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Background The healthcare burden posed by the coronavirus disease 2019 (COVID‐19) pandemic in the New York Metropolitan area has necessitated the postponement of elective procedures resulting in a marked reduction in cardiac catheterization laboratory (CCL) volumes with a potential to impact interventional cardiology (IC) fellowship training. Methods We conducted a web‐based survey sent electronically to 21 Accreditation Council for Graduate Medical Education accredited IC fellowship program directors (PDs) and their respective fellows. Results Fourteen programs (67%) responded to the survey and all acknowledged a significant decrease in CCL procedural volumes. More than half of the PDs reported part of their CCL being converted to inpatient units and IC fellows being redeployed to COVID‐19 related duties. More than two‐thirds of PDs believed that the COVID‐19 pandemic would have a moderate (57%) or severe (14%) adverse impact on IC fellowship training, and 21% of the PDs expected their current fellows' average percutaneous coronary intervention (PCI) volume to be below 250. Of 25 IC fellow respondents, 95% expressed concern that the pandemic would have a moderate (72%) or severe (24%) adverse impact on their fellowship training, and nearly one‐fourth of fellows reported performing fewer than 250 PCIs as of March 1st. Finally, roughly one‐third of PDs and IC fellows felt that there should be consideration of an extension of fellowship training or a period of early career mentorship after fellowship. Conclusions The COVID‐19 pandemic has caused a significant reduction in CCL procedural volumes that is impacting IC fellowship training in the NY metropolitan area. These results should inform professional societies and accreditation bodies to offer tailored opportunities for remediation of affected trainees.

Objective Debate continues as to the optimal minimally invasive treatment modality for complex disease of the left anterior descending coronary artery, with advocates for both robotic-assisted minimally invasive direct coronary artery bypass and percutaneous coronary intervention with a drug-eluting stent. We analyzed the midterm outcomes of patients with isolated left anterior descending disease, revascularized by minimally invasive direct coronary artery bypass or drug-eluting stent percutaneous coronary intervention, focusing on those with complex lesion anatomy. Methods A retrospective review was undertaken of all patients who underwent coronary revascularization between January 2008 and December 2016. From this population, 158 propensity-matched pairs of patients were generated from 158 individuals who underwent minimally invasive direct coronary artery bypass for isolated complex left anterior descending disease and from 373 patients who underwent percutaneous coronary intervention using a second-generation drug-eluting stent. Midterm survival and incidence of repeat left anterior descending intervention were analyzed for both patient groups. Results Overall 9-year survival was not significantly different between patient groups both before and after propensity matching. Midterm mortality in the matched minimally invasive direct coronary artery bypass group was low, irrespective of patient risk profile. By contrast, advanced age (hazard ratio, 1.10; P = .012) and obesity (hazard ratio, 1.09; P = .044) predicted increased late death after drug-eluting stent percutaneous coronary intervention among matched patients. Patients who underwent minimally invasive direct coronary artery bypass were significantly less likely to require repeat left anterior descending revascularization than those who had percutaneous coronary intervention, both before and after propensity matching. Smaller stent diameter in drug-eluting stent percutaneous coronary intervention was associated with increased left anterior descending reintervention (hazard ratio, 3.53; P = .005). Conclusions In patients with complex disease of the left anterior descending artery, both minimally invasive direct coronary artery bypass and percutaneous coronary intervention are associated with similar excellent intermediate-term survival, although reintervention requirements are lower after surgery.

Background Hybrid coronary revascularization (HCR) constitutes a left internal mammary artery graft to the left anterior descending (LAD) coronary artery, coupled with percutaneous coronary intervention (PCI) for non-LAD lesions. This management strategy is not commonly offered to patients with complex multivessel disease. Our objective was to evaluate 8-year survival in patients with triple-vessel disease (TVD) treated by HCR, compared with that of concurrent matched patients managed by traditional coronary artery bypass grafting (CABG) or multivessel PCI. Methods A retrospective review was undertaken of 4805 patients with TVD who presented between January 2009 and December 2016. A cohort of 100 patients who underwent HCR were propensity-matched with patients treated by CABG or multivessel PCI. The primary endpoint was all-cause mortality at 8 years. Results Patients with TVD who underwent HCR had similar 8-year mortality (5.0%) as did those with CABG (4.0%) or multivessel PCI (9.0%). A composite endpoint of death, repeat revascularization, and new myocardial infarction, was not significantly different between patient groups (HCR 21.0% vs CABG 15.0%, P = .36; HCR 21.0% vs PCI 25.0%, P = .60). Despite a higher baseline synergy between percutaneous coronary intervention with taxus and cardiac surgery(SYNTAX) score, HCR was able to achieve a lower residual SYNTAX score than multivessel PCI (P = .001). Conclusions In select patients with TVD, long-term survival and FREEDOM from major adverse cardiovascular events after HCR are similar to that seen after traditional CABG or multivessel PCI. HCR should be considered for patients with multivessel disease, presuming a low residual SYNTAX score can be achieved.

The American College of Cardiology/American Heart Association guidelines include a Class 1 recommendation to initiate therapeutic hypothermia (TH) in comatose patients with out-of-hospital cardiac arrest (OHCA) with an initial shockable rhythm who have achieved return of spontaneous circulation. There is also a Class 1 recommendation for immediate angiography in these patients whose initial electrocardiography shows ST-elevation myocardial infarction (STEMI). However, due to a lack of clinical trials evaluating these patients who have received both percutaneous coronary intervention (PCI) and TH, controversy remains regarding whether the two can be safely combined. Furthermore, in patients who receive TH and PCI, another question to address is which therapy to initiate first. This article focuses on how best to manage comatose OHCA survivors who have an initial shockable rhythm and STEMI.

We sought to evaluate midterm survival data and resource use for patients who received hybrid coronary revascularization for 2-vessel coronary disease (robotic-assisted left internal thoracic artery graft to left anterior descending coronary artery (minimally invasive direct coronary artery bypass), coupled with a stent to the circumflex or right coronary artery), compared with a concurrent cohort who had traditional coronary artery bypass grafting.A comprehensive retrospective review was undertaken of our prospectively collected database from January 2009 to December 2016. We propensity matched 207 patients who underwent hybrid coronary revascularization for double-vessel disease with patients who underwent coronary artery bypass grafting. Eight-year survival data were obtained from the National Death Index.Thirty-day mortality was 1 patient (0.5%) in each of the hybrid coronary revascularization and coronary artery bypass grafting groups. Eight-year survival for the hybrid coronary revascularization group was 187 of 207 patients (90.3%) compared with 182 of 207 patients (87.9%) for the coronary artery bypass grafting cohort. End-stage renal disease independently predicted late mortality in all patients (overall hazard ratio, 5.60, P .001; hybrid coronary revascularization hazard ratio, 5.58, P = .002; coronary artery bypass grafting hazard ratio, 4.59, P = .006). Female patients who underwent hybrid coronary revascularization had a higher incidence of late death (hazard ratio, 2.47, P = .05). Length of stay and perioperative transfusion requirements were lower in the hybrid coronary revascularization group (P .0001).Hybrid coronary revascularization for double-vessel coronary disease is associated with similar short-term outcomes and intermediate-term survival as traditional coronary artery bypass grafting. Hybrid coronary revascularization is associated with lower transfusion requirements and a shorter length of stay than coronary artery bypass grafting.

