Search

Aims: The aim of this study was to evaluate clinical outcome for different indications for PCI in an unselected, nationwide PCI population at short- and long-term follow-up., Methods and Results: We evaluated clinical outcome up to six years after PCI in all patients undergoing a PCI procedure for different indications in Sweden between 2006 and 2010. A total of 70,479 patients were treated for stable coronary artery disease (CAD) (21.0%), unstable angina (11.0%), non-ST-elevation myocardial infarction (NSTEMI) (36.6%) and ST-elevation myocardial infarction (STEMI) (31.4%). Mortality was higher in STEMI patients at one year after PCI (9.6%) compared to NSTEMI (4.7%), unstable angina (2.2%) and stable CAD (2.0%). At one year after PCI until the end of follow-up, the adjusted mortality risk (one to six years after PCI) and the risk of myocardial infarction were comparable between NSTEMI and STEMI patients and lower in patients with unstable angina and stable CAD. The adjusted risk of stent thrombosis and heart failure was highest in STEMI patients., Conclusions: The risk of short-term mortality, heart failure and stent thrombosis is highest for STEMI patients after PCI. Therapies to reduce stent thrombosis and heart failure appear to be most important in decreasing mortality in patients with STEMI or NSTEMI undergoing PCI.

Background: Erythropoiesis-stimulating agents (ESAs) have been investigated in small studies in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Erythropoiesis-stimulating agents did not show a clear effect on left ventricular function or clinical outcome, but some studies suggested an increased risk of thromboembolic events., Methods: A systematic literature search in MEDLINE was performed, until December 2012. We included randomized clinical trials investigating the effect of ESAs in STEMI patients undergoing primary PCI, with ≥30 days of follow-up. The primary end point was a composite of all-cause mortality, myocardial infarction, and stent thrombosis after PCI. Secondary end point was all-cause mortality., Results: Individual patient data were obtained from 10 of 11 trials, including 97.3% (1,242/1,277) of all patients randomized to control (n = 600) or to ESAs (n = 642). Baseline characteristics were well balanced between the treatment allocations. Mean follow-up time was 248 (±131) days. The primary end point occurred in 3.5% (20/577) in the control group and in 2.1% (13/610) in the ESA group (hazard ratio for ESAs, 0.63; 95% CI [0.31-1.27]; P = .20). Mortality occurred in 13 (2.3%) in the control group and 5 (0.8%) in the ESA group (hazard ratio for ESAs, 0.38; 95% CI [0.13-1.06]; P = .06)., Conclusions: Erythropoiesis-stimulating agent administration does not result in an increased risk of adverse cardiac events in STEMI patients undergoing primary PCI. Results of ongoing studies may provide further insight to the potential beneficial clinical effects of ESAs in STEMI patients., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Purpose: The HEBE III trial showed that epoetin alfa administration in patients with a first ST-elevation myocardial infarction (STEMI) did not improve left ventricular function at 6 weeks after primary percutaneous coronary intervention (PCI). The long term effects of erythropoiesis- stimulating agents on cardiovascular morbidity and mortality are unknown, therefore we evaluated clinical events at 1 year after PCI., Methods: A total of 529 patients with a first STEMI and successful primary PCI were randomized to standard optimal medical treatment (N = 266) or an additional bolus of 60,000 IU epoetin alfa administered intravenously (N = 263) within 3 h after PCI. Analyses were performed by intention to treat., Results: At 1 year after STEMI, 485 patients had complete follow-up. The rate of the composite end point of all-cause mortality, re-infarction, target vessel revascularization, stroke and/or heart failure was 6.4 % (N = 15) in the epoetin alfa group and 9.6 % (N = 24) in the control group (p = 0.18). Thromboembolic events were present in 1.3 % (N = 3) of patients in the epoetin alfa group and 2.4 % (N = 6) in the control group. There was no evidence of benefit from epoetin alfa administration in subgroups of patients., Conclusions: Administration of a single bolus of epoetin alfa in patients with STEMI does not result in a reduction of cardiovascular events at 1 year after primary PCI. There was a comparable incidence of thromboembolic complications in both treatment groups, suggesting that epoetin alfa administration is safe at long term.

