Publications by authors named "Axel de Labriolle"

51 Publications

Evaluation of the safety and efficacy of the Cobra PzF NanoCoated coronary stent in routine, consecutive, prospective, and high-risk patients: The e-Cobra study.

Catheter Cardiovasc Interv 2020 Jun 17. Epub 2020 Jun 17.

Center Hospitalier Annecy Genevois, Metz-Tessy, France.

Background: The Cobra PzF coronary stent is cobalt chromium with flat thin struts, nano-coated with Polyzene-F that enhance rapid reendothelialization and reduce the risk of stent thrombosis and restenosis. It is designed to overcome shortfalls of BMS and DES in patients requiring short DAPT duration.

Aims: To report procedural and 1-year clinical outcomes following Cobra PzF stent implantation in routine practice PCI.

Methods: e-Cobra registry is a multicenter prospective study to evaluate Cobra PzF stent in routine practice in patients deemed appropriate for short DAPT after PCI. The primary endpoint was MACE rate at 12 months (Cardiac death, MI, TLR). The secondary endpoint was definite stent thrombosis at 12 months.

Results: Among 940 patients (72% men, 72.8 ± 13.4 years) with multiple co-morbidities, 47% had acute coronary syndromes, and 62% were defined as high bleeding risk. A total of 1,229 lesions were treated with 1,314 stents. 36% of patients had lesion type B2 or C classification. Angiographic success was achieved in all cases. One-year follow-up was available for 97% of patients. The primary endpoint occurred in 9.0% of patients, including cardiac death 3.7%, MI 4.8%, and TLR 4.3%. Definite stent thrombosis occurred in six out of 915 (0.7%).

Conclusion: The Cobra PzF stent was safe and effective in routine practice patients and seems feasible in situations when short DAPT or Mono Antiplatelet Therapy (MAPT) is needed. One-year follow-up was associated with satisfactory clinical outcomes and validate previously reported data.
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http://dx.doi.org/10.1002/ccd.29065DOI Listing
June 2020

Prognostic impact of non-compliance with guidelines-recommended times to reperfusion therapy in ST-elevation myocardial infarction. The FAST-MI 2010 registry.

Eur Heart J Acute Cardiovasc Care 2017 Feb 20;6(1):26-33. Epub 2016 Sep 20.

1 Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Department of Cardiology, France; Université Paris-Descartes, France.

Aims: Current guidelines recommend short time delays from qualifying ECG to reperfusion therapy in ST-elevation myocardial infarction (STEMI) patients. Recently, however, it has been suggested that shortening door-to-balloon times might not result in lower mortality, thereby questioning the relevance of current guidelines. The aim of this study was to assess in-hospital and one-year mortality in patients with fibrinolysis or primary percutaneous coronary intervention (PPCI) according to guidelines-recommended times to reperfusion therapy.

Methods And Results: FAST-MI 2010 is a nationwide French registry including 4169 patients, of whom 1580 had ST-elevation myocardial infarction and had PPCI ( n=1289) or fibrinolysis ( n=291) as part of a pharmaco-invasive strategy. Four groups were constituted: Gr1 (within recommended times from ECG to PPCI; n=708), Gr2 (beyond recommended times from ECG to PPCI; n=581), Gr3 (time from ECG to lysis ⩽30 min, n=196), and Gr4 (time from ECG to lysis >30 min, n=95). In-hospital mortality was 3.6% in Gr2 vs. 1.0% in Gr1 and 3.2% in Gr4 vs. 1.0% in Gr3. After adjustment, hospital mortality was higher for reperfusion therapy beyond recommended times: odds ratio (OR) 3.29, 95% confidence interval (CI) 1.32-8.18; for PPCI, OR: 4.13; 95% CI: 1.50-11.35 and for fibrinolysis, OR: 2.72; 95% CI: 0.34-21.96. Likewise, one-year mortality was higher in patients with reperfusion beyond recommended times (hazard ratio 2.13, 95% CI:1.29-3.50). The results were confirmed by propensity score analyses.

Conclusions: Early and one-year mortality were lower for ST-elevation myocardial infarction patients when the recommended timelines for reperfusion therapy were met, suggesting that, in spite of recent interrogations, compliance with current guidelines remains a clinically relevant objective.
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http://dx.doi.org/10.1177/2048872615610893DOI Listing
February 2017

Genotypic and phenotypic assessment of platelet function and response to P2Y12 antagonists.

Curr Cardiol Rep 2011 Oct;13(5):439-50

Service de cardiologie, Clinique du pont de chaume, Montauban, France.

The P2Y12-ADP receptor antagonists are the cornerstone of oral antiplatelet therapy in the secondary prevention of coronary artery disease, especially after acute coronary syndrome or percutaneous coronary intervention. Currently, the therapeutic agents available to block the receptor include clopidogrel and prasugrel; ticagrelor is not available everywhere. Clopidogrel was the gold standard, but recently it has been challenged by prasugrel and ticagrelor. One pitfall of clopidogrel is that in some patients it cannot induce optimal platelet reactivity inhibition in connection with several factors, including some genetic polymorphisms of enzymes participating in its bioabsorption or metabolism. This variability of response can be evaluated by platelet reactivity monitoring. This comprehensive review provides the available data regarding the genotypic and phenotypic interaction with the response to P2Y12-ADP receptor antagonists and discusses the concept of personalized antiplatelet therapy based on a genotypic or phenotypic profile.
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http://dx.doi.org/10.1007/s11886-011-0208-zDOI Listing
October 2011

High on-treatment platelet reactivity after prasugrel loading dose and cardiovascular events after percutaneous coronary intervention in acute coronary syndromes.

J Am Coll Cardiol 2011 Jul;58(5):467-73

Département de Cardiologie, Hôpital Universitaire Nord, Faculté de Médecine, Chemin des Bourrely, Marseille, France.

Objectives: The aim of this study was to investigate the relationship between platelet reactivity (PR) after a loading dose (LD) of prasugrel and thrombotic events.

Background: Post-treatment PR has been shown to be strongly associated with the occurrence of major adverse cardiac events (MACE) after percutaneous coronary intervention (PCI) in the clopidogrel era. Prasugrel is a new P2Y(12)-adenosine diphosphate receptor with a higher potency on PR.

Methods: A prospective multicenter study included patients who underwent successful PCI for acute coronary syndromes and received prasugrel therapy. Vasodilator-stimulated phosphoprotein (VASP) index was measured after the prasugrel LD. High on-treatment PR was defined as a VASP index ≥50%. MACE included cardiovascular death, myocardial infarction, and definite stent thrombosis at 1 month.

