Fractional Flow Reserve\u2013Guided Deferred Versus Complete Revascularization in Patients With Diabetes Mellitus

To assess the safety and efficacy of deferred versus complete revascularization using a fractional flow reserve (FFR)\u2013guided strategy in patients with diabetes mellitus (DM), we analyzed all DM patients who underwent FFR-guided revascularization from January 1, 2010, to December 12, 2013. Patients were divided into 2 groups: those with 651 remaining FFR-negative (>0.80) medically treated lesions [FFR( 12)MT] and those with only FFR-positive lesions ( 640.80) who underwent complete revascularization [FFR(+)CR] and were followed until July 1, 2015. The primary end point was the incidence of major adverse cardiovascular events (MACE), a composite of death, myocardial infarction (MI), target lesion (FFR assessed) revascularization, and rehospitalization for acute coronary syndrome. A total of 294 patients, 205 (69.7%) versus 89 (30.3%) in FFR( 12)MT and FFR(+)CR, respectively, were analyzed. At a mean follow-up of 32.6 \ub1 18.1\ua0months, FFR( 12)MT was associated with higher MACE rate 44.0% versus 26.6% (log-rank p\ua0=\ua00.02, Cox regression\u2013adjusted hazard ratio [HR] 2.01, 95% confidence interval [CI] 1.21 to 3.33, p\ua0<0.01), and\ua0driven by both safety and efficacy end points: death/MI (HR 2.02, 95% CI 1.06 to 3.86, p\ua0= 0.03), rehospitalization for acute coronary syndrome (HR 2.06, 95% CI 1.03 to 4.10, p\ua0= 0.04), and target lesion revascularization (HR 3.38, 95% CI 1.19 to 9.64, p\ua0= 0.02). Previous MI was a strong effect modifier within the FFR( 12)MT group (HR 1.98, 95% CI 1.26 to 3.13, p <0.01), whereas this was not the case in the FFR(+)CR group (HR 0.66, 95% CI 0.27 to 1.62, p\ua0= 0.37). Significant interaction for MACE was present between FFR groups and previous MI (p\ua0= 0.03). In conclusion, in patients with DM, particularly those\ua0with previous MI, deferred revascularization is associated with poor medium-term outcomes. Combining FFR with imaging techniques may be required to guide our treatment strategy in these patients with high-risk, fast-progressing atherosclerosis

Long‐term impact of multivessel disease on cause‐specific mortality after ST elevation myocardial infarction treated with reperfusion therapy

OBJECTIVES: To investigate the long‐term impact of multivessel coronary artery disease (MVD) on cause‐specific mortality in patients with ST elevation myocardial infarction (STEMI) treated with reperfusion therapy. METHODS AND RESULTS: Patients with STEMI (n  =  395) treated with primary angioplasty or thrombolysis in the setting of a randomised clinical trial were enrolled in the study. Follow up was 8 (2) years. For patients who died all available records were reviewed to assess the specific cause of death. MVD was present in 57% of patients. Patients with MVD were older and more of them had diabetes and previous myocardial infarction. Compared with the non‐MVD group, residual left ventricular ejection fraction was lower (45.9% v 49.6%, p  =  0.001) and total mortality was higher in patients with MVD (32% v 19%, p  =  0.002). After adjustment for potential confounders this association was not significant (hazard ratio 1.4, 95% confidence interval (CI) 0.9 to 2.2). When the specific cause of death was considered, sudden death was comparable between patients with and without MVD (10% v 8%, p  =  0.49) but death caused by heart failure was significantly higher in patients with MVD (hazard ratio 7.4, 95% CI 1.7 to 32.2). CONCLUSION: Patients with STEMI and MVD have a higher long‐term mortality than do patients with non‐MVD. MVD is not an independent predictor of long‐term total mortality or sudden death. However, MVD is a very strong and independent predictor of long‐term death caused by heart failure

Is routine stenting for acute myocardial infarction superior to balloon angioplasty? A randomised comparison in a large cohort of unselected patients