Background: The study of the pathophysiologic mechanism of perioperative myocardial infarctions is limited to two small autopsy studies suggesting a major role for plaque rupture and thrombosis. However, the perioperative period is characterized by increased cardiac metabolic demand that may lead to infarction in patients with otherwise stable obstructive coronary artery disease. The purpose of this study is to investigate the pathophysiology of perioperative myocardial infarctions. Methods: Hospital records and coronary angiograms from patients from 1998 to 2006 who underwent noncardiac surgery complicated by a perioperative myocardial infarction (MI) were reviewed. The culprit lesion was identified based on ECG, left ventriculography, and coronary angiography. Degree of stenosis, TIMI flow, ACC thrombus grade, calcification score, and lesion morphology were evaluated. Based on these criteria, MIs were categorized as thrombotic, demand, or nonobstructive. Results: Sixty-six patients (average age, 71 years and 44% male), 77% of whom underwent an intermediate risk surgery with a 2% perioperative mortality, were identified. The distribution of demand, thrombotic, and nonobstructive MI was 55%, 26%, and 19%, respectively. There was neither statistical difference in the occurrence of prolonged hypotension or tachycardia between groups nor was there any difference in the use of antiplatelets, β-blockers, or statins. Conclusion: This study identified demand ischemia as the predominant etiology of perioperative MIs in this cohort. An improved understanding of the pathophysiologic mechanism of perioperative MIs may facilitate the evaluation and management of preoperative patients. © 2012 Wiley Periodicals, Inc.

Coronary artery disease (CAD) accounts for approximately one-half of the sizable mortality in patients with end-stage renal disease who have undergone transplantation. The study was a retrospective review of 1460 patients who underwent renal transplantation at the Mount Sinai Medical Center from January 1, 2000 to October 31, 2009. Noninvasive stress testing was performed in 848 patients (88.1%) with 278 patients (32.8%) having abnormal results. Cardiac catheterization was performed in 357 patients (37.1%) and of these, 212 patients had obstructive disease (59.4%). At 5 years posttransplant, there was no statistically significant difference between those with nonobstructive CAD and those who required percutaneous or surgical interventions (adjusted hazard ratio [aHR], 1.243; CI 95%, 0.513-3.010; p = 0.630). Those with medically managed obstructive CAD had significantly higher rates of death at the 5-year period when compared to those who received percutaneous intervention (aHR, 3.792; CI 95%, 1.320-10.895; p = 0.013) or those who received coronary artery bypass grafting (aHR, 6.691; CI 95%, 1.200-37.323). Because noninvasive imaging is poorly predictive of coronary disease in this high-risk population, an anatomic diagnosis is recommended. Revascularization may result in improved long-term outcomes.

Few data are available on factors associated with low adherence or early clopidogrel discontinuation after percutaneous coronary intervention (PCI). Patients (n = 284) were evaluated before hospital discharge after PCI to identify factors associated with low adherence to clopidogrel 30 days later. Adherence to daily medications before PCI was assessed using the 8-item Morisky Medication Adherence Scale (MMAS-8) and categorized as low (score6), medium (score 6 to8), or high (score 8). Low adherence to clopidogrel was defined as MMAS-8 score6 (n = 21) or having discontinued clopidogrel (n = 11), which was ascertained during a 30-day interview after PCI. At 30 days after PCI, 11% of patients had low adherence to clopidogrel. Odds ratios (95% confidence intervals [CIs]) for low adherence to clopidogrel were 3.78 (1.09 to 13.1), 3.06 (1.36 to 6.87), 2.46 (0.97 to 6.27), and 3.36 (0.99 to 11.4) for patients who before PCI reported taking smaller doses of medication because of cost, had difficulty filling prescriptions, had difficulty reaching their primary physician, and were not comfortable asking their doctor for instructions, respectively. Odds ratios (95% CIs) for low clopidogrel adherence after PCI in patients with medium and low versus high adherence to daily medications before PCI were 6.13 (1.34 to 28.2) and 10.9 (2.46 to 48.7), respectively. The c-statistic associated with MMAS-8 scores before PCI for discriminating low clopidogrel adherence at 30 days after PCI was 0.733 (95% CI 0.650 to 0.852). In conclusion, adherence to daily medications before PCI may be a useful indicator for identifying patients who will have low clopidogrel adherence after PCI.

Although current literature demonstrates metabolic abnormalities are associated with mortality, obese patients who tend to have more metabolic abnormalities paradoxically have lower overall mortality rates compared to their normal-weight counterparts. In this study, we examined the prevalence of metabolic abnormality clustering and its relation to mortality in obese and normal-weight patients after percutaneous coronary intervention (PCI). Patients (n = 9,673) undergoing elective PCI from October 2003 through December 2006 at a single urban hospital were categorized by body mass index (BMI) levels of 18.5 to 24.9, 25.0 to 29.9, 30.0 to 34.9, and ≥35 kg/m(2) and by number of metabolic abnormalities possessed (hypertension, impaired fasting glucose/diabetes, triglycerides ≥150 mg/dl, high-density lipoprotein cholesterol40 mg/dl, and C-reactive protein ≥2.0 mg/L). All-cause mortality was assessed through June 30, 2007. Mean age of patients was 65.9 years and 66% were men. Prevalences of 4 or 5 metabolic abnormalities were 12%, 18%, 24%, and 31% in patients with BMI levels of 18.5 to 24.9, 25.0 to 29.9, 30 to 34.9, and ≥35 kg/m(2), respectively. In patients with BMI of 30.0 to 34.9 kg/m(2), hazard ratios (95% confidence intervals) for mortality associated with 2, 3, and 4 to 5 metabolic abnormalities versus 0 to 1 metabolic abnormality were 1.31 (0.79 to 2.17), 1.42 (0.83 to 2.43), and 2.39 (1.24 to 4.59), respectively. Analogous hazard ratios for patients with BMI ≥35 kg/m(2) were 1.94 (0.90 to 4.20), 1.44 (0.63 to 3.28), and 2.17 (0.91 to 5.18). All-cause mortality rates per 1,000 person-years were 55.5, 33.7, 28.3, and 33.8 in patients with BMI levels of 18.5 to 24.9, 25 to 29.9, 30 to 34.9, and ≥35 kg/m(2), respectively. In conclusion, BMI levels of 25.0 to 29.9 and 30 to 34.9 kg/m(2) were associated with lower all-cause mortality after PCI. However, an increased number of metabolic abnormalities translated into increased all-cause mortality.

