-term mortality compared to a normal hematocrit. The measurement of hematocrit can be used as a useful prognostic marker in patients with STEMI.

Imaging of vulnerable coronary artery plaques.

Advances in the identification of vulnerable plaque can be an important step in preventing myocardial infarction and sudden cardiac death. The recognition that non‐flow‐limiting plaques often produce cardiac events has led to the development of invasive and non‐invasive methods to identify such plaques prospectively. This review will present the use of noninvasive imaging modalities for identifying vulnerable plaque such as computed tomography and magnetic resonance imaging. We will also review the different invasive modalities such as intravascular magnetic resonance imaging, intravascular ultrasound, coronary angioscopy, coronary thermography, optical coherence tomography, near‐infrared spectroscopy, and palpography.

The impact of circadian variation on outcomes in emergency acute anterior myocardial infarction percutaneous coronary intervention

Objectives: We investigated the impact of primary coronary angioplasty performed during night and compared to the impact of that performed during day‐time on outcomes of patients with acute ST elevation anterior wall myocardial infarction (AMI). Methods: We prospectively followed 273 consecutive patients of whom 160 (58.6%) were treated during day time (8:00 a.m. to 6 p.m.) and 113 (41.4%) were treated “off hours”/at night (6 p.m. to 8 a.m.). Baseline demographics, angiographic factors, and clinical outcomes (death, recurrent AMI, and need for repeat revascularization) were compared between the groups. Results: Baseline clinical characteristics were similar between the two groups. Unadjusted mortality at one‐month was significantly higher among patients who were treated during night compared with those treated at day‐time (9.7% vs. 3.1% P = 0.03), as was adverse cardiac event rate (15.9% vs. 6.9%; P = 0.02). Multiple logistic regression analysis adjusted for the CADILLAC risk score demonstrated that this score, which includes baseline LVEF, renal failure, Killip class, final TIMI flow, age>65 years, anemia, and the number of coronary vessel diseases, is a significant predictor of one‐month mortality, while the effect of time of treatment was borderline (night vs. day; odds ratio 2.7; 95% confidence interval, 0.8–9.4; P = 0.095). Conclusions: The results of this study indicate that patients with anterior myocardial infarction treated during night time have worse unadjusted short‐term clinical outcomes despite no delay from onset of symptoms to actual treatment. Larger studies are needed in order to identify potential contributors to this phenomenon.

The ACIST power injection system reduces the amount of contrast media delivered to the patient, as well as fluoroscopy time, during diagnostic and interventional cardiac procedures

The ACIST injection system is an automatic power injection device that allows for online control of injection rate and volume of contrast. Limited data is available whether this technology allows reducing use of contrast and fluoroscopy time. Accordingly, we compared the use of this system to manual injection among 450 consecutive patients who underwent diagnostic coronary angiography and/or angioplasty who were randomly assigned to either manual contrast injection (control; n = 198) or to the ACIST system (study group; n = 252). The amount of contrast, fluoroscopy and total procedural times were recorded for each patient. In the diagnostic group, the mean total amount of contrast (including wasted) was reduced by 63% when the ACIST was used compared to control (100±42 ml versus 163±56 ml; P<0.001, respectively). When only the net amount of contrast delivered to the patient was considered, the differences were smaller (20%, P = 0.004). During angioplasty, the amount of contrast was also lower in the ACIST group (206±65 versus 230±69, P = 0.008), whereas no difference were noted in net amount of contrast. Fluoroscopy time was significantly shorter in the ACIST group compared to control both during diagnostic catheterization (4.7±3.5 min versus 6.3±5.5 min, respectively; P = 0.014), and angioplasty (16.7±9.1 min versus 19.6±12.4 min, respectively; P = 0.05). Routine utilization of the ACIST system during diagnostic and interventional procedure significantly reduced the total amount of contrast media used and fluoroscopy time.