Objective: To evaluate the impact of routine stenting, compared with balloon angioplasty, in unselected patients presenting with ST segment elevation myocardial infarction (STEMI). Design: Randomised trial. Setting: Tertiary referral centre. Participants: All patients presenting with STEMI randomly assigned to stenting or balloon angioplasty. No exclusion criteria were applied. Main outcome measure: The primary end point was combined death or reinfarction at one year’s follow up. Results: 1683 consecutive patients with STEMI were randomly assigned before angiography to stenting (n  =  849) or balloon angioplasty (n  =  834). A total of 785 patients (92.5%) in the stent group and 763 patients (91.5%) in the balloon group actually underwent primary angioplasty. The groups were comparable in terms of postprocedural TIMI (thrombolysis in myocardial infarction) flow, myocardial blush grade, and distal embolisation. No difference was observed in clinical outcome at both intention to treat (14% v 12.5%, not significant) and actual treatment analyses (12.4% v 11.3%, not significant). Conclusions: Compared with balloon angioplasty, routine stenting does not seem to reduce death and reinfarction in a large cohort of unselected patients with STEMI

Atrial fibrillation after but not before primary angioplasty for ST-segment elevation myocardial infarction of prognostic importance

Item does not contain fulltextAIM: In patients with ST-segment elevation myocardial infarction (STEMI), it is uncertain whether atrial fibrillation has prognostic implications. There may be a difference between atrial fibrillation before and after reperfusion therapy. METHODS AND RESULTS: In patients with STEMI treated with primary percutaneous coronary intervention (PCI), ECGs were analysed before and after primary PCI. Of the 1623 patients with electrocardiographic data before primary PCI, 53 patients (3.3%) had atrial fibrillation. Patients with atrial fibrillation were older, were more often female, and less often had anterior MI location. Of the 1728 patients with electrocardiographic data after primary PCI, 52 patients (3.0%) had atrial fibrillation. Atrial fibrillation was more common in older patients and in those with Killip class >1. Also patients with occlusion of the right coronary artery or TIMI flow 0 before primary PCI more commonly had AF after the procedure. Not successful reperfusion was also associated with a higher incidence of AF after primary PCI. Although both atrial fibrillation before and after primary PCI were associated with increased mortality, multivariable analyses, adjusting for differences in age, gender and Killip class on admission, revealed that atrial fibrillation after PCI (OR 3.69, 95% CI 1.87-7.29) but not before PCI (OR 1.86, 95% CI 0.89-3.90) was independent and statistically significantly associated with long-term mortality. CONCLUSION: In patients with STEMI, atrial fibrillation after but not before primary PCI has independent prognostic implications. Possibly, atrial fibrillation after the PCI is a symptom of failed reperfusion and a sign of heart failure.1 april 201

Primary percutaneous coronary intervention versus thrombolytic treatment: long term follow up according to infarct location

OBJECTIVES: To study the clinical significance of infarct location during long term follow up in a trial comparing thrombolysis with primary angioplasty. DESIGN: Retrospective longitudinal cohort analysis of prospectively entered data. SETTING: Patients with acute ST elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). PATIENTS: In the Zwolle trial 395 patients with acute STEMI were randomly assigned to intravenous streptokinase or PCI. MAIN OUTCOME MEASURES: Survival according to infarct location and treatment after 8 (2) years of follow up. RESULTS: 105 patients died: 63 patients in the streptokinase group and 42 patients in the primary PCI group (relative risk (RR) 1.6, 95% confidence interval (CI) 1.0 to 2.6; p  =  0.03). In patients with non‐anterior STEMI there was no difference in mortality between streptokinase and PCI treated patients (RR 1.1, 95% CI 0.6 to 2.1; p  =  0.68) but the streptokinase group had significantly more major adverse cardiac events (MACE) than the PCI group (RR 2.1, 95% CI 1.2 to 3.6). The number needed to treat to prevent one MACE was four. In patients with anterior STEMI, mortality was higher in the streptokinase group than in the PCI group (RR 2.7, 95% CI 1.4 to 5.5; p  =  0.004). The number needed to treat to prevent one death was five. Kaplan‐Meier analysis confirmed the benefits of primary angioplasty in the first year and showed additional benefit of PCI compared with streptokinase between 1–8 years after the acute event. CONCLUSIONS: Patients with anterior STEMI have better long term survival when treated with PCI than with streptokinase. In patients alive one year after the acute event, PCI confers a significant additional survival benefit, probably due to better preserved residual left ventricular function