Objectives: The objective of this study is to analyze the clinical outcomes and treatment strategies of coronary wire perforations (WPs) in the era of heparin use compared to the era of bivalirudin use. Background: Percutaneous coronary intervention (PCI) advances have led to progressive decrease in complications. Therefore, complex coronary lesions such as chronic total occlusions and calcified lesions are being attempted with stiff/hydrophilic wires with resultant higher incidence of coronary WP. Methods: A single-center retrospective data analysis of coronary perforation (CP) for the last 4 years with review of coronary angiograms was done and WPs were identified. A simple classification scheme based on angiographic appearance of CP was made: Type I (“myocardial stain,” with no frank dye extravasation) and type II (“myocardial fan,” with dye extravasation to pericardial cavity or cardiac chambers). Results: Overall incidence of CP was 0.49% (82/16,859). Of these 50 (61%) were caused by WP; 30 occurred with heparin use (Group A) and 20 with bivalirudin use (Group B). WPs always occurred in type B2/C lesions (100%) and commonly with use of hydrophilic guidewires (70%). Major adverse cardiac events and cardiac tamponade were frequent in group A (50%) and none in group B (0%); P < 0.01. All WP in group B responded to stopping anticoagulation and prolonged balloon inflation, while group A type II perforations frequently required additional interventions (pericardiocentesis, coil embolization). Conclusions: Cardiac tamponade and major adverse cardiac events from WPs were less frequent with bivalirudin use compared to heparin use. This beneficial effect of bivalirudin may be explained on the basis of its short half-life and reversible thrombin inhibition property. Therefore, bivalirudin may offer a safer alternative for anticoagulation in complex PCI. © 2009 Wiley-Liss, Inc.

Background: Since their introduction, the use of drug-eluting stents (DES) has increasingly become standard practice due to their decreased rates of in-stent restenosis and target lesion revascularization (TLR) rates in comparison to bare metal stents (BMS). However, these benefits have not been reproduced in patients with severe renal disease (SRD). This study compared TLR rates in patients with severe renal insufficiency treated with DES vs. BMS. Methods: Between 2003 and 2006, we collected data on 6,220 consecutive patients receiving either DES or BMS. Both groups were similar in angiographic and clinical variables. TLR rates at 270 days and 1 year were then compared between patients receiving DES or BMS with varying creatinine clearance (CrCl). Results: At 1 year after PCI, TLR rates were significantly lower for DES in patients with CrCl >60 (5 vs. 9.3%; p < 0.0001). However, in patients with CrCl Conclusion: While DES showed improved clinical outcomes in patients with normal and mildly impaired renal function, they showed no benefit over BMS in patients with moderate to severe renal insufficiency. Coupled with the possibly increased risk of late stent thrombosis with DES, BMS may be a more appropriate and safer stent in this population.

There are limited data on the validity of the Thrombolysis In Myocardial Infarction (TIMI) risk score for unstable angina pectoris (UAP)/non-ST-elevation myocardial infarction in patients with moderate to advanced chronic kidney disease (CKD), including patients using dialysis. Accordingly, we evaluated the prognostic ability of the TIMI risk score in consecutive patients across the entire spectrum of CKD who presented with UAP or non-ST elevation myocardial infarction and underwent percutaneous coronary intervention from July 1, 1999, to June 30, 2007. Patients were categorized by estimated glomerular filtration rate (eGFR)or = 60 (n = 4,938), 30 to 59 (n = 1,592), and30 ml/min/1.73 m2 (n = 202) and use of dialysis (n = 208). Hazard ratios of all-cause mortality associated with TIMI risk score levels (0 to 2, 3 to 4,or = 5) were calculated within each eGFR category. Over a median follow-up of 3.2 years, 813 deaths occurred. For patients with an eGFRor = 60 ml/min/1.73 m2, race- and gender-adjusted hazard ratios of mortality associated with TIMI risk scores of 3 to 4 andor = 5 compared with 0 to 2 were 2.92 (95% confidence interval [CI] 1.93 to 4.40) and 4.26 (95% CI 2.82 to 6.43), respectively. Analogous hazard ratios were 1.26 (95% CI 0.80 to 1.98) and 1.77 (95% CI 1.13 to 2.78) for patients with an eGFR of 30 to 59 ml/min/1.73 m2, 2.23 (95% CI 0.71 to 6.94) and 2.83 (95% CI 0.89 to 8.99) for patients with an eGFR30 ml/min/1.73 m2, and 3.16 (1.33 to 7.48) and 3.67 (95% CI 1.52 to 8.86), respectively, for patients on dialysis. In conclusion, the TIMI risk score for UAP/non-ST elevation myocardial infarction discriminates mortality risk across the full range of CKD, including patients on dialysis.

High-density lipoprotein (HDL) cholesterol level is a strong predictor of morbidity and mortality in the general population. Conflicting data exist on the protective effects of high HDL cholesterol in patients with optimal low-density lipoprotein (LDL) cholesterol levels. To determine the association of high HDL cholesterol with mortality in patients with LDL cholesterol levels70 mg/dl who undergo percutaneous coronary intervention, 3,616 consecutive patients with LDL cholesterol levels70 mg/dl who underwent percutaneous coronary intervention from July 1, 1999, to June 1, 2007, were retrospectively analyzed and followed through July 1, 2007. All-cause mortality was identified using the National Death Index. The mortality rates was 34.7, 25.2, 23.7, and 18.8 per 1,000 person-years in patients with HDL cholesterol levels of40, 40 to 49, 50 to 59, andor =60 mg/dl, respectively (p for trend0.001). After multivariate adjustment for demographic characteristics, cigarette smoking, biochemical variables, and co-morbid conditions, the hazard ratios for mortality in patients with HDL cholesterol levels of 40 to 49, 50 to 59, andor =60 mg/dl, compared with their counterparts with HDL cholesterol levels40 mg/dl, were 0.68 (95% confidence interval [CI] 0.50 to 0.93), 0.55 (95% CI 0.35 to 0.85), and 0.45 (95% CI 0.27 to 0.74), respectively. For each 1-SD increase in HDL cholesterol level (14 mg/dl), the multivariate-adjusted hazard ratio for all-cause mortality was 0.68 (95% CI 0.58 to 0.79). In conclusion, in patients with LDL cholesterol levels70 mg/dl who underwent percutaneous coronary intervention, a strong inverse association was present between HDL cholesterol level and all-cause mortality.

Objectives: The aim of the present study was to study the outcome of coronary stenting in patients with symptomatic myocardial bridging refractory to standard medical therapy. Background: Medical therapy constitutes the first line treatment for patients with symptomatic myocardial bridge, surgical correction may be offered to select patients with refractory symptoms. Limited data exists on the outcome of coronary stenting in this patient cohort. Methods: Twenty-nine patients with symptoms of angina, documented myocardial ischemia and angiographically documented myocardial bridge of the left anterior descending artery (defined as [mt]50% systolic compression) were identified retrospectively. Seventeen (59%) patients responded to maximized medical therapy (mean age 51 ± 16 years, range 29–80, 7 female) and 12 (41%) patients received coronary stents following a failed attempt of minimum 3 months of maximal medical therapy (mean age 49 ± 15 years, range 32–76 years, 5 females). Medical therapy responders were compared with intracoronary stent group for recurrent severe angina, target vessel revascularization (TVR), myocardial infarction (MI), and death at follow-up. Results: Intracoronary stents were placed in all patients successfully. The incidence of recurrent severe angina and TVR were significantly greater in the stent group (P = 0.04) while MI and death in two groups were similar at mean follow-up of 15 ± 3 months. Conclusions: Coronary stent placement for medically refractory symptomatic myocardial bridge failed to relieve severe angina and is associated with high clinical restenosis and hence should be avoided. © 2008 Wiley-Liss, Inc.

