Silvia Homs

Impacto en tiempos de actuación y perfil de los pacientes tratados con angioplastia primaria en el área metropolitana sur de Barcelona al implantar el programa Código Infarto

INTRODUCTION AND OBJECTIVES A standardized protocol of emergent transfer for primary percutaneous coronary intervention for patients with ST elevation myocardial infarction, defined as the Infarction Code, was implemented in June 2009 in the Catalan regional health system. The objective of this study was to evaluate the impact of the new protocol on delay times, number of procedures and clinical characteristics compared with the previous period in the population of patients referred to our hospital. METHODS All consecutive patients undergoing primary percutaneous coronary intervention in our hospital were prospectively registered. The clinical characteristics, delay times and mortality in the follow-up of the protocol implementation period (June 2009-May 2010) were analyzed and compared with the previous year (June 2008-May 2009). RESULTS During the protocol period, 514 patients were included, compared with 241 in the previous year. Age, cardiovascular risk factors, anterior myocardial infarction and procedure characteristics were similar in the 2 groups. The first medical contact to balloon time was lower in the protocol period (median time 120 min vs 88 min; P<.001). Patients in the protocol period showed a trend toward less severe disease (Killip III, rescue angioplasty). The multivariate regression analysis showed a significant association between 1-year mortality and age, Killip class ≥ III at admission, anterior infarction and 3-vessel disease. CONCLUSIONS The introduction of the Infarction Code program increased the number of patients treated by primary percutaneous coronary intervention with a reduction in delay times and better clinical characteristics at presentation. Full English text available from:www.revespcardiol.org.

Lumen enlargement of the coronary segments located distal to chronic total occlusions successfully treated with drug-eluting stents at follow-up.

AIMS Chronic total occlusions (CTO) are the final stage of atherosclerosis. Occluded coronary arteries have large plaque burden and negative remodelling. The aim of this study was to assess lumen and vessel changes of segments located distal to successfully recanalised CTO. METHODS AND RESULTS Ninety-one CTO treated with drug-eluting stents underwent quantitative coronary angiography (QCA) at baseline and at 12-18 months; 31 underwent serial intravascular ultrasound (IVUS) imaging. Angiographic changes were assessed with QCA as differences in minimal, mean and maximal lumen diameter (MinLD, MeanLD and MaxLD, respectively). Vessel changes were assessed with IVUS as changes in plaque and vessel volume. At follow-up, angiographic MinLD increased 23.9% (from 0.88±0.32 to 1.09±0.35 mm; p<0.01), MeanLD 16.4% (from 1.59±0.44 to 1.85±0.45 mm; p<0.01) and MaxLD 11.7% (from 2.39±0.67 to 2.67±0.70 mm; p<0.01). Lumen enlargement was greater in non-restenotic lesions, small lumen area at the end of the index procedure and low LDL-cholesterol levels during the study. By IVUS, lumen volume increased 26.9% (from 108.1±89.2 to 137.3±115.3 mm3; p<0.01), vessel volume increased 12.1% (from 207.1±170.2 to 232.2±196.0 mm3; p<0.01) and plaque volume tended to decrease 3.9% (from 98.9±88.7 to 94.9±89.3 mm3; p=0.07). Small lumen at baseline was related to greater lumen enlargement. CONCLUSIONS Segments distal to recanalised CTO showed a notable lumen and vessel enlargement with a trend toward mild plaque regression. Low LDL-cholesterol levels increase lumen enlargement.

Clopidogrel pretreatment in primary percutaneous coronary intervention: Prevalence of high on-treatment platelet reactivity and impact on preprocedural patency of the infarct-related artery

To date, there is limited data on levels of platelet inhibition achieved in patients with ST-elevation myocardial infarction (STEMI) who are loaded with clopidogrel and aspirin (ASA) prior to undergoing primary percutaneous coronary intervention (P-PCI). The aim of this investigation was to evaluate the percentage of STEMI patients with high on-treatment platelet reactivity (HPR) to clopidogrel at the time of initiating P-PCI and its association with the initial patency of the infarct-related artery (IRA). This prospective pharmacodynamic study included 50 STEMI patients, previously naïve to oral antiplatelet agents, who received 500-mg ASA and 600-mg clopidogrel loading doses prior to P-PCI. Platelet function assessment was performed at the beginning of the procedure using various assays, including VerifyNow™ system (primary endpoint), light transmission aggregometry and multiple electrode aggregometry. The percentage of patients with suboptimal response to clopidogrel and ASA assessed with the VerifyNow™ system was 88.0% and 28.6%, respectively. Similar results were obtained with the other assays used. A higher percentage of patients with initial patency of the IRA was observed among those patients without HPR compared with those with HPR to clopidogrel (66.7% vs 15.9%; p=0.013), while no differences were observed regarding postprocedural angiographic or electrocardiographic outcomes. In conclusion, this study shows that a high percentage of STEMI patients have inadequate levels of clopidogrel-induced and, to a lesser extent, aspirin-mediated platelet inhibition when starting a P-PCI procedure, and suggests that a poor response to clopidogrel might be associated with impaired initial TIMI flow in the IRA.

