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Summary Background Dual antiplatelet therapy, comprising aspirin and clopidogrel, is recommended in patients undergoing coronary stenting to avoid the occurrence of stent thrombosis and others ischaemic events. Interindividual response to clopidogrel varies, however, with poor response associated with an increased risk of ischaemic events. New assays are available for testing aspirin and clopidogrel response routinely at the bedside. Aim To evaluate the prognostic value of testing antiplatelet response in an intermediate-risk population undergoing stent implantation. Methods We prospectively assessed clopidogrel and aspirin response using the VerifyNow assay at the time of coronary stenting in 1001 patients who presented with stable coronary disease or non-ST-segment elevation acute coronary syndrome. The main ischaemic endpoint was the composite of definite and probable stent thrombosis, cardiovascular death or spontaneous myocardial infarction at one year. The safety endpoint was major bleeding. Results Overall, 36.0% of patients had high on-clopidogrel platelet reactivity (OCR) and 8.6% had high on-aspirin platelet reactivity (OAR). The main ischaemic composite endpoint occurred in 3.9% of patients with high vs. 2.3% of patients with normal OCR (hazard ratio 1.66, 95% confidence interval 0.78–3.54; P = 0.18). Definite or probable stent thrombosis occurred in 1.1% of patients with high vs. 0.3% of patients with normal OCR ( P = 0.86). There was no significant difference in ischaemic endpoints according to OAR and there was no difference in rates of major bleeding between patients with high versus normal on-treatment platelet reactivity. Conclusions On-treatment platelet reactivity was not associated with 1-year ischaemic or bleeding events in an intermediate-risk population undergoing stent implantation.

SummaryTo assess the feasibility and safety of coronary angiography combined, where necessary, with ad hoc angioplasty in an outpatient setting; a prospective, single-center study. The first 172 patients (154 men, 59±11 years) considered at low risk for complications were enrolled for outpatient-coronary angiography with or without angioplasty via a radial approach. The inclusion criteria were clinical, not based on angiography. After angiography/angioplasty, creatinine and troponin were assayed (outside the hospital) within 24h and patients were telephoned and asked about their clinical condition. Angioplasty was performed in 69 (40%) patients and 130 patients (75.6%) were discharged on the same day. In the angioplasty group, a history of coronary dilatation was more common in patients discharged on the same day (p=0.05), whereas bifurcation lesions were more frequent in subjects who were kept in hospital (p

Summary Background In primary percutaneous coronary intervention (pPCI), conflicting data exist on the relative importance of patient presentation time (time from symptom onset (SO) to first medical contact [FMC]) and transfer time (time from FMC to sheath insertion). Objectives To evaluate the impact of transfer time on mortality in an unselected ST-elevation myocardial infarction (STEMI) population treated with pPCI. Methods In a well-organized urban network, using mobile intensive care units (MICU) whenever possible, the impact of transfer time on inhospital mortality was evaluated in 703 unselected consecutive STEMI patients transferred for pPCI. Results Our STEMI population included patients with cardiogenic shock (5.3%) and out-of-hospital cardiac arrest (3.7%). Longer transfer times were found to be associated with a stepwise increase in mortality ranging from 2.99% in the first quartile (Q1) up to 8.65% in the fourth quartile (Q4) ( P = 0.005). This result was noted in patients presenting early (≤ 2 h of SO, 0.96% for Q1 vs. 9.8% for Q4, P = 0.006) but not in late presenters (> 2 h of SO, 7.00% for Q1 vs. 7.8% for Q4, P = 0.85). After adjustment for confounding variables such as the severity of patients, the relationship between mortality and transfer time was no longer apparent. Conclusions In a well-organized urban network dedicated to pPCI, including unselected STEMI patients, transfer time does not appear to be a major contributor to mortality. The relationship of transfer time to mortality seems to be dependent on presentation time and patients’ clinical severity.

Summary Background It is unknown whether the efficacy and safety of drug-eluting stents (DES) apply in patients with chronic renal failure (CRF). Aims To compare DES with bare metal stents (BMS) for percutaneous coronary intervention (PCI) in CRF patients. Patients and methods Consecutive patients treated by PCI were allocated to four groups according to type of stent used (DES versus BMS) and creatinine clearance (CrCl). CRF was defined as CrCl less than 60 mL/minute. Cardiovascular death, major adverse cardiac events (MACE, defined as cardiovascular death, myocardial infarction, stroke and target lesion revascularization [TLR]), TLR and definite stent thrombosis (ST) were recorded at 1 year. Results We note that 1376 consecutive patients underwent PCI with stent within 18 months: 534 (39%) and 492 (36%) patients without CRF and 224 (16%) and 126 (9%) patients with CRF were treated with BMS and DES, respectively. In the entire cohort, patients treated with DES had a higher restenosis risk profile. BMS were predominantly (87%) used for ST-segment elevation myocardial infarction. At 1 year, 6.2% had cardiovascular death, 15.8% MACE, 7.3% TLR and 1.5% ST. Cardiovascular death and MACE occurred less frequently in DES groups. The TLR rate was not significantly different in the CRF groups (BMS 9.8% vs DES 7.1%; P = 0.44). No excess of ST was observed in the DES groups and use of DES was independently associated with absence of MACE and TLR. Conclusions In patients with CRF, DES appear to be at least as effective as BMS — despite a higher restenosis risk profile — with no excess of ST at 1 year.