Results: Three hundred one patients were enrolled. The mean VASP index after 60 mg of prasugrel was 34.3 ± 23.1%. High on-treatment PR was observed in 76 patients (25.2%). Patients experiencing thrombotic events after PCI had significantly higher VASP indexes compared with those free of events (64.4 ± 14.4% vs. 33.4 ± 22.7%; range: 51% to 64% and 5% to 47.6%, respectively; p = 0.001). Kaplan-Meier analysis comparing good responders and patients with high on-treatment PR demonstrated a significantly higher rate of MACE in patients with suboptimal PR inhibition (log-rank p < 0.001). Receiver-operating characteristic curve analysis found a cutoff value of 53.5% of the VASP index to predict thrombotic events at 1 month (r = 0.86, p < 0.001). Patients with minor or major Thrombolysis In Myocardial Infarction unrelated to coronary artery bypass grafting bleeding and those without had similar VASP indexes (30 ± 17.8% vs. 34.3 ± 23%, p = 0.70).

Conclusions: Despite the use of prasugrel, a significant number of patients undergoing PCI in the setting of acute coronary syndromes do not achieve optimal PR inhibition. Such patients have a higher risk for MACE after PCI.
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http://dx.doi.org/10.1016/j.jacc.2011.04.017DOI Listing
July 2011

Relation between clopidogrel discontinuation and early cardiovascular events after percutaneous coronary intervention with drug-eluting stents.

EuroIntervention 2011 Apr;6(9):1053-9

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA.

Aims: Clopidogrel discontinuation after percutaneous coronary intervention (PCI) with drug-eluting stent (DES) implantation has been reported to correlate with stent thrombosis. Whether these events are a consequence of the rebound phenomenon or a lack of protection in unhealed vessels is unclear. This study aimed to determine the link between clopidogrel cessation and cardiovascular events after PCI with DES.

Methods And Results: The population included 1,903 patients who underwent PCI with DES implantation from 2003 to 2007. We compared patients who stopped their clopidogrel within the first month (group 1, n=97), from one to six months (group 2, n=344), from six to 12 months (group 3, n=468), and after 12 months (group 4, n=994) following the PCI. In each group, the composite of death, myocardial infarction and stent thrombosis at 30 days and between 31 and 60 days after clopidogrel cessation was indexed. Baseline characteristics were similar among groups. The event rate observed in the 0-30 day interval following cessation was higher only in group 1 (5.2%) compared to all other groups: 1.2% (group 2), 0.9% (group 3) and 0.6% (group 4) (p=0.004). The event rates from 31 to 60 days following cessation were low and similar among the four groups. When the elapsed time between the index PCI and the clopidogrel cessation was analysed as a continuous variable, the probability of events occurring within the first 30 days became similar to that observed in the 31-60 day interval following cessation after a minimum of 10.2 months.

Conclusions: Cardiac events seen immediately after clopidogrel cessation are not related to a rebound phenomenon, but are more likely influenced by the lack of healing at the time of cessation, which decreases over time. This increased risk related to the lack of healing seems to disappear after 10.2 months.
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http://dx.doi.org/10.4244/EIJV6I9A184DOI Listing
April 2011

Outcomes in diabetic versus nondiabetic patients who present with acute myocardial infarction and are treated with drug-eluting stents.

Am J Cardiol 2010 Mar;105(6):819-25

Department of Medicine, Division of Cardiology, Washington Hospital Center, Washington, District of Columbia.

Patients with diabetes mellitus (DM) are at a greater risk of mortality and cardiovascular events after percutaneous coronary intervention than those without DM. We aimed to determine whether differences exist in the long-term mortality of patients with versus without DM who present with acute myocardial infarction and receive drug-eluting stents. Data were collected on 161 patients with and 395 without DM referred for primary percutaneous coronary intervention for acute myocardial infarction and treated with drug-eluting stents. The patients with cardiac arrest or cardiogenic shock were excluded. The 1-year major cardiac event (MACE) rates, defined as death, Q-wave myocardial infarction, or target lesion revascularization, were compared between the 2 groups. The patients with DM were sicker at baseline. The MACE rates at 1 year were significantly increased in those with DM compared to those without DM. This was primarily driven by all-cause mortality. No differences in Q-wave myocardial infarction, target lesion revascularization, stent thrombosis, type of drug-eluting stents used, or procedure-related renal failure were seen. No differences were found in death or MACE rates at 1 year after adjusting for age, gender, race, systemic hypertension, peripheral artery disease, and a history of chronic renal failure between the 2 groups (weighted log-rank statistic, p = 0.37 and p = 0.37, respectively). In patients presenting with acute myocardial infarction, those with DM were sicker than those without DM. In conclusion, after correction for co-morbid conditions, no difference was seen in the 1-year MACE or death rates between those with and without DM who presented with acute myocardial infarction and were treated with drug-eluting stents.
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http://dx.doi.org/10.1016/j.amjcard.2009.11.010DOI Listing
March 2010

Antithrombotic treatment and the risk of death and stroke in patients with atrial fibrillation and a CHADS2 score=1.

Thromb Haemost 2010 Apr 2;103(4):833-40. Epub 2010 Feb 2.

Service de Cardiologie, Pôle Coeur Thorax Vasculaire, Centre Hospitalier Universitaire Trousseau et Faculté de Médecine, Université François Rabelais, Tours, France.

In patients with atrial fibrillation (AF) and an intermediate risk of stroke (CHADS2 score =1), available evidence from clinical trials is inconclusive and the present guidelines for the management of AF indicate that the choice between oral anticoagulant and aspirin in these patients is open. Our goal was to evaluate whether, in patients with AF and only one moderate risk factor for thromboembolism, treatment with an oral anticoagulant is appreciably more beneficial than treatment with an antiplatelet agent. Among 6,517 unselected patients with AF, 1,012 of them (15.5%) had a CHADS2 score of 1 and were liable to treatment with an antiplatelet agent or an anticoagulant. An oral anticoagulant was prescribed for 606 patients (59.9%) and an antiplatelet agent or no antithrombotic treatment for 406 (40.1%). During follow-up (median=793 days, interquartile range=1,332 days), 105 deaths (10.4%) and 19 strokes (1.9%) were recorded. The administration of an anticoagulant was associated with a lower rate of events (relative risk=0.42, 95% confidence interval 0.29-0.60, p<0.0001) than when no anticoagulant was prescribed. Results remained similar after adjustment for age and other confounding factors. In contrast, prescription of an antiplatelet agent was not associated with a lower risk of events. Factors independently associated with an increased risk of events were older age (p<0.0001), concomitant heart failure (p=0.0002), diabetes (p=0.0025), lack of prescription of an anticoagulant (p<0.0001) and permanent AF (p=0.04). Thus, prescription of an anticoagulant is independently associated with a decreased risk of death or stroke among patients with AF and a CHADS2 score =1.
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http://dx.doi.org/10.1160/TH09-10-0746DOI Listing
April 2010

Decline in platelet count in patients treated by percutaneous coronary intervention: definition, incidence, prognostic importance, and predictive factors.

