RESUMEN
Managing antithrombotic therapy in patients undergoing complex and high-risk in indicated patients, including those treated with complex percutaneous coronary intervention (PCI) or presenting with cardiogenic shock (CS), is challenging. This review highlights the critical role of antithrombotic therapy, during and after PCI, to optimize the efficacy while minimizing risks. Unfractionated heparin remains the mainstay anticoagulant for complex PCI and CS, with bivalirudin as a potential safer alternative. Cangrelor offers consistent antiplatelet effects, especially when timely absorption of oral agents is uncertain.
Asunto(s)
Fibrinolíticos , Intervención Coronaria Percutánea , Choque Cardiogénico , Humanos , Intervención Coronaria Percutánea/métodos , Fibrinolíticos/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Hirudinas/administración & dosificación , Adenosina Monofosfato/análogos & derivados , Adenosina Monofosfato/uso terapéutico , Heparina/uso terapéutico , Heparina/administración & dosificación , Fragmentos de Péptidos , Proteínas RecombinantesRESUMEN
Dual antiplatelet therapy with aspirin and a P2Y12 inhibitor is fundamental in all patients undergoing percutaneous coronary intervention (PCI) to prevent coronary thrombosis. In patients with atrial fibrillation (AF), an oral anticoagulant gives protection against ischemic stroke or systemic embolism. AF-PCI patients are at high bleeding risk and decision-making regarding the optimal antithrombotic therapy remains challenging. Dual antithrombotic therapy (DAT) has been shown to reduce bleeding events but at the cost of a higher risk of stent thrombosis. Further studies are needed to clarify the optimal duration of triple antithrombotic therapy (TAT) or DAT and the role of more potent antiplatelet drugs.
Asunto(s)
Anticoagulantes , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Humanos , Intervención Coronaria Percutánea/métodos , Inhibidores de Agregación Plaquetaria/administración & dosificación , Inhibidores de Agregación Plaquetaria/uso terapéutico , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Administración Oral , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Enfermedad de la Arteria Coronaria/cirugía , Terapia Antiplaquetaria Doble/métodos , Hemorragia/inducido químicamente , Hemorragia/prevención & control , Trombosis Coronaria/prevención & controlRESUMEN
Percutaneous coronary and structural heart interventions are increasingly preferred over cardiac surgery due to reduced rates of periprocedural complications and faster recovery but often require postprocedural antithrombotic therapy for the prevention of local thrombotic events. Antithrombotic therapy is inevitably associated with increased bleeding, the extent of which is proportional to the number, duration, and potency of the antithrombotic agents used. Bleeding complications have important clinical implications, which may outweigh the expected benefit of reducing thrombotic events. Herein, we provide a comprehensive description of the classification and clinical relevance of high bleeding risk in patients undergoing coronary and structural heart interventions.
Asunto(s)
Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/efectos adversos , Factores de Riesgo , Hemorragia/epidemiología , Fibrinolíticos/uso terapéutico , Fibrinolíticos/efectos adversos , Medición de Riesgo/métodos , Trombosis/prevención & control , Trombosis/etiología , Trombosis/epidemiología , Procedimientos Quirúrgicos Cardíacos/métodos , Procedimientos Quirúrgicos Cardíacos/efectos adversosRESUMEN
The antithrombotic management of chronic coronary syndrome (CCS) involves a 6-month course of dual antiplatelet therapy (DAPT), followed by chronic aspirin therapy. In patients with a baseline indication for anticoagulation, a variable duration of triple antithrombotic therapy is administered, followed by dual antithrombotic therapy until the sixth month post-percutaneous coronary intervention (PCI), and ultimately a transition to chronic anticoagulation. However, advancements in stent technology reducing the risk of stent thrombosis and a growing focus on the impact of bleeding on prognosis have prompted the development of new therapeutic strategies. These strategies aim to enhance protection against ischemic events in the initial stages after PCI while mitigating the risk of bleeding in the long term. This article delineates the therapeutic strategies outlined in European and American guidelines for CCS management, with special attention to investigational strategies.
Asunto(s)
Fibrinolíticos , Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/métodos , Fibrinolíticos/uso terapéutico , Fibrinolíticos/administración & dosificación , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Enfermedad Crónica , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Terapia Antiplaquetaria Doble/métodosRESUMEN
Early mechanical reperfusion, primarily via percutaneous coronary intervention, combined with timely antithrombotic drug administration, constitutes the main approach for managing acute coronary syndrome (ACS). Clinicians have access to a variety of antithrombotic agents, necessitating careful selection to balance reducing thrombotic events against increased bleeding risks. This review offers a comprehensive update on current antithrombotic therapy in ACS, emphasizing the need for individualized treatment strategies.
