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Antiplatelet therapy is key to the care of coronary artery disease. Continuous improvement in the understanding of athero-thrombosis and the pathways of platelet activation has led to tremendous enhancement in the care of patients. The addition of a P2Y12-ADP receptor blocker in particular was a great leap forward in the care of acute coronary syndrome patients and those undergoing percutaneous coronary intervention (PCI). However, the development of platelet assays has demonstrated that the one fits it all dosing of clopidogrel resulted in various levels of platelet reactivity (PR) inhibition which translated into varying clinical outcomes. Clopidogrel resistance or high on-clopidogrel platelet reactivity (high on-treatment platelet reactivity, HTPR) was identified and correlated with poor clinical outcome. In addition further to this early finding, researchers have also demonstrated that low on-clopidogrel platelet reactivity was associated with bleedings. In the present review, we aimed to summarize the mechanism and etiologies of HTPR in clopidogrel-treated patients and its clinical importance.

In case of coronary artery disease (CAD), diabetic patients are at higher risk than their non-diabetic counterparts. Antithrombotics are therefore of key importance to decrease the risk of ischemic complications. A careful assessment of the benefit-risk balance is however needed to limit the risk of bleeding. Diabetic CAD patients are characterized by a pro-thrombotic milieu and by an impaired response to both aspirin and P2Y12 receptor inhibitors, especially to clopidogrel. When combined with aspirin, the new P2Y12 receptor inhibitors prasugrel and ticagrelor provide superior efficacy for the diabetic patients with acute coronary syndromes. In stable CAD, antiplatelet monotherapy (aspirin) remains for the time being the reference treatment for diabetic as well as for non-diabetic patients; further studies are however ongoing to test whether the antithrombotic strategy should be reinforced, particularly in case of diabetes mellitus. Finally, although chronic oral anticoagulation is rarely indicated for CAD management in itself, it is often prescribed for the concomitant treatment of atrial fibrillation. The combination of anticoagulation and antiplatelet therapy is associated with a high risk of bleeding and should only be prescribed for limited periods of time when the estimated benefits exceed the risks.

Background Prevalence and correlates of prolonged dual antiplatelet therapy (DAPT) in stable coronary artery disease (CAD) are unknown. Our aims were to assess the proportion of stable CAD patients under long-term DAPT and the correlates of its prescription, and to analyze its impact on prognosis. Methods Between 2010 and 2011, 3691 patients with stable CAD for at least 1 year (median 4 years) were divided in 2 groups according to their antiplatelet therapy regimen at inclusion: patients under DAPT were compared to those under single antiplatelet therapy (SAPT). Results Altogether, 868 (24%) patients received DAPT. Factors associated with long-term DAPT were a time interval since the last coronary event Conclusions Our study shows that a high proportion of stable CAD patients is under DAPT in modern practice. Several correlates of DAPT were identified. Of note and even so no increase in bleeding was observed, our results do not support the prescription of prolonged DAPT.

Background The clinical benefit of ticagrelor compared to clopidogrel in ACS patients suggested off-target property. Such pleiotropic effect could be mediated by circulating endothelial progenitor cells (EPC) which are critical for vascular healing. We aimed to investigate the impact of ticagrelor on EPC in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Methods We prospectively randomized 106 ACS patients to ticagrelor or clopidogrel. Sub-populations of CD34+ circulating progenitor cells (PC) were analyzed by flow cytometry allowing one to determine the levels of CD34+ PC, CD34+CD45+ Hematopoietic PC, CD34+133+ immature PC and CD34+KDR+ EPC on admission and at 1month. Changes in PC level were calculated as the difference between 1month and baseline value. Results The 2 groups were similar regarding baseline characteristics including PC numbers on admission. The 2 groups had similar change in overall CD34+ PC and hematopoietic CD34+45+ PC level (p=0.2). On the contrary, when considering CD34+133+ PC and CD34+KDR+ EPC, we observed that patients treated by ticagrelor had a significantly higher increase in levels of these PC subtypes compared to those treated by clopidogrel (0.23 (−0.33; 0.79) vs 0.00 (−0.5; 0.34); p=0.04 and 0.01 (−0.04; 0.05) vs −0.01 (−0.06; 0.03); p=0.02). Changes in the level of CD34+CD133+ PC correlated with platelet activity measured by the VASP index (r=−0.30; p=0.008). By contrast the increase in the level of CD34+KDR+ EPC in the ticagrelor group was independent of platelet activity. Conclusions Ticagrelor increases the number of EPC in ACS patients suggesting a benefit on endothelial regeneration that may participate in the pleiotropic property of the drug.

Background In patients with coronary artery disease (CAD), non-optimal use of evidence-based medications is associated with an increased risk of adverse outcome. Aims To assess the prevalence and correlates of non-optimal secondary medical prevention in patients with stable CAD. Methods We included 4184 consecutive outpatients with stable CAD. Treatment at inclusion was classified as optimal/non-optimal regarding the four major classes of secondary prevention drugs: antithrombotics; statins; angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs); and beta-blockers. For each treatment, the prescription was considered non-optimal if the drug was missing despite a class IA indication according to international guidelines. To assess the information globally, non-optimal secondary prevention was defined as at least one major treatment missing. Results The proportions of patients with non-optimal treatment were 0.7%, 7.8%, 12.9% and 10.3% for antithrombotics, statins, ACE inhibitors/ARBs and beta-blockers, respectively. Non-optimal secondary medical prevention was observed in 16.8% of cases. By multivariable analysis, the correlates of non-optimal secondary medical prevention were long time interval since last coronary event (P

Summary Background The ideal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is under debate. Lesion length is a well-recognized predictor of PCI complexity and long-term outcome. Aim To evaluate the determinants and impact on outcome of long-term DAPT in a retrospective cohort of patients treated for a long coronary lesion. Methods Patients ( n = 460) who underwent PCI for a long lesion (> 30 mm) were divided into two groups according to antiplatelet regimen at 1 year: patients who stopped DAPT before 1 year (single antiplatelet therapy group; n = 168) and patients who continued DAPT for longer than 1 year ( n = 292). Results Mean lesion length was 35.7 ± 7.1 mm. The proportion of patients who continued DAPT after 1 year was 63.5%. The main determinants of long-term DAPT were initial presentation as myocardial infarction and implantation of a drug-eluting stent. Median follow-up was 37.4 (23–51) months after the 1-year period following the index PCI. Long-term DAPT was highly associated with a lower risk of all-cause and cardiovascular mortality by multivariable analysis and after adjustment for other predictors: hazard ratios 0.11 (95% confidence interval 0.03–0.32) and 0.15 (95% confidence interval 0.04–0.62), respectively. No increase in major bleeding was noted. Conclusion In a contemporary practice, nearly two-thirds of patients who undergo PCI for a long lesion are treated with DAPT for several years. Our results suggest that long-term DAPT is beneficial in this subset of patients identified as being at high risk.

