Functional significance of recruitable collaterals during temporary coronary occlusion evaluated by 99mTc-sestamibi single-photon emission computerized tomography

AbstractOBJECTIVESThe present study evaluated the impact of recruitable collaterals on regional myocardial perfusion measured by 99mtechnetium (Tc)-sestamibi single-photon emission computerized tomography (SPECT) during temporary coronary occlusion and related these estimates to the coronary wedge pressure and electrocardiographic (ECG) ST-segment changes.BACKGROUNDClinical variables (angina and ECG changes) and intracoronary flow and pressure recordings have indicated a protective role of recruitable collaterals on myocardial perfusion during percutaneous transluminal coronary angioplasty (PTCA).METHODSThirty patients (mean age 55 years, SD 9; 20 men) with stable angina pectoris and proximal nonoccluding single-vessel left anterior descending coronary artery (LAD)-stenosis scheduled for PTCA were included. Visualization of recruitable collaterals by ipsilateral and contralateral contrast injection, registration of coronary wedge pressure and injection of 99mTc-sestamibi during 90-s LAD occlusions were undertaken. A rest perfusion study was performed within four days before PTCA. As an estimate of the severity of regional hypoperfusion during occlusion, an occlusion/rest count ratio was calculated (mean defect pixel count during occlusion divided by mean pixel count in identical regions at rest).RESULTSThe scintigraphic occlusion/rest count ratio was higher in patients with recruitable collaterals (n = 16), 67 ± 11%, compared to patients without collaterals (n = 14), 60 ± 6% (p < 0.05). The occlusion/rest count ratio correlated with the coronary wedge pressure (R2= 0.34; p < 0.001). The occlusion/rest count ratio was lower, 61 ± 6%, in patients with ST-segment elevation (n = 23) versus 74 ± 9% in patients without ST-segment elevation (n = 7) (p < 0.0001).CONCLUSIONSUsing 99mTc-sestamibi SPECT imaging during brief episodes of coronary occlusion, the severity of regional myocardial hypoperfusion was reduced by the presence of recruitable collaterals in a selected patient population with proximal LAD stenoses. Our results demonstrate a protective effect of recruitable collaterals on myocardial perfusion during temporary coronary occlusion

Increased Rate of Stent Thrombosis and Target Lesion Revascularization After Filter Protection in Primary Percutaneous Coronary Intervention for ST-Segment Elevation Myocardial Infarction 15-Month Follow-Up of the DEDICATION (Drug Elution and Distal Protection in ST Elevation Myocardial Infarction) Trial

ObjectivesThe purpose of this study was to evaluate the long-term effects of distal protection during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI).BackgroundThe use of distal filter protection during primary PCI increases procedure complexity and may influence lesion treatment and stent implantation.MethodsThe STEMI patients were assigned to distal protection (DP) (n = 312) or conventional treatment (CT) (n = 314). Clinical follow-up was performed after 1, 6, and 15 months, and angiographic follow-up after 8 months. All target lesion revascularizations (TLRs) were clinically driven. We report the pre-specified end points of stent thrombosis according to the criteria of the Academic Research Consortium, TLR, and reinfarction after 15 months.ResultsThe total number of stent thrombosis was 11 in the DP group and 4 in the CT group (p = 0.06). The rate of definite stent thrombosis was significantly increased in the DP group as compared with the CT group, with 9 cases versus 1 (p = 0.01). Clinically driven TLRs (31 patients vs. 18 patients, p = 0.05) and clinically driven target vessel revascularizations (37 patients vs. 22 patients, p = 0.04) were more frequent in the DP group.ConclusionsIn primary PCI for STEMI, the routine use of DP increased the incidence of stent thrombosis and clinically driven target lesion/vessel revascularization during 15 months of follow-up. (Drug Elution and Distal Protection in ST Elevation Myocardial Infarction Trial [DEDICATION]; NCT00192868

Comparison of zotarolimus-eluting and sirolimus-eluting coronary stents:a study from the Western Denmark Heart Registry

