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Resumen Introduccion y objetivos Se ha prestado poca atencion al efecto en la mortalidad que la via de acceso vascular produce tras una intervencion coronaria percutanea, aun cuando hay cada vez mas evidencia de que la via radial aporta un beneficio mucho mayor que el acceso femoral en los pacientes con infarto agudo de miocardio con elevacion del segmento ST. El objetivo de este estudio es evaluar la influencia del lugar de acceso vascular en la mortalidad a 30 dias y a 1 ano en pacientes con infarto agudo de miocardio con elevacion del segmento ST. Metodos Se incluyo en el estudio a todos los pacientes con infarto agudo de miocardio con elevacion del segmento ST a los que se practico una angioplastia primaria en dos hospitales de Galicia entre 2008 y 2010. Se aplicaron dos modelos de regresion multivariable para cada resultado de mortalidad (a 30 dias y a 1 ano). La unica diferencia entre estos modelos fue la inclusion o exclusion del lugar de acceso vascular (femoral o radial). Para cada uno de los cuatro modelos, se calculo la prueba de Hosmer-Lemeshow y el indice C . Tambien se evaluo la interaccion entre la inestabilidad hemodinamica y el acceso vascular para la mortalidad. Resultados Se incluyo a 1.461 pacientes con una media de edad de 64 anos. En el 86% se utilizo un acceso vascular radial y en el 7,4% habia inestabilidad hemodinamica. La mortalidad por cualquier causa fue del 6,8% (100/1.461) a los 30 dias y del 9,3% (136/1.461) a 1 ano. El lugar de acceso vascular sigue a la inestabilidad hemodinamica y a la edad en cuanto al efecto en el riesgo de mortalidad (mortalidad a 30 dias, odds ratio = 5,20; intervalo de confianza del 95%, 2,80-9,66). Se produce un efecto similar en la mortalidad a 1 ano. El indice C mejora ligeramente con la inclusion del lugar de acceso vascular, aunque sin alcanzar significacion estadistica. Conclusiones La via de acceso vascular deberia tenerse en cuenta en la prediccion de la mortalidad tras una intervencion coronaria percutanea primaria.

Introduction and objectives Little attention has been given to the effect of vascular access site on mortality, while an increasing body of evidence is showing that radial access has much more benefit than femoral access for ST-segment elevation myocardial infarction patients. We aimed to assess the influence of vascular access site on mortality at 30 days and at 1 year in ST-segment elevation myocardial infarction patients. Methods We included all patients with ST-segment elevation myocardial infarction who had undergone primary angioplasty at 2 Galician hospitals between 2008 and 2010. We performed 2 multivariate regression models for each endpoint (30-day and 1-year mortality). The only difference between these models was the inclusion or not of the vascular access site (femoral vs radial). For each of the 4 models we calculated the Hosmer-Lemeshow test and the C-index. We also tested the interaction between hemodynamic instability and vascular access. Results We included 1461 patients with a mean age of 64. Of these patients, 86% had radial access and 7.4% had hemodynamic instability. All-cause mortality was 6.8% (100/1461) at 30 days and 9.3% (136/1461) at 1 year. Vascular access site follows hemodynamic instability and age in terms of effect on mortality risk, with an odds ratio of 5.20 (95% confidence interval, 2.80-9.66) for 30-day mortality. A similar effect occurs for 1-year mortality. The C-index slightly improves (without achieving statistical significance) with the inclusion of the vascular access site. Conclusions Vascular access site should be taken into account when predicting mortality after a primary percutaneous coronary intervention.

Objectives and background Previous studies on contrast-induced nephropathy (CIN) have identified contrast volume (CV) as a risk factor. The aim of our research was to define the safe dose of contrast media based on absolute CV, maximum allowable contrast dose (MACD) and estimated glomerular filtrate rate (eGFR). Methods and Results A total of 940 consecutive patients with acute coronary syndrome (ACS) were enrolled. Fifty-four patients developed CIN. MACD was defined as 5*body weight/serum creatinine. When using a CV higher than MACD, CIN-risk was increased 19-fold (OR 9.810–39.307, P