Rationale: Long noncoding RNAs represent a novel class of molecules regulating gene expression. Long noncoding RNAs are present in body fluids, but their potential as biomarkers was never investigated in cardiovascular disease. Objective: To study the role of long noncoding RNAs as potential biomarkers in heart disease. Methods and Results: Global transcriptomic analyses were done in plasma RNA from patients with or without left ventricular remodeling after myocardial infarction. Regulated candidates were validated in 3 independent patient cohorts developing cardiac remodeling and heart failure (788 patients). The mitochondrial long noncoding RNA uc022bqs.1 (LIPCAR) was downregulated early after myocardial infarction but upregulated during later stages. LIPCAR levels identified patients developing cardiac remodeling and were independently to other risk markers associated with future cardiovascular deaths. Conclusions: LIPCAR is a novel biomarker of cardiac remodeling and predicts future death in patients with heart failure.

To assess the level of secondary prevention and the outcome of coronary artery disease (CAD) in patients who have a history of non-coronary vascular intervention.Patients with polyvascular disease have been reported to receive less evidence-based medications, with worse risk factor control and to be at higher risk than patients with single-bed disease. It is unknown whether these findings remain valid in the modern era of secondary prevention.We included 4184 patients with stable CAD. Two groups were formed according to the absence (n = 3704) or presence (n = 480) of a history of non-coronary vascular intervention. Treatments and risk factor control were recorded at inclusion. Follow-up was performed after 2 years.Antiplatelets, angiotensin system antagonists, beta-blockers and statins were widely prescribed in both groups. The number of antihypertensive drugs was higher in patients with non-coronary vascular intervention. Except for slight increases in the rate of current smokers and in systolic blood pressure, risk factor control was similar between groups. All-cause and cardiovascular mortality rates were higher in patients with non-coronary intervention with adjusted HR of 1.55 (1.13-2.13) (p = 0.007), and 1.98 (1.24-3.15) (p = 0.004), respectively.In modern practice and real life conditions, the higher risk of CAD patients with a history of non-coronary vascular intervention is taken into account, with more intense secondary prevention and similar risk factor control than patients without such history. In spite of the level of secondary prevention, patients with a history of non-coronary vascular intervention remain at high risk of cardiovascular events. This should be an incentive to discuss more stringent objectives for secondary prevention in patients with polyvascular disease.

Clopidogrel low response as assessed by several different biological tests correlates with poor prognosis after percutaneous coronary intervention (PCI). However, recent randomized clinical trials (RCT) testing the strategy of individual antiplatelet therapy tailoring based on one sole test have all shown negative results. Poor correlation between the different tests may explain the difficulties of patient selection and identification of "true poor responders" to clopidogrel. In this prospective study, clopidogrel response was assessed in 100 consecutive patients between 18 and 24 hours after a 600 mg clopidogrel loading dose using three different tests: light transmission aggregometry with 10 μmol ADP (LTA, results expressed as platelet aggregation percentage: PAP), Verify Now P2Y12 (VN, results expressed as P2Y12 reaction unit: PRU) and vasodilatator-stimulated phosphoprotein (VASP, results expressed as platelet reactivity index: PRI). Patients under chronic clopidogrel therapy were excluded. The mean PAP, PRU and PRI values were 38.6%, 176.1 PRU and 52.4%, respectively. When clopidogrel response was analyzed as continuous variable, there was a good correlation between the different tests: LTA/VN (R(2 )= 0.642, p 0.001), LTA/VASP (R(2 )= 0.409, p 0.001) and VN/VASP (R(2 )= 0.616, p 0.001). However, when clopidogrel response was analyzed as pre-specified cut-off points to define patients as "poor or good responders" (according to the literature: 50% PAP for LTA, 235 PRU for VN and 50% PRI for VASP), only 47% of the patients were defined as "good" or "poor responders" by the three tests. Altogether, 33% of the patients were defined as "poor responders" by only one test, 20% by two tests and only 16% by the three tests. The correlation between the different tests is good when clopidogrel response is analyzed as continuous variable. Each individual is however rarely (less than 50%) defined as "poor or good responder" by all the three tests when pre-specified cut-off values are used. A sole test might not be sufficient to manage antiplatelet therapy in an individual patient and these results may explain the results of recent RCT showing the lack of benefit of systematic antiplatelet therapy monitoring strategy.

[1] Tabib A, Loire R, Chalabreysse L, et al. Circumstances of death and gross and microscopic observations in a series of 200 cases of sudden death associated with arrhythmogenic right ventricular cardiomyopathy and/or dysplasia. Circulation 2003;108:3000–5. [2] Quarta G, Syrris P, Ashworth M, et al. Mutations in the Lamin A/C gene mimic arrhythmogenic right ventricular cardiomyopathy. Eur Heart J 2012;33:1128–36. [3] Taylor M, Graw S, Sinagra G, et al. Genetic variation in titin in arrhythmogenic right ventricular cardiomyopathy-overlap syndromes. Circulation 2011;124:876–85. [4] Marshall W, Furey M, Larsen B, et al. Correspondence to: right ventricular cardiomyopathy and sudden death in young people. N Eng J Med 1988;319:174–5. [5] Marcus FI, McKenna WJ, Sherrill D, et al. Diagnosis of arrhythmogenic right ventricular cardiomyopathy/dysplasia: proposed modification of the Task Force Criteria. Eur Heart J 2010;31:806–14. [6] Peters S, Trummel M, Koehler B. Special features of right bundle branch block in patients with arrhythmogenic right ventricular cardfiomyopathy/dysplasia. Int J Cardiol 2012;157:102–3. [7] Peters S, Trummel M, Koehler B. QRS fragmentation in standard ECG as a diagnostic marker of arrhythmogenic right ventricular dysplasia–cardiomyopathy. Heart Rhythm 2008;5:1417–21. [8] Vasawala SC, Finn C, Delpriore J, et al. Prospective study of cardiac sarcoid mimicking arrhythmogenic right ventricular dysplasia. J Cardiovasc Electrophysiol 2009;20:473–6. [9] Martini B, Nava A, Thiene G, et al. Ventricular fibrillation without apparent heart disease: description of six cases. Am Heart J 1989;118:1203–9. [10] Hodgkinson KA, Parfrey PS, Bassett AS, et al. The impact of implantable cardioverterdefibrillator therapy on survival in autosomal-dominant arrhythmogenic right ventricular cardiomyopathy (ARVD5). J Am Coll Cardiol 2005;45:400–8. [11] Von Tintelen JP, Van Gelder IC, Asimaki A, et al. Severe cardiac phenotype with right ventricular predominance in a large cohort of patients with a single missence mutation in the DES gene. Heart Rhythm 2009;6:1574–83.

