Yumiko Kanei

Transradial cardiac catheterization: a review of access site complications.

Transradial catheterization (TRC) has been associated with a lower incidence of major access site related complications as compared to the transfemoral approach. With the increased adoption of transradial access, it is essential to understand the potential major and minor complications of TRC. The most common complication is asymptomatic radial artery occlusion, which rarely leads to clinical events, owing to the dual collateral perfusion of the hand. Adequate anticoagulation, appropriate compression techniques, and smaller sheath size can minimize the risk of radial artery occlusion. Hand ischemia with necrosis has never been reported during TRC with thorough pre‐examination of intact collateral circulation. Radial artery spasm is relatively common, and can result in access and procedural failure. It can be prevented by the use of vasodilator cocktails and hydrophilic sheaths. Radial artery perforation can lead to severe forearm hematoma and compartment syndrome if not managed promptly. Careful observation, prompt detection of the hematoma, and management with a pressure bandage dressing are critical to avoid serious complications. Pseudoaneurym and arteriovenous fistula are rare complications, which can likely be managed conservatively without surgical intervention. Nerve injury occurring during access has been reported. Close observation for improvement is necessary, although symptoms usually improve over time. In summary, to prevent access site complications, avoidance of multiple punctures, gentle catheter manipulation, use of guided compression, coupled with careful observation for adverse warning signs such as hematoma, loss of pulse, pain, are critical for safe and effective TRC.

Randomized Comparison of Transradial Coronary Angiography Via Right or Left Radial Artery Approaches

Previous studies have shown that the right radial approach encounters more tortuosity than the left radial approach during transradial coronary angiography. The objective of this study was to compare the procedural difficulty of the right and left radial approaches in the modern era with dedicated transradial catheters. One hundred ninety-three patients scheduled for transradial coronary angiography with normal Allen test results and without histories of coronary artery bypass grafting were randomized to the right or left radial approach. The choice of catheter was left to the discretion of the operator, with the preferred catheter being a dedicated transradial Optitorque catheter. The primary end point was procedural difficulty, defined as (1) hydrophilic or coronary wire use for tortuosity, (2) stiff wire use for the coronary engagement, (3) multiple catheters used, or (4) nonselective injection. The clinical characteristics were similar between the 2 groups. Procedural success was achieved in 98 of 101 (98%) in the right radial group and 91 of 92 (99%) in the left radial group. Procedural difficulty, fluoroscopy time, and contrast use were similar between the 2 groups. The use of a single catheter was more common in the right radial group (73% vs 18%, p <0.001). In conclusion, procedural success and difficulty were similar in the comparison groups. The right and left radial approaches are feasible and effective to perform coronary angiography and intervention.

Meta-Analysis of Prospective Randomized Controlled Trials Comparing Intracoronary Versus Intravenous Abciximab in Patients With ST-Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Abciximab is a glycoprotein IIb/IIIa receptor inhibitor that has been shown to improve outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention (pPCI). An earlier study reported better efficacy with intracoronary (IC) compared to intravenous (IV) administration, but this finding has not been duplicated in other studies, thus leaving a great deal of uncertainty as to the most efficacious route of administration. To investigate if IC abciximab compared to IV administration decreases mortality and major adverse cardiac events in patients with ST-segment elevation myocardial infarction who undergo pPCI, a meta-analysis was performed consisting only of prospective randomized controlled trials. Subgroup analysis was performed to investigate the source of difference in efficacy between the 2 strategies. A meta-analysis of 4 trials including 1,148 subjects revealed that IC abciximab significantly reduced mortality compared to IV administration (1.5% vs 3.6%, odds ratio 0.44, 95% confidence interval 0.20 to 0.95, p = 0.04). Major adverse cardiac events were also reduced in a subgroup in which <30% of patients received aspiration thrombectomy (6.1% vs 16.2%, odds ratio 0.33, 95% confidence interval 0.18 to 0.61, p = 0.0004). In conclusion, the totality of the data available from relatively small but high-quality studies shows a significant mortality reduction associated using IC abciximab for pPCI compared to IV abciximab. IC abciximab in the setting of pPCI for ST-segment elevation myocardial infarction may be beneficial for patients with higher risk profiles.

ST-segment depression in aVr as a predictor of culprit artery and infarct size in acute inferior wall ST-segment elevation myocardial infarction

BACKGROUND ST-segment depression in lead aVR in acute inferior wall ST-segment elevation myocardial infarction (STEMI) has recently been suggested as a predictor of left circumflex (LCx) artery involvement. The purpose of this study is to evaluate the clinical significance of aVR depression during inferior wall STEMI. METHODS This study included 106 consecutive patients who presented with inferior wall STEMI and underwent urgent coronary angiogram. Clinical and angiographic findings were compared between patients with and without aVR depression > or = 0.1 mV. RESULTS The sensitivity and specificity of aVR depression as a predictor of LCx infarction were 53% and 86%, respectively. In patients with right coronary artery infarction, aVR depression was associated with increased cardiac enzymes and the involvement of a large posterolateral branch, which may explain the larger infarction. CONCLUSIONS ST-segment depression in lead aVR in inferior wall STEMI predicts LCx infarction or larger RCA infarction involving a large posterolateral branch.

