Drug-eluting stents for ST-elevation myocardial infarction: ready for prime time?

Primary percutaneus coronary intervention, performed in a timely manner, is currently the standard of care for patients with acute ST-elevation myocardial infarction (STEMI). Numerous clinical trials have shown the superiority of balloon angioplasty over thrombolytic therapy in decreasing the composite endpoint of death, reinfarction, and stroke in patients with STEMI The culprit plaques in STEMI patients usually contain a large necrotic core, a thin fibrous cap, and heavy inflammatory cell infiltration, together with extensive thrombus formation. Strut penetration into the necrotic core is apparently related to delayed endothelization and healing at the site of DES placement It is now accepted that DESs can markedly reduce the risk of restenosis and, accordingly, DES use has again been expanded to STEMI patients. Two randomized trials published in 2006 showed the benefits of DESs over baremetal stents in patients undergoing a primary percutaneous coronary intervention for STEM

Long-Term Clinical Outcomes of Sirolimus- Versus Paclitaxel-Eluting Stents for Patients With Unprotected Left Main Coronary Artery Disease Analysis of the MAIN-COMPARE (Revascularization for Unprotected Left Main Coronary Artery Stenosis: Comparison of Percutaneous Coronary Angioplasty Versus Surgical Revascularization) Registry

ObjectivesThe aim of this study was to evaluate long-term clinical outcomes after implantation of sirolimus-eluting stents (SES) or paclitaxel-eluting stents (PES) among patients with unprotected left main coronary artery (LMCA) disease.BackgroundThere have been few comparisons of long-term outcomes among currently available drug-eluting stents (DES) for the treatment of LMCA disease.MethodsA total of 858 consecutive patients with unprotected LMCA stenosis were treated with SES (n = 669) or PES (n = 189) between May 2003 and June 2006. Primary outcome was the composite of death, myocardial infarction (MI), or target vessel revascularization (TVR).ResultsBaseline clinical and angiographic characteristics were similar in the 2 groups. During 3 years of follow-up, the adjusted risk of primary composite outcome was similar among the groups (SES vs. PES: 25.8% vs. 25.7%, hazard ratio [HR]: 0.95, 95% confidence interval [CI]: 0.64 to 1.41, p = 0.79). The 2 groups also showed a comparable adjusted rate of each component of outcome: death (9.1% vs. 11.0%, HR: 0.92, 95% CI: 0.47 to 1.80, p = 0.82), MI (8.1% vs. 8.0%, HR: 0.80, 95% CI: 0.43 to 1.48, p = 0.47), and TVR (12.1% vs. 10.6%, HR: 1.10, 95% CI: 0.53 to 2.29, p = 0.81). The 3-year rates of definite or probable stent thrombosis were 0.6% in the SES group and 1.6% in the PES group (adjusted p = 0.18).ConclusionsIn consecutive patients with unprotected LMCA disease undergoing DES implantation, SES and PES showed similar long-term clinical outcomes in terms of death, MI, repeat revascularization, and stent thrombosis

Incidence, Predictors, Treatment, and Long-Term Prognosis of Patients With Restenosis After Drug-Eluting Stent Implantation for Unprotected Left Main Coronary Artery Disease

ObjectivesThe aim of this study was to evaluate the incidence, predictors, and long-term outcomes of patients with in-stent restenosis (ISR) after percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for unprotected left main coronary artery (LMCA) disease.BackgroundFew data on the clinical course and management of patients experiencing restenosis after DES treatment for unprotected LMCA disease have appeared.MethodsBetween February 2003 and November 2007, 509 consecutive patients with unprotected LMCA disease underwent DES implantation, with 402 (80.1%) undergoing routine surveillance or clinically driven angiographic follow-up. A major adverse cardiac event was defined as the composite of death, myocardial infarction (MI), or target-lesion revascularization.ResultsThe overall incidence of angiographic ISR in LMCA lesions was 17.6% (71 of 402 patients, 57 with focal-type and 14 with diffuse-type ISR. Forty patients (56.3%) underwent repeated PCI, 10 (14.1%) underwent bypass surgery, and 21 (29.6%) were treated medically. During long-term follow-up (a median of 31.7 months), there were no deaths, 1 (2.2%) MI, and 6 (9.5%) repeated target-lesion revascularization cases. The incidence of major adverse cardiac event was 14.4% in the medical group, 13.6% in the repeated PCI group, and 10.0% in the bypass surgery group (p = 0.91). Multivariate analysis showed that the occurrence of DES-ISR did not affect the risk of death or MI.ConclusionsThe incidence of ISR was 17.7% after DES stenting for LMCA. The long-term clinical prognosis of patients with DES-ISR associated with LMCA stenting might be benign, given that these patients were optimally treated with the clinical judgment of the treating physician