Eur Heart J 2010 May 19;31(9):1079-87. Epub 2010 Jan 19.

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, 110 Irving Street, NW, Suite 4B-1, Washington, DC 20010, USA.

Aims: We investigated the incidence, predictors, and prognostic impact of a decline in platelet count (DPC) in patients treated by percutaneous coronary intervention (PCI).

Methods And Results: A total of 10 146 consecutive patients treated by PCI from 2003 to 2006 were included. According to the magnitude of the DPC, the population was divided into four groups: no DPC (<10%), minor DPC (10-24%), moderate DPC (25-49%), and severe DPC (>or=50%). The primary haemorrhagic endpoint was a composite of post-procedure surgical repair major bleeding. The primary ischaemic endpoint was 30-day all-cause mortality-non-fatal myocardial infarction. Among the total population, 36% had a DPC <10%, 47.7% had a DPC of 10-24%, 14% had a DPC of 25-49%, and 2.3% had a DPC >or=50%. On multivariate analysis, moderate and severe DPC were independent predictive factors of the ischaemic outcome. Two procedural practices were identified that, if modified, might reduce the incidence of acquired thrombocytopaenia. Both the intraprocedural use of heparin (as opposed to bivalirudin) and of low molecular weight contrast material were independently associated with severe acquired thrombocytopaenia.

Conclusion: Moderate and severe DPC are independent predictors of adverse bleeding and ischaemic outcomes in PCI. Adoption of intraprocedural anticoagulant other than heparin and avoidance of a low molecular weight contrast agent could potentially decrease the occurrence of severe acquired thrombocytopaenia.
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http://dx.doi.org/10.1093/eurheartj/ehp594DOI Listing
May 2010

Personalized antiplatelet therapy for coronary artery disease patients: is this the future?

Expert Rev Cardiovasc Ther 2009 Dec;7(12):1525-32

Pôle de cardiologie, Hôpital Universitaire Nord, Chemin des Bourrely, 13015 Marseille, France.

Clopidogrel has decreased the rate of thrombotic events in patients undergoing percutaneous coronary intervention. However, two major limitations of the drug have been involved in the persistence of a relatively high rate of adverse events. The recent literature suggested that improved platelet reactivity inhibition using a higher or tailored dose of clopidogrel, or a more potent agent, could reduce the rate of events. The development of new antiplatelet agents and the increasing availability of platelet assays are likely to profoundly modify current practice and favor personalized antiplatelet therapy.
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http://dx.doi.org/10.1586/erc.09.146DOI Listing
December 2009

Relation of body mass index to high on-treatment platelet reactivity and of failed clopidogrel dose adjustment according to platelet reactivity monitoring in patients undergoing percutaneous coronary intervention.

Am J Cardiol 2009 Dec;104(11):1511-5

Département de Génétique Médicale, Hôpital de la Timone enfant, Marseille, France.

High on-treatment platelet reactivity (HTPR) after a clopidogrel loading dose predicts the risk of thrombotic events after percutaneous coronary intervention. We have demonstrated that HTPR could be overcome in most cases using dose adjustment according to PR monitoring resulting in an improved clinical outcome. However, this strategy failed in nearly 10% of patients with HTPR. Cytochrome P450 (CYP) 2C19 polymorphism was a major determinant of the response to clopidogrel and could be responsible for a failure of dose adjustment. We aimed to determine the clinical and genetical predictors of a failure of the dose-adjustment strategy. Seventy-three patients undergoing percutaneous coronary intervention were included in this prospective multicenter study. A vasodilator phosphoprotein index >or=50% after a 600-mg loading dose of clopidogrel defined HTPR. Dose adjustment was performed according to PR monitoring to reach a vasodilator phosphoprotein index <50%. Genetic polymorphism of CYP2C19 was determined by direct sequencing. Clinical predictors of HTPR were body mass index (BMI; p = 0.01), diabetes mellitus (p = 0.03), and acute coronary syndrome (p = 0.02). The mutant 2 allele of CYP2C19 681A > G loss of function polymorphism was also significantly associated with HTPR (p = 0.04). The rate of successful dose adjustment was similar in carriers of the CYP2C19 2 allele and carriers of the wild-type allele. The only independent predictor of a failed dose adjustment was a high BMI (p = 0.01). In conclusion, high BMI, acute coronary syndrome, diabetes mellitus, and CYP2C19 2 are associated with HTPR after a 600-mg loading dose of clopidogrel. Dose adjustment overcomes HTPR in carriers of the CYP2C19 2 allele. BMI is the only independent predictor of failed dose adjustment. Thus, drug underdosage seems to be the main determinant of HTPR.
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http://dx.doi.org/10.1016/j.amjcard.2009.07.015DOI Listing
December 2009

Head-to-head comparison of bivalirudin versus heparin without glycoprotein IIb/IIIa inhibitors in patients with acute myocardial infarction undergoing primary angioplasty.

Cardiovasc Revasc Med 2009 Jul-Sep;10(3):156-61

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA.

Background: In patients receiving primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI), bivalirudin with provisional glycoprotein (GP) IIb/IIIa inhibitors has been demonstrated to be noninferior to heparin plus systematic GP IIb/IIIa inhibitors in preventing recurrent ischemic events with improved safety in terms of bleeding. However, no study has been performed comparing head-to-head bivalirudin with heparin without GP IIb/IIIa inhibitor infusion in STEMI patients.

Methods: We retrospectively studied 899 consecutive patients who presented with STEMI treated by primary angioplasty within 12 h after symptoms. Among them, 566 received bivalirudin and 333 received unfractionated heparin. Their in-hospital outcome in terms of efficacy and safety was assessed using rates of major adverse cardiac events (MACE) and major bleeding, respectively. Clinical, angiographic and procedural characteristics were well matched between the two groups.