Seguimiento a largo plazo tras el tratamiento percutáneo del tronco coronario izquierdo no protegido en pacientes de alto riesgo no aptos para cirugía de revascularización

INTRODUCTION AND OBJECTIVES Percutaneous coronary intervention is recommended in patients with unprotected left main stenosis non suitable for coronary artery bypass graft. Long-term follow-up of those patients remains uncertain. METHODS All patients with de novo unprotected left main stenosis treated with stent implantation were consecutively enrolled. Percutaneous coronary intervention was indicated according to the standards of care, taking into account clinical and anatomical conditions unfavorable for coronary artery bypass graft. The primary end point was the occurrence of major adverse cardiac events, a composite of death, nonfatal acute myocardial infarction, or target lesion revascularization. RESULTS Of 226 consecutive patients included, 202 (89.4%) were treated with drug-eluting stents. Mean age was 72.1 years, 41.1% had renal dysfunction, and mean Syntax score and EuroSCORE were 28.9 and 7.4, respectively. Angiographic and procedural success was achieved in 99.6% and 92.9% of patients. At 3 years, the rates of major adverse cardiac events, death, nonfatal acute myocardial infarction and target lesion revascularization were 36.2%, 25.2%, 8.4%, 8.0%, respectively. Target lesion revascularization was more frequently observed when ≥ 2 stents were implanted rather than a single stent (18.5% vs 5.8%, P=.03); and with bare metal stents rather than drug-eluting stents (13.0% vs 7.9%, P=.24). Definite stent thrombosis was observed in 2 patients (0.9%) and probable stent thrombosis in 7 (3.1%). Female sex, impaired left ventricular function, and use of bare metal stents were significantly related with all-cause mortality. CONCLUSIONS High-risk patients with unprotected left main stenosis treated with percutaneous coronary intervention presented with a high rate of major adverse cardiac events at long-term follow-up. Female sex, impaired left ventricular function, and use of bare metal stents were predictors of poor prognosis.

Preserved endothelial vasomotor function after everolimus-eluting stent implantation

AIMS To compare the degree of endothelial dysfunction (ED) in patients treated with everolimus-eluting stent (EES) versus bare metal stent (BMS) implantation. METHODS AND RESULTS This is an observational study. A total of 30 elective patients (15 treated with EES and 15 with BMS) were recruited. All patients underwent coronary angiography and intracoronary acetylcholine (Ach) test at different doses at six months after stent implantation. Quantitative coronary angiography analysis was performed to evaluate the changes in mean luminal diameter (MLD) of the segments distal to the distal stent edge after increasing doses of Ach. Both EES and BMS groups had similar baseline characteristics except for stent length (18.6±2.5 vs. 16.5±2.5 mm; p=0.033) and diameter (3.1±0.2 vs. 3.4±0.3 mm; p=0.007). The vasomotion test showed that EES had 3.14% of MLD decrease after Ach infusion and BMS had 2.35% of vasoconstriction (p=0.62). After adjustment for baseline characteristics, no statistical difference was observed between groups. CONCLUSIONS In our study EES implantation was associated with a low degree of ED and had a similar vasomotion response as compared to BMS. Prospective randomised investigations are warranted to confirm these findings.

MGuard Mesh-Covered Stent for Treatment of ST-Segment Elevation Myocardial Infarction with High Thrombus Burden Despite Manual Aspiration

OBJECTIVES To assess the usefulness of the MGuard stent in patients with ST-segment elevation myocardial infarction (STEMI) in whom a high thrombus burden persists after manual aspiration. BACKGROUND In some patients with STEMI, a high thrombus burden may persist after manual aspiration. These patients may be at high risk of distal embolization and therefore impaired myocardial reperfusion. The MGuard is a novel mesh-covered stent designed to minimize thrombus embolization. METHODS Single-arm, prospective registry of patients with STEMI and high thrombus burden after aggressive thrombus aspiration treated with the MGuard stent. High thrombus burden was defined as thrombus burden grade 4 or 5 according to the TIMI score. Lesions with a side branch ≥2 mm and patients with cardiogenic shock were not included. The study end-points were proportion of final TIMI 3 flow, normal myocardial blush, and complete ST-segment resolution. RESULTS Fifty-six patients were included. After MGuard stent implantation >85% of cases had thrombus score = 0. Final TIMI 3 flow was achieved in 82% of cases, normal myocardial blush in 55%, and complete ST-segment resolution in 59%. Occlusion of a side branch (<2 mm) occurred in 2 cases (3.5%), embolization to a distal branch in 5 cases (8.9%), and transient no-reflow in 4 cases (7.1%). Major adverse cardiac events rate at 9 months was 3.6%, including 1 definite acute stent thrombosis and 1 target-vessel revascularization. CONCLUSIONS The MGuard stent may be useful to prevent distal embolization in patients with STEMI and high thrombus burden despite mechanical aspiration.