Objectives: The aim of this study was to describe the characteristics and outcome of all consecutive patients treated with percutaneous coronary intervention (PCI) in an unselected nationwide cohort over the past 2 decades., Background: Over the last 20 years, treatment with PCI has evolved dramatically, but the change in patient characteristics has not been well described., Methods: We included all patients undergoing a PCI procedure for the first time between January 1990 and December 2010 from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry). Patients were divided into different cohorts on the basis of the year of the first PCI procedure., Results: A total of 144,039 patients was included. The mean age increased from 60.1 ± 9.9 years in 1990 to 1995 to 67.1 ± 11.2 years in 2009 to 2010. The proportion of patients presenting with unstable coronary artery disease and ST-segment elevation myocardial infarction increased from 27.4% and 6.2% to 47.7% and 32.5%, respectively. Diabetes mellitus and multivessel disease were more often present in the later-year cohorts. The 1-year mortality increased from 2.2% in 1990 to 1995 to 5.9% in 2009 to 2010, but after adjustment for age and indication, a modest decrease was shown, mainly in ST-segment elevation myocardial infarction patients., Conclusions: Characteristics of PCI patients have changed substantially over time, reflecting the establishment of new evidence. The increasing age and proportion of patients undergoing PCI for acute coronary syndromes greatly influence outcome. Understanding the changing patient characteristics is important for the translation of evidence to real-world clinical practice.

Early reperfusion of the infarct-related coronary artery is an important issue in improvement of outcomes after ST-segment elevation myocardial infarction (STEMI). In this study, the clinical significance of total ischemic time on myocardial reperfusion and clinical outcomes was evaluated in patients with STEMI treated with primary percutaneous coronary intervention and thrombus aspiration and additional triple-antiplatelet therapy. Total ischemic time was defined as time from symptom onset to first intracoronary therapy (first balloon inflation or thrombus aspiration). All patients with STEMI treated with primary percutaneous coronary intervention with total ischemic times ≥30 minutes and <24 hours from 2005 to 2008 were selected. Ischemic times were available in 1,383 patients, of whom 18.4% presented with total ischemic times ≤2 hours, 31.2% >2 to 3 hours, 26.8% >3 to 5 hours, and 23.5% >5 hours. Increased ischemic time was associated with age, female gender, hypertension, and diabetes. Patients with total ischemic times <5 hours more often had myocardial blush grade 3 (40% to 45% vs 22%, p <0.001) and complete ST-segment resolution (55% to 60% vs 42%, p = 0.002) than their counterparts with total ischemic times >5 hours. In addition, patients with total ischemic times ≤5 hours had lower 30-day mortality (1.5% vs 4.0%, p = 0.032) than patients with total ischemic times >5 hours. In conclusion, in this contemporary cohort of patients with STEMI treated with primary percutaneous coronary intervention, triple-antiplatelet therapy, and thrombus aspiration, short ischemic time was associated with better myocardial reperfusion and decreased mortality. After a 5-hour period in which outcomes remain relatively stable, myocardial reperfusion becomes suboptimal and mortality increases., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: Administration of abciximab during primary percutaneous coronary intervention is an effective adjunctive therapy in the treatment of patients with ST-segment elevation myocardial infarction. Recent small-scaled studies have suggested that intracoronary administration of abciximab during primary percutaneous coronary intervention is superior to conventional intravenous administration. This study has been designed to investigate whether intracoronary bolus administration of abciximab is more effective than intravenous bolus administration in improving myocardial perfusion in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration., Methods/design: The Comparison of IntraCoronary versus intravenous abciximab administration during Emergency Reperfusion Of ST-segment elevation myocardial infarction (CICERO) trial is a single-center, prospective, randomized open-label trial with blinded evaluation of endpoints. A total of 530 patients with STEMI undergoing primary percutaneous coronary intervention are randomly assigned to either an intracoronary or intravenous bolus of weight-adjusted abciximab. The primary end point is the incidence of >70% ST-segment elevation resolution. Secondary end points consist of post-procedural residual ST-segment deviation, myocardial blush grade, distal embolization, enzymatic infarct size, in-hospital bleeding, and clinical outcome at 30 days and 1 year., Discussion: The CICERO trial is the first clinical trial to date to verify the effect of intracoronary versus intravenous administration of abciximab on myocardial perfusion in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention with thrombus aspiration.

