Tone Svilaas

Thrombus aspiration during primary percutaneous coronary intervention.

BACKGROUND Primary percutaneous coronary intervention (PCI) is effective in opening the infarct-related artery in patients with myocardial infarction with ST-segment elevation. However, the embolization of atherothrombotic debris induces microvascular obstruction and diminishes myocardial reperfusion. METHODS We performed a randomized trial assessing whether manual aspiration was superior to conventional treatment during primary PCI. A total of 1071 patients were randomly assigned to the thrombus-aspiration group or the conventional-PCI group before undergoing coronary angiography. Aspiration was considered to be successful if there was histopathological evidence of atherothrombotic material. We assessed angiographic and electrocardiographic signs of myocardial reperfusion, as well as clinical outcome. The primary end point was a myocardial blush grade of 0 or 1 (defined as absent or minimal myocardial reperfusion, respectively). RESULTS A myocardial blush grade of 0 or 1 occurred in 17.1% of the patients in the thrombus-aspiration group and in 26.3% of those in the conventional-PCI group (P<0.001). Complete resolution of ST-segment elevation occurred in 56.6% and 44.2% of patients, respectively (P<0.001). The benefit did not show heterogeneity among the baseline levels of the prespecified covariates. At 30 days, the rate of death in patients with a myocardial blush grade of 0 or 1, 2, and 3 was 5.2%, 2.9%, and 1.0%, respectively (P=0.003), and the rate of adverse events was 14.1%, 8.8%, and 4.2%, respectively (P<0.001). Histopathological examination confirmed successful aspiration in 72.9% of patients. CONCLUSIONS Thrombus aspiration is applicable in a large majority of patients with myocardial infarction with ST-segment elevation, and it results in better reperfusion and clinical outcomes than conventional PCI, irrespective of clinical and angiographic characteristics at baseline. (Current Controlled Trials number, ISRCTN16716833.)

Incidence and clinical consequences of distal embolization on the coronary angiogram after percutaneous coronary intervention for ST-elevation myocardial infarction

AIMS We investigated the incidence and sequelae of angiographically visible distal embolization (AVDE) after primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction patients treated with aspirin, heparin, clopidogrel, and glycoprotein-IIb/IIIa inhibitors. METHODS AND RESULTS As part of TAPAS, AVDE was a predefined secondary endpoint. We compared angiographic and clinical characteristics, and outcomes of patients with and without AVDE after PCI. AVDE was present on 6.3% of 883 post-procedural angiograms. Angiographically visible distal embolization was associated with significantly worse outcomes, as expressed by lower myocardial blush grade, impaired ST-segment resolution, and higher enzyme levels (all P </= 0.001). Mortality 1 year after PCI was 4 of 56 (7.1%) in patients with AVDE and 43 of 827 (5.2%) in patients without AVDE (P= ns), re-infarction occurred in 5 of 56 (8.9%), and 25 of 827 (3.0%) patients (P = 0.018). The thrombus aspirate more often contained erythrocytes in patients with AVDE than in patients without AVDE (50.0% vs. 15.7%, P < 0.001), and the size of the aspirated thrombus was larger in patients with AVDE (P = 0.002). CONCLUSION In patients with triple anti-platelet therapy, the incidence of AVDE after PCI is low, compared with previous reports. Nevertheless, AVDE is associated with impaired myocardial reperfusion and poor outcome. Thrombus composition and size are related to AVDE after PCI.

Impact of Pretreatment With Clopidogrel on Initial Patency and Outcome in Patients Treated With Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction. A Systematic Review

Background— The main goal of the initial treatment of ST-segment elevation myocardial infarction is prompt reperfusion of the infarct-related artery. The value of pretreatment with clopidogrel before primary percutaneous coronary intervention is currently unclear. Methods and Results— Studies were retrieved through MEDLINE and Cochrane Controlled Trials Register searches over the past 20 years. Two authors independently performed the study selection and data extraction. Randomized controlled studies were included when the research subjects were unselected patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention. Pilot trials, studies that enrolled patients undergoing rescue percutaneous coronary intervention, and studies with angiographic assessment not performed by a core laboratory or 2 blinded investigators were excluded. Thirty-eight treatment groups, including 8429 patients, were included. Initial patency was higher in treatment groups in which patients received pretreatment with clopidogrel (34.3%; 95% confidence interval, 32.9 to 35.8) compared with those in which patients did not receive clopidogrel before initial coronary angiography (25.8%; 95% confidence interval, 24.5 to 27.1). In multivariate-weighted logistic regression analysis, pretreatment with clopidogrel was an independent predictor of early reperfusion (odds ratio, 1.51; 95% confidence interval, 1.31 to 1.74; P<0.0001) and improved clinical outcome. Conclusions— Initial patency and clinical outcome were improved in treatment groups that received pretreatment with clopidogrel. These results in patients undergoing primary percutaneous coronary intervention are in line with the experience of pretreatment with clopidogrel in elective patients, non–ST-elevation coronary syndromes, and thrombolytic studies.

Role of coronary artery bypass grafting during the acute and subacute phase of ST-elevation myocardial infarction.

