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Background Aspiration thrombectomy is used in primary percutaneous coronary interventions, but the importance of thrombus constituency has been scarcely investigated. The objective of this study was to evaluate thrombus constituency and its association with clinical, laboratory, and angiographic findings in patients with ST-segment elevation myocardial infarction. Methods From April 2010 to May 2011, 562 patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary interventions were considered for inclusion, and information on thrombi characteristics was available for 113 patients. Thrombus material were obtained and classified as white or red based on its constituency. Samples were analyzed by 3 independent pathologists blinded to clinical characteristics. Results The mean age of patients was 58.6 ± 12.7 years, and 69% were men. White thrombi were present in 31% of cases, and red thrombi, in 69%. Patients with white thrombi had smaller vessels and lower ischemic times. All other clinical, angiographic, and laboratory characteristics did not differ. White thrombi were smaller and associated with fibrin infiltration, whereas red thrombi were associated with red blood cell infiltration. Thirty-day death rates were lower in patients with white thrombi than red (0% vs 10.1%, respectively; P = .05), as were 30-day major adverse cardiac event rates (4.2% vs 13.9%; P = .10). Total ischemic time was well correlated with fibrin infiltration (R = �0.30; P b .01), red blood cell infiltration (R = 0.27; P b .01), and thrombus volume (R = 0.22; P = .02). Conclusions White thrombi were present in one-third of cases and were associated with lower ischemic times, higher fibrin infiltration, smaller thrombus volume, and lower mortality. These findings suggest that thrombus constituency may be a useful prognostic tool in this setting. (Am Heart J 2012;164:553-60.)

INTRODUÇÃO: A via radial é um acesso seguro para procedimentos percutâneos e reduz as complicações vasculares locais. Neste estudo comparou-se a evolução hospitalar de pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAMCSST) submetidos a intervenção coronária percutânea primária (ICPp) por via radial vs. via femoral. MÉTODOS: Estudo de coorte prospectivo com pacientes consecutivamente atendidos entre dezembro de 2009 e maio de 2011. RESULTADOS: Foram incluídos 794 pacientes, 82 (10,3%) tratados por via radial e 712 (89,7%), por via femoral. Pacientes do grupo radial eram mais jovens (56,2 ± 10,7 anos vs. 61,2 ± 11,9 anos; P < 0,01), mais frequentemente do sexo masculino (78% vs. 68%; P = 0,06), com menor prevalência de diabetes (9,8% vs. 20%; P = 0,02) e maior fração de ejeção do ventrículo esquerdo (61,2 ± 11,8% vs. 55,5 ± 12,1%; P = 0,05). Não houve diferença em relação à maior parte das características angiográficas. Tromboaspiração (44% vs. 31%; P = 0,01) e administração de glicoproteína IIb/IIIa (41% vs. 26%; P = 0,004) foram mais utilizadas no grupo radial. O fluxo TIMI 3 final (93% vs. 88%; P = 0,47) e o blush miocárdico 3 (70% vs. 66%; P = 0,87) foram semelhantes entre os grupos. Não foram observadas diferenças em relação a óbito (7,5% vs. 8,4%; P = 0,78), reinfarto (4,9% vs. 4,4%; P = 0,77), revascularização de urgência (3,7% vs. 4,1%; P > 0,99), trombose do stent (2,4% vs. 3%; P > 0,99), sangramento maior (0 vs. 1,6%; P = 0,61) ou sangramento menor (5,3% vs. 7,3%; P = 0,81). CONCLUSÕES: A abordagem transradial mostrou-se segura e efetiva, com resultados semelhantes aos da abordagem transfemoral em pacientes com IAMCSST. BACKGROUND: Radial access is a safe approach for percutaneous procedures and reduces local vascular complications. This study compared the hospital outcomes of patients with ST-elevation acute myocardial infarction (STEMI) submitted to primary percutaneous coronary intervention (pPCI) using the radial vs. femoral approaches. METHODS: Prospective cohort study with consecutive patients treated between December 2009 and May 2011. RESULTS: Seven hundred and ninety-four patients were included, 82 (10.3%) treated by radial access and 712 (89.7%) treated by femoral access. Radial access patients were younger (56.2 ± 10,7 years vs. 61,2 ± 11,9 years; P < 0.01), more often male (78% vs. 68%; P = 0.06), had a lower prevalence of diabetes (9.8% vs. 20%; P = 0.02) and higher left ventricle ejection fraction (61.2 ± 11.8% vs. 55.5 ± 12.1%; P = 0.05). There was no difference for most angiographic characteristics. Thromboaspiration (44% vs. 31%; P = 0.01) and glycoprotein IIb/IIIa administration (41% vs. 26%; P = 0.004) were used more often in the radial group. The final TIMI 3 flow (93% vs. 88%; P = 0.47) and myocardial blush grade 3 (70% vs. 66%; P = 0.87) were similar between groups. There were no differences for death (7.5% vs. 8.4%; P = 0.78), reinfarction (4.9% vs. 4.4%; P = 0.77), emergency revascularization (3.7% vs. 4.1%; P > 0.99), stent thrombosis (2.4% vs. 3%; P > 0.99), major bleeding (0 vs. 1.6%; P = 0.61) or minor bleeding (5.3% vs. 7.3%; P = 0.81) rates. CONCLUSIONS: The transradial approach has proven to be safe and effective with similar results to transfemoral approach in patients with STEMI.