Results: Patients in the heparin group more frequently required intra-aortic balloon pumping (6.6% vs. 3.6%, P=.037). Regarding the safety end point, the MACE rate, including death, ischemic stroke and urgent repeated revascularization, was low and similar in both groups (2.7% bivalirudin vs. 1.2% heparin, P=.15). The rate of major bleeding, including major hematoma, gastrointestinal bleeding and hematocrit drop >15% during hospitalization, was high and identical in the two groups (4.1% bivalirudin vs. 4.2% heparin, P=.92).

Conclusion: This study suggests that bivalirudin and heparin present similar safety and efficacy profiles when used without GP IIb/IIIa inhibitor infusion during primary angioplasty.
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http://dx.doi.org/10.1016/j.carrev.2008.12.005DOI Listing
September 2009

Prognostic value of hemoglobin A1C levels in patients with diabetes mellitus undergoing percutaneous coronary intervention with stent implantation.

Am J Cardiol 2009 Jul;104(1):41-5

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC, USA.

The optimal glycosylated hemoglobin (HbA1C) target in diabetic patients is a subject of ongoing controversy that may be especially pertinent in diabetic patients with coronary artery disease. This study aimed to determine the prognostic value of preprocedural HbA1C levels in diabetic patients undergoing percutaneous coronary intervention (PCI) with stent implantation. From 2002 to 2007, a cohort of 952 consecutive diabetic patients underwent PCI with stent implantation in our center. We compared patients with a normal preprocedural HbA1C (< or = 7%, n = 429) with patients with an increased HbA1C (>7%, n = 523). One-year rate of major adverse cardiovascular events (MACEs) including death, myocardial infarction, and target vessel revascularization was indexed. Baseline characteristics were similar between groups, except for body mass index, which was higher in the high HbA1C group (32.2 vs 31.2 kg/m(2), p = 0.03). Patients in the high HbA1C group were more likely insulin dependent (45.5% vs 26.3%, p <0.001). Rates of MACEs were similar (23.7% vs 20.8%) in the high HbA1C and low HbA1C groups (p = 0.45). By multivariate analysis, age, renal failure, clinical presentation as myocardial infarction, and history of congestive heart failure were independently associated with MACEs. In contrast, HbA1C was not associated with patient outcome. In conclusion, this study suggests that HbA1C is not a predictor of cardiac events in diabetic patients with advanced coronary artery disease. These results could explain, at least in part, recent findings of randomized clinical trials that suggest the absence of benefit in macrovascular complications of a strict glycemia control.
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http://dx.doi.org/10.1016/j.amjcard.2009.02.060DOI Listing
July 2009

Comparison of degree of stenosis and plaque volume for the assessment of carotid atherosclerosis using 2-D ultrasound.

Ultrasound Med Biol 2009 Sep 26;35(9):1436-42. Epub 2009 Jun 26.

Departement de Cardiologie, Centre hospitalier universitaire, Tours, France.

The degree of carotid stenosis (%ST) remains the most frequently used parameter for identifying patients with high risk of stroke but the relationship between %ST and the occurrence of stroke remains controversial. The objectives of this study were to check (1) the relationship between the %ST and the plaque volume index (PVI) as measured by echography and Doppler, (2) the relationship between the intima media thickness (IMT), a vessel wall remodeling index and the PVI an atheromatous growth index. For each of the 128 patients, (165 carotid stenosis), we measured the % ST (section or diameter), the max stenosis velocity (V(max)), the PVI and the common carotid IMT. The %ST (section) ranged from 10% to 93% (mean 66+/-18), V(max) from 0.3m/s to 3m/s (mean 1.2+/-0.8), PVI from 0.61cm(3) to 1.17cm(3) (mean 0.41+/-0.21) and the IMT from 0.08cm up to 0.31cm (mean 0.12+/-0.03). There was no significant correlation between either PVI and %ST (section or diameter), PVI and minimal stenosis section area (S1) or between PVI and V(max). There was no significant correlation between IMT and both %ST area and PVI. PVI was significantly correlated with the whole artery section area (S2) and the plaque length (L). The %ST (section or diameter) was significantly correlated with S1 but not with S2. The absence of correlation between the PVI and the %ST confirm that these two parameters describe two different processes of the atheromatous development.
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http://dx.doi.org/10.1016/j.ultrasmedbio.2009.03.013DOI Listing
September 2009

Clinical manifestation and prognosis of early versus late stent thrombosis of drug-eluting stents.

J Interv Cardiol 2009 Jun 14;22(3):228-33. Epub 2009 Apr 14.

Washington Hospital Center, Washington, DC 20010, USA.

Background: Stent thrombosis (ST) is a serious complication of drug-eluting stents (DES), leading to catastrophic events. ST can occur early or late following the percutaneous coronary intervention (PCI) with different possible consequences.

Methods: The records of 91 consecutive patients who presented with a definite ST (as defined by the Academic Research Consortium) from 2003 to 2007 were reviewed. Clinical presentation and outcome were compared based on the time of the event. Fifty-one patients presented with an early ST versus 40 with a late ST. The primary end-point was a composite of death-recurrent myocardial infarction (MI)-recurrent ST at 1 year.

Results: Baseline characteristics were similar. Patients with early ST had more initial stent implantation for an acute MI indication and presented more with cardiogenic shock when compared to patients with late ST: 43.1% versus 17.5% (P = 0.007) and 39.2% versus 20% (P = 0.042), respectively. There was no difference in the ST treatment except for more intraaortic balloon pump (IABP) use in the early ST group (28% vs. 10%, P = 0.034). Angiographic success rates were similar. The incidence of the composite primary end-point was 52.9% in the early ST group versus 30% in the late ST group (P = 0.034).

Conclusion: Early definite ST is associated with more dramatic presentation and worse long-term prognosis when compared with definite late ST. This could be explained at least in part by the occurrence of two successive MIs within 30 days in almost 45% of the patients with early ST, leading to a higher rate of cardiogenic shock.
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http://dx.doi.org/10.1111/j.1540-8183.2009.00466.xDOI Listing
June 2009

Impact of thrombus aspiration use for the treatment of stent thrombosis on early patient outcomes.

J Invasive Cardiol 2009 May;21(5):210-4

Washington Hospital Center, Washington, D.C. 20010, USA.

Background: Recent data suggest a clinical benefit with the systematic use of thrombus aspiration (TA) for the treatment of ST-elevation myocardial infarction (STEMI). Nevertheless, the impact of TA as a treatment strategy for stent thrombosis (ST) is unknown. This study aimed to analyze the impact of TA use for the treatment of ST on patient outcomes.