Asunto(s)
Síndrome Coronario Agudo , Fibrinolíticos , Intervención Coronaria Percutánea , Humanos , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/cirugía , Fibrinolíticos/uso terapéutico , Intervención Coronaria Percutánea/métodos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Anticoagulantes/uso terapéutico , Anticoagulantes/administración & dosificación , Hemorragia/inducido químicamente , Hemorragia/prevención & controlRESUMEN
Antiplatelet therapy is integral to reduce the risk of future ischemic events following acute coronary syndrome (ACS) or percutaneous coronary intervention (PCI); this aim must be balanced by limiting the risk of bleeding. Women with ACS or undergoing PCI have distinct platelet physiology, vascular anatomy, and clinical profiles that can influence the selection of an appropriate regimen. There are procedural techniques that can enhance safety in women. The poor inclusion of women in ACS and PCI trials limits our understanding of the ideal antiplatelet regimen in women, and future studies must find ways to increase the participation of female patients.
Asunto(s)
Síndrome Coronario Agudo , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Humanos , Síndrome Coronario Agudo/cirugía , Intervención Coronaria Percutánea/métodos , Inhibidores de Agregación Plaquetaria/uso terapéutico , Femenino , Hemorragia/inducido químicamente , Hemorragia/prevención & controlRESUMEN
The CYP2C19 enzyme metabolizes clopidogrel, a prodrug, to its active form. Approximately 30% of individuals inherit a loss-of-function (LoF) polymorphism in the CYP2C19 gene, leading to reduced formation of the active clopidogrel metabolite. Reduced clopidogrel effectiveness has been well documented in patients with an LoF allele following an acute coronary syndrome or percutaneous coronary intervention. Prasugrel or ticagrelor is recommended in those with an LoF allele as neither is affected by CYP2C19 genotype. Although data demonstrate improved outcomes with a CYP2C19-guided approach to P2Y12 inhibitor selection, genotyping has not yet been widely adopted in clinical practice.
Asunto(s)
Citocromo P-450 CYP2C19 , Antagonistas del Receptor Purinérgico P2Y , Humanos , Antagonistas del Receptor Purinérgico P2Y/uso terapéutico , Citocromo P-450 CYP2C19/genética , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/genética , Clopidogrel/uso terapéutico , Intervención Coronaria Percutánea/métodos , Genotipo , Ticagrelor/uso terapéutico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Clorhidrato de Prasugrel/uso terapéutico , Polimorfismo GenéticoRESUMEN
BACKGROUND: Dual antiplatelet therapy (DAPT) for 12 months is the standard of care after coronary stenting in patients with acute coronary syndrome (ACS). The aim of this individual patient-level meta-analysis was to summarise the evidence comparing DAPT de-escalation to ticagrelor monotherapy versus continuing DAPT for 12 months after coronary drug-eluting stent implantation. METHODS: A systematic review and individual patient data (IPD)-level meta-analysis of randomised trials with centrally adjudicated endpoints was performed to evaluate the comparative efficacy and safety of ticagrelor monotherapy (90 mg twice a day) after short-term DAPT (from 2 weeks to 3 months) versus 12-month DAPT in patients undergoing percutaneous coronary intervention with a coronary drug-eluting stent. Randomised trials comparing P2Y12 inhibitor monotherapy with DAPT after coronary revascularisation were searched in Ovid MEDLINE, Embase, and two websites (www.tctmd.com and www.escardio.org) from database inception up to May 20, 2024. Trials that included patients with an indication for long-term oral anticoagulants were excluded. The risk of bias was assessed using the revised Cochrane risk-of-bias tool. The principal investigators of the eligible trials provided IPD by means of an anonymised electronic dataset. The three ranked coprimary endpoints were major adverse cardiovascular or cerebrovascular events (MACCE; a composite of all-cause death, myocardial infarction, or stroke) tested for non-inferiority in the per-protocol population; and Bleeding Academic Research Consortium (BARC) 3 or 5 bleeding and all-cause death tested for superiority in the intention-to-treat population. All outcomes are reported as Kaplan-Meier estimates. The non-inferiority was tested using a one-sided α of 0·025 with the prespecified non-inferiority margin of 1·15 (hazard ratio [HR] scale), followed by the ranked superiority testing at a two-sided α of 0·05. This study is registered with PROSPERO (CRD42024506083). FINDINGS: A total of 8361 unique citations were screened, of which 610 records were considered potentially eligible during the screening of titles and abstracts. Of these, six trials that randomly assigned patients to ticagrelor monotherapy or DAPT were identified. De-escalation took place a median of 78 days (IQR 31-92) after intervention, with a median duration of treatment of 334 days (329-365). Among 23 256 patients in the per-protocol population, MACCE occurred in 297 (Kaplan-Meier estimate 2·8%) with ticagrelor monotherapy and 332 (Kaplan-Meier estimate 3·2%) with DAPT (HR 0·91 [95% CI 0·78-1·07]; p=0·0039 for non-inferiority; τ2<0·0001). Among 24 407 patients in the intention-to-treat population, the risks of BARC 3 or 5 bleeding (Kaplan-Meier estimate 0·9% vs 2·1%; HR 0·43 [95% CI 0·34-0·54]; p<0·0001 for superiority; τ2=0·079) and all-cause death (Kaplan-Meier estimate 0·9% vs 1·2%; 0·76 [0·59-0·98]; p=0·034 for superiority; τ2<0·0001) were lower with ticagrelor monotherapy. Trial sequential analysis showed strong evidence of non-inferiority for MACCE and superiority for bleeding among the overall and ACS populations (the z-curve crossed the monitoring boundaries or the required information size without crossing the futility boundaries or approaching the null). The treatment effects were heterogeneous by sex for MACCE (p interaction=0·041) and all-cause death (p interaction=0·050), indicating a possible benefit in women with ticagrelor monotherapy, and by clinical presentation for bleeding (p interaction=0·022), indicating a benefit in ACS with ticagrelor monotherapy. INTERPRETATION: Our study found robust evidence that, compared with 12 months of DAPT, de-escalation to ticagrelor monotherapy does not increase ischaemic risk and reduces the risk of major bleeding, especially in patients with ACS. Ticagrelor monotherapy might also be associated with a mortality benefit, particularly among women, which warrants further investigation. FUNDING: Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale.
Asunto(s)
Síndrome Coronario Agudo , Terapia Antiplaquetaria Doble , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Ensayos Clínicos Controlados Aleatorios como Asunto , Ticagrelor , Humanos , Ticagrelor/uso terapéutico , Ticagrelor/administración & dosificación , Síndrome Coronario Agudo/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/administración & dosificación , Terapia Antiplaquetaria Doble/métodos , Hemorragia/inducido químicamente , Stents Liberadores de Fármacos , Resultado del TratamientoRESUMEN
BACKGROUND: Angina pectoris can occur in up to 40% of patients following percutaneous coronary intervention (PCI). There is limited data assessing whether the type of stent implanted during revascularization can predict post-PCI angina symptoms. METHODS: In this study, data regarding revascularization characteristics including the stent type in patients admitted for PCI was collected. Prospective data including occurrence of angina and the presenting class, new onset ST-segment elevation myocardial infarction (STEMI), and other clinical outcomes were collected at 1, 3, and 6-month follow-up intervals. Univariable and multivariable logistic regression models were used to assess the potential predictors of angina symptoms at 6-month follow-up. RESULTS: A total of 787 patients (64.5% males) undergoing PCI with three stent types (Orsiro, Promus, and Xience) were included in the study. The occurrence of post PCI angina pectoris and new STEMI was similar among the stent types (p > 0.05). A linear association was found between the development of new STEMI (p = 0.018) and stroke (p = 0.003) and the worsening of angina class. The stent type was not a predictor of angina during the follow-up period. Other variables including dyslipidemia (odds ratio (OR) (95% CI), 1.51 (1.08; 2.10)), prior coronary artery disease (CAD) (OR (95% CI), 1.63 (1.02; 2.61)), and previous hospitalization (OR (95% CI), 2.10 (1.22; 3.63)) were independent predictors of angina. CONCLUSIONS: Although the type of stent may not have an association with the post-PCI angina, other predictors such as dyslipidemia and previous CAD and hospitalization may predict recurrence of cardiac angina. The class of angina severity may have a linear association with new-onset STEMI and stroke.