Introduction: Atherosclerosis is an active process and the inflammatory component appears to be particularly correlated with the development of acute coronary syndromes (ACS). C-reactive protein (CRP) is an acute phase protein that appears in the circulation in response to inflammatory cytokines. The present study investigated the association between high-sensitivity C-reactive protein (hsCRP) on admission and follow-up prognosis after an ACS. Methods: We included 151 consecutive patients admitted to the coronary care unit with a diagnosis of ACS (47% ST-segment elevation myocardial infarction [STEMI]). The primary endpoint was the combination of cardiac death and myocardial reinfarction during the follow-up period (median 19.8 months, interquartile range 16.3–23.7 months). Results: The occurrence of follow-up events was significantly related to admission hsCRP level, which was an excellent predictor of cardiac death and reinfarction during follow-up (HR 1.091, 95% CI 1.014–1.174; p=0.019). Stratifying the population based on type of ACS, adjusted by variables associated with cardiac events in univariate analysis (hsCRP, diabetes, depressed ejection fraction and GRACE risk score), hsCRP proved to be an independent predictor of follow-up outcomes only in non-STEMI patients (HR 1.217, 95% CI: 1.093–1.356, p

Objectives To determine security and benefits of high pressure postdilatation (HPP) of bioresorbable vascular scaffolds (BVS) in percutaneous coronary intervention (PCI) of complex lesions whatever its indication is. Background Acute scaffold disruption has been proposed as the main limitation of BVS when they are overexpanded. However, clinical implications of this disarray are not yet clear and more evidence is needed. Methods A total of 25 BVS were deployed during PCI of 14 complex lesions after mandatory predilatation. In all cases HPP was performed with NC balloon in a 1:1 relation to the artery. After that, optical coherence tomography (OCT) analyses were performed. Results Mean and maximal postdilatation pressure were 17±3.80 and 20 atmospheres (atm) respectively. Postdilatation balloon/scaffold diameter ratio was 1.01. A total of 39,590 struts were analyzed. Mean, minimal and maximal scaffold diameter were respectively: 3.09±0.34mm, 2.88±0.31mm and 3.31±0.40mm. Mean eccentricity index was 0.13±0.05. ISA percentage was 1.42% with a total of 564 malapposed struts. 89 struts were identified as disrupted, which represents a percentage of disrupted struts of 0.22%. At 30days, none of our patients died, suffered from stroke, stent thrombosis or needed target lesion revascularization (TLR). Conclusions NC balloon HPP of BVS at more than 17atm (up to 20atm) is safe during PCI and allows to achieve better angiographic and clinical results.

Chronic renal failure has been described as a risk factor for the development of atrial fibrillation (AF). The aim of this study was to examine the association between contrast-induced nephropathy (CIN) and new-onset AF in patients with acute coronary syndromes. A total of 1,520 consecutive patients (mean age 67.1 ± 12.7 years) with acute coronary syndromes (34.4% with ST-segment elevation myocardial infarctions) who underwent coronary angiography were studied. CIN was defined as an increase in serum creatinine of 0.5 mg/dl within 72 hours of contrast exposure. The independent effect of AF history (chronic or paroxysmal AF before catheterization) on the development of CIN, as well as the independent effect of CIN on the development of new-onset AF (after catheterization, during the in-hospital phase), were tested by using different logistic regression models. One hundred thirty-nine patients (9.1%) had histories of AF before catheterization (60 with paroxysmal and 79 with chronic AF), and 56 (4.1%) developed new-onset AF after catheterization. Eighty-seven patients (5.7%) had CIN. AF history was a predictor of CIN in univariate analysis (odds ratio 2.19, 95% confidence interval 1.22 to 3.95, p = 0.007) but not in multivariate analysis, after adjusting for confounding variables (odds ratio 1.69, 95% confidence interval 0.89 to 3.22, p = 0.111). In contrast, those with CIN had an increased prevalence of new-onset AF (15.3% vs 3.4%, p0.001). After adjusting for those variables associated with new-onset AF in the univariate analysis, CIN continued to show a significant association with new-onset AF, with a twofold increased risk (odds ratio 2.45, 95% confidence interval 1.07 to 5.64, p = 0.035). In conclusion, the development of CIN is an independent predictor of new-onset AF in the context of acute coronary syndromes.