Methods: From 2003 to 2008, 91 consecutive patients who presented with a definite ST were included in this analysis. We compared procedural success rates and the incidence of the composite criteria death-recurrent MI-recurrent ST at 30 days in patients who were treated with TA (TA group, n = 36) versus those who were not (No-TA group, n = 55).

Results: Baseline characteristics were similar between the two groups except for the body mass index: 26.2 +/- 5.4 vs. 29.3 +/- 6.2 in the TA and No- TA groups, respectively (p = 0.028). ST presented more likely as STEMI in the TA group: 86.1% vs. 67.3% (p = 0.043). Except for TA use, there was no difference in the treatment therapeutics between groups, including for glycoprotein IIb/IIIa inhibitors. The rate of procedural success was higher in the TA group than in the No-TA group: 88.9% vs. 70.9% (p = 0.043). The incidence of the endpoint of death-recurrent MI-recurrent ST was significantly lower in the TA group: 22.2% vs. 47.2% (p = 0.026). By multivariate analysis, TA use was independently associated with a decrease in the composite criteria (HR = 0.45, p = 0.039).

Conclusion: This study suggests that TA use for ST treatment permits an improvement in patient outcomes at 30 days with a significant decrease in the incidence of the composite criteria death-recurrent MI-recurrent ST. Further prospective studies are needed, however, to definitively address the benefit of TA use in this particular setting.
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May 2009

Incidence, predictors, and outcome of new, subsequent lesions treated with percutaneous coronary intervention in patients presenting with myocardial infarction.

Am J Cardiol 2009 May 13;103(9):1189-95. Epub 2009 Mar 13.

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC, USA.

Despite improving strategies for control of risk factors, progression of atherosclerosis may lead to recurrent cardiac events related to a lesion other than that treated with initial percutaneous coronary intervention (PCI) after ST-elevation myocardial infarction (STEMI). Of 1,007 consecutive patients undergoing primary or rescue PCI for STEMI, 897 who were discharged alive were followed for up to 3 years. Those who underwent nontarget lesion revascularization (non-TLR) were compared with those who did not. Those who underwent a second procedure were followed for an additional 1 year. Altogether, 94 patients (10.5%) required a non-TLR. The median time from the first to the second PCI was 396 days (interquartile range 131 to 533). Subsequent PCI was required for non-STEMI in 46.1% and STEMI in 9.7% of cases. Independent predictors of need for non-TLR were diabetes mellitus, history of coronary bypass surgery, or peripheral vascular disease. By 1 year after the second PCI, 9 patients (9.6%) died, 4 (4.3%) had sustained MI, and 4 (4.3%) had TLR. One of these major adverse events had occurred in 17 (18%). In conclusion, after STEMI, nearly 10% of patients will develop an event that requires subsequent PCI to an unrelated lesion. Patients with diabetes mellitus, history of coronary bypass surgery, or peripheral vascular disease are at increased risk for this event. Aggressive preventive and medical management should be applied to this population for prevention of these subsequent events.
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http://dx.doi.org/10.1016/j.amjcard.2009.01.029DOI Listing
May 2009

Prognostic value of procedure-related myocardial infarction according to the universal definition of myocardial infarction in saphenous vein graft interventions.

Am Heart J 2009 May;157(5):894-8

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA.

Background: In the recently published universal definition of myocardial infarction (MI), a troponin elevation above 3x above the 99th percentile of normal after percutaneous coronary intervention (PCI) is a procedure-related (type 4a) MI. Although troponin rise is common after saphenous vein graft (SVG) PCI, its prognostic value remains undetermined. We aimed to investigate the prognostic value of the universal definition of PCI-related MI in SVG interventions.

Methods: A cohort of 589 unselected consecutives patients with normal preprocedural troponin Ic undergoing isolated SVG PCI with drug-eluting stent implantation was included. Patients were divided into 2 groups according to the peak troponin value post PCI: those with MI defined as a peak troponin value above 3x the 99th percentile of normal post-PCI (MI group, n = 166) and those without (no MI group, n = 423). The primary end point was the rate of major adverse cardiac events including death, MI, and target vessel revascularization at 1-year follow-up.

Results: Baseline characteristics were similar between the 2 groups. In the MI group, patients had more complex angiographic features (type C lesions: 44.7 vs 34.8%; P = .006). The rate of direct stenting and distal protection use were similar in the 2 groups (MI vs no MI: 29.2 vs 28.7%; P = .9 and 32 vs 37.5%; P = .24, respectively). Patients in the MI group had a worse inhospital course but a similar 1-year rate of major adverse cardiac events (22.3 vs 19.1%; P = .39).

Conclusion: Procedure-related MI after PCI, as defined by the universal definition, is associated with an adverse inhospital course but may not predict long-term outcome in SVG PCI.
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http://dx.doi.org/10.1016/j.ahj.2008.12.020DOI Listing
May 2009

Clinical presentation and outcome of patients hospitalized for symptomatic in-stent restenosis treated by percutaneous coronary intervention: comparison between drug-eluting stents and bare-metal stents.

Arch Cardiovasc Dis 2009 Mar 17;102(3):209-17. Epub 2009 Mar 17.

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, 110, Irving Street, NW, Suite 4B-1, Washington DC 20010, USA.

Background: In-stent restenosis remains the major limitation of percutaneous coronary intervention (PCI), particularly after bare-metal stent (BMS) implantation. Drug-eluting stents (DES) decrease in-stent restenosis, which is thought to have minimal clinical consequences, but may increase the risk of stent thrombosis and its attendant high mortality rate.

Aims: To assess the clinical consequences of in-stent restenosis, including severity of associated illness and acute and 1-year outcomes and to compare DES and BMS in-stent restenosis.

Methods: Using our prospective PCI registry, we compared data from 1958 consecutive patients hospitalized with BMS in-stent restenosis between January 2000 and April 2003 and all 190 patients with DES in-stent restenosis admitted between April 2003 and September 2006. Risk-adjusted outcomes were calculated using propensity-score matching.

Results: An unstable presentation was noted in 78.1% of 2148 patients. Patients with DES in-stent restenosis presented more often with acute myocardial infarction (4.3% versus 1.6%, p<0.001). At 1 year, mortality for all patients was 5.7% and target-vessel revascularization was 21.5%. After risk adjustment, target-vessel revascularization and target-vessel revascularization-major adverse cardiac events were greater in patients with DES in-stent restenosis (respectively, 27.8% versus 19.7%, p=0.05; 32.5% versus 24.3%, p=0.06).