Background Stent thrombosis remains among the most feared complications of percutaneous coronary intervention (PCI) with stenting. However, data on its incidence and predictors are sparse and conflicting. We thus aimed to perform a collaborative systematic review on incidence and predictors of stent thrombosis. Methods PubMed was systematically searched for eligible studies from the drug-eluting stent (DES) era (1/2002–12/2010). Studies were selected if including ≥2000 patients undergoing stenting or reporting on ≥25 thromboses. Study features, patient characteristics, and incidence of stent thrombosis were abstracted and pooled, when appropriate, with random-effect methods (point estimate [95% confidence intervals]), and consistency of predictors was formally appraised. Results A total of 30 studies were identified (221,066 patients, 4276 thromboses), with DES used in 87%. After a median of 22months, definite, probable, or possible stent thrombosis had occurred in 2.4% (2.0%; 2.9%), with acute in 0.4% (0.2%; 0.6%), subacute in 1.1% (1.0%; 1.3%), late in 0.5% (0.4%; 0.6%), and very late in 0.6% (0.4%; 0.8%). Similar figures were computed for studies reporting only on DES. From a total of 47 candidate variables, definite/probable stent thrombosis was more commonly and consistently predicted by early antiplatelet therapy discontinuation, extent of coronary disease, and stent number/length, with acute coronary syndrome at admission, diabetes, smoking status, and bifurcation/ostial disease also proving frequent predictors, but less consistently. Conclusions Despite numerous possible risk factors, the most common and consistent predictors of stent thrombosis are early antiplatelet therapy discontinuation, extent of coronary disease, and stent number/length.

BackgroundClopidogrel low response correlates with poor prognosis after percutaneous coronary intervention (PCI). Many biological tests are currently available to test the clopidogrel response. However, the presence of any correlation between the different tests is today poorly reported.MethodsIn this prospective study, clopidogrel response was assessed in 100 consecutive patients. All patients were tested between 18h and 24h after a600mg clopidogrel loading dose using 3 different tests: light transmission aggregometry with 10μmol ADP (LTA, results expressed as platelet inhibition percentage), VerifyNow-P2Y12 (VN, results expressed as PRU) and vasodilatator stimulated phosphoprotein (VASP, results expressed as IRP). Patients under chronic clopidogrel therapy were excluded.ResultsThe mean platelet inhibition percentage, PRU value and IRP value were 38.5±13% by LTA, 178±89 PRU by VN and 52±21% by VASP. When results were analyzed as continuous variables, there was a good correlation between the different tests: LTA/VN (R2=0,642, p

ObjectiveLeft ventricular (LV) remodeling following myocardial infarction (MI) is characterized by progressive alterations of structure and function, named LV remodeling. Although several risk factors such as infarct size have been identified, LV remodeling remains difficult to predict in clinical practice. Changes within the extracellular matrix, involving matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinases (TIMPs), are an integral part of left ventricular (LV) remodeling after myocardial infarction (MI). We investigated the temporal profile of circulating MMPs and TIMPs and their relations with LV remodeling at 1 year and clinical outcome at 3 years in post-MI patients.MethodsThis prospective multicentre study included 246 patients with a first anterior MI. Serial echocardiographic studies were performed at hospital discharge, 3 months, and 1 year after MI, and analysed at a core laboratory. LV remodeling was defined as the percent change in LV end-diastolic volume (EDV) from baseline to 1 year. Serum samples were obtained at hospital discharge, 1, 3, and 12 months. Multiplex technology was used for analysis of MMP-1, -2, -3, -8, -9, -13, and TIMP-1, -2, -3, -4 serum levels.ResultsBaseline levels of MMP-8 and MMP-9 were positively associated with changes in LVEDV (P = 0.01 and 0.02, respectively). When adjusted for major baseline characteristics, MMP-8 levels remained an independent predictor LV remodeling (P = 0.025). By univariate analysis, there were positive relations between cardiovascular death or hospitalization for heart failure during the 3-year follow-up and the baseline levels of MMP-2 (P = 0.03), MMP-8 (P = 0.002), and MMP-9 (P = 0.03). By multivariate analysis, MMP-8 was the only MMP remaining significantly associated with clinical outcome (P = 0.02).ConclusionBaseline serum MMP-8 is a significant predictor of LV remodeling and cardiovascular outcome after MI and may help to improve risk stratification.

Summary. Background: Post-treatmentplateletreactivity(PR)is associated with ischemic and bleeding events in patientsreceivingP2Y12receptorantagonists. Objectives: Weaimedtostudytherelationshipbetween post-treatmentPRaftera60-mgloading dose (LD) of prasugrel and 1-year thrombotic andbleeding events. Method: Patients were prospectively includedin this multicenter study if they had a successful percutaneouscoronary intervention (PCI) for acute coronary syndrome(ACS) and received prasugrel. The platelet reactivity index(PRI) was measured using the Vasodilator-Stimulated Phos-phoprotein index (VASP) after a prasugrel LD. Endpointsincluded the rate of thrombotic events and bleeding events at1year.Results: Among the 301 patients enrolled, 9 (3%) werelosttofollow-upat1 year.Theratesofthromboticandbleedingeventsat1 yearwereof7.5%and6.8%,respectively.Receiver-operating curve (ROC) analysis demonstrated an optimal cut-off value of 53.5% of PRI to predict thrombotic events at1 year. Using this cut-off value we observed that patientsexhibiting high on-treatment platelet reactivity (HTPR) had ahigher rate of thromboticevents (22.4%vs.2.9%; P 16%(15.6%vs.3.3%; P < 0.001).Inmultivariateanalysis,thePRIpredictedboththromboticandbleedingevents(OR:1.44,95%confidence interval [CI]: 1.2–1.72; P < 0.001 and OR: 0.75,95% CI: 0.59–0.96; P = 0.024 [respectively, per 10%increase]). Conclusion: Platelet reactivity measurement after aprasugrel LD predicts both ischemic and bleeding events at1 year follow-up for ACS patients undergoing PCI.Keywords: bleedings, P2Y12-ADP receptor antagonist, plate-letmonitoring,stentthrombosis,Vasodilator-StimulatedPhos-phoprotein index.IntroductionPlatelet reactivity (PR) inhibition is critical to preventthrombotic events in acute coronary syndrome (ACS) patientsundergoing percutaneous coronary intervention (PCI). In fact,the addition of a P2Y12 receptor antagonist to aspirin hasdramatically reduced the risk of thrombotic events includingstent thrombosis [1]. Several studies have demonstrated astrong association between high on-treatment platelet reactiv-ity (HTPR) after a clopidogrel loading dose (LD), asmeasured by various platelet assays, and post-PCI thromboticevents such as cardiovascular death, myocardial infarction(MI) or stent thrombosis [2]. The Vasodilator-StimulatedPhosphoprotein (VASP) index is a specific and reproducibletest to assess P2Y12 receptor blockade [3]. While therelationship between PR and thrombotic events is wellestablished, a potential link between PR and bleedings hasrecently emerged. Sibbing et al. [4] observed, in a prospectivetrial including patients treated with PCI, an associationbetween a high level of PR inhibition and bleeding events.These preliminary findings were confirmed by other investi-gators showing that excessive PR inhibition after a clopidogrel

