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The objective of this study was to evaluate the clinical and angiographic factors associated with significant saphenous vein graft (SVG) atherosclerosis progression at mid-term follow-up in a series of unselected coronary patients who had previously received a coronary artery bypass graft (CABG). A total of 123 SVGs from 86 patients who underwent cardiac catheterization twice, 15 +/- 12 months apart, were included in the study. None of the SVGs presented any > or =50% diameter stenosis (DS) lesion or underwent any intervention at baseline. All SVGs were divided into 3 segments and each SVG segment was scored from 0 to 3 depending on the presence of lesions, with percent DS ranging from 0% to 19% (score 0), 20% to 29% (score 1), 30% to 39% (score 2), and > or =40% (score 3). The SVG atherosclerotic burden score (ABS) was calculated by adding the score obtained for each of the 3 SVG segments. Significant progression was defined as > or =10% increase in lesion percent DS or > or =0.6 mm decrease in minimal lumen diameter between baseline and follow-up studies. Mean age of the study population was 66 +/- 9 years, and most of the patients were receiving statin therapy with mean low-density lipoprotein cholesterol of 85 +/- 26 mg/dl. Significant angiographic progression occurred in > or =1 SVG in 41 patients (48%). On multivariate analysis, the variables associated with SVG atherosclerosis progression were SVG ABS (odds ratio [OR], 1.52 for each increase of 1 point in SVG ABS; 95% confidence interval [CI] 1.1 to 2.29) and high-density lipoprotein (HDL) cholesterol (OR 1.38 for each decrease of 5 mg/dl in HDL cholesterol levels, 95% CI 1.09 to 1.85). Twenty-two patients (26%) had a cardiac event at follow-up related to SVG disease progression. The percent DS of the SVG segment at baseline was associated with SVG disease progression leading to a cardiac event (OR 3.67 for each increase of 5% in percent DS, 95% CI 2.11 to 6.38). In conclusion, simple clinical and angiographic variables such as HDL cholesterol, ABS, and lesion severity remain independent predictors of significant SVG atherosclerosis progression in mild to moderately diseased SVGs despite mean low-density lipoprotein levels <90 mg/dl. [ABSTRACT FROM AUTHOR]

This study determined the safety of deferring coronary revascularization based on a fractional flow reserve (FFR) value > or = 0.75 in a series of consecutive unselected coronary patients with moderate coronary lesions, including patients with unstable angina, myocardial infarction (MI), and/or positive noninvasive test findings. The study included 201 consecutive coronary patients (mean age 62 +/- 10 years; 65% men) with 231 lesions evaluated by FFR measurement for which revascularization was deferred based on a FFR value > or = 0.75. Lesions associated with a positive noninvasive test result were those located in an artery supplying a myocardial territory in which myocardial ischemia was demonstrated by a noninvasive test. Cardiac events (cardiac death, MI, revascularization) and Canadian Cardiovascular Society angina class were evaluated at follow-up. Indications for coronary angiography included unstable angina or MI (62%), stable angina (30%), or atypical chest pain (8%). Forty-four patients (22%) had > or = 1 coronary lesion associated with a positive noninvasive test result in which FFR was evaluated. Mean FFR value was 0.87 +/- 0.06 and mean lesion percent diameter stenosis was 41 +/- 8%. At 11 +/- 6 months of follow-up, cardiac events occurred in 20 patients (10%), and no significant differences were observed between patients with unstable angina or MI and those with stable angina (9% vs 13%, p = 0.44) or between patients with and without lesions associated with positive noninvasive test results (9% vs 10%, p = 1.00). At the end of follow-up, 88% of patients were asymptomatic in angina class 0 or I, with no differences across various groups. In conclusion, these results suggest that patients with moderate coronary lesions can be safely managed without revascularization on the basis of FFR measurements, irrespective of clinical presentation and/or presence of positive noninvasive test results. [ABSTRACT FROM AUTHOR]