Conclusion: In-stent restenosis is associated with unstable presentation and a higher 1-year adverse events rate than expected in patients undergoing elective PCI. For an identical level of cardiac risk, it seems that DES in-stent restenosis outcomes are slightly worse than BMS in-stent restenosis outcomes.
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http://dx.doi.org/10.1016/j.acvd.2009.01.004DOI Listing
March 2009

Impact of bivalirudin on in-hospital bleeding and six-month outcomes in octogenarians undergoing percutaneous coronary intervention.

Catheter Cardiovasc Interv 2009 Sep;74(3):428-35

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC, USA.

Objectives: This study aimed to analyze the impact of replacing heparin with bivalirudin in octogenarians undergoing percutaneous coronary intervention (PCI) on postprocedure hemorrhage and 6-month mortality.

Background: Randomized trials comparing the antithrombin agent bivalirudin with heparin as the intraprocedural anticoagulant identify a reduction in periprocedural bleeding after PCI. Further, the occurrence of such bleeding seems to predict an increased risk of death or myocardial infarction both in-hospital and at long-term follow-up. Importantly, elderly people who are at the greatest risk of post-PCI bleeding complications are underrepresented in these randomized trials.

Methods: From 2000 to 2007, 2,766 consecutive patients from our center who were > or = 80 years of age underwent PCI with stent implantation and were included in this analysis. Bivalirudin was used in 1,207 (43.6%) patients and heparin in 1,559 (56.4%). We compared the rates of post-PCI bleeding complications and 6-month mortality.

Results: The overall in-hospital bleeding and 6-month mortality rates were 4.6% and 11.8%, respectively. By multivariate logistic regression and after adjustment by propensity score analysis, bivalirudin was associated with a significant decrease in in-hospital bleedings (HR = 0.41, 95% CI = 0.23-0.73, P = 0.003). By multivariate Cox analysis, bivalirudin was also associated with a significant decrease (HR = 0.6, 95% CI = 0.4-0.9, P = 0.01) and in-hospital bleedings with a significant increase in the 6-month mortality (HR = 2.5, 95% CI = 1.6-3.9, P < 0.001).

Conclusion: This study suggests an important subset for use of bivalirudin in lieu of heparin that will benefit the very elderly.
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http://dx.doi.org/10.1002/ccd.22007DOI Listing
September 2009

Requirement for emergent coronary artery bypass surgery following percutaneous coronary intervention in the stent era.

Am J Cardiol 2009 Apr;103(7):950-3

Division of Cardiology, Washington Hospital Center, Washington, DC, USA.

Performance of percutaneous coronary intervention (PCI) at centers without cardiothoracic surgery is a contentious issue. Although this practice allows greater access to care, there are safety concerns. The aim was to assess the requirement for emergent coronary artery bypass grafting (CABG) after PCI and characterize patients at highest risk using independent predictors. The study population consisted of 21,957 unselected patients who underwent PCI from August 1994 (Food and Drug Administration stent approval) to January 2008 at a single medical center. Patients requiring emergent CABG (defined as within 24 hours of the index procedure) were identified. Logistic regression analysis was performed to assess for independent correlates of emergent CABG. Emergent CABG was required in 90 patients (cumulative incidence 0.41%). Indications for CABG included triple-vessel disease, dissection, acute closure, perforation, and failure to cross. These patients had significantly higher in-hospital cardiac death rates (7.8% vs 0.7%; p <0.01) and higher rates of Q-wave myocardial infarction, neurologic events, and renal insufficiency. Independent correlates of emergent CABG after PCI were acute ST-segment elevation myocardial infarction presentation, cardiogenic shock, triple-vessel disease, and type C lesion. Risk assessment based on these predictors identified 0.3% of the patient population to have a 9.3% cumulative incidence of emergent CABG. In conclusion, the need for emergent CABG after PCI in the stent era was low and was associated with poor in-hospital outcomes. Risk was nonuniform, with 0.3% of the study population, characterized by acute presentation and complex coronary disease, at heightened risk of emergent surgery.
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http://dx.doi.org/10.1016/j.amjcard.2008.12.025DOI Listing
April 2009

Paclitaxel-eluting balloon: from bench to bed.

Catheter Cardiovasc Interv 2009 Apr;73(5):643-52

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC, USA.

Since the first clinical angioplasty by Gruntzig in 1977, restenosis has been the primary drawback of percutaneous coronary intervention (PCI). In the balloon era. restenosis was correlated with elastic recoil and negative remodeling of the arterial wall. Later, introduction of stents proved to be a significant advance in reducing the elastic recoil and negative remodeling at the treatment site but stimulated proliferation, migration of smooth muscle cells, and neointimal hyperplasia, thereby generating a new type of restenosis, in-stent restenosis. Brachytherapy and drug-eluting stents (DES) may be considered the two breakthroughs against neointimal hyperplasia. However, concerns about stent thrombosis and incomplete elimination of in-stent restenosis with DES in complex lesions and patients justify the pursuit of research in this field. Non-stent based local drug delivery and particularly the use of paclitaxel-eluting balloons could be one of these strategies. We aimed to review the concept, preclinical-, and clinical data available with non-stent based local drug delivery and, in particular, with paclitaxel-eluting balloons.
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http://dx.doi.org/10.1002/ccd.21895DOI Listing
April 2009

Prognostic value of the Syntax score in patients undergoing coronary artery bypass grafting for three-vessel coronary artery disease.

Catheter Cardiovasc Interv 2009 Apr;73(5):612-7

Division of Cardiology, Washington Hospital Center, USA.

Background: The Syntax score prognostic value has recently been highlighted in patients undergoing percutaneous coronary intervention (PCI) for multivessel coronary artery disease (CAD), however its prognostic value in patients undergoing coronary artery bypass grafting (CABG) for multivessel CAD is still unknown. The aim of this study was to evaluate the prognostic value of the Syntax score in patients undergoing CABG for 3-vessel CAD.

Methods: A cohort of 320 consecutive patients with multivessel (3-vessel) CAD who were subjected for CABG were included in this study and divided into tertiles according to the Syntax score (<24.5, 24.5-34, and >34). During the 1-year follow-up, cardiovascular events including death, myocardial infarction (MI), and stroke were systematically indexed. The primary end point was the composite criteria death/MI/stroke.

Results: The Syntax score ranged from 11-74 with a mean of 31.2 +/- 12.6 and a median of 28.5 [22-38]. Baseline clinical characteristics were similar among the tertiles. No statistical difference was found for the composite criteria death/MI/stroke: 9.4% versus 7.5% versus 10.4% in the groups with a Syntax score <24.5, 24.5-34, and >34, respectively (P = 0.754).