This study sought to assess the impact of invasive strategy (IS) versus a conservative strategy (CS) on in-hospital complications and 3-year outcomes in patients with non-ST-segment elevation myocardial infarction (NSTEMI) from the FAST-MI (French Registry of Acute Coronary Syndrome).Results from randomized trials comparing IS and CS in patients with NSTEMI are conflicting.Of the 3,670 patients in FAST-MI, which included patients with acute myocardial infarction (within 48 h) over a 1-month period in France at the end of 2005, 1,645 presented with NSTEMI.Of the 1,645 patients analyzed, 80% had an IS. Patients in the IS group were younger (67 ± 12 years vs. 80 ± 11 years), less often women (29% vs. 51%), and had a lower GRACE (Global Registry of Acute Coronary Events) risk score (137 ± 36 vs. 178 ± 34) than patients treated with CS. In-hospital mortality and blood transfusions were significantly more frequent in patients with CS versus IS (13.1% vs. 2.0%, 9.1% vs. 4.6%). Use of IS was associated with a significant reduction in 3-year mortality and cardiovascular death (17% vs. 60%, adjusted hazard ratio [HR]: 0.44, 95% confidence interval [CI]: 0.35 to 0.55 and 8% vs. 36%, adjusted HR: 0.37, 95% CI: 0.27 to 0.50). After propensity score matching (181 patients per group), 3-year survival was significantly higher in patients treated with IS.In a real-world setting of patients admitted with NSTEMI, the use of IS during the initial hospital stay is an independent predictor of improved 3-year survival, regardless of age. (French Registry of Acute Coronary Syndrome [FAST-MI]; NCT00673036).

Corevalve dislocation has been reported to significantly increase the perioperative risk for severe complications and poor outcomes. We describe the case of an 87-year-old man who was referred to our center for transcatheter aortic valve implantation and who experienced an original complication after Corevalve dislocation by subclavian approach. Indeed, during the attempt to retrieve the partially expanded and dislocated valve through the subclavian introducer sheath, we experienced a dislodgment of the valve from the housing sheath that led to a delivery catheter cone separation and systemic embolization.

Antiplatelet agents are critical to prevent thrombotic events in patients with acute coronary syndromes, particularly those who undergo percutaneous coronary intervention. Prasugrel is a potent P2Y(12)-adenosine diphosphate receptor antagonist that is superior to clopidogrel in such patients. Previous studies have observed that nuisance and internal bleedings were relatively frequent in patients under clopidogrel therapy and were associated with noncompliance. Furthermore, premature drug discontinuation is associated with thrombotic recurrences. The aim of the present study was to investigate the rate of nuisance or internal bleedings in patients receiving prasugrel and its relation with compliance. This prospective multicenter study included 396 patients. Bleeding events were recorded and classified as alarming, nuisance, or internal according. Compliance with prasugrel therapy was assessed. Almost half of the patients (48.5%) were included for ST-segment elevation acute coronary syndromes. During the 1-month follow-up period, 54 patients (13.6%) had bleeding events. Most bleeding events were classified as internal or nuisance (96%). Internal and nuisance bleedings were associated with high rates of prasugrel discontinuation (16.6% and 14.7%, respectively). Nuisance and internal bleedings were significantly associated with prasugrel discontinuation in multivariate analysis (odds ratio 3.1, 95% confidence interval 1.01 to 9.2, p = 0.04). The rate of major adverse cardiovascular events was 2.3%. No relation was observed between minor bleeds, compliance, and major adverse cardiovascular events. In conclusion, in the present study, minor bleedings were common during the first month after percutaneous coronary intervention and were significantly associated with prasugrel withdrawal.

Regarding the various responses to our report, “Does Black Ethnicity Influence the Development of Stent Thrombosis in the Drug-Eluting Stent Era?”,1 we appreciate the thoughtful remarks by Smith et al and Ferdinand et al, and welcome the opportunity to clarify our viewpoints. Our conclusions do not imply that blacks do not benefit from, or should not receive, drug-eluting stents. It would be unfounded to conclude from our findings that current clinical practice should be modified. We applaud initiatives such as the Coalition to Reduce Disparities in CV Outcomes (CREDO) and organizations such as the Association of Black Cardiologists (ABC), which aim to increase …

Background Previous studies have reported ambiguous results regarding the effect of acute exercise on platelet reactivity in healthy and cardiac patients. Objectives We aimed to assess platelet reactivity among diabetic patients before and immediately after an acute exercise stress test. Methods Patients (controls: mean age 53.1±12.1 years; four males; body mass index 27.0±5.7 kg/m 2 ; HbA 1c 6.0±1.1%, n =8) and diabetic patients (52.9±11.3; six males; body mass index 30.7±2.2 kg/m 2 ; HbA 1c 7.8±1.7%, n =8) referred for diagnostic nuclear exercise stress test were recruited. Blood samples obtained at rest and immediately post-exercise were stimulated with adenosine diphosphate (ADP), collagen and arachidonic acid. Expression of CD41 (pan-platelet marker) and CD62p (platelet stimulation marker) were measured by flow cytometry. Aspirin responsiveness was measured using VerifyNow. Results Although peak systolic blood pressure was significantly higher in the diabetics compared with nondiabetics (186.3±25.4 vs. 157.1±19.1, respectively, P =.028), peak exercise heart rate was similar (156.5±8.3 vs. 155.5±12.1 for diabetics and nondiabetics, respectively). No differences were observed between groups for aspirin resistance. Platelet stimulation with ADP exhibited significantly lower CD62p-positive cell population (%) in the diabetic patients both prior to and following the exercise stress test ( P =.03). In addition, although not significant, platelet stimulation was higher post-exercise in the diabetic patients (6.3±4.7% vs. 12.0±5.6%, for pre- and post-exercise, respectively, P =.2) with no difference in controls (9.2±5.5% vs. 8.9±5.9%). Conclusion Platelet stimulation in diabetic patients is blunted and might be explained by the prolonged exposure of platelets to multiple diabetic risk factors.