Stent Thrombosis, Clinical Events, and Influence of Prolonged Clopidogrel Use After Placement of Drug-Eluting Stent Data From an Observational Cohort Study of Drug-Eluting Versus Bare-Metal Stents

ObjectivesThe purpose of this study was to evaluate the risk of stent thrombosis (ST), clinical outcomes, and the benefits of extended clopidogrel use after drug-eluting stent (DES) implantation.BackgroundData are limited regarding uniform evaluation of ST and the influence of clopidogrel continuation beyond 12 months on late events after DES treatment.MethodsWe identified 7,221 patients who received DES implantation (n = 3,160) or bare-metal stent (BMS) implantation (n = 4,061), and compared long-term adverse outcomes. Additionally, 2,851 patients with DES surviving 12 months without major events were analyzed according to clopidogrel continuation.ResultsThe adjusted-risk of overall ST was similar in the 2 groups. After 1 year, however, DES patients showed a higher risk of ST; definite/probable (hazard ratio [HR]: 3.55, 95% confidence interval [CI]: 1.26 to 9.99). The adjusted-risk of death (HR: 0.60, 95% CI: 0.46 to 0.79), death/myocardial infarction (HR: 0.63, 95% CI: 0.49 to 0.81), and target lesion revascularization (HR: 0.32, 95% CI: 0.24 to 0.43) were significantly lower in the DES group than in the BMS group. Continuing clopidogrel beyond 12 months was not associated with a reduced risk for ST (HR: 0.54, 95% CI: 0.07 to 4.23), death (HR: 1.20, 95% CI: 0.55 to 2.66), or death/myocardial infarction (HR: 1.16, 95% CI: 0.56 to 2.42) after DES implantation.ConclusionsAs compared with BMS, DES showed a similar risk of overall ST, but a higher risk of very late ST. The rates of death, death/myocardial infarction, and target lesion revasuclarization were significantly lower in the DES group. Clopidogrel continuation beyond 1 year did not appear to reduce ST and clinical events after DES implantation

A STUDY ON THE LONG-TERM MONITORING OF SPORTS ACTIVITIES

INTRODUCTION: Lots of studies to analyze and classify human movement patterns using various sensors have been carried out (Mathie, 2004; Allen, 2006) because accurate information of body activity is required to provide promotion of health and health plan. Thus this study was conducted to study the classification and monitoring of various sports activities in real-time environment using single waist mounted tri-axial accelerometer

Drug-Eluting Stenting Followed by Cilostazol Treatment Reduces Late Restenosis in Patients With Diabetes Mellitus The DECLARE-DIABETES Trial (A Randomized Comparison of Triple Antiplatelet Therapy With Dual Antiplatelet Therapy After Drug-Eluting Stent Implantation in Diabetic Patients)

ObjectivesWe sought to evaluate the impact of cilostazol on neointimal hyperplasia after drug-eluting stent (DES) implantation in patients with diabetes mellitus (DM).BackgroundAlthough cilostazol has reduced the extent of neointimal hyperplasia and restenosis in patients after bare-metal stent implantation, it is not known whether this effect occurs after DES implantation in diabetic patients.MethodsThis randomized, multicenter, prospective study compared triple antiplatelet therapy (aspirin, clopidogrel, and cilostazol, triple group, n = 200) and dual antiplatelet therapy (aspirin and clopidogrel, standard group, n = 200) for 6 months in patients with DM receiving DES. The primary end point was in-stent late loss at 6 months.ResultsThe 2 groups had similar baseline clinical and angiographic characteristics. The in-stent (0.25 ± 0.53 mm vs. 0.38 ± 0.54 mm, p = 0.025) and in-segment (0.42 ± 0.50 mm vs. 0.53 ± 0.49 mm, p = 0.031) late loss were significantly lower in the triple versus standard group, as were 6-month in-segment restenosis (8.0% vs. 15.6%, p = 0.033) and 9-month target lesion revascularization (TLR) (2.5% vs. 7.0%, p = 0.034). At 9 months, major adverse cardiac events, including death, myocardial infarction, and TLR, tended to be lower in the triple than in the standard group (3.0% vs. 7.0%, p = 0.066). Multivariate analysis showed that sirolimus-eluting stents and the use of cilostazol were strong predictors of reduced restenosis or TLR.ConclusionsTriple antiplatelet therapy after DES implantation decreased angiographic restenosis and extent of late loss, resulting in a reduced risk of 9-month TLR compared with dual antiplatelet therapy in diabetic patients