We hypothesized that direct thrombin inhibition could attenuate platelet activation and release of soluble CD40 ligand (sCD40L), a marker of inflammation, during percutaneous coronary intervention (PCI). To assess platelet function under flow conditions with bivalirudin versus unfractionated heparin (UFH), we employed the cone and plate(let) analyzer (CPA) assay in drug-spiked blood samples from volunteers (n = 3) in vitro, and then in PCI patients who received bivalirudin alone (n = 20), UFH alone (n = 15), and clopidogrel pretreatment plus bivalirudin (n = 15). Scanning electron microscopy was employed to image bivalirudin or UFH-treated platelets to determine whether platelet function observations had a morphologic explanation. Enzyme immunoassay was used to measure sCD40L levels in PCI patients. In vitro, bivalirudin decreased platelet surface coverage; UFH increased platelet surface coverage. In PCI patients, bivalirudin alone decreased platelet surface coverage, UFH alone increased platelet surface coverage, and clopidogrel pretreatment plus bivalirudin additively reduced platelet surface coverage. Unlike UFH, bivalirudin did not activate platelets in SEM studies. Bivalirudin alone or coupled with clopidogrel significantly reduced plasma sCD40L in PCI patients. In conclusion, our findings suggest that under flow conditions, bivalirudin alone or coupled with clopidogrel may have an antiplatelet effect versus UFH alone during PCI. These data suggest that bivalirudin and UFH may confer an anti-inflammatory effect by reducing sCD40L during PCI.

Coronary stenting of nonaorto ostial coronary lesions is challenging because of plaque shift into the main vessel, triggering the use of additional stents. Furthermore, inappropriate coverage of the ostium of the side branch increases the risk of restenosis and target vessel revascularization (TVR). To improve the treatment of nonaorto ostial coronary lesions with a novel interventional technique, we tested the hypothesis that inflating a balloon in the main vessel before stenting the side branch (stent pull-back technique) will limit plaque shifting and reduce the use of additional stents. In addition, proper coverage of the side branch ostium may also reduce 8-month TVR. A case-control design with 100 consecutive patients who underwent drug-eluting stent placement was performed; 55 patients were treated with the stent pull-back technique and 45 patients with a conventional stent technique. Procedural success was 100% for the 2 techniques. The use of additional stents was reduced in the stent pull-back group compared with the conventional stent group (2% vs 18%, p = 0.007). A tendency toward lower ostial miss was also observed in the stent pull-back group (4% vs 13%, p = 0.11). The incidence of in-hospital and 30-day cardiac events was similar between the 2 groups. TVR was lower in the stent pull-back group compared with the conventional group (5% vs 20%; p = 0.03). In conclusion, the stent pull-back technique improves the percutaneous treatment of nonaorto ostial coronary lesions. The technique is associated with a lower use of additional stents and improved clinical outcome, reducing TVR at 8 months of follow-up.

Radiographic contrast nephropathy (RCN), acute worsening of renal function due to contrast agents, can occur in 15%-40% of patients with baseline renal dysfunction undergoing percutaneous coronary intervention (PCI) and is associated with increased morbidity and in-hospital mortality. The purpose of this study was to evaluate whether the selective dopamine-1 (DA-1) receptor agonist fenoldopam would be beneficial in patients with chronic renal insufficiency (CRI) undergoing PCI and also to design a protocol for prevention of RCN. We analyzed 150 consecutive patients with CRI [baseline serum creatinine (BSCr) +/- 1.5% mg] who underwent PCI and received fenoldopam during and after the procedure, in addition to saline hydration. RCN, defined as > 25% increase of BSCr 48-72 hr after PCI, occurred in 4.7% (n = 7) of 150 PCI patients receiving fenoldopam and 3.5% in diabetics (n = 85) vs. 6.1% in nondiabetics (n = 65; P = NS). No patients required dialysis. The observed 4.7% incidence of RCN with fenoldopam was significantly lower than 18.8% incidence in the historical control group (P < 0.001). Our data suggest that fenoldopam is a useful adjunct in the prevention of RCN during PCI, especially in diabetics.

Sodium bicarbonate has been proposed for protection of the kidney from contrast-induced AKI (CIAKI). However, the effects of bicarbonate on long-term important clinical outcomes are uncertain.In a prospective, double-blind, multicenter randomized clinical trial, 391 patients with an eGFR45 ml/min per 1.73 m(2) undergoing elective coronary or peripheral angiography were randomized to an infusion with a high dose of isotonic sodium bicarbonate (target 2.0 mEq/kg) or a similar molar amount of isotonic sodium chloride. The primary outcome was a composite of mortality, dialysis, or a sustained 20% reduction in eGFR at 6 months.There were 391 patients enrolled between March 2010 and May 2012. The incidence of the primary outcome was 14.9% in the bicarbonate group and 16.3% in the control group in the intention-to-treat population (P=0.78). There was also no difference in the incidence of CIAKI between the treatment groups (14.5% versus 12.1%, respectively; P=0.20). CIAKI was associated with a higher incidence of sustained loss of kidney function at 6 months compared with those without CIAKI (21.2% versus 7.7%, respectively; P=0.06).High-dose sodium bicarbonate infusion in patients with eGFR45 ml/min per 1.73 m(2) undergoing angiography did not demonstrate a difference in incidence of the composite of death, dialysis, or sustained 6-month reduction in eGFR or CIAKI compared with sodium chloride.

To compare outcomes of elective percutaneous coronary interventions (PCI) in same-day discharge and overnight hospital stays.Advances in PCI techniques and equipment have allowed same-day discharge after elective PCI. In this study, we investigated the safety of same-day discharge ambulatory PCI in patients according to age, creatinine, and ejection fraction (ACEF) scores.The ambulatory PCI group consisted of all PCIs with same-day discharge, while the overnight-stay group consisted of all elective PCIs with in-hospital observation and discharge the following day. Patients were stratified into tertiles based on ACEF score: low (1.08), mid (≥1.08 and1.31), and high (≥1.31). The primary endpoint was 30-day major adverse cardiac events, defined as readmission, all-cause mortality, non-fatal myocardial infarction, and target lesion revascularization. Propensity score matching was done to evaluate outcomes based on similar baseline characteristics.There were 16,407 elective PCIs, of which 21.2% were in the ambulatory group. Patients who stayed overnight had similar 30-day composite outcomes as their same-day discharge counterparts in the high ACEF score (odds ratio [OR], 1.213; 95% confidence interval [CI], 0.625-2.355; P=.57) and mid ACEF score (OR, 0.636; 95% CI, 0.356-1.134; P=.13) comparisons, but had worse outcomes in the low ACEF score comparison (OR, 1.867; 95% CI, 1.134-3.074; P=.01).In this single-center registry, patients who underwent same-day discharge ambulatory PCI had no worse outcomes, and in some cases better outcomes, than overnight-stay patients; this result was found in the group as a whole, as well as in all ACEF score subcategories.