Objectives: To determine predictors of failure of transradial approach (TRA) in patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and develop a novel score specific for this population., Methods: Consecutive patients with STEMI undergoing primary PCI in a tertiary care high-volume radial centre were included. TRA-PCI failure was categorised as primary (primary transfemoral approach (TFA)) or crossover (from TRA to TFA). Multivariate analysis was performed to determine independent predictors of TRA-PCI failure, and an integer risk score was developed. Clinical outcomes up to 1 year were assessed., Results: From January 2006 to January 2011, 2020 patients were studied. Primary TRA-PCI failure occurred in 111 (5%) patients and crossover to TFA in 44 (2.2%) patients. Independent predictors of TRA-PCI failure were: weight ≤65 kg (OR: 3.0; 95% CI 1.9 to 4.8, p<0.0001), physician with ≤5% TFA conversion (OR: 0.45; 95% CI 0.2 to 0.9, p=0.033), and physician with ≥10% conversion to TFA (OR: 2.2; 95% CI 1.2 to 3.7, p=0.005), intra-aortic balloon pump (OR: 2.0; 95% CI 0.9 to 4.3, p=0.066), cardiogenic shock (OR: 2.8; 95% CI 1.4 to 5.6, p=0.0035), endotracheal intubation (OR: 107; 95% CI 42 to 339, p<0.0001), creatinine >133 μmol/L (OR: 3.6; 95% CI 1.9 to 6.8, p<0.0001), age ≥75 (OR: 1.7; 95% CI 1.0 to 2.9, p=0.031), prior PCI (OR: 2.6; 95% CI 1.5 to 4.5, p=0.0009), hypertension (OR: 1.8; 95% CI 1.2 to 2.9, p=0.009). An integer risk score ranging from -1 to 12 was developed, and predicted TRA-PCI failure from 0% to 100% (c-statistic of 0.868; 95% CI 0.866 to 0.869). Mortality at 1 year remained significantly higher after TRA-PCI failure (adjusted OR 2.2; 95% CI 1.2 to 3.9, p=0.011)., Conclusions: In a high-volume radial centre, the incidence of TRA-PCI failure is low and can be accurately predicted using a 9-variables risk score. Since outcomes after TRA-PCI failure remained inferior, further effort to maximise the use of radial approach for primary PCI should be investigated., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Dual antiplatelet therapy (DAPT) with clopidogrel and aspirin is used for the prevention of cardiovascular events following percutaneous coronary intervention (PCI). These agents increase the risk of gastrointestinal bleeding. To prevent these events, proton pump inhibitors (PPI) are routinely prescribed. It has been reported that with the exception of pantoprazole and dexlanzoprazole, PPIs can impede conversion of clopidogrel by cytochrome P450 2C19 (CYP2C19) to its active metabolite, a critical step required for clopidogrel efficacy. Changes in CYP2C19 enzyme activity (phenotype) and its correlation with platelet reactivity following PPI therapy has not yet been fully described. In this study we attempted to determine if the [ (13)C]-pantoprazole breath test (Ptz-BT) can evaluate changes in CYP2C19 enzyme activity (phenoconversion) following the administration of PPI in coronary artery disease (CAD) patients treated with DAPT after PCI. Thirty (30) days after successful PCI with stent placement, 59 patients enrolled in the Evaluation of the Influence of Statins and Proton Pump Inhibitors on Clopidogrel Antiplatelet Effects (SPICE) trial (ClinicalTrials.gov Identifier: NCT00930670) were recruited to participate in this sub study. Patients were randomized to one of 4 antacid therapies (omeprazole, esomeprazole. pantoprazole or ranitidine). Subjects were administered the Ptz-BT and platelet function was evaluated by vasodilator-stimulated phosphoprotein (VASP) phosphorylation and light transmittance aggregometry before and 30 d after treatment with antacid therapy. Patients randomized to esomeprazole and omeprazole had greater high on-treatment platelet reactivity and lowering of CYP2C19 enzyme activity at Day 60 after 30 d of PPI therapy. Patients randomized to ranitidine and pantoprazole did not show any changes in platelet activity or CYP 2C19 enzyme activity. In patients treated with esomeprazole and omeprazole, changes in CYP2C19 enzyme activity (phenoconversion) correlated well with changes in platelet reactivity. Co-administration of omeprazole or esomeprazole in patients treated with clopidogrel results in lower CYP2C19 enzyme activity and increased platelet reactivity as measured by VASP phosphorylation test while patients given pantoprazole or ranitidine did not show any significant changes in CYP2C19 enzyme activity and platelet reactivity.

Background: Very few data exist on the long-term follow-up of patients with intermediate nonobstructive saphenous vein graft (SVG) lesions. The purpose of this study was to evaluate the 5-year clinical outcomes of the patients enrolled in the Moderate Vein Graft Lesion Stenting With the Taxus Stent and Intravascular Ultrasound (VELETI) and the factors associated with SVG disease progression and outcomes., Methods: Patients with ≥ 1 intermediate SVG lesion (30%-60% diameter stenosis) were randomized to either stenting the SVG lesion with a paclitaxel-eluting stent (PES group, n = 30) or to medical treatment alone (MT group, n = 27). All patients were followed yearly up to 5 years., Results: Major adverse cardiac events (MACEs) (cardiac death, myocardial infarction [MI], revascularization) related to the target SVG lesion tended to be lower in the PES group (17% vs 33%; P = 0.146) due to a lower lesion revascularization rate (13% vs 33%; P = 0.072), with no difference in cardiac death or MI between groups. MACEs related to the target SVG and global MACEs were similar between groups (P > 0.20 for both). A higher cholesterol level at baseline was the only independent predictive factor of MACEs related to the target SVG (P = 0.016)., Conclusions: Over a 5-year period, one third of intermediate lesions in old SVGs progressed, leading to a cardiac event. Stenting these lesions with PESs tended to improve clinical outcomes by reducing lesion progression but not SVG failure. Higher cholesterol levels were associated with SVG disease progression and clinical events. This pilot study provides the basis for a larger trial to determine the efficacy of intermediate SVG lesion plaque sealing., (Copyright © 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Background: Many patients delay or interrupt dual antiplatelet therapy (DAT) after drug-eluting stent (DES) implantation, which increases the risk of stent thrombosis and death., Objective: To test the hypothesis that simple telephone contact made by nurses would improve adherence to and persistence of DAT., Design: Randomised controlled trial., Patients and Intervention: A total of 300 patients (mean±SD 64±10 years, 73% male) were recruited immediately after DES implantation performed between June 2009 and June 2010. The last patient recruited reached the 1-year follow-up time point in June 2011. Patients were randomised to one of two groups: intervention, with four telephone follow-ups, versus a control group. In the intervention group, phone calls were made within 7 days of the DES implantation and at 1, 6 and 9 months to support drug adherence. Control patients were followed as per usual clinical practice. Pharmacy data were collected to assess drug prescription filling and refill., Setting: Tertiary care university cardiovascular centre and community., Main Outcome Measures: The primary end point was the proportion of days covered with aspirin and clopidogrel over the year after discharge as assessed by pharmacy refill data. Secondary outcome measures included persistence of aspirin and clopidogrel treatment, defined as no gaps longer than 14 days during follow-up., Results: Most patients (73%) underwent DES implantation in the context of an acute coronary syndrome. All patients had drug insurance cover, either from the public plan (59%) or through private plans (41%). Complete pharmacy follow-up data were available for 96% of the cohort. At 12 months, median scores (25th-75th centile) for adherence to aspirin and clopidogrel were 99.2% (97.5-100%) and 99.3% (97.5-100%), respectively, in the intervention group compared with 90.2% (84.2-95.4%) and 91.5% (85.1-96.0%), respectively, in the control group (p<0.0001 for aspirin and clopidogrel). Patients in the intervention group were significantly more persistent in the aspirin and clopidogrel treatment than those in the control group. For clopidogrel, 87.2% of patients in the intervention group were still persistent at 12 months compared with only 43.1% in the control group (p<0.0001)., Conclusions: A simple approach of four telephone calls to patients after DES implantation significantly improved 1-year drug adherence to near-perfect scores. Persistence of DAT was also significantly improved by the intervention.