Contexte Le systeme renine-angiotensine-aldosterone constitue une cible therapeutique majeure dans le traitement de la maladie coronarienne. Des travaux recents suggerent l’interet pronostique de l’aldosterone dans les syndromes coronariens aigus (SCA). Nous avons etudie la valeur pronostique potentielle de l’aldosterone dans une population de coronariens plus large : ceux beneficiant d’une angioplastie coronaire programmee. Methodes De juin 2000 a Septembre 2001, nous avons inclus les patients hospitalises au CHRU de Lille beneficiant d’une angioplastie coronaire non urgente. Des prelevements sanguins etaient realises durant la coronarographie pour dosage de l’aldosterone plasmatique et le suivi etait d’au moins 12 mois, le critere de jugement etant la mortalite cardiovasculaire. Resultats 807 patients ont ete inclus, âges en moyenne de 61 ans, essentiellement des hommes (78 %) fumeurs (71 %) hypertendus (53 %). 32 % etaient diabetiques, la FEVG moyenne etait de 58 ± 15 % et 93 % des patients ont recu une endoprothese. 50 % des patients etaient des coronariens stables. Le taux moyen d’aldosterone etait de 25 (13-5) pg/mL. Les facteurs associes a une augmentation de l’aldosterone etaient l’IMC (p = 0.003), une classe NYHA > 1 (p = 0.0001) et une elevation de la troponine (p = 0.01). Inversement un âge eleve (p = 0.0001), une fonction renale normale (p = 0.01) et la prise de betabloquants (p = 0.01) etaient associes a une diminution de l’aldosterone. Le suivi moyen etait de 14.9 mois et il y a eu 40 deces d’origine cardiovasculaire. Les facteurs predictifs independants de mortalite cardiovasculaire en analyse multivariee etaient un âge eleve (RR = 1.42, p = 0.04), la presence d’un diabete (RR = 2.20, p = 0.04), une fraction d’ejection alteree (RR = 1.58, p = 0.001), la survenue recente d’un SCA (RR = 3.23, p = 0.02), une CRP elevee (RR = 2.59, p = 0.004) et un taux d’aldosterone eleve (RR = 3.48, p = 0.004). Conclusion L’aldosterone plasmatique semble etre un facteur pronostique independant chez les patients beneficiant d’une angioplastie coronaire non urgente et son utilisation permettrait d’ameliorer la stratification du risque cardiovasculaire. Cela pourrait n’etre que le reflet de l’activation generale du systeme neurohormonal mais l’aldosterone induit divers effets extrarenaux (developpement d’une dysfonction endotheliale, d’une fibrose vasculaire et myocardique, effets pro-thrombotiques et proinflammatoires) qui en font un marqueur de risque cardiovasculaire tres seduisant. Download : Download full-size image

Summary Background The transradial approach for percutaneous coronary intervention (PCI) is associated with a better outcome in myocardial infarction (MI), but patients with cardiogenic shock (CS) were excluded from most trials. Aims To compare outcomes of PCI for MI-related CS via the transradial versus transfemoral approach. Methods A prospective cohort of 101 consecutive patients admitted for PCI for MI-related CS were treated via the transradial (n = 74) or transfemoral (n = 27) approach. Cox proportional hazards models adjusted for prespecified variables and a propensity score for approach were used to compare mortality, death/MI/stroke and bleeding between the two groups. A complementary meta-analysis of six studies was also performed. Results Patients in the transradial group were younger (P = 0.039), more often male (P = 0.002) and had lower GRACE and CRUSADE scores (P = 0.003 and 0.001, respectively) and rates of cardiac arrest before PCI (P = 0.009) and mechanical ventilation (P = 0.006). Rates of PCI success were similar. At a mean follow-up of 756 days, death occurred in 40 (54.1%) patients in the transradial group versus 22 (81.5%) in the transfemoral group (adjusted hazard ratio [HR]: 0.49, 95% confidence interval [CI] 0.28–0.84; P = 0.012). The transradial approach was associated with reduced rates of death/MI/stroke (adjusted HR: 0.53, 95%CI: 0.31–0.91; P = 0.02) and major bleeding (adjusted HR: 0.34, 95%CI: 0.13–0.87; P = 0.02). The meta-analysis confirmed the benefit of transradial access in terms of mortality (relative risk [RR]: 0.63, 95%CI: 0.58–0.68) and major bleeding (RR: 0.43, 95%CI: 0.32–0.59). Conclusion The transradial approach in the setting of PCI for ischaemic CS is associated with a dramatic reduction in mortality, ischaemic and bleeding events, and should be preferred to the transfemoral approach in radial expert centres.