Asunto(s)
Angina de Pecho , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Diseño de Prótesis , Infarto del Miocardio con Elevación del ST , Stents , Humanos , Masculino , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/instrumentación , Femenino , Persona de Mediana Edad , Angina de Pecho/terapia , Angina de Pecho/etiología , Angina de Pecho/diagnóstico , Factores de Riesgo , Anciano , Resultado del Tratamiento , Factores de Tiempo , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/diagnóstico , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Medición de Riesgo , Estudios ProspectivosAsunto(s)
Implantes Absorbibles , Magnesio , Humanos , Resultado del Tratamiento , Andamios del Tejido , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/métodos , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/cirugía , Masculino , Diseño de Prótesis , Femenino , Persona de Mediana Edad , Stents Liberadores de FármacosRESUMEN
BACKGROUND: Acute ischaemic stroke (AIS) after percutaneous coronary intervention (PCI) is a rare, but debilitating, complication. However, contemporary data from real-world unselected patients are scarce. AIMS: We aimed to explore the temporal trends, outcomes and variables associated with AIS as well as in-hospital all-cause mortality in a nationwide cohort. METHODS: A retrospective analysis of healthcare records from 2006-2021 was implemented. Patients were stratified according to the occurrence of AIS in the setting of PCI. The temporal trends of AIS were analysed. A stepwise regression model was used to identify variables associated with AIS and in-hospital all-cause mortality. RESULTS: A total of 4,910,430 PCIs were included for the current analysis. AIS occurred in 4,098 cases (0.08%). An incremental increase in the incidence of AIS after PCI from 0.03% to 0.14% per year was observed from 2006-2021. The strongest associations with AIS after PCI included carotid artery disease, medical history of stroke, atrial fibrillation, presentation with an ST-segment elevation myocardial infarction (STEMI) or non-STEMI and coronary thrombectomy. For patients with AIS, a higher in-hospital all-cause mortality (18.11% vs 3.29%; p<0.001) was documented. With regard to all-cause mortality, the strongest correlations in the stroke cohort were found for cardiogenic shock, dialysis and clinical presentation with a STEMI. CONCLUSIONS: In an unselected nationwide cohort of patients hospitalised for PCI, a gradual increase in AIS incidence was noted. We identified several variables associated with AIS as well as with in-hospital mortality. Hereby, clinicians might identify the patient population at risk for a peri-interventional AIS as well as those at risk for an adverse in-hospital outcome after PCI.
Asunto(s)
Mortalidad Hospitalaria , Accidente Cerebrovascular Isquémico , Intervención Coronaria Percutánea , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/tendencias , Intervención Coronaria Percutánea/mortalidad , Masculino , Femenino , Anciano , Accidente Cerebrovascular Isquémico/mortalidad , Accidente Cerebrovascular Isquémico/epidemiología , Estudios Retrospectivos , Persona de Mediana Edad , Mortalidad Hospitalaria/tendencias , Anciano de 80 o más Años , Factores de Riesgo , Resultado del Tratamiento , Incidencia , Hospitalización/estadística & datos numéricos , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/cirugía , Factores de TiempoRESUMEN
BACKGROUND: The clinical benefits of optical frequency domain imaging (OFDI)-guided percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS) remain unclear. AIMS: We sought to compare intravascular ultrasound (IVUS)- and OFDI-guided PCI in patients with ACS. METHODS: OPINION ACS is a multicentre, prospective, randomised, non-inferiority trial that compared OFDI-guided PCI with IVUS-guided PCI using current-generation drug-eluting stents in ACS patients (n=158). The primary endpoint was in-stent minimum lumen area (MLA), assessed using 8-month follow-up OFDI. RESULTS: Patients presented with ST-segment elevation myocardial infarction (55%), non-ST-segment elevation myocardial infarction (29%), or unstable angina pectoris (16%). PCI procedural success was achieved in all patients, with comparably low periprocedural complications rates in both groups. Immediately after PCI, the minimum stent area (p=0.096) tended to be smaller for OFDI versus IVUS guidance. Proximal stent edge dissection (p=0.012) and irregular protrusion (p=0.03) were significantly less frequent in OFDI-guided procedures than in IVUS-guided procedures. Post-PCI coronary flow, assessed using corrected Thrombolysis in Myocardial Infarction frame counts, was significantly better in the OFDI-guided group than in the IVUS-guided group (p<0.001). The least squares mean (95% confidence interval [CI]) in-stent MLA at 8 months was 4.91 (95% CI: 4.53-5.30) mm2 and 4.76 (95% CI: 4.35-5.17) mm2 in the OFDI- and IVUS-guided groups, respectively, demonstrating the non-inferiority of OFDI guidance (pnon-inferiority<0.001). The average neointima area tended to be smaller in the OFDI-guided group. The frequency of major adverse cardiac events was similar. CONCLUSIONS: Among ACS patients, OFDI-guided PCI and IVUS-guided PCI were equally safe and feasible, with comparable in-stent MLA at 8 months. OFDI guidance may be a potential option in ACS patients. This study was registered in the Japan Registry of Clinical Trials (jrct.niph.go.jp: jRCTs052190093).