BACKGROUND: We evaluated the effectiveness and safety of a zotarolimus-eluting (ZES) versus a sirolimus-eluting (SES) coronary stent in a large cohort of patients treated with one of these stents in Western Denmark. METHODS: A total of 6,122 patients treated with ZES (n=2,282) or SES (n=3,840) were followed for up to 27 months. We ascertained clinical outcomes based on national medical databases. RESULTS: Incidence of target lesion revascularization (no. per 100 person-years) was 5.3 in the ZES group compared to 1.9 in the SES group (adjusted hazard ratio (HR)=2.19, 95% confidence intervals (CI): 1.39-3.47; p=0.001). All-cause mortality was also higher in the ZES group (ZES: 6.3; SES: 3.3; adjusted HR=1.34, 95% CI: 1.05-1.72; p=0.02), while stent thrombosis (ZES: 1.2; SES: 0.5; adjusted HR=1.98, 95% CI: 0.75-5.23; p=0.14) did not differ significantly. CONCLUSIONS: In agreement with previously published randomised data, this observational study indicated that the ZES was associated with an increased risk of death and TLR in a large cohort of consecutive patients

Dimensions of socioeconomic status and clinical outcome after primary percutaneous coronary intervention

Background— The association between low socioeconomic status (SES) and high mortality from coronary heart disease is well-known. However, the role of SES in relation to the clinical outcome after primary percutaneous coronary intervention remains poorly understood. Methods and Results— We studied 7385 patients treated with primary percutaneous coronary intervention. Participants were divided into high-SES and low-SES groups according to income, education, and employment status. The primary outcome was major adverse cardiac events (cardiac death, recurrent myocardial infarction, and target vessel revascularization) at maximum follow-up (mean, 3.7 years). Low-SES patients had more adverse baseline risk profiles than high-SES patients. The cumulative risk of major adverse cardiac events after maximum follow-up was higher among low-income patients and unemployed patients compared with their counterparts (income: hazard ratio, 1.68; 95% CI, 1.47–1.92; employment status: hazard ratio, 1.75; 95% CI, 1.46–2.10). After adjustment for patient characteristics, these differences were substantially attenuated (income: hazard ratio, 1.12; 95% CI, 0.93–1.33; employment status: hazard ratio, 1.27; 95% CI, 1.03–1.56). Further adjustment for admission findings, procedure-related data, and medical treatment during follow-up did not significantly affect the associations. With education as the SES indicator, no between-group differences were observed in the risk of the composite end point. Conclusions— Even in a tax-financed healthcare system, low-SES patients treated with primary percutaneous coronary intervention face a worse prognosis than high-SES patients. The poor outcome seems to be largely explained by differences in baseline patient characteristics. Employment status and income (but not education level) were associated with clinical outcomes. </jats:sec

Primary Percutaneous Coronary Intervention as a National Reperfusion Strategy in Patients With ST-Segment Elevation Myocardial Infarction

Background— In Denmark, primary percutaneous coronary intervention (PPCI) was chosen as a national reperfusion strategy for patients with ST-segment elevation myocardial infarction in 2003. This study describes the temporal implementation of PPCI in Western Denmark, the gradual introduction of field triage for PPCI (patients rerouted from the scene of the event directly to the invasive center), and the associated outcome. Methods and Results— The study population comprised 9514 patients treated with PPCI from 1999 to 2009 with symptom duration ≤12 hours and either a delay from the emergency medical service (EMS) call to PPCI (healthcare system delay) of ≤6 hours or as self-presenters. The median follow-up time was 3.7 years. The number of patients treated with PPCI increased from 190 in 1999 to 1212 in 2009. Among patients transported by the EMS from the scene of the event, the proportion who were field triaged directly to a PCI center increased from 33% (34/103) to 72% (616/851, P &lt;0.001). Patients who were field triaged had lower long-term mortality, with adjusted hazard ratios (95% CI) of 1.26 (1.12–1.43) among patients transported by the EMS to a local hospital and then transferred, 1.28 (1.10–1.49) among patients self-presenting at a local hospital and then transferred, and 1.37 (1.18–1.58) among patients self-presenting at a PCI center. Conclusions— A reperfusion strategy with PPCI only for patients with ST-segment elevation myocardial infarction was successfully implemented in Western Denmark, and the majority of patients transported by the EMS are now triaged directly to the PPCI centers. This strategy is associated with lower mortality. </jats:sec