Conclusion: Unlike for PCI, the Syntax score has a poor prognostic value for severe cardiovascular events in patients undergoing CABG for 3-vessel CAD. Other risk scores should be used to predict the outcome of this population.
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http://dx.doi.org/10.1002/ccd.21883DOI Listing
April 2009

Intravascular ultrasound-guided percutaneous coronary interventions in contemporary practice.

Arch Cardiovasc Dis 2009 Feb 7;102(2):143-51. Epub 2009 Feb 7.

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, 110, Irving Street, NW, Suite 4B-1, Washington, DC 20010, USA.

Intravascular ultrasound imaging has been pivotal in the understanding of coronary artery disease and the development of percutaneous coronary intervention. The ability to analyse vessel walls and measure atherosclerotic lesions more accurately has enabled the field of invasive cardiology to overcome the limits of angiography. In fact, intravascular ultrasound measurements correlate with functional measurement of coronary blood flow, as a result interest in their use for the diagnosis of lesion severity in ambiguous lesions and for left main trunk analysis has grown. On the interventional side, intravascular ultrasound is used to determine the major predictors of restenosis and stent thrombosis, which are the main pitfalls of percutaneous coronary intervention. In the bare-metal stent era, intravascular ultrasound-guided percutaneous coronary intervention was associated with a reduction in restenosis rates because it enabled identification and treatment of the risk factors for complications. Although drug-eluting stents have provided a great technological advance in percutaneous coronary intervention, further reducing the rate of in-stent restenosis, they have not abolished restenosis completely; intravascular ultrasound has also been used in this setting to identify the mechanisms responsible for drug-eluting stent restenosis. As in the bare-metal stent era, identification of the predictors of restenosis and stent thrombosis and their subsequent treatment may offer the promise of improved outcome in the drug-eluting stent era. This review focuses on the potential benefit of intravascular ultrasound-guided percutaneous coronary intervention with regard to restenosis and stent thrombosis in the bare-metal stent and drug-eluting stent eras.
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http://dx.doi.org/10.1016/j.acvd.2008.11.002DOI Listing
February 2009

Impact of bivalirudin use on outcomes in nonagenarians undergoing percutaneous coronary intervention.

J Interv Cardiol 2009 Feb;22(1):61-7

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA.

Background: With an aging population, nonagenarians constitute an increasing percentage of patients with coronary artery disease. The aim of this study was to determine the predictors and outcome of nonagenarians undergoing percutaneous coronary intervention (PCI) for symptomatic coronary artery disease.

Methods: From 2002 to 2007, a cohort of 171 consecutive nonagenarians underwent PCI and stent implantation in our center. Patients given bivalirudin (n = 79) during the procedure were compared to those given heparin (n = 92). In-hospital and 6-month rates of major adverse cardiovascular events (MACE) including death, myocardial infarction (MI), and target lesion revascularization were indexed. In-hospital bleedings were also indexed.

Results: The mean age was 92.5 +/- 2.5 years. The population was 52% female. Nearly 30% of patients had diabetes mellitus and >25% had renal failure. The mean left ventricular ejection fraction was 45%+/- 14%. The clinical presentation was an acute MI in 59% of the cases. The in-hospital rates of death and bleedings were 4.1% and 17.5%, respectively. Clinical presentations as MI or cardiogenic shock were associated with high rates of in-hospital death: 19.3% and 30%, respectively. Bivalirudin use was associated with a 41.5% decrease in in-hospital bleedings. The 6-month incidence of MACE was 13.6% and was driven by death. Predictors of 6-month outcomes were clinical presentations as MI or cardiogenic shock, renal failure, and total stent length.

Conclusion: Nonagenarians represent a particular population with a high percentage of females and a high incidence of comorbidities. In this study, we highlighted that nonagenarians have logically a worse prognosis than is reported in younger patients, with especially high rates of in-hospital bleedings. Bivalirudin use was associated with an important decrease in in-hospital bleedings; thus, it should be systematically considered in such patients to improve early outcome.
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http://dx.doi.org/10.1111/j.1540-8183.2008.00422.xDOI Listing
February 2009

Prognostic significance of small troponin I rise after a successful elective percutaneous coronary intervention of a native artery.

Am J Cardiol 2009 Mar 17;103(5):639-45. Epub 2009 Jan 17.

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC, USA.

Cardiac troponin I is a sensitive marker of myonecrosis. Data regarding the prognostic value of troponin I increase after percutaneous coronary intervention (PCI) are conflicting. A recent American College of Cardiology/American Heart Association statement defined a troponin I increase >3 times the 99th percentile as periprocedural myocardial infarction (MI). We sought to evaluate whether or not, in patients with a successful elective PCI judged on angiographic and clinical criteria, the postprocedural increase of troponin I could predict 1-year outcomes. A cohort of 3,200 consecutive patients with successful elective PCI was studied. End points included death/MI and major adverse cardiac events at 1 year. A troponin I increase >97.5th percentile was observed in 1,402 patients (43.8%, mean 0.32 ng/ml, range 0.01 to 4.94). A total of 751 patients (23.4%) had a troponin I increase >3 x 99th percentile. Troponin I status was associated with more complex coronary disease (19.6% vs 16.4%, p <0.005) and multivessel PCI (2.1 vs 1.6, p <0.001). At 1 year, there was no difference in death/MI (2.8% vs 3.5%, p = 0.3) or in major adverse cardiac events (9.6% vs 10.4%, p = 0.5) according to the level of troponin I increase. The lack of association between troponin I increase after PCI and outcome was found when troponin I increase was used as a continuous or a categorical variable. Logistic regression models failed to find any threshold from which troponin I increase could affect outcome. In conclusion, a small troponin I increase after a successful elective PCI was not infrequent and did not affect outcome in our study. The definition of periprocedural MI may be too strict. Measurement of troponin I after a successful PCI is questionable.
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http://dx.doi.org/10.1016/j.amjcard.2008.10.044DOI Listing
March 2009

Acute myocardial infarction following oral methyl-ergometrine intake.

Cardiovasc Toxicol 2009 Mar 14;9(1):46-8. Epub 2009 Feb 14.

Service de Cardiologie, Pôle Coeur Thorax Vasculaire Hémostase, Centre Hospitalier Universitaire Trousseau, 37044, Tours, France.