Temporal patterns of gene expression after acute hindlimb ischemia in mice insights into the genomic program for collateral vessel development

AbstractObjectivesWe sought to understand the genomic program leading to collateral vessel formation.BackgroundRecently, technology has advanced to the point that it is now possible to elucidate the large array of genes that must be expressed, as well as the temporal expression pattern, for the development of functionally important collateral vessels. In this investigation, we used deoxyribonucleic acid array expression profiling to determine the time course of differential expression of 12,000 genes after femoral artery ligation in C57BL/6 mice.MethodsRibonucleic acid was extracted from the adductor muscle, which showed no signs of ischemia. Sampling was at baseline, 6 h, and 1, 3, 7, and 14 days after femoral artery ligation or sham operation.ResultsFemoral artery ligation caused the differential expression (>2-fold) of 783 genes at one or multiple time points: 518 were induced and 265 were repressed. Cluster analysis generated four temporal patterns: 1) early upregulated (6 to 24 h)—immediate early transcriptional factors, angiogenesis, inflammation, and stress-related genes; 2) mid-phase upregulated (day 3)—cell cycle and cytoskeletal and inflammatory genes; 3) late upregulated (days 7 to 14)—angiostatic, anti-inflammatory, and extracellular matrix-associated genes; and 4) downregulated—genes involved in energy metabolism, water channel, and muscle contraction. Microarray data were validated using quantitative reverse transcription polymerase chain reaction.ConclusionsThis study documents the large number of genes whose differential expression and temporal functional clustering appear to contribute to collateral formation. These results can serve as a genomic model for arteriogenesis and as a database for developing new therapeutic strategies

Randomized Trial of Stents Versus Bypass Surgery for Left Main Coronary Artery Disease 5-Year Outcomes of the PRECOMBAT Study

AbstractBackgroundIn a previous randomized trial, we found that percutaneous coronary intervention (PCI) was not inferior to coronary artery bypass grafting (CABG) for the treatment of unprotected left main coronary artery stenosis at 1 year.ObjectivesThis study sought to determine the 5-year outcomes of PCI compared with CABG for the treatment of unprotected left main coronary artery stenosis.MethodsWe randomly assigned 600 patients with unprotected left main coronary artery stenosis to undergo PCI with a sirolimus-eluting stent (n = 300) or CABG (n = 300). The primary endpoint was a major adverse cardiac or cerebrovascular event (MACCE: a composite of death from any cause, myocardial infarction, stroke, or ischemia-driven target vessel revascularization) and compared on an intention-to-treat basis.ResultsAt 5 years, MACCE occurred in 52 patients in the PCI group and 42 patients in the CABG group (cumulative event rates of 17.5% and 14.3%, respectively; hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 0.84 to 1.90; p = 0.26). The 2 groups did not differ significantly in terms of death from any cause, myocardial infarction, or stroke as well as their composite (8.4% and 9.6%; HR, 0.89; 95% CI, 0.52 to 1.52; p = 0.66). Ischemia-driven target vessel revascularization occurred more frequently in the PCI group than in the CABG group (11.4% and 5.5%, respectively; HR: 2.11; 95% CI: 1.16 to 3.84; p = 0.012).ConclusionsDuring 5 years of follow-up, our study did not show significant difference regarding the rate of MACCE between patients who underwent PCI with a sirolimus-eluting stent and those who underwent CABG. However, considering the limited power of our study, our results should be interpreted with caution. (Bypass Surgery Versus Angioplasty Using Sirolimus-Eluting Stent in Patients With Left Main Coronary Artery Disease [PRECOMBAT]; NCT00422968