Asunto(s)
Síndrome Coronario Agudo , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Ultrasonografía Intervencional , Humanos , Ultrasonografía Intervencional/métodos , Intervención Coronaria Percutánea/métodos , Masculino , Síndrome Coronario Agudo/terapia , Síndrome Coronario Agudo/diagnóstico por imagen , Síndrome Coronario Agudo/cirugía , Femenino , Persona de Mediana Edad , Anciano , Resultado del Tratamiento , Estudios Prospectivos , Tomografía de Coherencia Óptica/métodos , Infarto del Miocardio con Elevación del ST/diagnóstico por imagen , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/cirugía , Angina Inestable/terapia , Angina Inestable/diagnóstico por imagen , Angina Inestable/cirugíaRESUMEN
OBJECTIVE: Femoral access site complications (ASC) are frequent yet significant conditions associated with percutaneous intervention procedures that affect patient-physician comfort. In this study, we compared ASC rates between patients who received compression with a sandbag, the standard practice in many clinics, and patients monitored solely with bedrest without sandbag compression. METHODS: This study included patients undergoing any transfemoral percutaneous intervention (mostly coronary interventions) between April 2019 and May 2023 at our clinic. Patients were classified into two groups: those monitored without a sandbag (n = 160) and those with a sandbag (n = 158). ASC rates (ecchymosis, pseudoaneurysm, hematoma, bleeding) were compared between the two groups. RESULTS: No differences were observed between the two groups in gender, age, sheath size, and bed rest times. Complications were observed in 16.9% (n = 27) of patients without sandbags and 25.3% (n = 40) of patients with sandbags. The most common complication was ecchymosis, seen in 10.6% (n = 17) of the no-sandbag group and 13.9% (n = 22) of the sandbag group. CONCLUSION: Following manual compression after femoral sheath removal, patients receiving bedrest without sandbag use are less likely to develop ASC. Additionally, dismissing sandbag use leads to a significant increase in patient comfort.
Asunto(s)
Arteria Femoral , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Intervención Coronaria Percutánea/métodos , Intervención Coronaria Percutánea/efectos adversos , Presión , Estudios de SeguimientoRESUMEN
BACKGROUND: Percutaneous coronary intervention (PCI) has become one of the most commonly performed interventional life-saving procedures worldwide. Intravascular Imaging (intravascular ultrasound (IVUS) and optical coherence tomography (OCT)) have initially evolved to guide PCI compared with angiography. However, this technology is not universally employed in all PCI procedures, and there is ongoing controversy regarding its additional benefits to patient outcomes. We aim to estimate the efficacy and safety of imaging modalities during PCI, allowing pre-, per, and post-intervention assessment of coronary vascularization. METHODS: A systematic review and Bayesian network meta-analysis of randomized controlled trials (RCTs), which were retrieved from PubMed, WOS, SCOPUS, EMBASE, and CENTRAL through September 2023. We used R, version 4.2.0. Effect sizes will be presented as odds ratios with accompanying 95% credible intervals. PROSPERO ID: CRD42024507821. RESULTS: Our study, encompassing 36 RCTs with a total of 17,572 patients, revelead that compared to conventional angiography, IVUS significantly reduced the risk of major adverse cardiovascular events (MACE) (OR: 0.71 [95% CrI: 0.56 to 0.87]) but not OCT (OR: 0.91 [95% CrI: 0.62 to 1.39]), IVUS and OCT significantly reduced the risk of cardiac death (OR: 0.50 [95% CrI: 0.33 to 0.76]) and (OR: 0.55 [95% CrI: 0.31 to 0.98]), respectively, IVUS significantly reduced the risk of target vessel-related revascularization (OR: 0.60 [95% CrI: 0.48 to 0.75]) but not OCT (OR: 0.86 [95% CrI: 0.60 to 1.19]), IVUS and OCT significantly reduced the risk of stent thrombosis (OR: 0.50 [95% CrI: 0.28 to 0.92]) and (OR: 0.48 [95% CrI: 0.22 to 0.98]), respectively, IVUS significantly reduced the risk of re-stenosis (OR: 0.65 [95% CrI: 0.46 to 0.88]) but not OCT (OR: 0.55 [95% CrI: 0.15 to 1.99]), neither IVUS (OR: 0.97 [95% CrI: 0.71 to 1.38]) nor OCT (OR: 0.75 [95% CrI: 0.49 to 1.22]) were associated with statistically significant reductions in all-cause mortality, neither IVUS (OR: 0.70 [95% CrI: 0.45 to 1.32]) nor OCT (OR: 0.81 [95% CrI: 0.47 to 1.59]) were associated with statistically significant reductions in target vessel failure, neither IVUS (OR: 0.88 [95% CrI: 0.43 to 2.44]) nor OCT (OR: 0.81 [95% CrI: 0.37 to 2.04]) were associated with statistically significant reductions in target lesion failure, and neither IVUS (OR: 0.82 [95% CrI: 0.60 to 1.06]) nor OCT (OR: 0.84 [95% CrI: 0.59 to 1.19]) were associated with statistically significant reductions in myocardial infarction. CONCLUSION: Intravascular imaging-guided, including IVUS and OCT, improved the postinterventional outcomes of PCI, notably suggesting their advantage over traditional angiography with no significant difference between IVUS and OCT.