Timing of intervention in high-risk non-ST-elevation acute coronary syndromes in PCI versus non-PCI centres:Sub-group analysis of the ELISA-3 trial

AIMS: To compare the effect of timing of intervention in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) in percutaneous coronary intervention (PCI) versus non-PCI centres. METHODS AND RESULTS: A post-hoc sub-analysis was performed of the ELISA III trial, a randomised multicentre trial investigating outcome of early (< 12 h) versus late (> 48 h) angiography and revascularisation in 542 patients with high-risk NSTE-ACS. 90 patients were randomised in non-PCI centres and tended to benefit more from an early invasive strategy than patients included in the PCI centre (relative risk 0.23 vs. 0.85 [p for interaction = 0.089] for incidence of the combined primary endpoint of death, reinfarction and recurrent ischaemia after 30 days of follow-up). This was largely driven by reduction in recurrent ischaemia. In non-PCI centres, patients randomised to the late group had a 4 and 7 day longer period until PCI or coronary artery bypass grafting, respectively. This difference was less pronounced in the PCI centre. CONCLUSIONS: This post-hoc analysis from the ELISA-3 trial suggests that NSTE-ACS patients initially hospitalised in non-PCI centres show the largest benefit from early angiography and revascularisation, associated with a shorter waiting time to revascularisation. Improved patient logistics and transfer between non-PCI and PCI centres might therefore result in better clinical outcome

A comparison between upfront high-dose tirofiban versus provisional use in the real-world of non-selected STEMI patients undergoing primary PCI: Insights from the Zwolle acute myocardial infarction registry

Background. Despite the proven benefit of glycoprotein IIb/IIIa blockers in patients with acute ST-segment elevation myocardial infarction (STEMI), there is still debate on the timing of administration of these drugs and whether all or only a selection of patients should be treated. We evaluated the effect of routine upfront versus provisional use of high-dose tirofiban (HDT) in a large real-world population of non-selected STEMI patients. Methods. Consecutive STEMI patients were registered in a single-centre dedicated database. Patients with upfront HDT therapy before first balloon inflation were compared with patients who received the drug on a provisional basis, after first balloon inflation. Initial TIMI flow of the infarct-related vessel and enzymatic infarct size and 30-day clinical outcome were assessed. Results. Out of 2679 primary PCI patients HDT was given upfront in 885 (33.0%) and provisionally in 812 (45.3%). Upfront as compared with provisional HDT showed higher initial patency (22.3 vs. 17.9%, p= 0.006), smaller infarct size (1401 IU/l (IQR 609 to 2948) vs. 1620 (753 to 3132), p= 0.03) and a lower incidence of death or recurrent MI at 30 days (3.3 vs. 5.1%, p= 0.04) without an increase in TIMI bleeding (p= 0.24). Upfront HDT independently predicted initial patency (odds ratio (OR) 1.47, 95% confidence interval (CI) 1.15 to 1.88, p= 0.02), enzymatic infarct size (OR 0.70, 95% CI 0.56 to 0.86, p= 0.001) and 30-day death or recurrent MI (OR 0.59, 95% CI 0.37 to 0.95, p= 0.03). Conclusion. Our findings support the use of upfront potent antiplatelet and antithrombotic therapy in STEMI patients and encourage further clinical investigations in this field. (Neth Heart J 2010; 18: 592-7.