Myocardial reperfusion injury is defined as the adverse effects that ensue upon restoration of the circulation, which allows blood and nutrients to reach cells previously subjected to ischemia. Restoration of blood flow can be accompanied by the release of oxygen free radicals, the appearance of intracellular calcium overload, and alterations in cell metabolism -all situations that can give rise to functional or structural myocardial injury. Clinical signs of injury may appear after circulation is restored or after the use of extracorporeal circulation during heart surgery, and are manifested as stunned or hibernating myocardium after acute coronary syndromes, as the no-reflow phenomenon (microvascular injury) after blood flow is restored during angioplasty or after >, and especially after surgical revascularization. This review examines the pathophysiological substrates, clinical manifestations and current approaches to treatment for each of these entities.

In the setting of primary percutaneous coronary intervention (PPCI), encountering with chronic total oclussion (CTO) in a noninfarct-related artery (IRA) is not a rare situation. The impact of CTO on clinical outcomes in acute ST-elevation myocardial infarction (STEMI) patients is not well defined.

SummaryMembrane microvesicles (MVs) are released from activated cells, most notably platelets, into the circulation. They represent an important mode of intercellular communication, and their number is increased in patients with acute coronary syndromes. We present here a differential proteomic analysis of plasma MVs from ST-elevation myocardial infarction (STEMI) patients and stable coronary artery disease (SCAD) controls. The objective was the identification of MVs biomarkers/drug targets that could be relevant for the pathogenesis of the acute event. Proteome analysis was based on 2D-DIGE, and mass spectrometry. Validations were by western blotting in an independent cohort of patients and healthy individuals. A systems biology approach was used to predict protein-protein interactions and their relation with disease. Following gel image analysis, we detected 117 protein features that varied between STEMI and SCAD groups (fold change cut-off ≥2; p

Purpose: Bifurcations lesions represent a challenge for percutaneous coronary interventions (PCI). The provisional SB stenting strategy has emerged as the preferred bifurcation treatment technique. In this strategy, final kissing balloon dilatation (FKBD) is performed. We investigated clinical and angiographic results,and predictors of adverse outcomes after PCI for coronary bifurcations with this 1-stent strategy. Methods: Consecutive patients with non-ST elevation myocardial infarction between January 2010 to November 2012 were included. Inclusion criteria were: coronary bifurcation lesions, a MV diameter 2.5 mm, and SB 2.0 mm. Exclusion criteria were: cardiogenic shock or left main bifurcation. Bifurcation lesions were classified according to the Medina classification. To assess the effect of FKBD after main vessel stenting on clinical and angiographic outcomes in patients undergoing the provisional stenting approach, we selected patients treated with the 1-stent technique in one bifurcation lesion with TIMI III flow result and residual lesion

Introduction: Contrast-induced nephropathy (CIN) is an usual complication of percutaneous coronary interventions (PCI). Here we report the validation of the new cystatin C (CyC)-based glomerular filtrate rate GFR equations (CKD-EPI\_CyC and CKD-EPI\_Cr&CyC) to predict CIN in patients with ACS. We evaluated their performance, as compared with existing creatinine (Cr)-based GFR equations (CG, MDRD-4 and CKD-EPI_Cr), and tested their usefulness in improving the classification of patients in risk of CIN. Methods: 497 subjects admitted consecutively to our hospital (2008-2010) with a diagnosis of ACS and underwent PCI were included. Discriminative power and calibration index of each eGFR equation were calculated and compared, together with the predictive values (sensitivity, specificity). The incremental value that the new CyC-based eGFR equations brings over the sCr-based eGFR equations was assessed by the Net Reclassification Improvement (NRI). Results: 33 (6.6%) patients developed CIN. For GFR, the greatest C statistic was for CKD-EPI_CyC, significantly superior to CG (p

The 2 most common non-thrombotic in-hospital complications in patients with Acute Coronary Syndorme (ACS) were contrast-induced nephropathy (CIN) and bleeding. The aim was to analyse the relationship between CIN and bleeding in a contemporaneous cohort of ACS patients, together with the predictive