Asunto(s)
Teorema de Bayes , Angiografía Coronaria , Enfermedad de la Arteria Coronaria , Metaanálisis en Red , Intervención Coronaria Percutánea , Valor Predictivo de las Pruebas , Ensayos Clínicos Controlados Aleatorios como Asunto , Tomografía de Coherencia Óptica , Ultrasonografía Intervencional , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Intervención Coronaria Percutánea/instrumentación , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/mortalidad , Resultado del Tratamiento , Factores de Riesgo , Medición de Riesgo , Femenino , Persona de Mediana Edad , Masculino , Anciano , Vasos Coronarios/diagnóstico por imagenRESUMEN
Congenital Quadricuspid Aortic Valve (QAV) malformation is a relatively rare cardiac valve malformation, especially with abnormal coronary opening and severe stenosis of Coronary Artery Disease (CAD). The patient underwent "one-stop" interventional treatment with transcatheter aortic valve replacement and percutaneous coronary stent implantation. Follow up for 12-month with good outcomes.
Asunto(s)
Válvula Aórtica , Enfermedad de la Arteria Coronaria , Reemplazo de la Válvula Aórtica Transcatéter , Humanos , Válvula Aórtica/cirugía , Válvula Aórtica/anomalías , Válvula Aórtica/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/complicaciones , Reemplazo de la Válvula Aórtica Transcatéter/métodos , Masculino , Stents , Intervención Coronaria Percutánea/métodos , Angiografía Coronaria , AncianoRESUMEN
BACKGROUND: Aorto-ostial (AO) coronary interventions may be associated with multiple problems, including the potential embolization of atherothrombotic debris into the aorta and systemic circulation. Such embolization could theoretically lead to stroke or silent brain injury (SBI). In this study, we aimed to investigate whether there is an increased risk of SBI in patients undergoing AO stent implantation. METHODS: Fifty-five consecutive patients undergoing AO stenting and 55 consecutive patients undergoing non-AO stenting were included. Venous blood samples were obtained before and 12 h after the procedure to measure neuron-specific enolase (NSE), which is a sensitive marker of brain injury. Newly developed NSE elevation after the procedure in an asymptomatic patient was defined as SBI. RESULTS: SBI was detected in 24 (43.6%) patients in the AO stenting group and 17 (30.9%) patients in the non-AO stenting group (p = .167). Although the SBI rates were statistically comparable between the groups, the presence of significant (≥50%) AO stenosis was found to be an independent predictor of SBI in multivariate logistic regression analysis [odds ratio (OR) 2.856; 95% confidence interval (CI) 1.057-7.716; p = .038]. A longer procedure time was another independent predictor for the development of SBI (OR 1.037; 95% CI 1.005-1.069; p = .023). CONCLUSION: This study suggests that AO stenting may be associated with an increased risk of SBI if the lesion in the ostium is significant.
Asunto(s)
Intervención Coronaria Percutánea , Fosfopiruvato Hidratasa , Stents , Humanos , Masculino , Femenino , Anciano , Persona de Mediana Edad , Stents/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Fosfopiruvato Hidratasa/sangre , Lesiones Encefálicas/etiología , Factores de Riesgo , Biomarcadores/sangreRESUMEN
BACKGROUND: In acute heart failure (HF), reduced cardiac output, vasoconstriction and congestion may damage the intestinal mucosa and disrupt its barrier function. This could facilitate the leakage of bacterial products into circulation and contribute to inflammation and adverse cardiac remodelling. We aimed to investigate gut leakage markers and their associations with inflammation, infarct size and cardiac function. METHODS: We examined 61 ST-elevation myocardial infarction (STEMI) patients who developed acute HF within 48 hours of successful percutaneous coronary intervention (PCI). Serial blood samples were taken to measure lipopolysaccharide (LPS), LPS-binding protein (LBP), soluble cluster of differentiation 14 (sCD14) and intestinal fatty acid binding protein (I-FABP). Cumulative areas under the curve (AUCs) from baseline to day 5 were calculated. Serial echocardiography was performed to assess left ventricular ejection fraction (LVEF), global longitudinal strain (GLS) and wall motion score index (WMSI). Single-photon emission CT (SPECT) was performed at 6 weeks to determine infarct size and LVEF. RESULTS: I-FABPAUC correlated positively with infarct size (rs=0.45, p=0.002), GLS (rs=0.32, p=0.035) and WMSI (rs=0.45, p=0.002) and negatively with LVEF measured by SPECT (rs=-0.40, p=0.007) and echocardiography (rs=-0.33, p=0.021) at 6 weeks. LPSAUC, LBPAUC and sCD14AUC did not correlate to any cardiac function marker or infarct size. Patients, who at 6 weeks had above median GLS and WMSI, and below-median LVEF measured by SPECT, were more likely to have above median I-FABPAUC during admission (adjusted OR (aOR) 5.22, 95% CI 1.21 to 22.44; aOR 5.05, 95% CI 1.25 to 20.43; aOR 5.67, 95% CI 1.42 to 22.59, respectively). The same was observed for patients in the lowest quartile of LVEF measured by echocardiography (aOR 9.99, 95% CI 1.79 to 55.83) and three upper quartiles of infarct size (aOR 20.34, 95% CI 1.56 to 264.65). CONCLUSIONS: In primary PCI-treated STEMI patients with acute HF, I-FABP, a marker of intestinal epithelial damage, was associated with larger infarct size and worse cardiac function after 6 weeks.