Clopidogrel has decreased the rate of thrombotic events in patients undergoing percutaneous coronary intervention. However, two major limitations of the drug have been involved in the persistence of a relatively high rate of adverse events. The recent literature suggested that improved platelet reactivity inhibition using a higher or tailored dose of clopidogrel, or a more potent agent, could reduce the rate of events. The development of new antiplatelet agents and the increasing availability of platelet assays are likely to profoundly modify current practice and favor personalized antiplatelet therapy.

Patients with severe aortic stenosis and considered at high surgical risk or inoperable, and not eligible for a randomized clinical trial evaluating percutaneous aortic valve replacement (PAVR), were studied. Many of the patients referred to the study did not meet the inclusion criteria and/or had conditions listed in the exclusion criteria. These patients were then deferred to other treatment modalities. The study cohort consisted of 285 patients with severe aortic stenosis referred to participate in a clinical trial of PAVR. Patients were screened for eligibility on the basis of the protocol inclusion and exclusion criteria and deferred to other treatment modalities if they did not meet the enrollment criteria. Those patients were followed clinically by telephone contact or office visits. Of the 285 patients referred for PAVR, 216 (75.8%) were not included. The leading reasons for lack of eligibility were significant peripheral vascular disease in 50 (23.1%), Society of Thoracic Surgeons score10% in 48 (22.9%), aortic valve area0.8 cm(2) in 30 (13.9%), significant coronary artery disease in 25 (11.6%), and renal failure in 22 (10.2%). Sixty-nine of these patients (31.9%) were treated medically, 102 (47.2%) with balloon aortic valvuloplasty, and 45 (20.9%) with surgical aortic valve replacement. Major baseline characteristics were similar. Society of Thoracic Surgeons scores were lower in the surgical group compared with the medical and balloon aortic valvuloplasty groups (10.2 +/- 2.5 vs 12.8 +/- 3.3 vs 13.7 +/- 3.3, respectively, p0.001). During a median follow-up period of 175.5 days (range 55.7 to 344.75), the mortality rate was higher in the balloon aortic valvuloplasty group compared with the medical and surgical aortic valve replacement groups (46 [45.1%] vs 22 [31.9%] vs 10 [22.2%], respectively, p = 0.01). In conclusion, high-risk patients with severe aortic stenosis who are deferred from PAVR often do poorly and incur high mortality rates, especially when treated with balloon valvuloplasty or medical therapy, while a loss of quality of life is apparent in those treated surgically.

Preoperative evaluation with contrast-enhanced multidetector computed tomographic angiography (MDCTA) is considered an "appropriate" indication based on expert consensus. We aimed to evaluate how the presurgical evaluation with MDCTA impacts the outcomes after reoperative cardiac surgery (RCS).We retrospectively studied 364 patients undergoing RCS between 2004 and 2008, including 137 referred for MDCTA. High-risk CT findings were defined as the presence of right ventricle or aorta10 mm from the sternum or a bypass graft10 mm from the sternum crossing the midline. The primary clinical end point was the composite of perioperative death, myocardial infarction (MI), stoke, and hemorrhage-related reoperation. Secondary end points included surgical procedural variables and the perioperative volume of bleeding and of red blood cell (RBC) transfusion.Baseline clinical characteristics were similar between the 2 groups. Individuals referred for MDCTA showed a trend toward a lower incidence of the composite primary end point (17.5% vs 24.2%, P = .13), primarily related to a significantly lower incidence of perioperative MI (0% vs 5.7%, P = .002). Multidetector computed tomographic angiography was also associated with shorter perfusion (90 vs 110 minutes, P = .002), cross clamp time (63 vs 75 minutes, P = .003), and total time in intensive care unit (103 vs 148 hours, P = .04), and a lower volume of postoperative RBC transfusion (627 vs 824 mL, P = .09). These differences remained significant after adjustment for the Society of Thoracic Surgeons score and the performing surgeon.The use of MDCTA before RCS was associated with shorter perfusion and cross clamp time, shorter intensive care unit stays, and less frequent perioperative MI.

C-reactive protein (CRP) elevation is associated with an adverse cardiovascular prognosis after bare metal stent implantation. Data have suggested a similar association between preprocedural CRP and adverse events after drug-eluting stent (DES) implantation. The present study was designed to address whether such a relation exists after DES placement. After excluding patients presenting with an acute coronary syndrome with troponin I elevation, we analyzed the data from 936 consecutive patients who had undergone DES implantation from 2003 to 2007 and had a preprocedural CRP measurement. The patients were divided into 3 groups according to the preprocedural CRP level (1.31, 1.31-3.76, and3.76 mg/L). The primary end point was the composite of death and Q-wave myocardial infarction (QWMI) at 2 years of follow-up. Target vessel revascularization was also assessed. The rate of death/QWMI was not significantly different statistically among the CRP tertiles during the in-hospital period (0.6% vs 0.0% vs 0.6%, p = 0.5) or at 1 year of follow-up (1.9% vs 2.9% vs 4.5%, p = 0.2). At 2 years, death/QWMI had occurred in 2.9% of patients in the lowest, 5.2% in the middle, and 8.8% in the highest tertile (p = 0.006). The incidence of target vessel revascularization was similar in the 3 groups at 2 years of follow-up (13.2% vs 14.9% vs 16.9%, p = 0.5). On multivariate analysis, the upper tertile of CRP was an independent predictor of death/QWMI at 2 years (hazard ratio 2.5, 95% confidence interval 1.1 to 5.4, tertile 3 vs tertile 1, p = 0.006). In conclusion, high preprocedural CRP levels are associated with an increased risk of death and QWMI after DES implantation at long-term follow-up but not acutely. The CRP levels were not related to target vessel revascularization. Thus, an elevated CRP level in this population appears to be more of a marker of global cardiovascular risk than a predictor of post-DES-related complications.