Door-to-balloon (DTB) time is an important metric in primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction to optimize clinical outcomes. The aim of this study was to compare the impact of immediate PCI on culprit lesions in patients with ST-segment elevation myocardial infarctions versus diagnostic angiography followed by PCI on DTB times and procedural data at a high-volume tertiary care radial center. All patients who underwent primary PCI <12 hours after symptom onset were studied. Procedural data and all-cause mortality were assessed in all patients. The primary outcome was DTB time. From January 2006 to June 2011, 1,900 patients were included and divided into 2 groups: 562 patients (30%) underwent primary PCI followed by contralateral diagnostic angiography, and 1,338 patients (70%) underwent diagnostic angiography before primary PCI. No significant differences were observed in baseline characteristics. Left anterior descending coronary artery-related ST-segment elevation myocardial infarctions were more often found in patients who underwent PCI first (54% vs 34%, p <0.0001). Overall, there was a reduction of 8 minutes in DTB time between patients who underwent PCI first and those who underwent angiography first (32 minutes [interquartile range 24 to 52] vs 40 minutes [interquartile range 30 to 69], respectively, p <0.0001). After adjustment, immediate PCI remained an independent predictor of DTB time ≤90 minutes (odds ratio 2.42, 95% confidence interval 1.70 to 3.52, p <0.0001). There were no differences in early and late clinical outcomes. In conclusion, a strategy of transradial direct PCI of the infarct-related artery in selected patients before complete coronary angiography was associated with a benefit of 8 minutes in DTB time. Further study is required to determine whether this strategy can favorably affect clinical outcomes., (Copyright © 2013. Published by Elsevier Inc.)

Background: Transradial approach (TRA) for cardiac catheterizations and interventions improves clinical outcomes compared with transfemoral access, and its use is increasing worldwide. However, there are limited data on successive use of same artery for repeat procedures., Methods: Between May 2010 and May 2011, all consecutive patients undergoing a repeat TRA procedure (≥2) were retrospectively identified. Success rates and reasons for failure to use ipsilateral radial artery for repeat access were identified., Results: A total of 519 patients underwent 1,420 procedures. In 480 patients (92%), right radial artery was used as initial access, and left radial artery, in 39 patients. All patients underwent ≥2 procedures; 218 patients, ≥3; 87 patients, ≥4; 39 patients, ≥5; 19 patients, ≥6; 11 patients, ≥7; and 5 patients, ≥8 procedures. Two patients had, respectively, 9 and 10 procedures. The success rate for second attempt was 93%, 81% for third, and declining to 60% for ≥8. Linear regression analysis estimated a 5% failure rate for each repeat attempt (R(2) = 0.87, P = .007). The main reason for failure was related to clinical radial artery occlusion (RAO) including absent or faint pulse, poor oximetry, and failed puncture. All patients with clinical RAO were asymptomatic. By multivariate analysis, female gender (odds ratio [OR] 3.08, 95% CI 1.78-5.39, P < .0001), prior coronary artery bypass graft (OR 5.26, 95% CI 2.67-10.42, P < .0001), and repeat radial access (OR 2.14, 95% CI 1.70-2.76, P < .0001) were independent predictors of radial access failure., Conclusion: Successive TRA is both feasible and safe in most cases for up to 10 procedures. However, failure rate for TRA increases with successive procedures, primarily due to clinical RAO. Strategies to minimize the risks of chronic clinical RAO and allow repeat use of ipsilateral radial artery need to be further defined., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Background: The association between cardiogenic shock and 1 or >1 chronic total occlusion (CTO) in unselected patients presenting with ST-elevation myocardial infarction (MI) (STEMI) has not been characterized., Methods: Patients with STEMI referred with or without cardiogenic shock were categorized into no CTO, 1 CTO, and >1 CTO. The primary end point was the 30-day mortality., Results: Between 2006 and 2011, 2,020 consecutive patients were included. A total of 141 patients (7%) presented with cardiogenic shock on admission. The prevalence of 1 CTO and >1 CTO in a non-infarct-related artery was 23% and 5%, respectively, among patients with shock compared with 6% and 0.5% in patients without shock (P < .0001). Independent predictors of cardiogenic shock included left main-related MI (odds ratio [OR] 6.55, 95% CI 1.39-26.82, P = .019), CTO (OR 4.20, 95% CI 2.64-6.57, P < .001), creatinine clearance <60 mL/min (OR 3.41, 95% CI 2.32-4.99, P < .0001), and left anterior descending-related MI (OR 2.20, 95% CI 1.51-3.23, P < .0001). Thirty-day mortality was 100% in shock patients with >1 CTO, 65.6% with 1 CTO, and 40.2% in patients without CTO (P < .0001). After adjustment for left ventricular ejection fraction and renal function, CTO remained an independent predictor for 30-day mortality (hazard ratio [HR] 1.83; 95% CI 1.10-3.01, P = .02)., Conclusion: In patients with STEMI, CTO was strongly associated with cardiogenic shock on admission. In this setting, mortality was substantially higher in patients with 1 CTO and exceedingly high in those with >1 CTO. The presence of CTO was an independent predictor of early mortality., (Copyright © 2012 Mosby, Inc. All rights reserved.)