Right versus left radial artery access for coronary procedures: An international collaborative systematic review and meta-analysis including 5 randomized trials and 3210 patients

BACKGROUND Radial artery access is a mainstay in the diagnosis and treatment of coronary artery disease. However, there is uncertainty on the comparison of right versus left radial access for coronary procedures. We thus undertook a systematic review and meta-analysis comparing right versus left radial access for coronary diagnostic and interventional procedures. METHODS Pertinent studies were searched in CENTRAL, Google Scholar, MEDLINE/PubMed, and Scopus, together with international conference proceedings. Randomized trials comparing right versus left radial (or ulnar) access for coronary diagnostic or interventional procedures were included. Risk ratios (RR) and weighted mean differences (WMD) were computed to generate point estimates (95% confidence intervals). RESULTS A total of 5 trials (3210 patients) were included. No overall significant differences were found comparing right versus left radial access in terms of procedural time (WMD=0.99 [-0.53; 2.51]min, p=0.20), contrast use (WMD=1.71 [-1.32; 4.74]mL, p=0.27), fluoroscopy time (WMD=-35.79 [-3.54; 75.12]s, p=0.07) or any major complication (RR=2.00 [0.75; 5.31], p=0.49). However, right radial access was fraught with a significantly higher risk of failure leading to cross-over to femoral access (RR=1.65 [1.18; 2.30], p=0.003) in comparison to left radial access. CONCLUSIONS Right and left radial accesses appear largely similar in their overall procedural and clinical performance during transradial diagnostic or interventional procedures. Nonetheless, left radial access can be recommended especially during the learning curve phase to reduce femoral cross-overs.

Relation of Race (Asian, African-American, European-American, and Hispanic) to Activated Clotting Time After Weight-Adjusted Bolus of Heparin During Percutaneous Coronary Intervention

A weight-adjusted bolus of heparin (70 to 100 IU/kg) is recommended to achieve adequate anticoagulation during percutaneous coronary intervention (PCI). Proper dosing is mandatory to avoid bleeding and thrombotic complications. We investigated whether sensitivity to heparin is affected by difference in race. We performed a retrospective study with 874 consecutive PCI cases in our catheterization laboratory. The amount of initial heparin bolus (international units) per weight and subsequent activated clotting time (ACT; seconds) were obtained. Patients were divided into 4 categories based on race: Asian, African-American, European-American, and Hispanic. Multiple regression analysis was performed to validate the variables that determine the ACT. After adjusting for these variables, analysis of variance revealed the presence of a significant racial difference in ACT (p = 0.002). Successively, Student-Newman-Keuls test and Bonferroni t test revealed that Asian patients have higher ACT levels compared to other racial groups (p <0.03 for Asian vs others, p >0.26 between non-Asian groups). There was a positive relation between ACT and Asian race (p = 0.0004). Further analyses showed that Asians require 10 IU/kg less heparin per weight than other racial groups to achieve the same goal of ACT. In conclusion, decreased heparin dosing should be considered for Asian patients undergoing PCI.

Prognostic impact of terminal T wave inversions on presentation in patients with ST-Elevation myocardial infarction undergoing urgent percutaneous coronary intervention

INTRODUCTION Terminal T wave inversions (TTWI) indicate advanced stages of ST-elevation myocardial infarction (STEMI). The present study investigated whether TTWI predict unfavorable in-hospital outcomes in STEMI patients treated with urgent percutaneous coronary intervention (PCI). METHODS A retrospective cohort study was performed with consecutive 188 STEMI cases undergoing urgent PCI. The primary endpoint was in-hospital major adverse cardiac event (MACE), and the secondary endpoints were ST resolution (STR) after PCI and length of stay (LOS). RESULTS TTWI on presentation were independently associated with higher incidence of in-hospital MACE (adjusted OR 2.8; 95% CI 1.1-7.0; p=0.03), inadequate STR (adjusted OR 5.5; 95% CI 2.1-14.3; p=0.01), and longer LOS (adjusted mean increase 4.1 days; 95% CI 0.3-7.9; p=0.03). TTWI predicted these outcomes better than patient-reported ischemic time or pathologic Q waves. CONCLUSIONS TTWI on presentation are an independent risk factor for poor inpatient prognosis among patients presenting with STEMI undergoing urgent PCI.