Objectives: The aim of this study was to examine the utility of routine intravascular ultrasound (IVUS) guidance in patients with acute myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) with stent implantation. Background: Stent thrombosis (ST) is a serious complication of PCI with stent implantation for patients presenting with acute MI. Mechanical factors such as incomplete stent expansion and smaller stent diameters are known to correlate with ST and restenosis. IVUS guidance for stent deployment is reported to reduce these events in stable patients. Methods: We analyzed a cohort of 905 consecutive patients who underwent primary PCI for acute MI and were discharged alive. The clinical outcomes of 382 patients who underwent IVUS-guided PCI were compared to those of 523 patients who did not. Patients who presented with cardiogenic shock and rescue PCI were excluded. The primary composite endpoint of death, MI, and target lesion revascularization at 1-year follow-up was systematically indexed and a propensity score was performed with regard to the use of IVUS-guided PCI. Results: Patients undergoing IVUS-guided PCI were older, more diabetic and hypertensive, but presented with less history of previous MI. The severity of coronary artery disease was balanced between both groups. The number of treated lesions and stents used was higher in the IVUS-guided group, with a longer procedural duration. The overall rates of the composite primary outcome were similar (14.5% vs. 14.3%, P = 0.94) as were the rates of definite and probable stent thrombosis at 1 year (2.1% vs. 2.1%, P = 0.99) in the IVUS-guided and no-IVUS groups, respectively. After multivariate and propensity score adjustment, IVUS guidance was not an independent predictor for the primary endpoint. Conclusion: This study does not support the routine use of IVUS guidance for stent deployment in patients who present with acute MI and undergo primary PCI. © 2009 Wiley-Liss, Inc.

Recent data suggest a clinical benefit with the systematic use of thrombus aspiration (TA) for the treatment of ST-elevation myocardial infarction (STEMI). Nevertheless, the impact of TA as a treatment strategy for stent thrombosis (ST) is unknown. This study aimed to analyze the impact of TA use for the treatment of ST on patient outcomes.From 2003 to 2008, 91 consecutive patients who presented with a definite ST were included in this analysis. We compared procedural success rates and the incidence of the composite criteria death-recurrent MI-recurrent ST at 30 days in patients who were treated with TA (TA group, n = 36) versus those who were not (No-TA group, n = 55).Baseline characteristics were similar between the two groups except for the body mass index: 26.2 +/- 5.4 vs. 29.3 +/- 6.2 in the TA and No- TA groups, respectively (p = 0.028). ST presented more likely as STEMI in the TA group: 86.1% vs. 67.3% (p = 0.043). Except for TA use, there was no difference in the treatment therapeutics between groups, including for glycoprotein IIb/IIIa inhibitors. The rate of procedural success was higher in the TA group than in the No-TA group: 88.9% vs. 70.9% (p = 0.043). The incidence of the endpoint of death-recurrent MI-recurrent ST was significantly lower in the TA group: 22.2% vs. 47.2% (p = 0.026). By multivariate analysis, TA use was independently associated with a decrease in the composite criteria (HR = 0.45, p = 0.039).This study suggests that TA use for ST treatment permits an improvement in patient outcomes at 30 days with a significant decrease in the incidence of the composite criteria death-recurrent MI-recurrent ST. Further prospective studies are needed, however, to definitively address the benefit of TA use in this particular setting.

The presence of anemia before percutaneous coronary intervention (PCI) and/or the development of bleeding or anemia after PCI has been shown to increase mortality and morbidity rates. However, the definition of severe anemia varies among reports. In this context, the roles of hematocrit at baseline and hematocrit drop after PCI, both treated as continuous variables, have not yet been described in the risk assessment of patients undergoing PCI.We analyzed 6,025 consecutive patients who underwent PCI from 2003 to 2007 at our institution. In the entire population, we analyzed by multivariable Cox analysis the clinical value of both hematocrit at baseline and hematocrit drop after PCI as continuous variables. The primary end point was the composite of death and myocardial infarction at 1-year follow-up.The rate of the 1-year composite end point death/myocardial infarction increased continuously every time hematocrit at baseline decreased and/or hematocrit dropped after PCI. After multivariable adjustment using the relevant covariables, both hematocrit at baseline (hazard ratio = 0.92, P.001) and hematocrit drop after PCI (hazard ratio = 1.11, P.001) strongly predicted the primary end point at 1-year follow-up.Hematocrit at baseline and the drop after PCI should be recognized as important risk factors for adverse outcomes after PCI. The inclusion of hematocrit or hemoglobin values as continuous variables in a risk-stratification scheme should be strongly considered.

Background: The Syntax score prognostic value has recently been highlighted in patients undergoing percutaneous coronary intervention (PCI) for multivessel coronary artery disease (CAD), however its prognostic value in patients undergoing coronary artery bypass grafting (CABG) for multivessel CAD is still unknown. The aim of this study was to evaluate the prognostic value of the Syntax score in patients undergoing CABG for 3-vessel CAD. Methods: A cohort of 320 consecutive patients with multivessel (3-vessel) CAD who were subjected for CABG were included in this study and divided into tertiles according to the Syntax score ( 34). During the 1-year follow-up, cardiovascular events including death, myocardial infarction (MI), and stroke were systematically indexed. The primary end point was the composite criteria death/MI/stroke. Results: The Syntax score ranged from 11–74 with a mean of 31.2 ± 12.6 and a median of 28.5 [22–38]. Baseline clinical characteristics were similar among the tertiles. No statistical difference was found for the composite criteria death/MI/stroke: 9.4% versus 7.5% versus 10.4% in the groups with a Syntax score 34, respectively (P = 0.754). Conclusion: Unlike for PCI, the Syntax score has a poor prognostic value for severe cardiovascular events in patients undergoing CABG for 3-vessel CAD. Other risk scores should be used to predict the outcome of this population. © 2009 Wiley-Liss, Inc.

Background: With an aging population, nonagenarians constitute an increasing percentage of patients with coronary artery disease. The aim of this study was to determine the predictors and outcome of nonagenarians undergoing percutaneous coronary intervention (PCI) for symptomatic coronary artery disease. Methods: From 2002 to 2007, a cohort of 171 consecutive nonagenarians underwent PCI and stent implantation in our center. Patients given bivalirudin (n = 79) during the procedure were compared to those given heparin (n = 92). In-hospital and 6-month rates of major adverse cardiovascular events (MACE) including death, myocardial infarction (MI), and target lesion revascularization were indexed. In-hospital bleedings were also indexed. Results: The mean age was 92.5 ± 2.5 years. The population was 52% female. Nearly 30% of patients had diabetes mellitus and >25% had renal failure. The mean left ventricular ejection fraction was 45%± 14%. The clinical presentation was an acute MI in 59% of the cases. The in-hospital rates of death and bleedings were 4.1% and 17.5%, respectively. Clinical presentations as MI or cardiogenic shock were associated with high rates of in-hospital death: 19.3% and 30%, respectively. Bivalirudin use was associated with a 41.5% decrease in in-hospital bleedings. The 6-month incidence of MACE was 13.6% and was driven by death. Predictors of 6-month outcomes were clinical presentations as MI or cardiogenic shock, renal failure, and total stent length. Conclusion: Nonagenarians represent a particular population with a high percentage of females and a high incidence of comorbidities. In this study, we highlighted that nonagenarians have logically a worse prognosis than is reported in younger patients, with especially high rates of in-hospital bleedings. Bivalirudin use was associated with an important decrease in in-hospital bleedings; thus, it should be systematically considered in such patients to improve early outcome.