RED BLOOD CELL TRANSFUSION INCREASES PLATELET REACTIVITY IRRESPECTIVE OF ANTIPLATELET THERAPY

background: Red blood cell (RBC) transfusion is an independent risk factor of ischemic events, including mortality, in patients with an acute coronary syndrome. It has been reported that RBC transfusion enhances platelet activation and aggregation in vitro in healthy volunteers. The aim of the present investigation was to evaluate ex vivo if RBC transfusion increases platelet activation in patients with and without antiplatelet therapy.

[Superiority of levosimendan to dobutamine in postoperative low cardiac output syndrome: is it due to previous beta-blocker treatment?].

We have read with interest the article of Levin et al1 in which the authors present a randomized comparison between levosimendan (LS) and dobutamine (Db) in postoperative low cardiac output syndrome. They conclude that LS is superior to Db in terms of morbidity, mortality, and length of hospital stay. A key aspect is the fact that, of the 68 patients randomized to Db, 45 (85.3%) had received preoperative treatment with beta-blockers. As expressed in the clinical practice guidelines concerning acute heart failure,2 patients who receive treatment with beta-blockers require higher doses of Db to restore its inotropic effect. Likewise, the LIDO study,3 which demonstrates that LS brings about a greater improvement in the hemodynamic parameters in patients with severe left ventricular dysfunction than Db, concludes that treatment with beta-blockers attenuates the action of Db, but not that of LS. The statistically significant differences between LS and Db in terms of hemodynamic parameters encountered in the study of Levin et al could be due to the lower chronotropic and inotropic activity of Db, as the majority of the patients had previously received treatment with beta-blockers. These hemodynamic differences at such a crucial time as when early postoperative low cardiac output develops (initiation of inotropy 3.5 hours after the surgical intervention) can ultimately have an impact on morbidity and mortality. In short, we can conclude that the action of LS, in contrast to that of Db, is not attenuated by treatment with beta-blockers. This aspect is important, since LS can be considered a highly appropriate treatment in cases of severe left ventricular dysfunction and as a concomitant treatment with previous beta-blockers.

Superioridad del levosimendán comparado con dobutamina en el síndrome de bajo gasto cardiaco postoperatorio. ¿Se debe al tratamiento previo con bloqueadores beta?

Hemos leído con interés el artículo de Levin et al en el que se presenta una comparación aleatorizada entre levosimendán (LS) y dobutamina (Db) en el síndrome de bajo gasto cardiaco postoperatorio; en él se concluye la superioridad del LS frente a Db en cuanto a morbimortalidad y estancia hospitalaria. Un aspecto clave es que, de los 68 pacientes aleatorizados a dobutamina, 45 (85,3%) se encontraban en tratamiento preoperatorio con bloqueadores beta. Tal y como expresan las Guías de Práctica Clínica de la insuficiencia cardiaca aguda, los pacientes que reciben tratamiento con bloqueadores beta precisan mayores dosis de Db para restaurar su efecto inotrópico. Asimismo, el estudio LIDO —que muestra que el LS mejora los parámetros hemodinámicos en pacientes con disfunción ventricular izquierda severa respecto a la Db— concluye que el tratamiento con bloqueadores beta atenúa la acción de la Db pero no la del LS. Las diferencias estadísticamente significativas en los parámetros hemodinámicos entre LS y Db encontrados en el estudio de Levin et al pudieran deberse a la menor actividad cronotrópica e inotrópica de la Db, por encontrarse la mayoría de los pacientes en tratamiento previo con bloqueadores beta. Estas diferencias hemodinámicas en un momento tan crucial como es el bajo gasto cardiaco postoperatorio precoz (inicio de inotropo 3,5 h tras la intervención quirúrgica) pueden acabar repercutiendo en la morbimortalidad. En definitiva, podemos concluir que la acción del LS, a diferencia de la Db, no resulta atenuada por el tratamiento con bloqueadores beta. Este aspecto es importante, ya que el LS puede considerarse un tratamiento muy apropiado en casos de disfunción ventricular izquierda severa y tratamiento concomitante previo con bloqueadores beta.