PURPOSE: To review the efficacy of inhibitors of matrix metalloproteinase-9, corticosteroids, and doxycycline for treatment of recalcitrant recurrent corneal erosion. METHODS: Retrospective, clinic-based, interventional case series. The medical records of seven consecutive patients who were treated between January 1995 to January 2000 for recurrent corneal erosion who had not responded to conventional therapy were reviewed. Treatment of seven eyes of seven patients consisted of oral doxycycline (50 mg, two times a day) for 2 months along with a topical corticosteroid (either methylprednisolone 1%, prednisolone acetate 1%, or fluoromethalone 0.1%) three times a day, for 2 to 3 weeks. The effects of doxycycline and methylprednisolone on metalloproteinase-9 activity in human corneal epithelial cultures were evaluated by gelatin zymography and a commercial metalloproteinase-9 activity assay kit. RESULT: Fingernail injury in three of the seven eyes was the most common form of corneal injury. There was no evidence of epithelial basement membrane or corneal stromal dystrophy in any of the patients, although epithelial microcysts were observed in the involved area in three patients. One eye had intact elevated corneal epithelium that showed abnormal diffuse staining with fluorescein dye, and six eyes had a corneal epithelial defect at the time of presentation. In all seven eyes, pain resolved and epithelial defects healed within 2 to 10 days after initiation of therapy. No recurrence was observed during an average follow-up period of 21.9 months (range, 1.5 to 60 months). Methylprednisolone and doxycycline each produced a statistically significant decrease in amount and activity of metalloproteinase-9 in conditioned media of human corneal epithelial cultures. CONCLUSIONS: Therapy with a combination of medications that inhibit metalloproteinase-9 produced rapid resolution and prevented further recurrence of cases of recurrent corneal erosions that were unresponsive to conventional therapies.

To compare the discriminatory value of differing risk scores for predicting clinical outcomes following PCI in routine practice.Various risk scores predict outcomes after PCI. However, these scores consider markedly different factors, from purely anatomical (SYNTAX risk score [SRS]) to purely clinical (ACEF, modified ACEF [ACEFmod], NCDR), while other scores combine both elements (Clinical SYNTAX score [CSS], NY State Risk Score [NYSRS]).Patients with triple vessel and/or LM disease with 12 month follow-up were studied from a single center PCI registry. Exclusion criteria included STEMI presentation, prior revascularization and shock. Clinical events at 12 months were compared to baseline risk scores, according to score tertiles and area under receiver-operating-characteristic curves (AUC).We identified 584 eligible patients (69.8±12.3yrs, 405 males). All scores were predictive of mortality, with the SRS being least predictive (AUC=0.66). The most accurate scores for mortality were the CSS and ACEF (AUC=0.76 for both: P = 0.019 and 0.08 vs. SRS, respectively). For TLR, while the SRS trended toward being positively predictive (P = 0.075), several scores trended towards a negative association, which reached significance for the NCDR (P = 0.045). The SRS and CSS were the only scores predictive of MI (both P0.05). No score was particularly accurate for predicting MACE (death+MI+TLR), with AUCs ranging from 0.53 (NCDR) to 0.63 (SRS).Competing factors influence mortality, MI and TLR after PCI. An increasing burden of comorbidities is associated with mortality, whereas anatomical complexity predicts MI. By combining these outcomes to predict MACE, all scores show reduced utility.

Background— Same-day discharge after percutaneous coronary intervention (PCI) may be safe for some patients. Few data are available on patient-reported outcomes and preferences for same-day discharge after PCI. Methods and Results Between March 2008 and March 2010, a total of 298 patients undergoing elective PCI via femoral access at 2 medical centers (Mount Sinai Hospital, New York, NY, and Baylor Medical Center, Dallas, TX) were randomized to same-day (n=150) or next-day (n=148) discharge. The primary outcome was high patient coping during the 7 days after discharge defined as scores P Conclusions— Same-day discharge after PCI was associated with patient-reported and clinical outcomes similar to those of next-day discharge and was preferred by most patients. Clinical Trial Registration— URL: http://www.clinicaltrials.gov/show/NCT01230606 . Unique identifier: NCT01230606.

The burden of cardiovascular disease is high in patients with chronic kidney disease or end-stage renal disease. The presence of kidney dysfunction affects the cardiovascular system in multiple ways, including accelerated progression of atherosclerosis and valvular disease, the exacerbation of congestive heart failure, and the development of pericardial disease. This comorbidity results not only from the concordance of shared risk factors, but also from other issues specific to this population, such as systemic inflammation and vascular calcification. Furthermore, both the sensitivity and specificity of noninvasive testing modalities, and the efficacy of several pharmacotherapeutic strategies, are diminished in this population. The exclusion of patients with severe kidney disease from many clinical trials of cardiac interventions raises various therapeutic uncertainties, and kidney disease itself is likely to alter the underlying cardiovascular physiology. In this Review, we discuss aspects of the epidemiology, pathophysiology, and diagnosis of cardiovascular disease in patients with kidney disease, and propose specific, evidence-based recommendations for pharmacological and surgical treatment.

A case of symptomatic myocardial bridge requiring intracoronary stent complicated by in-stent restenosis is reported. A stratified approach for the treatment of a symptomatic myocardial bridge is proposed.

This work describes the longest reported interval between drug-eluting stent (DES) placement and very late stent thrombosis (VLST). A 69-year-old male presented with substernal chest pain associated with ST-segment myocardial infarction (STEMI) after having a DES deployed 6.9 years (2506 days) prior. The patient's medical history revealed several risk factors for VLST. The patient suspended clopidogrel therapy in preparation for elective cystoscopy approximately 10 days before presenting.

A 51-year-old male with untreated hepatitis C infection, cirrhosis, and dilated cardiomyopathy with a HeartMate II LVAD presented with right heart failure and cardiogenic shock, INR of 7, hemolysis, and renal failure. Acute LVAD thrombosis was suspected. Alteplase was injected into the inflow cannula of the LVAD with little effect. Intravenous alteplase was given but failed to restore an adequate pump output, resulting in the need for emergency pump exchange. The patient had an uncomplicated postoperative recovery and was discharged uneventfully. Inspection of the pump identified a thrombus wedged between the spines of the impeller. Our case highlights the challenges in managing pump thrombosis which is often resistant to thrombolysis and may instead rely upon prompt surgical intervention to be resolved.

We evaluated the impact of the everolimus-eluting stent (EES) on the frequency of stent thrombosis (ST), target vessel revascularization (TVR), myocardial infarction (MI), and cardiac death in randomized controlled trials comparing the EES to non-everolimus-eluting drug-eluting stents (EE-DES).Whether or not the unique properties of the EES translate into reductions in ST remains unknown.We searched MEDLINE, Scopus, the Cochrane Library, and Internet sources for articles comparing outcomes between EES and non-EE-DES without language or date restriction. Randomized controlled trials reporting the frequency of ST were included. Variables relating to patient and study characteristics and clinical endpoints were extracted.We identified 13 randomized trials (n = 17,101) with a weighted mean follow-up of 21.7 months. Compared with non-EE-DES, the EES significantly reduced ST (relative risk [RR]: 0.55; 95% confidence interval [CI]: 0.38 to 0.78; p = 0.001), TVR (RR: 0.77; 95% CI: 0.64 to 0.92; p = 0.004), and MI (RR: 0.78; 95% CI: 0.64 to 0.96; p = 0.02). There was no difference in cardiac mortality between the groups (RR: 0.92; 95% CI: 0.74 to 1.16; p = 0.38). The treatment effect was consistent by different follow-up times and duration of clopidogrel use. The treatment effects increased with higher baseline risks of the respective control groups with the strongest correlation observed for ST (R(2) = 0.89, p0.001).Intracoronary implantation of the EES is associated with highly significant reductions in ST with concordant reductions in TVR and MI compared to non-EE-DES. Whether these effects apply to different patient subgroups and DES types merits further investigation.