The objective of this study was to evaluate the impact of diffuse coronary atherosclerosis on the functional evaluation of moderate coronary lesions in the proximal-mid segment of a coronary artery and its clinical implications. This was a prospective study including 100 consecutive patients with a moderate lesion (45 ± 9% diameter stenosis) in the proximal-mid coronary segment who were evaluated with fractional flow reserve (FFR) measurement. No patient had any other angiographic stenosis distal to the evaluated coronary stenosis. FFR measurements were obtained just distal (~2 to 3 cm) to the lesion (FFR proximal measurement [FFR-PM]) and as distally as possible in the artery (FFR distal measurement [FFR-DM]) after administration of the same dose of intracoronary adenosine. Thirty-nine patients underwent dipyridamole or exercise myocardial single-photon emission computed tomography within 3 months of the FFR study. Mean FFR-PM was significantly higher compared to FFR-DM (0.84 ± 0.08 vs 0.78 ± 0.09, median gradient 0.06, 25th to 75th interquartile range 0.02 to 0.10, p <0.0001). FFR-DM was <0.75 in 33% of patients with FFR-PM ≥0.75, leading to the decision of revascularization in these patients. Performing FFR measurement in the left main/left anterior descending artery predicted a higher gradient between FFR-DM and FFR-PM (odds ratio 4.58, 95% confidence interval 1.4 to 15.03, p = 0.007). FFR-DM exhibited a better correlation with results of myocardial single-photon emission computed tomography compared to FFR-PM (kappa 0.33 vs 0.22, p <0.0001). In conclusion, significant differences between FFR-DM and FFR-PM were observed in patients with moderate coronary stenosis in the proximal-mid segment of a coronary artery, with FFR-DM exhibiting a better correlation with results of noninvasive functional tests. These differences influenced the treatment decision in about 1/3 of patients and highlight the potential clinical relevance of coronary pressure wire positioning for functional evaluation of lesions in the proximal-mid segment of the coronary arteries., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The use of routine aspiration thrombectomy in primary percutaneous coronary intervention (PCI) remains controversial., Methods: Patients in the EArly Discharge after Transradial Stenting of CoronarY Arteries in Acute Myocardial Infarction (n = 105) study were treated with aspirin, clopidogrel, and abciximab within 6 hr of symptoms onset. Operators were allowed to use 6 Fr Export aspiration catheter at their discretion. In this observational analysis, we compared acute and late results in patients treated with and without thrombectomy using cardiac biomarkers, angiographic, cardiovascular magnetic resonance (CMR), and clinical parameters., Results: Patients in the thrombectomy group (n = 44) had longer symptoms to balloon time (196 ± 86 min vs. 164 ± 62, P = 0.039) and higher incidence of preprocedural TIMI flow grade 0 or 1 (84% vs. 64%, P = 0.028). Following PCI, both groups had similar incidence of TIMI flow grade 3 (93 vs. 92%, P = 0.73) and myocardial blush grade 2 or 3 (80 vs. 77%, P = 0.86), respectively. Patients in thrombectomy group had significantly higher post-PCI maximum values of creatine kinase-MB (P = 0.0007) and troponin T (P = 0.0010). Accordingly, post-PCI myocardial necrosis by CMR was higher (P = 0.0030) in patients in the thrombectomy group. At 6-month follow-up, necrosis size remained higher (20.7% ± 13.3% vs. 13.5% ± 11.1%, P = 0.012) in the thrombectomy group. Ejection fraction at 6 months was 65% ± 9% in patients in thrombectomy group compared to 70% ± 11% in patients without (P = 0.070). Results were not affected by initial TIMI flow or symptoms to balloon time. Clinical events remained comparable in both groups at 12 months follow-up., Conclusion: In patients with ST-segment elevation myocardial infarction presenting within 6 hr of symptoms and undergoing primary angioplasty with maximal antiplatelet therapy, acute and late results did not suggest significant benefit for additional aspiration thrombectomy, irrespective of initial TIMI flow or total ischemic time., (Copyright © 2010 Wiley-Liss, Inc.)

A 42-year-old-woman presented with de novo crescendo angina. Thallium-scintigraphy showed inferior ischemia. Coronary angiogram revealed a right coronary artery (RCA), originating from the left sinus of Valsalva with a severe proximal systolic compression. She underwent successful transradial percutaneous coronary intervention with stent implantation. Multislice-computed tomography (MSCT) is usually used to evaluate coronary artery anomalies and can effectively show the anomalous RCA and the inter-arterial trajectory between the aorta and pulmonary arteries. Anomalies of the origin of the coronary arteries are rare, but can produce specific clinicopathological entities that should be diagnosed with accuracy. This case report illustrates the role of MSCT in the detailed description of an abnormal coronary artery and the use of stenting for symptoms relief.