We sought to identify patients at risk for premature discontinuation of thienopyridines and to develop a risk score for thienopyridine adherence after coronary stent implantation. Patients were prospectively included from December 2007 to March 2008. At 1-month follow-up, all patients were given the Morisky questionnaire and asked if they had stopped taking thienopyridines. Multivariate analysis identified predictors of thienopyridine discontinuation; points were assigned to each variable according to the odds ratios and the c-statistic of the score was calculated. Mean age of the 400 patients included was 61.0 ± 10.4 years; 66 patients (16.5%) stopped thienopyridines after 1 month. Reasons for discontinuation were cost (62%), lack of information (17%), and recommendation by another doctor to stop treatment (15%). Factors associated with discontinuation included unmarried status (odds ratio 2.48, p = 0.046), lack of private health insurance (odds ratio 4.68, p = 0.041), acute coronary syndrome (odds ratio 2.31, p = 0.004), nondiabetics (odds ratio 2.20, p = 0.041), and patients who earned2 times (odds ratio 8.23, p0.001) and 2 to 3 times (odds ratio 4.46, p = 0.021) the minimum wage. Total risk score was 0 to 14 points and was strongly associated with thienopyridine discontinuation. For total scores of 0 to 4, 5 to 8, 9 to 12, and ≥13, 0%, 7%, 20%, and 37% of patients, respectively, stopped thienopyridines (c-statistic 0.76, p0.0001). Risk score was also significantly associated with complete adherence as assessed by the Morisky questionnaire (c-statistic 0.74, p0.001). In conclusion, we have identified patients at risk for premature discontinuation of thienopyridines using variables obtained before stent implantation and developed a risk score that accurately predicts premature thienopyridine discontinuation.

INTRODUÇÃO: Estudos demonstram que as angioplastias primárias realizadas fora do horário de rotina estão relacionadas a pior prognóstico. É objetivo deste estudo avaliar os desfechos das angioplastias primárias realizadas dentro e fora do horário de rotina do serviço de hemodinâmica. MÉTODOS: Estudo de coorte prospectivo, incluindo 112 pacientes consecutivamente atendidos por infarto agudo do miocárdio com supradesnivelamento do segmento ST (IAM) entre dezembro de 2009 e janeiro de 2010. Características clínicas e angiográficas e evolução hospitalar foram registradas em banco de dados específico. Houve dois grupos para comparação: grupo A, IAM tratado entre as 20 horas e as 8 horas e B, IAM tratado entre as 8 horas e as 20 horas. RESULTADOS: A amostra incluiu 44 pacientes no grupo A e 68 no grupo B. As características basais foram semelhantes em ambos os grupos. O tempo porta-balão foi significativamente maior no grupo A (133 minutos vs. 90 minutos; P < 0,001). No entanto, não houve diferença significante entre os grupos A e B em relação a mortalidade (13,7% vs. 5,9%; P = 0,28), reinfarto (6,8% vs. 4,4%; P = 0,90), evolução para choque cardiogênico (11,4% vs. 4,4%; P = 0,30), trombose de stent (6,8% vs. 1,5%; P = 0,33) ou presença de sangramento maior (2,3% vs. 1,5%; P > 0,99). O único preditor do desfecho hospitalar combinado foi a frequência cardíaca à admissão (razão de chance 1,02; P < 0,001). CONCLUSÕES: Pacientes com IAM apresentam taxas de desfechos clínicos semelhantes, independentemente do horário de realização da angioplastia, porém o tempo porta-balão é significativamente maior nos pacientes tratados entre as 20 horas e as 8 horas. BACKGROUND: Previous studies have reported that off-hours primary percutaneous coronary intervention is related to worse prognosis. The objective of this study is to evaluate the outcomes of normal and off-hours primary percutaneous coronary interventions. METHODS: A prospective observational study including 112 consecutive patients with ST elevation myocardial infarction (MI) was conducted from December 2009 to January 2010. Clinical and angiographic characteristics and in-hospital follow up were registered in a specific database. There were two groups for comparison: group A, MI treated between 8 pm and 8 am and group B, MI treated between 8 am and 8 pm. RESULTS: The sample included 44 patients in group A and 68 in group B. Baseline characteristics were similar in both groups. Door-to-balloon time was significantly longer in group A (133 minutes vs. 90 minutes; P < 0.001). However, there was no significant difference between groups A and B regarding mortality (13.7% vs. 5.9%; P = 0.28), reinfarction (6.8% vs. 4.4%; P = 0.90), progression to cardiogenic shock (11.4% vs. 4.4%; P = 0.30), stent thrombosis (6.8% vs. 1.5%; P = 0.33), or major bleeding (2.3% vs. 1.5%; P > 0.99). The only predictor of combined in-hospital outcome was heart rate at admission (odds ratio 1.02; P < 0.001). CONCLUSIONS: Patients with MI have similar in-hospital clinical outcomes during normal and off-hours primary percutaneous coronary intervention. However, door-to-balloon time is significantly longer during off-hours procedures.