Previous studies on contrast-induced nephropathy (CIN) have identified contrast volume (CV) as a risk factor. The aim of our research was to define the safe dose of contrast media based on absolute CV, maximum allowable contrast dose (MACD) and estimated glomerular filtrate rate (eGFR).A total of 940 consecutive patients with acute coronary syndrome (ACS) were enrolled. Fifty-four patients developed CIN. MACD was defined as 5*body weight/serum creatinine. When using a CV higher than MACD, CIN-risk was increased 19-fold (OR 9.810-39.307, P0.001). For the CV/eGFR ratio, we found that for every increase of one-tenth, CIN-risk increased by 4.9% (OR 1.037-1.061, P0.001). The discriminative ability of CV (C statistic = 0.626 ± 0.038) was significantly lower than for the CV/MACD (C statistic = 0.782 ± 0.036, P = 0.003) and CV/eGFR (C statistics: 0.796 ± 0.033 for MDRD-4, 0.796 ± 0.034 for Cockcroft-Gault, and 0.803 ± 0.033 for CKD-EPI; P0.001). There were no differences in the discriminative ability to predict CIN between the three eGFR equations. The combination of CV/MACD and CV/eGFR in a single protocol increases the positive predictive value of the Mehran risk score (40.7% vs. 8.8%) with the same sensitivity (90.7% vs. 83.3%). High doses of relative CV (CV/MACD and CV/eGFR) were also significantly associated with higher in-hospital mortality, reinfarction, and heart failure.A sequential protocol based on CV/MACD and CV/eGFR appropriately identified those ACS patients who developed CIN, with predictive values similar to a Mehran score, reducing the false positive rate. It is also useful to predict risk of in-hospital cardiac events regardless of GRACE score.

Myocardial reperfusion injury is defined as the adverse effects that ensue upon restoration of the circulation, which allows blood and nutrients to reach cells previously subjected to ischemia. Restoration of blood flow can be accompanied by the release of oxygen free radicals, the appearance of intracellular calcium overload, and alterations in cell metabolism -all situations that can give rise to functional or structural myocardial injury. Clinical signs of injury may appear after circulation is restored or after the use of extracorporeal circulation during heart surgery, and are manifested as stunned or hibernating myocardium after acute coronary syndromes, as the no-reflow phenomenon (microvascular injury) after blood flow is restored during angioplasty or afterreperfusion arrhythmia, and especially after surgical revascularization. This review examines the pathophysiological substrates, clinical manifestations and current approaches to treatment for each of these entities.

The controversy surrounding the best approach for reperfusion in acute myocardial infarction has been all but resolved in the last year. The latest battles of the “reperfusion wars” (a term used by W. O’Neill et al 1 ) have shown angioplasty to be superior in almost every context tested. The last remaining stronghold for fibrinolytic therapy is in the comparison of angioplasty with prehospital thrombolysis, although such therapy can be considered part of rescue angioplasty. 2 During 2003, logistic objections were largely refuted when benefit was shown in patients who were transferred to a hospital with percutaneous facilities in less than 3 hours. 3-5 On the other hand, use of potent glycoprotein IIb/IIIa inhibitors is gaining support despite contradictory results, 6,7 and many laboratories systematically administer such inhibitors during primary angioplasty. Finally, facilitated angioplasty with administration of thrombolytics and glycoprotein IIb/IIIa inhibitors prior to angioplasty is being investigated in numerous studies, the forerunner of which was the GRACIA-2 study. 8 In any case, the drug facilitated invasive procedure is particularly attractive when angioplasty cannot be carried out within 3 hours. The study of Diaz de la Llera et al should be considered in this context. 9 The authors of this important article retrospectively analyzed their experience with angioplasty in acute myocardial infarction, classifying patients according to whether transradial or transfemoral approach was used. Doubts about whether such groups are comparable aside, the authors found that 64% of interventions used the transradial approach and that examination times were similar and within reasonable bounds in both groups. Furthermore, no vascular complications were reported in the group with transradial approach despite extensive use of abciximab (68%) and rescue or facilitated angioplasty in 42% of the patients. The authors correctly highlight the subjective nature of the choice of approach, with the possible bias that this introduces. Nevertheless, even the most conservative interpretation of the article would lead us to conclude that an experienced team is able to select patients in which primary angioplasty with transradial approach can be safety and effectively used. One may ask whether the approach used is of genuine interest or a technical mirage invented by bored interventional cardiologists in the grip of the snobbism sometimes present in the environment of