Background: Primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) may be limited by thrombus embolization. Export aspiration catheter (EAC) is a thrombectomy device which may enhance angiographic results, but its impact on clinical outcomes is unclear. This trial objective was to assess the impact of EAC on angiographic and clinical outcomes in patients with STEMI., Methods: All STEMI patients undergoing primary or rescue PCI in a tertiary care center were included. Patients were divided in two groups according to the use of the EAC. Patients were followed up prospectively for death, reinfarction, revascularization, or stroke. Thrombolysis In Myocardial Infarction (TIMI) flow in the culprit vessel was assessed before and after PCI., Results: Included in the analysis were 535 patients. EAC was used in 165 patients before angioplasty (Group 1) and 370 patients underwent PCI without thrombus aspiration (Group 2). More patients in Group 1 had initial TIMI flow 0-1 compared to Group 2 (88% vs. 62%, P<.001). Proportion of patients with a final TIMI flow 3 was the same in both groups (89.1% vs. 87.6% for Groups 1 and 2, respectively; P=.67). An analysis restricted to patients with initial TIMI flow 0-1 yielded similar results. No difference in clinical outcomes was observed between the two groups (P=.70)., Conclusions: Selective use of the EAC based on the judgment of operators results in excellent angiographic and clinical results. Further clinical investigation is needed to definitely answer whether thromboaspiration needs to be performed in all STEMI patients undergoing primary PCI., (Crown Copyright © 2010. Published by Elsevier Inc. All rights reserved.)

Background: Late-presenting ST-elevation myocardial infarction (STEMI) patients possess larger, more organized coronary thrombus leading to greater ventricular remodeling and arrhythmia despite angioplasty and pharmacological therapies. We hypothesized that myocardial injury would be reduced in late STEMI by proximal embolic protection (PEP)., Methods: 31 patients with first STEMI 12-24 hr after pain onset and TIMI 0-1 flow were treated with or without PEP (cohort design matched for age, gender, and infarct-related artery). Contrast-enhanced magnetic resonance determined myocardial function, area at risk, necrosis, salvaged myocardium, and arrythmogenic peri-infarct region. Clinical follow-up was performed., Results: Pain to balloon time was 18 hr (95% CI 15.5-21.2 h), and Q waves were present in 87%. Angioplasty was performed with PEP in 15 and without in 16. Left ventricular (LV) volumes and ejection fraction were similar (EF 46.9% vs. 49.0% without PEP, P = 0.9). Although myocardial necrosis was similar (32.5 vs. 37.3% of LV, P = 0.3), PEP improved microvascular obstruction (8.7 vs. 11.2% of LV, P = 0.02) salvaged myocardium (39.6% vs. 29.6% of area at risk, P = 0.001), and the peri-infarct region (20.9 vs. 29.6% of infarct, P < 0.0001). On multivariate analysis, the use of PEP was an independent predictor of decreased arrythmogenic peri-infarct region and greater myocardial salvage., Conclusion: In this pilot study, PEP improved myocardial salvage and the arrythmogenic peri-infarct region in late-presentation STEMI. Randomized trials are required to assess the clinical impact of improving salvaged myocardium and the peri-infarct region with PEP., (© 2010 Wiley-Liss, Inc.)

Anemia and major bleeding are independent predictors of outcomes after acute coronary syndromes and percutaneous coronary intervention (PCI). Although the transradial approach reduces the incidence of bleeding, the hemoglobin changes after transradial PCI have not been defined. We serially assessed the hemoglobin values before and after transradial PCI and evaluated the effect of hemoglobin changes on outcomes. In the EArly Discharge After Transradial Stenting of CoronarY Arteries (EASY) trial, 1,348 patients underwent transradial PCI. All patients received aspirin, clopidogrel, and a bolus of abciximab before PCI. The hemoglobin values were assessed immediately before and 4 to 6 hours and 12 to 24 hours after PCI. The major adverse cardiac events (death, myocardial infarction, and target vessel revascularization) were assessed < or =3 years after PCI. According to the World Health Organization classification, 206 patients (15%) had anemia before PCI and 410 (30%) developed anemia within 24 hours after PCI. A mean hemoglobin decrease of 0.6 +/- 1.0 g/dl occurred within 24 hours after PCI. At 30 days, the major adverse cardiac events were significantly increased when the hemoglobin decrease within 24 hours after PCI was >3 g/dl (p = 0.0002). Patients with anemia within 24 hours after PCI had significantly more major adverse cardiac events at 30 days, 6 months, 1 year, and 3 years than patients without anemia (log-rank p = 0.0044). After adjustment for differences in the baseline characteristics, anemia within 24 hours after PCI remained an independent predictor of major averse cardiac events at 3 years (hazard ratio 1.30, 95% confidence interval 1.01 to 1.67, p = 0.045). In conclusion, within 24 hours after transradial PCI with maximal antiplatelet therapy, only a mild hemoglobin decrease was observed. The choice of a hemoglobin decrease >3 g/dl after PCI as a cutoff value for current definitions of major bleeding in modern PCI trials appears reasonable. Measures to prevent anemia and blood loss during PCI remain to be further studied., (Copyright (c) 2010 Elsevier Inc. All rights reserved.)