BACKGROUND: There is great scientific interest with respect to socioeconomic status and population health, and several studies have shown the influence of these variables on clinical outcome of patients. The present study assesses the influence of income on the distribution of risk factors, clinical and angiographic characteristics in patients undergoing percutaneous coronary intervention. METHOD: Patients undergoing percutaneous coronary intervention in a tertiary center from December 2007 to March 2008 were prospectively included. The information on income was directly collected from the patient by one of the investigators. In this analysis, subjects were divided into quartiles according to their respective monthly income. RESULTS: Four hundred patients with mean age of 61.01 ± 10.36 years, 64.7% males and 24.6% diabetics were included. A majority had stable angina (54.9%), and there were no differences between groups regarding comorbidities. Income was associated with the percentage of male patients (48% in the first quartile vs. 81.3% in the last quartile; P < 0.001), the weight and height (P < 0.05), but there was no association with mean body mass index. We also observed a significant association between income and use of drug-eluting stents with the following rates from first to fourth quartile: 0, 1%, 1.9% and 7.7% (P = 0.003). CONCLUSION: In this study, there was an association between income and gender, anthropometric characteristics and use of drug-eluting stents. There was no association between income and risk factors, medical history and angiographic characteristics of patients.

Background: Percutaneous coronary interventions (PCI) are associated with quality of life (QoL) and health status improvements in stable angina patients. There are few studies assessing the magnitude of this effect and its predictors in contemporary daily practice. Methods: Prospective cohort study with stable angina patients submitted to PCI in a tertiary interventional cardiology center. The clinical characteristics and the Seattle Angina Questionnaire (SAQ) were assessed before PCI, and patients were followed-up for 1 year. Mixed linear regression and ANOVA were used to compare SAQ indices, and multivariate analysis to identify predictors of QoL improvement. Results: Between September 2006 and May 2007, 110 patients were included. The mean age of the study population was 62.8 ± 8.7 years, and 62% of the patients were of the male gender. Diabetes mellitus was present in 29%, arterial hypertension in 82%, previous myocardial infarction in 32%, and previous PCI in 29%. Before PCI, only 5% of the patients were free of angina, and this rate improved to 68% in the one-year followup (P < 0.001). There was improvement in all SAQ scales in the one-year followup, which was already shown in the 6-month assessment (P < 0.0001). Quality of life before the procedure was the main predictor of QoL improvement by multivariate analysis (P < 0.001). Conclusions: Patients with stable angina submitted to PCI in the real-world practice present significant improvement in one-year health status, as assessed by the SAQ. Quality of life before the procedure is the main determinant of improvement in QoL. © 2011 Wiley-Liss, Inc.