Background/Objectives. We aimed to investigate the incidence and clinical outcome of coronary artery bypass grafting (CABG) performed in contemporary patients with ST-elevation myocardial infarction (STEMI) within 30 days after presentation.Methods. All 1071 patients enrolled in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS) were included in this analysis. CABG was indicated for both ischaemic and anatomical reasons according to the current treatment guidelines for STEMI. For all surgical as well as non-surgical patients, clinical outcome was assessed at both 30 days and one year. Results. CABG was performed within 30 days of presentation in 59/1071 (5.5%) patients, in 13 (22%) within 24 hours, in eight (14%) between one and three days, and in 38 (64%) between four and 30 days. Compared with non-surgical patients, surgical patients required more initial intra-aortic balloon pump support (33 vs. 5%, p<0.001) and more often had multi-vessel disease (p<0.001). Overall, rethoracotomy was performed in 9/59 (15%) patients. In patients operated within three days, the rethoracotomy rate was markedly higher than after three days (33 vs. 5%, p=0.004). Cardiac mortality at 30 days and one year was 1.7% in the surgical group and 3.2 and 5.3%, respectively, in the non-surgical group. Conclusion. STEMI patients treated with CABG within three days after presentation are at increased risk of rethoracotomy. However, despite this higher incidence of surgical complications and multiple high-risk features at presentation, surgical management during the acute and subacute phase is associated with excellent 30-day and one-year survival. (Neth Heart J 2010;18:348-54.)

A quantitative estimate of bare-metal stenting compared with balloon angioplasty in patients with acute myocardial infarction: angiographic measures in relation to clinical outcome

We performed a systematic review of all randomised controlled trials (RCTs) from the pre-drug-eluting-stent era comparing bare-metal stenting (BMS) with balloon angioplasty in patients with acute myocardial infarction (MI) to examine coronary angiographic parameters of infarct-related vessel patency and to relate the angiographic measures to clinical outcome. The search was restricted to published RCTs in humans. 10 RCTs, (6192 patients) were analysed. Compared with balloon angioplasty, BMS was associated with reduced rates of reocclusion (6.7% vs 10.1%, OR 0.62, 95% CI 0.40 to 0.96, p = 0.03) and restenosis (23.9% vs 39.3%, OR 0.45, 95% CI 0.34 to 0.59, p<0.001), but not with reduced rates of subacute thrombosis (1.7% in both groups). BMS showed a reduction in target vessel revascularisation (TVR; 12.2% vs 19.2%, OR 0.50, 95% CI 0.37 to 0.69, p<0.001), but not in mortality (5.3% vs 5.1%) or reinfarction (3.9% vs 4%). The findings of this study support BMS placement in acute MI. The discrepancy between angiographic and clinical parameters has important implications for future studies investigating further technical improvements in mechanical reperfusion therapy.

Predictive value of Q waves on the 12-lead electrocardiogram after reperfusion therapy for ST elevation myocardial infarction

DESIGN The data used for the present study were obtained as part of a clinical trial evaluating the effect of thrombus aspiration after primary percutaneous coronary intervention (PCI). SETTING The study was conducted at a tertiary referral facility for primary PCI at a University Medical Center Groningen in The Netherlands. BACKGROUND Prognosis after ST elevation myocardial infarction (STEMI) is strongly related to infarct size. METHODS As part of a randomized clinical trial, the first electrocardiogram (ECG) after primary PCI for STEMI was analyzed for the incidence of Q waves (>0.1 mV) on the 12-lead ECG. Infarct size was measured as area under curve (AUC) of creatine kinase (CK) and CK-myocardial band (CK-MB). RESULTS AND CONCLUSION Nine hundred thirty-three patients were included, the median number of Q waves on the postprocedural ECG was 3 (interquartile range, 1-4). The number of Q waves on the postprocedural ECG was an independent predictor of infarct size measured either as AUC of CK (P < .001) or AUC of CK-MB (P < .001) and was a significant predictor of mortality during follow-up of 14 months. In conclusion, the number of Q waves on the postprocedural 12-lead ECG after primary PCI for STEMI is a strong predictor of infarct size and long-term mortality.

Long-term arterial complications of chemotherapy in patients with cancer

The number of cancer survivors has gradually increased in recent decades. However, the cancer survivors are at risk for conditions related to their initial disease and its treatment, i.e. surgery, systemic treatment or radiotherapy. Cardiovascular complications, such as myocardial infarction, are common side effects of these therapies. Cardiovascular damage can occur during treatment or month to years after the initial treatment, as late effect of the cancer treatment. The pathophysiology of these effects is not yet fully understood, but an important part of the cardiovascular complications are thought to be the result of effects of anticancer agents on the structural and functional properties of the endothelium. Because these conditions can result in a high degree of morbidity and mortality, understanding how to improve the prevention, recognition, and treatment of vascular disease is an important medical priority in the care for cancer survivors. This review will focus on the long-term arterial complications of chemotherapy in cancer survivors. It will summarize the epidemiology and pathophysiology of these complications. Furthermore, important long-term clinical conditions related to these effects will be outlined, including cardiovascular risk management in terms of prevention, evaluation and therapy.

Response to Letter Regarding Article, “Impact of Pretreatment With Clopidogrel on Initial Patency and Outcome in Patients Treated With Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction: A Systematic Review

We thank Dr Ryding et al for their comments on our systematic review that investigated the impact of pretreatment with clopidogrel on initial coronary patency (Thrombolysis in Myocardial Infarction trial 2/3 flow) before primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction.1 No published randomized trials on this subject exist, so we investigated the impact of clopidogrel pretreatment by comparing treatment groups in studies in which patients received pretreatment with clopidogrel with those in which patients did not. To eliminate as …