The optimal value of activated clotting time (ACT) during percutaneous coronary intervention (PCI) with unfractionated heparin remains controversial. No data are available on the relation between the ACT at the end of the procedure (final ACT) and the clinical outcomes after transradial PCI and maximal antiplatelet therapy. By dividing the final ACT values in tertiles, we analyzed the ischemic and bleeding events in 1,234 consecutive patients with acute coronary syndrome recruited in the EArly Discharge after Transradial Stenting of CoronarY Arteries (EASY) trial. All patients were pretreated with aspirin and clopidogrel. After radial sheath insertion, patients received 70 IU/kg unfractionated heparin. Abciximab was given before the first balloon inflation. The median final ACT value was 312 seconds (interquartile range 279 to 344). At 30 days, the rate of major adverse cardiac events, including death, myocardial infarction, and target vessel revascularization, from the lower to upper tertiles was 4%, 4%, and 2%, respectively (p = 0.16), and the rate of major bleeding was 2%, 1% and 0.7%, respectively (p = 0.20). During the 3 years of follow-up, the incidence of myocardial infarction was less in the tertile with the greatest ACT value (>330 seconds) than in the other 2 tertiles (4%, 8%, and 8%, respectively; p = 0.038). Troponin-T and creatine kinase-MB release after PCI indicated that the effect was related to periprocedural myonecrosis protection. After adjustment for baseline and procedural differences, a final ACT of >330 seconds remained associated with a 47% relative reduction in myocardial infarction (odds ratio 0.53, 95% confidence interval 0.29 to 0.93, p = 0.024). Death and target vessel revascularization remained similar in all tertiles for < or =3 years. In conclusion, with the combination of aspirin, clopidogrel pretreatment, and abciximab, a final ACT value of >330 seconds appears protective against peri-PCI myonecrosis, and this benefit was maintained for < or =3 years. With a transradial approach and maximal antiplatelet therapy, greater ACT values did not correlate with an increased risk of bleeding.

Background: Female gender has been associated with poorer outcomes after percutaneous coronary intervention (PCI) and femoral approach. However, no data are available on the impact of gender and transradial PCI with maximal antiplatelet therapy on bleeding and ischemic outcomes., Methods: In the EArly discharge after Stenting of coronarY arteries (EASY) trial, 1,348 patients with acute coronary syndrome underwent transradial PCI. All patients were pretreated with aspirin and clopidogrel. After sheath insertion, 70 U/kg heparin was administered and a bolus of abciximab was given before first balloon inflation. Major adverse cardiac events including death, myocardial infarction, and target vessel revascularization; major bleeding; and local hematomas were evaluated at 30 days, 6 months, and 12 months., Results: Women (n = 298, 22%) were older, had more hypertension, more family history, and less previous PCI than men. Weight, baseline hemoglobin, and creatinine clearance were significantly lower in women. The number of dilated sites, complex lesions, and procedure duration was similar, but 5F sheath size was more frequent in women. Major adverse cardiac events remained similar at 30 days (3.4% vs 3.9%, P = .86), at 6 months (11.5% vs 7.8%, P = .06), and at 1 year (14.1% vs 12.6%) in both groups. There was no significant difference in the incidence of major bleeding between the 2 groups, but female gender was the only independent predictor of hematomas (odds ratio 4.40, 95% confidence interval 2.49-7.81, P < .0001)., Conclusion: Despite more comorbidities, female gender was not a predictor of adverse clinical outcomes after transradial PCI with maximal antiplatelet therapy. Still, female gender remained associated with a higher risk of local hematomas. Efforts should continue to identify modifiable factors to reduce procedural bleeding in women, regardless of the access site.

Background: Bleeding has recently emerged as predictor of early and late mortality after percutaneous coronary intervention (PCI) using femoral approach. Transradial PCI is associated with a lower risk of access-site complications than femoral approach. We evaluated the predictors of bleeding and the impact of major bleeding on death and major adverse cardiac events (MACE) after transradial PCI and maximal antiplatelet therapy., Methods: In the EASY (EArly discharge after transradial Stenting of coronarY arteries) trial, 1,348 patients with acute coronary syndrome were enrolled and underwent transradial PCI. All patients received clopidogrel (90% > or =12 hours pre-PCI) and a bolus of abciximab before first balloon inflation. Univariate and multivariate analyses to identify predictors and prognostic impact of major bleeding on death and MACE (death, myocardial infarction, and target vessel revascularization) were performed., Results: From the study population, 19 (1.4%) patients presented major bleeding. Patients with bleeding were older, had lower creatinine clearance, more often had 3-vessel disease and > or =3 dilated sites, and had longer procedures. Independent predictors of bleeding were creatinine clearance <60 mL/min (odds ratio [OR] 3.26, 95% confidence interval [CI] 1.10-8.67, P = .022), procedure duration (OR 2.95, 95% CI 1.12-8.31, P = .032), and sheath size (OR 5.34, 95% CI 1.44-34.65, P = .029). In patients with major bleeding, the incidence of MACE was higher at 30 days (37% vs 3%), 6 months (42% vs 8%), and 12 months (53% vs 12%; P < .0001 for all comparisons). By multivariate analysis, major bleeding was an independent predictive factor of 1-year mortality and MACE., Conclusion: After transradial PCI and maximal antiplatelet therapy, the incidence of major bleeding remains low. Major bleeding is an independent predictive factor of adverse acute and 1-year outcomes, regardless of the access site.