Asunto(s)
Biomarcadores , Proteínas de Unión a Ácidos Grasos , Insuficiencia Cardíaca , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Función Ventricular Izquierda , Humanos , Masculino , Proteínas de Unión a Ácidos Grasos/sangre , Femenino , Insuficiencia Cardíaca/fisiopatología , Insuficiencia Cardíaca/etiología , Insuficiencia Cardíaca/sangre , Insuficiencia Cardíaca/diagnóstico , Persona de Mediana Edad , Biomarcadores/sangre , Anciano , Función Ventricular Izquierda/fisiología , Intervención Coronaria Percutánea/métodos , Infarto del Miocardio con Elevación del ST/fisiopatología , Infarto del Miocardio con Elevación del ST/sangre , Volumen Sistólico/fisiología , Tomografía Computarizada de Emisión de Fotón Único , Proteínas Portadoras/sangre , Ecocardiografía/métodos , Proteínas de Fase Aguda , Glicoproteínas de Membrana/sangre , Factores de Tiempo , Receptores de Lipopolisacáridos/sangre , Enfermedad Aguda , Estudios Prospectivos , Lipopolisacáridos , Remodelación Ventricular/fisiologíaRESUMEN
OBJECTIVE: To assess long-term clinical outcomes and factors associated with target vessel revascularisation in patients with deferred revascularisation based on negative fractional flow reserve and negative instantaneous wave-free ratio. METHODS: The longitudinal, retrospective study was conducted from July 1, 2020, to January 1, 2022, at the Aga Khan University Hospital, Karachi, and comprised medical records from January 2012 to January 2020 of patients with deferred revascularisation having intermediate to severe coronary lesions on coronary angiogram and had negative fractional flow reserve >0.80 or instantaneous wave-free ratio >0.89 and had not undergone immediate or planned revascularisation on the basis of negative physiological assessment. Data was collected from the institutional records, while final follow-up was taken by reviewing the medical records or telephonic interviews regarding any major adverse cardiac event after the index procedure. Data was analysed using Stata 14.2. RESULTS: Of the 345 patients, 245(71%) were males. The overall mean age was 62±11 years. There were 194(56%) patients who presented with stable angina and 151(44%) presented with acute coronary syndrome. Mean fractional flow reserve was 0.87±0.04 and mean instantaneous wave-free ratio was 0.93±0.03. Multivessel disease was present in 223(65%) patients. Median follow-up period was 29 months (IQR: 24-36 months). Major adverse cardiovascular events occurred in 22(6%) patients, and target vessel revascularisation was required in 11(3%). Diabetes and percentage of stenosis were found to be independent predictors of major adverse cardiovascular events (p<0.05). CONCLUSIONS: Deferral of revascularisation and opting for medical treatment for coronary artery stenosis with higher fractional flow reserve or instantaneous wave-free ratio could be considered a safe and reasonable strategy.