Objectives: To investigate if previously reported gender-based outcome disparities following percutaneous coronary intervention (PCI) are applicable in a large and racially-diverse cohort in the drug eluting stent (DES) era. Background: It is generally believed that women suffer inferior outcomes compared to men after PCI. However, various strategies have evolved that may have mitigated this imbalance, including improved medical therapy, attention to risk-factors, and procedural advances of PCI including DES. Methods: We identified 13,752 patients (4,761 female, 34.6%) with complete follow-up data who underwent de novo lesion PCI from 04/2003 to 04/2009. Relevant data were extracted from an IRB-approved registry. Results: Compared to males, females were significantly older (69.0 vs. 64.8 years) and more frequently from a minority or non-Caucasian background. Females smoked less, but more were hypertensive and/or diabetic. Women had higher HDL, but also higher LDL cholesterol levels. More women presented with an unstable coronary syndrome and required left anterior descending artery PCI. While unadjusted post-PCI mortality rates were higher in females versus males (30 days, 1.3 vs. 0.8%, P = 0.009; 1 year, 6.1 vs. 4.8%, P = 0.001; 3 year, 10.4 vs. 8.4%, P < 0.0001), multivariable regression analyses failed to identify female gender as an independent predictor of mortality. Propensity-adjusted modeling confirmed that females were not at intrinsically higher risk for mortality after PCI. Conclusions: Females undergoing PCI exhibit more comorbidities and adverse prognostic factors than males. However, risk-adjusted analyses identified that gender is not an independent predictor of mortality after PCI in the DES era. © 2011 Wiley Periodicals, Inc.

Background In adult inpatients with acute kidney injury (AKI), clinicians routinely order a renal ultrasonography (RUS) study. It is unclear how often this test provides clinically useful information. Methods Cross-sectional study, including derivation and validation samples, of 997 US adults admitted to Yale–New Haven Hospital from January 2005 to May 2009, who were diagnosed as having AKI and who underwent RUS to evaluate elevated creatinine level. Pregnant women, renal transplant recipients, and patients with recently diagnosed hydronephrosis (HN) were excluded. Demographic and clinical characteristics were abstracted from the medical records. A multivariable logistic regression model was developed to create risk strata for HN and HN requiring an intervention (HNRI); a separate sample was used for validation. The frequency of incidental findings on RUS was assessed for each stratum. Results In a derivation sample of 200 patients, 7 factors were found to be associated with HN: history of HN; recurrent urinary tract infections; diagnosis consistent with obstruction; nonblack race; and absence of the following: exposure to nephrotoxic medications, congestive heart failure, or prerenal AKI. Among 797 patients in the validation sample (mean age, 65.6 years), 10.6% had HN and 3.3% had HNRI. Of 223 patients in the low-risk group, 7 (3.1%) had HN and 1 (0.4%) had HNRI (223 patients needed to be screened to find 1 case of HNRI). In this group, there were 0 incidental findings on RUS unknown to the clinical team. In the higher-risk group, 15.7% had HN and 4.7% had HNRI. Conclusion In adult inpatients with AKI, specific factors can identify patients unlikely to have HN or HNRI on RUS.

Left main coronary artery (LMCA) disease remains an important risk factor for increased mortality and morbidity at all stages of diagnosis and treatment of coronary artery disease. Left main stem pathology is often silent, with unpredictable presentation: as such it poses diagnostic and management challenges. This article reviews the anatomy, epidemiology and diagnosis of left main stem disease, as well as advances in multidisciplinary concepts of diagnosis and management, and summarises the outcomes of recent prospective studies comparing percutaneous and surgical revascularisation in LMCA disease.

The occurrence of contrast induced nephropathy (CIN) is associated with increased mortality after percutaneous revascularization procedures. However, the exact correlation between various levels of creatinine elevation relative to the baseline and subsequent mortality in patients with chronic renal insufficiency (CRI) is not well established. In addition, the relationship between elevated postprocedural creatinine and ensuing mortality in patients with normal baseline renal function needs to be investigated.All percutaneous coronary intervention (PCI) patients (n = 12,997) were analyzed for any rise in serum creatinine (SCr): CRI group (BSCor = 1.5 mg/dl) (n = 1,853) and normal baseline renal function (NBR BSC1.5 mg/dl) group (n = 11,144). Patients in each group were analyzed for any elevation in SCr postprocedure and subdivided based on the SCr ratio [peak SCr/Baseline creatinine (BSC)] of1.25, 1.25-1.5, and1.5. The overall incidence of CIN (defined as an increment of 25% over baseline creatinine) was 5.9%: 11.3% in the CRI group versus 5.1% in normal BSC group (P0.01). Recursive partitioning and Cox hazard modeling were used to assess significant variables associated with mortality within 1 year. Only serum creatinine ratio (SCrR)1.5 correlated with increased mortality in both CRI group as well as normal BSC group.SCrR1.5 predicts mortality at 1 year after PCI. The association between SCrR1.5 and increased mortality at follow-up is observed in patients with CRI as well as normal baseline renal function. SCrR may thus serve as a useful clinical tool for risk stratification and prognostication of patients after PCI.

The objectives of the present study were to evaluate the feasibility and safety of implanting a prophylactic left ventricular (LV) assist device prior to high-risk percutaneous coronary intervention (PCI) and to assess the impact of suturemediated preclosure of the arteriotomy site on minimizing vascular complications.Patients with multivessel disease, left main coronary artery disease (LMCA) or left main equivalent and/or moderate-to-severe LV dysfunction with elevated LV end-diastolic pressure are at increased risk of complications during PCI. The TandemHeart (TH) is a nonpulsatile percutaneous transseptal ventricular assist device (PTVA) that offers vital temporary hemodynamic support during high-risk PCI.Between April 2004 and November 2005, the TH was implanted in 20 patients undergoing high-risk PCI. Eight patients underwent unprotected LMCA stenting, and rotational atherectomy was used in 17 patients. Suture-mediated femoral artery preclosure was performed prior to inserting a large-bore arterial cannula.The TH was successfully implanted in all 20 patients. Mean LV ejection fraction of the study patients was 38 +/- 18%. Time-to-implantation of the TH, duration of hemodynamic support and mean flow of the TH device were 31 +/- 9 minutes, 74 +/- 40 minutes and 2.5 +/- 1.3 L/minute, respectively. At the end of PCI, the TH was removed in all cases and Perclose sutures were deployed in 18/20 (90%) patients. There was only 1 minor vascular complication, and the average length of stay was 2 +/- 1 days. Periprocedural and inhospital mortality was 0%.Implantation of the TH PTVA is safe and feasible in patients undergoing high-risk PCI with excellent hemodynamic support. Application of suture-mediated devices prior to large arteriotomies can significantly reduce the incidence of vascular complications.