Background: In ST-segment elevation acute myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), all efforts must be made to improve door-to-balloon (DTB) times. This study was designed to assess the impact of electrocardiographic-guided immediate intervention (EGII) without performing a complete coronary evaluation on DTB times and clinical outcomes of STEMI patients treated with primary PCI., Methods: Consecutive STEMI patients undergoing primary PCI at Laval Hospital between May 2006 and August 2007 were considered for inclusion. Patients with thrombolysis in myocardial infarction (TIMI) 2-3 flow in the culprit vessel on initial angiography and patients with previous coronary bypass surgery were excluded from the analysis. The primary evaluation was DTB time. Clinical outcomes consisted of cardiac death, reinfarction, revascularization or stroke., Results: Two hundred seventy-nine (279) patients were included in the present analysis. Eighty-seven (87) patients underwent EGII (Group 1) and 192 underwent PCI after a complete angiographic diagnostic evaluation (Group 2). Median catheterization laboratory DTB was 21 minutes in Group 1 and 25.5 minutes in Group 2 (p < 0.0001). The median DTB time was 80 minutes for patients in Group 1, compared to 90 minutes for patients in Group 2 (p = 0.01). More patients in Group 1 received timely reperfusion (DTB < 90 min) than patients in Group 2 (63% vs. 49%; p = 0.04). There was a trend towards reduced mortality in Group 1 compared to Group 2 (p = 0.11, unadjusted)., Conclusion: A strategy of EGII reduces DTB times with a possible impact on clinical outcomes in STEMI patients undergoing primary PCI.

Background: To develop a safe practice of same-day discharge after percutaneous coronary intervention (PCI), it is important to identify early the patients who need to remain hospitalized and potentially require more careful follow-up. In the EASY trial, a large number of patients with acute coronary syndromes were enrolled prior to PCI to be randomized between same-day discharge or overnight hospitalization. Based on a few angiographic criteria, suboptimal results, or clinical complications, some patients were excluded from randomization after PCI., Objectives: We report the early and late outcomes of those patients, and evaluate the use of simple criteria precluding same-day discharge., Results: The rate of major adverse cardiac events including death, myocardial infarction, and target vessel revascularization in patients excluded from randomization (n = 343) was significantly higher at 30 days (10.2% vs. 1.6%), 6 months (17.5% vs. 5.6%), and 12 months (24.5% vs. 9%) compared with randomized patients (n = 1,005; P < 0.0001). At 12 months, only transient vessel closure (HR 1.78, 95% CI 1.10-2.65, P = 0.023) and a residual dissection >or= grade B post-PCI (HR 1.53, 95% CI 1.11-2.05, P = 0.011) were independent predictive factors of adverse outcomes., Conclusion: Criteria associated with angiographic suboptimal results or clinical complications are useful to identify patients ineligible for same-day discharge after PCI, regardless of the clinical presentation. Patients excluded from same-day discharge after PCI for safety concerns have worse early and late outcomes. Transient vessel closure and persisting moderate dissection after PCI remain independent predictors of late adverse outcomes after PCI with maximal antiplatelet therapy., ((c) 2008 Wiley-Liss, Inc.)

Purpose: Fractional flow reserve (FFR) is often performed to assess the severity of coronary artery stenoses. However, the usefulness of measuring FFR when a noninvasive test has been obtained prior to coronary angiography has not been studied., Methods and Materials: We retrospectively reviewed 122 patients who underwent noninvasive stress test with cardiac imaging (SPECT or stress echocardiography) prior to FFR assessment of a coronary lesion. The usefulness of FFR measurement was determined. FFR was judged useful if decision to revascularize the patient reflected the result of FFR rather than the result of the stress test., Results: A total of 136 lesions were evaluated. Of these, 66 were associated with a positive noninvasive test and 70 had no ischemia present in the territory of the evaluated vessel. When FFR was negative (> or =0.75) and the test positive (57 lesions), revascularization was deferred in 55. When FFR was positive (<0.75) and the functional test negative (8 lesions), revascularization was performed in 8. FFR measurement changed the clinical decision to revascularize the patient in 55 (83%) of the 66 lesions with ischemia documented on noninvasive tests compared to 8 (11%) of the 70 lesions without ischemia (P<.0001)., Conclusion: FFR can be helpful in patients with coronary artery disease even when noninvasive testing is performed prior to coronary angiography. In this study, FFR measurement had the greatest impact in the evaluation of lesions with documented ischemia on noninvasive tests. In these patients, appropriate use of FFR based on the operator's judgment can prevent unnecessary revascularizations of intermediate lesions.

Objectives: This study compared acute and late outcomes following a strategy of selective drug-eluting stent (DES) use guided by a set of 4 criteria defining higher risk of in-stent restenosis compared to an exclusive DES strategy in 362 patients with multilesion (n = 900) percutaneous coronary interventions., Results: At a mean follow up of 412 +/- 110 days, major adverse cardiac events (death, myocardial infarction, revascularization) were 16.8% in the exclusive DES group compared to 18.4% in the selective DES group (p = 0.78). By univariate analysis, revascularization rates (9.9% in the exclusive DES group versus 10.5% in the selective DES group; p = 1.0) and target lesion revascularization (TLR) rates (5.5% versus 6.2%; p = 0.77) were similar in the 2 groups. By multivariate analysis adjusted by propensity score to account for differences in baseline characteristics, the strategy of exclusive DES use was not associated with lower risks of revascularization (hazard ratio [HR]: 0.91, 95% confidence interval [CI] 0.64-1.29) or TLR (HR: 0.81, 95% CI 0.59-1.08) compared with selective DES use. Using the Academic Research Consortium criteria, stent thrombosis occurred in 6/161 (3.7%) cases in the exclusive DES group and in 1/201 (0.5%) case in the selective DES group (p = 0.03)., Conclusions: In patients with multiple coronary lesions, a selective DES strategy for lesions at higher risk of restenosis and bare-metal stents for other lesions was safe and effective when compared to the exclusive use of DES. A large, prospective, randomized trial is required to validate a criteria-based selective DES strategy compared to systematic DES use.