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Angiografía Coronaria , Reserva del Flujo Fraccional Miocárdico , Revascularización Miocárdica , Humanos , Reserva del Flujo Fraccional Miocárdico/fisiología , Masculino , Femenino , Persona de Mediana Edad , Pakistán/epidemiología , Estudios Retrospectivos , Anciano , Revascularización Miocárdica/métodos , Revascularización Miocárdica/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/cirugía , Enfermedad de la Arteria Coronaria/fisiopatología , Estudios Longitudinales , Estenosis Coronaria/fisiopatología , Estenosis Coronaria/cirugía , Síndrome Coronario Agudo/cirugía , Síndrome Coronario Agudo/fisiopatología , Angina Estable/cirugía , Angina Estable/fisiopatología , Resultado del Tratamiento , Intervención Coronaria Percutánea/métodosRESUMEN
BACKGROUND: Recent observations in silico and in vivo reported that, during proximal optimisation technique, drug-eluting stents (DES) elongate, challenging conventional wisdom. The interaction between plaque morphology and radial expansion is well established, but little is known about the impact of plaque morphology on elongation. AIMS: We aimed to assess the longitudinal mechanical behaviour of contemporary DES in vivo and evaluate the relationship between post-percutaneous coronary intervention (PCI) stent elongation and lesion morphology, as assessed with optical coherence tomography (OCT). METHODS: Patients treated with OCT-guided PCI to left main or left anterior descending artery bifurcations, between July 2017 and March 2022, from the King's Optical coherence Database Analysis Compendium were included. Patients were excluded if there were overlapping stents, if they had undergone prior PCI, or if there was inadequate image quality. Lesions were characterised as fibrocalcific, fibrous or lipid-rich by pre-PCI OCT. Following stent post-dilatation, stent expansion and final stent length were assessed. The primary outcome was the percentage change in stent length from baseline. RESULTS: Of 501 eligible consecutive patients from this period, 116 were included. The median age was 66 years (interquartile range [IQR] 57-76), 31% were female, and 53.4% were treated for an acute coronary syndrome. A total of 50.0% of lesions were classified as fibrocalcific, 6.9% were fibrous, and 43.1% were lipid-rich. The change in relative stent length was 4.4% (IQR 1.0-8.9), with an increase of 3.1% (IQR 0.5-6.3) in fibrocalcific lesions, 3.3% (IQR 0.5-5.9) in fibrous lesions, and 6.4% (IQR 3.1-11.1) in lipid-rich plaque (p=0.006). In multivariate regression modelling, lipid-rich plaque was an independent predictor of stent elongation (odds ratio 3.689, 95% confidence interval: 1.604-8.484). CONCLUSIONS: Contemporary DES elongate following implantation and post-dilatation, and this is significantly mediated by plaque morphology. This is an important consideration when planning a strategy for DES implantation.
Asunto(s)
Enfermedad de la Arteria Coronaria , Stents Liberadores de Fármacos , Intervención Coronaria Percutánea , Placa Aterosclerótica , Tomografía de Coherencia Óptica , Humanos , Femenino , Tomografía de Coherencia Óptica/métodos , Masculino , Anciano , Persona de Mediana Edad , Intervención Coronaria Percutánea/instrumentación , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Enfermedad de la Arteria Coronaria/diagnóstico por imagen , Enfermedad de la Arteria Coronaria/terapia , Enfermedad de la Arteria Coronaria/cirugía , Resultado del Tratamiento , Vasos Coronarios/diagnóstico por imagen , Vasos Coronarios/patologíaRESUMEN
BACKGROUND: The 12-month outcomes of BIOMAG-I - the first-in-human study investigating the third-generation drug-eluting resorbable magnesium scaffold (DREAMS 3G) - showed promising results regarding clinical outcomes and late lumen loss. AIMS: The current study aimed to investigate vascular healing parameters assessed by optical coherence tomography (OCT) and intravascular ultrasound (IVUS), focusing on strut visibility, vessel and scaffold areas, and neointimal growth patterns. METHODS: This is a BIOMAG-I substudy including patients with available serial OCT and IVUS data. We conducted a frame-based analysis of OCT findings in conjunction with IVUS-derived vessel and scaffold areas, evaluating the qualitative and quantitative aspects of vascular healing. RESULTS: Among the 116 patients enrolled in this trial, 56 patients treated with DREAMS 3G were included in the analysis. At 12 months, OCT imaging revealed that 99.0% of the struts were invisible, and no malapposed struts were depicted. While the vessel area showed no significant difference between the timepoints, the minimum lumen area significantly decreased from post-percutaneous coronary intervention to 6 months (6.88 mm2 to 4.75 mm2; p<0.0001), but no significant changes were observed between 6 and 12 months. Protruding neointimal tissue (PNT) - a unique neointimal presentation observed following resorbable magnesium scaffold implantation - was observed in 89.3% of the study patients at 12 months, and its area exhibited a 47.4% decrease from 6 to 12 months. CONCLUSIONS: This imaging substudy revealed that, at 12-month follow-up, virtually all struts of the DREAMS 3G scaffold became invisible, without evident malapposition. The vascular healing response to DREAMS 3G implantation also appeared favourable up to 12 months, which is indicated by advanced strut degradation and spontaneous regressing PNT between 6 and 12 months.