Drug-eluting stents (DESs) have largely demonstrated their superiority to bare-metal stents (BMSs) with respect to in-stent restenosis. Since the US Food and Drug Administration (FDA) approved the first DES in 2003, there has been a significant increase in the use of these devices. They are used in 70–80% of all stent procedures worldwide. Nevertheless, safety concerns stemming from reports of increased risk of late stent thrombosis (ST) and myocardial infarction (MI) have tempered the enthusiasm that the advent of these stents originally generated. New generation DESs with novel polymers, antiproliferative drugs, and improved platforms are now approved and available for use. In this review we provide a critical appraisal, based on published clinical data, of the safety and efficacy of various DESs. Clinical Pharmacology & Therapeutics (2009); 85, 5, 474–480 doi:10.1038/clpt.2009.8

Objective: To assess the prognosis of patients presenting with an acute coronary syndrome (ACS) despite chronic clopidogrel therapy (CCT). Background: CCT has been shown to be beneficial in decreasing the frequency of major adverse cardiovascular events (MACE) in patients after an ACS or drug-eluting stent (DES) implantation. Some patients, however, still suffer thrombotic events while on CCT. The outcome of this particular subgroup of patients is unknown. Methods: A cohort of 1,281 patients undergoing percutaneous coronary intervention (PCI) for an ACS was studied. They were divided according to their treatment prior to the ACS. The CCT group was composed of all patients who had been taking clopidogrel for ≥30 days before the onset of the ACS (n = 175) and the no CCT group of all patients not on clopidogrel before the ACS (n = 1,106). Rates of cardiovascular death and myocardial infarction at 6 months' follow-up were compared. Results: Patients in the CCT group were older (66 ± 11 vs. 63 ± 13; P< 0.001), and more often diabetic (46.8 vs. 31.9%; P < 0.01). In-hospital outcomes were similar, including the rate of death and myocardial infarction (no CCT vs. CCT group: 4.2 vs. 2.3%; P = 0.2). At 6 months, patients already taking clopidogrel before the ACS had a higher rate of MACE than patients who were not (18.3 vs. 11.8%; P = 0.02). In multivariate analysis, CCT before the ACS was associated with a hazard ratio of 1.7 for MACE. Conclusion: This study suggests that patients suffering an ACS while under on CCT have a poor long-term prognosis, which could be linked to clopidogrel low-response. © 2008 Wiley-Liss, Inc.

Clinical trials have demonstrated the beneficial impact of clopidogrel in preventing major adverse cardiovascular events (MACE), particularly in patients undergoing percutaneous coronary intervention (PCI). The concept of biological clopidogrel resistance emerged with the finding of persistent platelet activation despite clopidogrel therapy in some patients. Further, a link between biological clopidogrel resistance and thrombotic recurrence after PCI was observed and a threshold of platelet reactivity (PR) for thrombotic events was suggested. Consistently, in recent trials, enhanced PR inhibition translated into a reduction in the rate of MACE after PCI. This review aims to present the emergence of the concept of PR monitoring in patients undergoing PCI following recent advances in this field.

Stent thrombosis (ST) is a catastrophic complication that frequently presents as an acute myocardial infarction and/or death. The most recently accepted definition established by the Academic Research Consortium classifies ST as: early (occurring within 30 days), late (30 days to 1 year) or very late (after 1 year). Very late ST has been reported following drug-eluting stent implantation with rates up to 0.6% per year and has been attributed to delayed strut endothelialization. However, very late ST is unusual after bare-metal stent (BMS) implantation. We report two cases of patients presenting with ST-elevation myocardial infarction due to very late ST 6 and 8 years after BMS implantation.

The optimal glycosylated hemoglobin (HbA1C) target in diabetic patients is a subject of ongoing controversy that may be especially pertinent in diabetic patients with coronary artery disease. This study aimed to determine the prognostic value of preprocedural HbA1C levels in diabetic patients undergoing percutaneous coronary intervention (PCI) with stent implantation. From 2002 to 2007, a cohort of 952 consecutive diabetic patients underwent PCI with stent implantation in our center. We compared patients with a normal preprocedural HbA1C (or = 7%, n = 429) with patients with an increased HbA1C (7%, n = 523). One-year rate of major adverse cardiovascular events (MACEs) including death, myocardial infarction, and target vessel revascularization was indexed. Baseline characteristics were similar between groups, except for body mass index, which was higher in the high HbA1C group (32.2 vs 31.2 kg/m(2), p = 0.03). Patients in the high HbA1C group were more likely insulin dependent (45.5% vs 26.3%, p0.001). Rates of MACEs were similar (23.7% vs 20.8%) in the high HbA1C and low HbA1C groups (p = 0.45). By multivariate analysis, age, renal failure, clinical presentation as myocardial infarction, and history of congestive heart failure were independently associated with MACEs. In contrast, HbA1C was not associated with patient outcome. In conclusion, this study suggests that HbA1C is not a predictor of cardiac events in diabetic patients with advanced coronary artery disease. These results could explain, at least in part, recent findings of randomized clinical trials that suggest the absence of benefit in macrovascular complications of a strict glycemia control.