INTRODUÇÃO: A reestenose clínica após o implante de stent coronário costuma ser tratada com revascularização da lesão-alvo (RLA). Nosso objetivo foi relatar o perfil clínico e os desfechos de pacientes com reestenose intrastent (RIS) sintomática que não foram submetidos a nova RLA. MÉTODO: Identificamos pacientes que apresentaram reestenose clínica após colocação de stent coronário entre janeiro de 1997 e dezembro de 2001. As características clínicas e angiográficas e os desfechos clínicos dos pacientes que não passaram por nova revascularização (grupo sem RLA) foram comparados aos de pacientes revascularizados (grupo com RLA). Todos os pacientes tiveram acompanhamento de pelo menos dois anos após implante do stent para ocorrência de eventos cardíacos adversos maiores (ECAM). RESULTADOS: No período do estudo, 1.221 stents foram implantados em 1.149 pacientes. Observou-se RIS em 135 pacientes (12%), dos quais 104 tiveram acompanhamento clínico e angiográfico completo, 23 no grupo sem RLA e 81 no grupo com RLA. O período médio de acompanhamento após a colocação de stent coronário foi de 30,8 ± 7,5 meses. Pacientes do grupo sem RLA tiveram porcentual significativamente mais alto de doença de um vaso (82% vs. 47%; P < 0,01). Pacientes do grupo sem RLA apresentaram taxa de ECAM de longo prazo de 21,7% (5 pacientes: 2 óbitos, 3 infartos do miocárdio), enquanto nos pacientes do grupo com RLA a taxa de ECAM foi de 9,8% (8 pacientes: 1 óbito, 4 infartos do miocárdio, 3 cirurgias de revascularização miocárdica; P = 0,11). CONCLUSÃO: Pacientes com RIS clínica não tratados com RLA apresentaram doença de um vaso com maior frequência e tendência para maior incidência de ECAM em comparação com pacientes tratados com nova RLA. BACKGROUND: Clinical restenosis after coronary stenting is generally treated by target vessel revascularization (TVR). This study was aimed at reporting the clinical profile and outcomes of patients with symptomatic in-stent restenosis (ISR) who were not submitted to a TVR. METHOD: Patients who presented clinical restenosis after coronary stenting between January 1997 and December 2001 were identified. Clinical and angiographic characteristics and clinical outcomes of patients who did not undergo a new revascularization (no-TVR group) were compared with revascularized patients (TVR group). All of the patients had at least 2 years of follow-up for the occurrence of major adverse cardiac events (MACE) after stent implantation. RESULTS: In the study period, 1,221 stents were implanted in 1,149 patients. ISR was observed in 135 patients (12%), of which 104 had complete clinical and angiographic follow-up, 23 in the no-TVR group and 81 in the TVR group. The mean follow-up period after coronary stenting was 30.8 ± 7.5 months. Patients in the no-TVR group had a significantly higher percent of one vessel disease (82% vs. 47%; P < 0.01). Patients in the no-TVR group had a long-term MACE rate of 21.7% (5 patients: 2 deaths, 3 myocardial infarctions), whereas those submitted to a new revascularization showed a subsequent MACE rate of 9.8% (8 patients: 1 death, 4 myocardial infarctions, 3 coronary artery bypass graft surgery; P = 0.11). CONCLUSION: Patients with clinical ISR not treated with a TVR more frequently presented one-vessel disease and a trend towards higher incidence of MACE when compared to those treated with a new TVR.

Our aim was to validate a risk score for new target vessel revascularization (TVR) after bare-metal stent (BMS) implantation.The risk score was developed in a cohort of patients previously treated with BMS at our institution. This risk score ranges from 0 to 5 points, according to the presence of diabetes mellitus (1 point), reference vessel diameter (3.5 mm = 0 points; 3-3.5 mm = 1;3 mm = 2) and lesion length (or = 10 mm = 0 points; 10-20 mm = 1;20 mm = 2). Patients included in the validation cohort were treated between January and December 2005. Patient characteristics and 1-year clinical follow up were prospectively recorded into a dedicated database. A new coronary angiography was performed only when recurrent ischemia was suspected.The mean age of the 491 patients included was 61 +/- 10.5 years, and 35% were women. Diabetes mellitus was present in 22%, a previous percutaneous coronary intervention in 12% and previous myocardial infarction in 35%. The mean reference vessel diameter was 2.80 +/- 0.56 mm and the mean lesion length was 12.45 +/- 6.3 mm. The overall 1-year TVR rate was 13.9%. TVR rates increased with each score level: Score = 0, TVR = 0% (n = 16); Score 1 = 5.3% (n = 48); Score 2 = 12% (n = 170); Score 3 = 14% (n = 146); and Score 4/5 = 25% (n = 54); (p = 0.008).The risk score was significantly associated with TVR rates and can be used as a simple clinical tool to identify those patients at a low risk for a new revascularization procedure.