Objectives: (1) To evaluate the clinical outcomes of patients with moderate coronary lesions and borderline fractional flow reserve (FFR) measurements (between 0.75 and 0.80), comparing those who underwent coronary revascularization (CR) to those who had medical treatment (MT), and (2) to determine the predictive factors of major adverse cardiac events (MACE) at follow-up., Methods: A total of 107 consecutive patients (mean age 62 +/- 10 years) with at least one moderate coronary lesion (mean percent diameter stenosis 47 +/- 12%) evaluated by coronary pressure wire with FFR measurement between 0.75 and 0.80 (mean 0.77 +/- 0.02) were included in the study. MACE [CR, myocardial infarction (MI), cardiac death) and the presence of angina were evaluated at follow-up., Results: Sixty-three patients (59%) underwent CR and 44 patients (41%) had MT, with no clinical differences between groups. At a mean follow-up of 13 +/- 7 months, MACE related to the coronary lesion evaluated by FFR were higher in the MT group compared with CR group (23% vs. 5%, P = 0.005). Most MACE consisted of CRs, with no differences between groups in MI and cardiac death rate at follow-up. Both MT and FFR measurements in an artery supplying a territory with previous MI were independent predictive factors of MACE at follow-up, respectively (hazard ratio 5.2, 95% CI 1.4-18.9, P = 0.01; hazard ratio 4.1, 95% CI 1.1-15.3, P = 0.03). The presence of angina at follow-up was more frequent in the MT group compared with the CR group (41% vs. 9%, P = 0.002)., Conclusions: In patients with moderate coronary lesions and borderline FFR measurements deferral of revascularization was associated with a higher rate of MACE (CR) and a higher prevalence of angina at follow-up, especially in those with previous MI in the territory evaluated by FFR. Further prospective randomized studies should confirm whether or not an FFR cut-off point of 0.80 instead of 0.75 would be more appropriate for deferring CR in these cases., ((c) 2008 Wiley-Liss, Inc.)

Outpatient practice after percutaneous coronary intervention (PCI) is gaining momentum due to constantly optimizing results. Furthermore, the availability of limited beds to handle the large volume of coronary interventions also promotes outpatient practice. The present report relates the current experience with same-day discharge and defines persisting challenges in promoting accelerated in-hospital turnover. Since the mid-1990s, there have been several reports on same-day discharge following uncomplicated procedures. Overall, the success of outpatient PCI practice is based on a few technological and pharmacological advances. First, the systematic use of stents and potent antiplatelet agents have revolutionized the acute success rates of PCI by virtually eliminating the risks of acute vessel closure within the first 24 h following a successful procedure. Second, the miniaturization of catheter sizes has also simplified access site management, accelerated ambulation time and limited the risks of puncture site bleeding. In this regard, the transradial approach initially described in Canada and later popularized in Europe has transformed the acute care of patients after PCI. Today, however, the practice of transradial PCI still varies largely from country to country. From the literature review, it appears that after a short period of observation (4 h to 6 h), the majority of eligible patients who have undergone uncomplicated coronary stenting can be discharged on the same day. Whereas implementation of same-day discharge to referring centres is simple, home discharge requires the development of structured outpatient programs with dedicated resources to assist the patient and family with short-term logistics, to provide reassurance, to serve as a 'safety net' and, lastly, to promote medication compliance and cardiovascular risk factor management. Further studies are required to better define the cost-minimization effects of outpatient PCI practice, as well as patient perception of fast-track PCI. It is proposed that outpatient PCI will likely continue to expand over the next decade.

Background: Current guidelines for ST elevation myocardial infarction (STEMI) recommend performing primary percutaneous coronary intervention (PCI) within 90 min of hospital arrival. However, recent data suggest that in a real-world setting, median door-to-balloon (DTB) time is closer to 180 min for transfer patients, with less than 5% of patients being treated within 90 min. A retrospective observational study was conducted to assess time to treatment in patients undergoing primary PCI at the Quebec Heart and Lung Institute (QHLI)., Methods: Consecutive lytic-eligible patients undergoing primary PCI at the QHLI for STEMI between April 2004 and March 2005 were included in the present analysis. The primary evaluation was DTB time measured from arrival at the first hospital to first balloon inflation. Clinical outcomes were in-hospital death, reinfarction and bleeding. DTB times and hospital outcomes of patients transferred from referring hospitals were compared with those of patients presenting directly to the QHLI., Results: During the study period, 203 lytic-eligible patients were treated with primary PCI. Sixty-nine patients presented directly to the QHLI and 134 were transferred from other hospitals. Six transfer patients were excluded because of missing time variables. The median DTB time was 114 min in transfer patients, compared with 87 min in patients presenting directly to the QHLI (P<0.001). DTB time was less than 90 min in 24% of the transfer population compared with 55% of patients presenting directly to the QHLI (P<0.001). In patients referred from hospitals within a radius of 30 km from the QHLI (n=100), median DTB time was 106 min with 30% receiving PCI within 90 min. In these patients, estimated PCI-related delay was 74 min. For patients presenting to hospitals beyond 30 km (n=28), median DTB time was 142 min with 4% receiving reperfusion within 90 min. In these patients, estimated PCI-related delay was 110 min. Median DTB time for patients presenting during off hours at the QHLI was 92 min compared with 79 min for patients presenting during regular business hours (P=0.02). In patients transferred from other hospitals, median DTB time was 118 min during off hours and 108 min during normal business hours (P=0.07)., Conclusions: A DTB time of less than 90 min can be achieved in the majority of patients presenting directly to a primary PCI centre. However, for patients presenting to community hospitals, transfer for primary PCI is often associated with delayed revascularization. The present study highlights the need for careful patient selection when deciding between on-site thrombolytic therapy and transfer for primary PCI for STEMI patients presenting to hospitals without PCI facilities.