Background: Based on biological studies of platelet reactivity (PR), the recent ACC/AHA guidelines recommend a 600-mg loading dose (LD) of clopidogrel in patients undergoing percutaneous coronary intervention (PCI). However, there is lack of studies addressing the clinical impact of such a LD of clopidogrel. Objective: We aimed to compare the clinical efficacy and safety of a 600-mg LD of clopidogrel compared to a 300-mg LD in an unselected cohort of patients undergoing PCI. Methods: A cohort of 4105 unselected patients undergoing PCI in our institution was included in the study and divided according to the LD used: the high LD group (600mg) included 3146 patients and the low LD (300mg) group included 959. The primary endpoint was the rate of major adverse cardiovascular events (MACE) at 1 month. Results: Patients in lthe ow LD group more often had diabetes mellitus and a history of myocardial infarction (36.8 vs 31.9%; p = 0.01). Left ventricular ejection fraction was similar (0.49 ± 0.14 vs 0.48 ± 0.14; p = 0.25). Angiographic and procedural characteristics were identical between the 2 groups. Patients in the high LD group had fewer MACE after 1 month (2.9 vs 5.2%; p < 0.001). In multivariate analysis, a 600-mg LD of clopidogrel was significantly associated with MACE at 1-month follow-up, with an odds ratio of 0.62 (95% CI 0.41– 0.95; p = 0.03). Conclusions: A 600-mg LD was associated with a significant decrease in the rate of post PCI-MACE at 1 month without any increase in bleeding complications. The results of our study therefore support the current guideline of a 600-mg LD of clopidogrel in patients undergoing PCI.

Background: Chronic clopidogrel therapy (CCT) has been shown to be beneficial in decreasing the frequency of major adverse cardiovascular events (MACE) in coronary artery disease. However, some patients suffer an acute coronary syndrome (ACS) despite CCT. Objective : To assess the prognosis of patients suffering an ACS while on CCT compared to patients naive to clopidogrel. Method: Retrospective analysis of propensity matched cohorts of patients undergoing PCI for an ACS was performed. Patients under CCT before the ACS were matched 1:2 with patients not under CCT before the ACS. The primary endpoint was a composite of cardiac death and myocardial infarction (MI) at 1-year follow-up. A cohort of 2325 patients undergoing PCI for an ACS was studied. Among them, 256 patients were taking CCT for > 1 month at the time of the ACS and 2069 weren’t taking clopidogrel prior to the ACS. After propensity score matching 1:2, the 2 groups included, respectively, 84 and 168 patients. Results: Patients in both groups had similar rates of previous MI (no CCT vs CCT 47.6 vs 48.8%; p = 0.86) or PCI (40.5 vs 40.5%; p = 1). There was no difference in drug use on discharge between the 2 groups; in particular for thienopyridines (94 vs 96.4%; p = 0.6). At 1-year follow-up, patients under CCT before the ACS exhibited a worse prognosis than patients who were not under CCT prior to the ACS, with a higher rate of cardiac death and MI (14.2 vs 5.5%; p = 0.015). Conclusions: This study suggests that patients suffering an ACS while under CCT have a poor long-term prognosis, which could be linked to clopidogrel low response.

BACKGROUND: Severe decline in platelet count (DPC) ≥ 50% has been shown to be predictor of outcome after PCI. The prognosis of mild or moderate DPC is unknown. This study aimed to examine the impact of various degrees of DPC on clinical outcome. METHODS: The study included 10,146 consecutive patients who were subjected to PCI. The population was divided in four groups according to the magnitude of the decline in platelet post PCI: no DPC (DPC ≤ 10 %), minor DPC (10 –25 %), mild DPC (26 –50 %) and severe DPC (≥50%). The primary endpoint for this analysis was the composite criteria of death-MI at 30 days. RESULTS: Among the 10,146 patients, 36 % had a DPC ≤10 %, 47.7% had a DPC 10 –25%, 14% had a DPC 26 –50% and 2.3% had a DPC ≥50%. At 30 days, there was a worsening of clinical outcome with the severity of DPC (table 1 ). In univariate analysis, numerous variables were detected associated with the risk of death-MI at 30 days including both mild and severe DPC. After adjustment in multivariate analysis, DPC (25–50 %) and DPC (≥50%) were independently associated with the composite criteria death-MI at 30 days. All independent predictors in multivariate analysis are listed in table 2 . CONCLUSIONS: DPC after PCI is an independent predictor of death-MI at 30 days. The clinical significance of DPC is not limited to major DPC (≥50%) but also seen with moderate DPC (26 –50 %). Careful attention to platelet count is required in patients subjected to PCI who experienced more than 25% decline in their platelet count following the intervention. Relation between Decline in platelet count and Death - MI Independent predictors of death-MI at 30 days

Stent thrombosis (ST) is the most concerning adverse outcome of drug-eluting stent (DES) placement. Clinical outcomes of patients experiencing definite and definite/probable ST by the Academic Research Consortium definitions, among the 9535 patients undergoing unrestricted percutaneous coronary intervention (PCI) with DES since April 2003, were examined. Clinical outcomes up to 3 years following DES implant of the patients with definite or probable ST were compared to those without ST. Baseline demographics were similar. The population was 65.7% male with a mean age of 63.7 years. 104 patients presented with 109 definite ST events. 233 patients were adjudicated to have experienced definite or probable ST events, 50 due to unexplained death within 30 days of DES implantation and 79 due to target vessel myocardial infarction with unknown culprit. Outcomes in both these groups were uniformly poorer with a much higher incidence of death, Q-wave myocardial infarction, and target vessel revascularization up to 3 years when compared to patients who did not experience definite or probable ST. (Table ) DES ST is an infrequent, but at 3 years 2/3 of the patients with DES ST are dying and the remaining are experiencing high morbidity.

Patients presenting with ST elevation myocardial infarction (STEMI) often require percutaneous treatment of lesion not targeted at the time of the primary percutaneous coronary intervention (PCI). This study aimed to detect the incidence, predictors and outcome of recurrent PCI that was not staged and not related to the initial treatment of the STEMI. Between January 2003 and December 2005, 1007 consecutive patients presenting with a STEMI were screened. Of these 94 (10.5%) pts returned within 36 months for a second PCI, not planned and not related to the index procedure at the time of the primary PCI. The baseline and the angiographic features of these patients were compared to 913 patients who did not require a subsequent PCI. Patients who were subjected for subsequent PCI were followed clinically for additional 12 months for major adverse cardiovascular events (MACE) including death, MI and target lesion revascularization (TLR). The median time to the second PCI was 396 days. The clinical presentation at the time of the recurrent PCI was a non-ST-elevation ACS in 46.1% and a new ST elevation in 9.7%. Independent predictors of recurrent PCI occurrence are detailed in the table . At 1 year after the recurrent PCI, there were 9 (9.6%) deaths, 4 Q-Wave MI (4.3%), 4 TLR (4.3%) and 17 MACE (18%). Following STEMI, nearly 10% of patients experiencing a cardiac event that requires subsequent unplanned PCI unrelated to the initial PCI. Patients with diabetes and peripheral vascular disease are at high risk to develop such an event which is associated with high mortality and morbidity. Aggressive preventive and medical management should be applied to this population for prevention of these subsequent events. Table: Independent predictors of recurrent PCI by multivariate Cox analysis.