The present study was done to analyze if glycoprotein IIb/IIIa inhibitors (GPI) bolus-only will reduce vascular/bleeding complications and cost with similar major adverse cardiac events (MACE) when compared with GPI bolus + infusion. Evidence-based therapy of GPI inhibitors during percutaneous coronary intervention (PCI) incorporates intravenous bolus followed by 12 to 18 hours of infusion. However, GPI bolus + infusion may increase vascular/bleeding complications and may not reduce MACE when compared with GPI bolus-only.From January 1, 2003, to December 31, 2004, 2,629 consecutive patients received GPI during PCI at a single center. Of these, 1,064 patients received GPI bolus + infusion in 2003 and were compared with 1,565 patients that received GPI bolus-only in 2004. Baseline characteristics were similar in both groups.Patients receiving GPI bolus-only had reduced vascular/bleeding complications when compared with bolus + infusion (4.9% vs 7%, P.05, odds ratio 0.62, 95% confidence interval 0.45-0.89). Furthermore, ischemic complications were similar in both groups, including periprocedural creatine kinase-MB enzyme release (12.8% vs 15.3%, P = NS), MACE at 30 days (3.2% vs 3%, P = NS), and death and myocardial infarction at 1 year (7.1% vs 7.8%, P = NS). In addition, GPI bolus-only reduced cost in US dollars ($323 vs $706, P.001) and increased ambulatory PCI (13.1% vs 3.2%, P.01), with reduced length of stay (1.1 vs 1.6 days, P.01), when compared with GPI bolus + infusion.Glycoprotein inhibitor bolus-only reduces vascular/bleeding complications with similar MACE and reduced cost when compared with GPI bolus + infusion. In addition, GPI bolus-only improved ambulatory PCI and reduced length of stay. These results are consistent with a safer and cost-effective strategy for bolus-only when GPI therapy is considered during PCI.

Patients with diabetes mellitus (DM) have poor long-term outcome after percutaneous coronary intervention (PCI) partly because of microvascular disease and distal embolization. Microvascular obstruction can be assessed by measuring coronary flow reserve (CFR). The Prediction of CK-MB RElease During Successful Stenting Correlating with Indicators of Microvascular ObstruCTion (PREDICT) trial compared the CFR in patients with versus without DM during PCI. Patients undergoing elective PCI were prospectively enrolled according to diabetic (n = 36) and nondiabetic (n = 36) status. All patients received drug-eluting stent with abciximab and were followed for 30-day major adverse cardiac events. CFR and FFR (fractional flow reserve) before and after stenting were measured before and after intracoronary adenosine bolus. Procedural success, MB enzyme of creatine-kinase (CK-MB), troponin I, and high-sensitive C-reactive protein elevation, vascular complications, and major adverse cardiac events were not different. FFR before stenting was 0.77 +/- 0.03 in patients with DM versus 0.76 +/- 0.02 in patients without DM (p = 0.69). FFR after stenting was 0.97 +/- 0.03 and 0.99 +/- 0.01 (p = 0.26), respectively. CFR before stenting was 1.36 +/- 0.31 in patients with DM versus 1.49 +/- 0.25 in patients without DM (p = 0.064). However, CFR after stenting was significantly lower in patients with versus without DM (1.89 +/- 0.30 versus 2.44 +/- 0.67, p0.001, respectively). CFR after stenting only moderately correlated with CK-MB and high-sensitive C-reactive protein after PCI but did not correlate with 30-day major adverse cardiac events. In conclusion, patients with DM have significantly lower CFR after stenting despite equivalent FFR and myonecrosis compared with patients without DM, indicating greater microvascular obstruction after PCI despite abciximab.

This article summarizes the vascular closure device technologies that are available to physicians who perform percutaneous catheter-based procedures.

The use of suture-mediated arterial closure devices has dramatically increased with the increased number of percutaneous procedures being performed. Complications from suture-mediated closure devices have been underreported. Specifically, arterial stenosis resulting in claudication has not been previously described in detail. We present nine patients who presented with various leg symptoms after Perclose was used to achieve arterial hemostasis following percutaneous procedures. All cases were found to have significant arterial stenoses from the Perclose sutures. Once diagnosis was correctly made, the patients either underwent surgical repair or percutaneous balloon angioplasty and in all cases the symptoms abated.

Age is well recognized as a powerful prognostic factor in the setting of cardiovascular disease. With the aging of the US population, it is projected that more than 50 million people will be aged over 65 years by the year 2020. This growing elderly population has increased rates of morbidity and mortality owing to cardiovascular disease; however, proven therapies for prevention and treatment are often underused in older patients, largely because physicians perceive them as being frail and have limited understanding of age-related unique adverse and therapeutic effects. Advancing age is associated with a number of physiologic and pathophysiologic changes that impact the toxic effects, efficacy and dosing of many medications. Decreases in lean muscle mass affect the volume of distribution, and reductions in hepatic function affect the metabolism of many medications. Age-related reductions in renal function might have the most profound impact on the safety profile and dosing of medications in elderly patients. The strong association between renal and cardiovascular disease makes recognition of renal dysfunction and appropriate dose adjustment particularly important in elderly patients with cardiovascular disease. This article reviews current approaches to the estimation of renal function, and unique considerations related to prescribing medication for elderly patients with concomitant renal and cardiovascular disease.

The implantation of intracoronary stents for the treatment of coronary atherosclerotic disease is one of the most common percutaneous procedures. While the procedure brings long-term benefit for a large percentage of patients, a significant number of patients experience in-stent restenosis (ISR). ISR may be caused by a number of biological and procedural factors, including lesion characteristics as well as co-existing disease states like diabetes. Many strategies have been developed to try to reduce the incidence of ISR. The primary methods include systemic pharmacologic treatments, as well as attempts at modifying stents to reduce their role in the development of ISR. Drug-eluting stents are one such modality, and are expected to become a widely used tool in the field of interventional cardiology. This review will focus on the pathophysiology of ISR and possible ways to prevent it, including drug-eluting stents.

Creatine kinase-MB (CK-MB) and troponin I elevations after successful percutaneous coronary intervention (PCI) are common, and different gradations have been correlated with mortality. To establish which of these 2 markers of myonecrosis, CK-MB and troponin I, accurately predicts mortality after successful PCI, we analyzed 2,873 patients without acute myocardial infarction who underwent PCI for in-hospital events and mid-term mortality. Patients were stratified into 4 groups based on peak post-PCI cardiac markers values: group I: normal CK-MB (16 U/L) or troponin I (2 ng/ml); group II: CK-MB or troponin I levels 1 to 3 times normal; group III:3 to 5 times normal; and group IV:5 times normal. CK-MB elevation occurred in 16.1% of patients, with 12.2%, 2.3%, and 1.6% in groups II to IV, respectively. Troponin I elevation was detected in 38.9% of patients, with 16.4%, 8.4%, and 14.1% in groups II to IV, respectively. There was poor correlation between postprocedural CK-MB and troponin I values (r = 0.10) and in their individual subgroups. Kaplan-Meier estimates of death for postprocedure CK-MB were 2.1%, 2.7%, 1.7%, and 10.3% (p = 0.002) for groups I to IV, respectively; for troponin I, these estimates were 2.2%, 2.3%, 2.9%, and 2.1% for groups I to IV, respectively (p = 0.58). A Cox proportional hazards model showed that CK-MB5 times normal was the strongest predictor of mortality (hazard ratio 6.7, 95% confidence interval 1.9 to 22.9; p = 0.002), although heart failure, peripheral vascular disease, pre-PCI digoxin therapy, and post-PCI renal failure also predicted mortality. However, neither troponin I peak elevation nor any subgroup predicted mortality. Troponin I is frequently elevated after PCI, but does not predict mortality. Periprocedural CK-MB elevation5 times normal remains an independent predictor of mid-term mortality and a valuable marker for PCI prognosis in low-to-medium risk patients.