Background: Coronary microvascular dysfunction is frequently seen in patients with ST-elevation myocardial infarction after primary percutaneous coronary intervention. Previous studies have suggested that the administration of intravenous adenosine resulted in an improvement of myocardial perfusion and a reduction in infarct size. Intracoronary adenosine (bolus of 30 to 60 microg) is a guideline-recommended therapy to improve myocardial reperfusion. The effect of intracoronary adenosine during primary percutaneous coronary intervention has not been investigated in a large randomized trial., Methods and Results: Patients presenting with acute ST-elevation myocardial infarction were randomized to 2 bolus injections of intracoronary adenosine (2 x 120 microg in 20 mL NaCl) or placebo (2 x 20 mL NaCl). The first bolus injection was given after thrombus aspiration and the second after stenting of the infarct-related artery. The primary end point was the incidence of residual ST-segment deviation <0.2 mV, 30 to 60 minutes after percutaneous coronary intervention. Secondary end points were ST-segment elevation resolution, myocardial blush grade, Thrombolysis in Myocardial Infarction flow on the angiogram after percutaneous coronary intervention, enzymatic infarct size, and clinical outcome at 30 days. A total of 448 patients were randomized to intracoronary adenosine (N=226) or placebo (N=222). The incidence of residual ST-segment deviation <0.2 mV did not differ between patients randomized to adenosine or placebo (46.2% versus 52.2%, P=NS). In addition, there were no significant differences in secondary outcome measures., Conclusions: In this randomized placebo controlled trial enrolling 448 patients with ST-elevation myocardial infarction, administration of intracoronary adenosine after thrombus aspiration and after stenting of the infarct-related artery did not result in improved myocardial perfusion.

Background: Reinfarction and stent thrombosis are major complications after primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI)., Objective: We sought to investigate the incidence, predictors, and outcome of reinfarction and stent thrombosis in a contemporary cohort of STEMI patients., Methods: Reinfarction and stent thrombosis within 1 year after primary PCI for STEMI were analyzed in the Thrombus Aspiration during Percutaneous coronary intervention in Acute myocardial infarction Study (TAPAS)., Results: Reinfarction was observed in 3.4% (34/995) of patients within 1 year after primary PCI. Angiographic evidence of stent thrombosis was observed in 15/34 (44.1%). During the index primary PCI, intra-aortic balloon counterpulsation was used in 10/32 (31.3%) patients with and 47/900 (5.2%) without reinfarction (P < 0.001). After the index primary PCI, thrombus was visible in 6/34 (17.7%) with reinfarction when compared with that in 25/952 (2.6%) without reinfarction (P < 0.001), and complete ST-segment resolution in 8/33 (24.2%) compared with that in 462/892 (51.8%, P = 0.002). Mortality at 1 year after the index PCI was higher after reinfarction: 6/34 (17.7%) compared with 53/961 (5.5%, P = 0.003). Patients with stent thrombosis showed myocardial blush grade 0-1 in 11/15 (73.3%) cases, distal embolization in 8/15 (53.3%), and a mortality at 1 year of 4/15 (26.7%)., Conclusions: In contemporary practice with primary PCI and triple antiplatelet therapy for STEMI, the incidence of reinfarction is low. Outcome characteristics after the index PCI were important determinants of reinfarction. However, reinfarction was associated with poor prognosis, and in particular patients with stent thrombosis had poor outcome., (Copyright 2009 Wiley-Liss, Inc.)

Aims: We investigated the incidence and sequelae of angiographically visible distal embolization (AVDE) after primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction patients treated with aspirin, heparin, clopidogrel, and glycoprotein-IIb/IIIa inhibitors., Methods and Results: As part of TAPAS, AVDE was a predefined secondary endpoint. We compared angiographic and clinical characteristics, and outcomes of patients with and without AVDE after PCI. AVDE was present on 6.3% of 883 post-procedural angiograms. Angiographically visible distal embolization was associated with significantly worse outcomes, as expressed by lower myocardial blush grade, impaired ST-segment resolution, and higher enzyme levels (all P

Thrombus aspiration is an effective adjunctive therapy to prevent distal embolization during primary percutaneous coronary intervention (PCI). In some patients, thrombus aspiration results in complete restoration of flow without significant residual stenosis or plaque rupture at the site of occlusion. It is currently unclear if additional angioplasty with balloon or stenting is necessary in these patients. We present 5 cases in which thrombus aspiration was performed without additional angioplasty as treatment for ST-elevation myocardial infarction. During follow up, no patient had an adverse cardiac event. These cases indicate that thrombus aspiration can be performed safely and effectively as definitive treatment in selected patients.