Electrocardiographic predictors of culprit artery in acute inferior ST elevation myocardial infarction

BACKGROUND In acute inferior ST-segment elevation myocardial infarction (STEMI), multiple electrocardiographic algorithms have been proposed to predict the culprit artery. Our purpose is to review these and compare them to ST depression in lead aVR to predict culprit artery in inferior STEMI. METHODS In 106 patients with acute inferior STEMI who underwent emergent coronary angiography, we correlated electrocardiographic and angiographic findings pertaining to the culprit artery. We then reviewed the algorithms proposed by Fiol et al and Tierala et al, and applied them and our own from Kanei et al using ST depression in aVR for predicting the left circumflex artery (LCx) as the culprit, to the population. Finally, we compared the sensitivities and specificities of the respective algorithms for predicting the culprit artery. RESULTS The sensitivity and specificity of ST depression in lead aVR to predict LCx as the culprit were 53% and 86%, respectively, and 86% and 55%, respectively for predicting the right coronary artery (RCA) as the culprit. When their algorithms were applied to our population, the sensitivities and specificities of Fiol et al and Tierala et al were slightly higher. CONCLUSION Compared to other proposed algorithms, ST depression in aVR is a simple method with satisfactory sensitivity and specificity to predict the culprit artery in inferior STEMI.

Does Oral Beta-Blocker Therapy Improve Long-Term Survival in ST-Segment Elevation Myocardial Infarction With Preserved Systolic Function? A Meta-Analysis.

Background: The effect of oral beta-blocker therapy on long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) who are treated with primary percutaneous coronary intervention (PCI) and who have preserved left ventricular ejection fraction (LVEF) remains unclear. Methods: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies evaluating the effect of oral beta-blocker therapy in patients with STEMI who underwent primary PCI and who had preserved LVEF. The primary outcome was all-cause mortality. Randomized controlled trials and the observational studies that reported an adjusted hazard ratio (or hazard ratio in the propensity score-matched patients) with follow-up duration equal to or more than 6 months were included. Pooled hazard ratio with 95% confidence interval (CI) was calculated using a random effect model. Results: No randomized controlled trials met the inclusion criteria. Seven observational studies totaling 10 857 patients met the inclusion criteria. Follow-up duration ranged from 6 months to 5.2 years. Preserved LVEF was defined as 40% in 4 studies and 50% in 3 studies. Based on the pooled estimate, oral beta-blocker therapy was associated with a reduction in all-cause mortality (combined hazard ratio 0.79, 95% CI 0.65-0.97). Conclusion: This meta-analysis demonstrates that oral beta-blocker therapy is associated with decreased all-cause mortality in patients with STEMI who are treated with primary PCI and who have preserved LVEF. This supports the current American College of Cardiology Foundation/American Heart Association 2013 Guideline for the Management of STEMI.

Shock Index as a predictor for In-hospital mortality in patients with non-ST-segment elevation myocardial infarction☆

BACKGROUND/PURPOSE Shock index (SI), a ratio of heart rate/systolic blood pressure, has been reported to predict increased mortality in patients with ST-segment elevation myocardial infarction. However, the prognostic value of SI has not been fully elucidated in patients with non-ST-segment elevation myocardial infarction (NSTEMI). METHODS/MATERIALS We performed a retrospective analysis of 481 consecutive NSTEMI patients who underwent coronary angiography from January 2013 to June 2014. Systolic blood pressure and heart rate on presentation were recorded, and SI was calculated as heart rate/systolic blood pressure. Patients were divided into those with SI≧0.7 and those with SI<0.7. Baseline and angiographic characteristics were recorded. In addition, cardiogenic shock and in-hospital mortality were recorded and compared between the two groups. RESULTS Among 481 patients, 103 patients (21.4%) had SI≧0.7. No statistically significant difference was observed in baseline characteristics between the two groups. Patients with SI≧0.7 had a lower left ventricular ejection fraction than those with SI<0.7 (56 [35-60] % vs. 60 [45-64] %, p=0.035). Patients with SI≧0.7 had a higher rate of cardiogenic shock on admission (2.9% vs. 0.3%, p=0.032). Patients with SI≧0.7 had a higher, albeit statistically insignificant, incidence of cardiogenic shock after admission (5.0% vs. 1.9%, p=0.074). The total incidence of cardiogenic shock was higher in patients with SI≧0.7 (7.8% vs. 2.1%, p=0.001). Patients with SI≧0.7 had higher in-hospital mortality (4.9% vs. 0.5%, p=0.006) than those with SI<0.7. CONCLUSION Elevated SI was associated with higher in-hospital mortality in patients with NSTEMI.