The seven-component Thrombolysis In Myocardial Infarction (TIMI) score has been used to risk stratify, and to guide the medical management of, patients with unstable angina or non-ST-elevation myocardial infarction. We assessed the usefulness of the risk score in predicting in-hospital and 30-day outcomes in such patients who were undergoing percutaneous coronary intervention.Using the TIMI score, 2501 patients with unstable angina or non-ST-elevation myocardial infarction were divided into low-risk (zero to two risk factors; n = 974), intermediate-risk (three to four risk factors; n = 1339), and high-risk (five to seven risk factors; n = 188) groups, and outcomes were compared.Angiographic/clinical success and the rate of minor procedural events were similar among the three groups. A higher TIMI risk score was associated with more cardiac comorbid conditions and more complicated angiographic lesions: longer lesions (P = 0.0009), more thrombotic lesions (P = 0.03), more multivessel disease (P0.0001), and more American College of Cardiology/American Heart Association type B2/C lesions (P = 0.05). Although the risk score did not predict interventional technical success or intraprocedural complications, a high score was associated with prolonged hospital stay, higher postprocedural peak troponin levels, and 30-day major adverse cardiac events. Stepwise logistic regression showed that in conjunction with lesion length and patient sex, a high score was an independent predictor of 30-day major adverse cardiac events (odds ratio = 2.3; 95% confidence interval: 1.1 to 4.1; C statistic = 0.62).Although a higher TIMI risk score in patients with unstable angina or non-ST-elevation myocardial infarction who were undergoing percutaneous coronary intervention correlated with adverse clinical outcome, the score alone cannot be used to guide diagnostic or therapeutic strategies.

Percutaneous rotational coronary atherectomy (PRCA) is commonly used in the percutaneous treatment of diffuse, calcified coronary lesions in stable coronary syndromes (SCSs) and facilitates successful delivery and deployment of balloons and stents. Early experience with PRCA cautioned its use in acute coronary syndromes (ACSs). However, the evolution of the PRCA technique and improved antiplatelet pharmacotherapy has broadened its use in ACSs also. A total of 1,112 consecutive patients with an ACS (n=269) or SCS (n=843) who underwent PRCA of 1,483 lesions were examined retrospectively to evaluate the angiographic and short-term clinical outcomes. Troponin-I was elevated in 33.3% of the ACS group and in 0.6% of the SCS group at baseline (p0.001). Angiographic complications occurred more frequently in the ACS group (18.6% vs 13.1%, p=0.02). There was no difference in major complications between the groups (ACS 1.1% vs SCS 0.8%; p=0.44). The incidence of any periprocedural creatinine kinase-MB elevation was 17.1% versus 18.9% (p=NS) and 30-day major adverse cardiac events (death, disabling stroke, creatine kinase-MB3 times the upper limit of normal, urgent revascularization) was 5.9% versus 4.6% (p=NS) when comparing the ACS and SCS groups, respectively. With current techniques and antiplatelet therapy, PRCA can be safely performed in ACSs when lesion morphology dictates, with outcomes comparable to that achieved in SCSs. Although angiographic complications occurred more frequently in the ACS group, this did not result in a significantly higher incidence of postprocedural myonecrosis or 30-day major adverse cardiac events.

showed that selective dopa-mine-1 receptor agonist fenoldopam protects againstcontrast-mediated reduction in renal bloodfl ow com-pared with Schering 23390, a dopamine-1 receptorantagonist. Although fenoldopam has been shown tobe a “reno-protective” agent in the setting of renalischemic injury during percutaneous coronary inter-vention (PCI)

As the survival of patients with primary coronary events continues to increase, the number of patients presenting with coronary artery disease unsuitable to further revascularization techniques and symptoms refractory to medical therapy also continues to rise. The aims of this review were to define the population of patients with refractory angina pectoris and to present the therapeutic options currently available for this condition. Refractory angina pectoris is defined, and traditional medical therapies are discussed. Then, current therapeutic options for patients with refractory angina are extensively reviewed. A multitude of therapeutic options exist for patients with refractory angina pectoris. Small, uncontrolled studies have shown a potential benefit for additional antiplatelet and antithrombotic therapy. In randomized trials, neurostimulation has been shown to be effective in reducing angina symptoms. Enhanced external counterpulsation is a viable treatment option for select patients with refractory angina. In many randomized trials, laser revascularization has been shown to diminish angina symptoms, although no placebo-controlled studies exist to date. Gene therapy is a promising area of research in this field. Percutaneous in situ coronary venous arterialization is in its infancy, but may be able to treat many patients if proved successful. No data support the role of chelation therapy in this population. Heart transplantation remains a final option for these patients. Further research of the techniques mentioned in this review is warranted. The importance of randomized, double-blinded, placebo-controlled trials cannot be overemphasized, as the placebo effect of these therapies is probably marked.

Objectives This study evaluated the outcomes of patients discharged the day of percutaneous coronary intervention (PCI) by analyzing the data from a single-center, large, multioperator registry of interventions. Background Although same-day discharge is likely safe after interventions on low-risk stable patients, there is limited data to guide selection of a broader population of patients. Due to numerous patient variables and physician preferences, standardization of the length of stay after PCI has been a challenge. Most of the reported studies on same-day discharge have strict inclusion criteria and hence do not truly reflect a real-world population. Methods We analyzed the outcomes of consecutive same-day discharge in 2,400 of 16,585 patients who underwent elective PCI without any procedural or hospital complication. Composite end point included 30-day major adverse cardiac cerebral events and bleeding/vascular complications. Results The mean age of the study population was 57.0 ± 23.7 years with 12% aged over 65 years. Twenty-eight percent received glycoprotein IIb/IIIa inhibitor with closure devices in 90.5%. Clinical and angiographic success was noted in 97% of all PCIs. The average length-of-stay following PCI was 8.2 ± 2.5 h. The composite end point was reached in 23 patients (0.96%). Major adverse cardiac cerebral events occurred in 8 patients (0.33%) and vascular/bleeding complications in the form of Thrombolysis In Myocardial Infarction minor bleeding in 14 patients (0.58%) and pseudoaneurysm in 1 patient (0.04%). Conclusions When appropriately selected, with strict adherence to the set protocol, same-day discharge after uncomplicated elective PCI is safe despite using femoral access in a wide spectrum of patients.