Ergot derivatives are frequently administrated during cesarean delivery, induced abortion, or post-partum hemorrhage to promote uterine contractions. Ergot derivatives may also induce coronary spasm and intravenous ergonovine is used in cardiac catheterization laboratories as a diagnostic agent. Serious ischemic cardiac events related to ergonovine are rare and have most often been described after intravenous use. We report the case of a 38-year-old woman with a ST elevation myocardial infarction (STEMI) few days after artificially induced abortion by oral prescription of methylergometrine. Coronary angiography performed 2 days after onset of chest pain did not reveal any abnormalities of the coronary arteries but a provocative test using intravenous methylergometrine was positive with reproduction of chest pain, ECG changes and with a significant narrowing localized on the second segment of the left anterior descending artery at the angiogram. Thus, since methylergometrin may clearly induce coronary spasm when prescribed orally, chest pain occurring under oral treatment should require immediate attention even if atypical or in the absence of cardiovascular risk factors.
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http://dx.doi.org/10.1007/s12012-009-9031-9DOI Listing
March 2009

Prognosis of patients suffering an acute coronary syndrome while already under chronic clopidogrel therapy.

Catheter Cardiovasc Interv 2009 Jun;73(7):866-70

Department of Internal Medicine, Division of Cardiology, Washington Hospital Center, Washington, DC 20010, USA.

Objective: To assess the prognosis of patients presenting with an acute coronary syndrome (ACS) despite chronic clopidogrel therapy (CCT).

Background: CCT has been shown to be beneficial in decreasing the frequency of major adverse cardiovascular events (MACE) in patients after an ACS or drug-eluting stent (DES) implantation. Some patients, however, still suffer thrombotic events while on CCT. The outcome of this particular subgroup of patients is unknown.

Methods: A cohort of 1,281 patients undergoing percutaneous coronary intervention (PCI) for an ACS was studied. They were divided according to their treatment prior to the ACS. The CCT group was composed of all patients who had been taking clopidogrel for >or=30 days before the onset of the ACS (n = 175) and the no CCT group of all patients not on clopidogrel before the ACS (n = 1,106). Rates of cardiovascular death and myocardial infarction at 6 months' follow-up were compared.

Results: Patients in the CCT group were older (66 +/- 11 vs. 63 +/- 13; P< 0.001), and more often diabetic (46.8 vs. 31.9%; P < 0.01). In-hospital outcomes were similar, including the rate of death and myocardial infarction (no CCT vs. CCT group: 4.2 vs. 2.3%; P = 0.2). At 6 months, patients already taking clopidogrel before the ACS had a higher rate of MACE than patients who were not (18.3 vs. 11.8%; P = 0.02). In multivariate analysis, CCT before the ACS was associated with a hazard ratio of 1.7 for MACE.

Conclusion: This study suggests that patients suffering an ACS while under on CCT have a poor long-term prognosis, which could be linked to clopidogrel low-response.
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http://dx.doi.org/10.1002/ccd.21935DOI Listing
June 2009

Comparison of outcomes of drug-eluting stents versus bare-metal stents in nonostial proximal left anterior descending coronary arteries.

Am J Cardiol 2009 Feb;103(4):496-500

Department of Internal Medicine, Washington Hospital Center, Washington, DC, USA.

Drug-eluting stents (DES) have reduced the rate of in-stent restenosis compared with bare-metal stents, but are associated with an increased risk of late stent thrombosis. The proximal left anterior descending artery (LAD) is a large vessel and is considered to be at increased risk of both restenosis and stent thrombosis. The risk-benefit ratio of each type of stent therefore is of great clinical interest in this location. The aim was to compare 1-year outcomes of DESs and bare-metal stents in nonostial proximal LADs. Historic cohorts of patients who underwent percutaneous coronary intervention of nonostial proximal LAD lesions were compared. A total of 137 patients in the bare-metal stent group and 350 patients in the DES group were compared. The primary and secondary end points were target-lesion revascularization (TLR) rate and major adverse cardiac event rate, including death, myocardial infarction and TLR at 1-year follow-up. Patients in both groups had similar baseline characteristics. Intravascular ultrasound guidance was used in most percutaneous coronary intervention (bare-metal stents vs DESs 72.4% vs 74.5%; p = 0.6). Stent diameter was large in both groups (3.2 +/- 0.5 vs 3.2 +/- 0.3 mm; p = 0.6). Patients in the DES group had longer stents implanted (15 +/- 7 vs 17 +/- 7 mm; p <0.01). Major adverse cardiac event and TLR rates were not different (bare-metal stents vs DESs 16.4% vs 14.7%; p = 0.7 and 4.5% vs 5.2%; p = 0.8). In multivariate analysis, the TLR rate was independent of type of stent used. In conclusion, DESs carry no clinical benefit over bare-metal stents for nonostial proximal LAD lesions. Bare-metal stents therefore could be a cost-effective alternative in this location.
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http://dx.doi.org/10.1016/j.amjcard.2008.10.028DOI Listing
February 2009

Outcome differences with the use of drug-eluting stents for the treatment of in-stent restenosis of bare-metal stents versus drug-eluting stents.

Am J Cardiol 2009 Feb;103(4):491-5

Department of Internal Medicine, Washington Hospital Center, Washington, DC, USA.

Drug-eluting stent (DES) implantation is the standard treatment for patients with bare-metal stent (BMS) in-stent restenosis (ISR) and is associated with low rates of target-vessel revascularization. Outcomes in patients with DES ISR treated using repeated DES placement are less certain. A total of 119 patients who presented with BMS ISR and 119 patients with DES ISR matched for baseline characteristics were evaluated. Both groups of patients were treated using DESs and compared with regard to major adverse cardiac events, including death, myocardial infarction, and target-vessel revascularization, at 1 year. Baseline characteristics were similar between groups. Compared with patients with BMS ISR, those with DES ISR had similar 1-year rates of death (5.1% BMS ISR vs 3.5% DES ISR; p = 0.75) and myocardial infarction (2.6% BMS ISR vs 3.5% DES ISR; p = 0.72) when treated using DESs. However, at 1 year, patients with DES ISR experienced significantly higher rates of target-vessel revascularization (10.3% BMS ISR vs 22.2% DES ISR; p = 0.01), with a trend toward increased overall major adverse cardiac events, including death, myocardial infarction, and target-vessel revascularization (16.0% BMS ISR vs 25.2% DES ISR; p = 0.08). Stent thrombosis occurred with similar frequency in both groups (2.5% BMS ISR vs 0.8% DES ISR; p = 0.62). In conclusion, DES ISR continues to be a therapeutic challenge because patients with DES ISR treated using DESs experience higher rates of recurrence compared with patients with BMS ISR treated using DESs. The optimal treatment of patients with DES restenosis remains to be defined.
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http://dx.doi.org/10.1016/j.amjcard.2008.09.107DOI Listing
February 2009