021: Clopidogrel low response and correlation between the different tests: light transmission aggregometry, VerifyNow-P2Y12 and V ASP

BackgroundClopidogrel low response correlates with poor prognosis after percutaneous coronary intervention (PCI). Many biological tests are currently available to test the clopidogrel response. However, the presence of any correlation between the different tests is today poorly reported.MethodsIn this prospective study, clopidogrel response was assessed in 100 consecutive patients. All patients were tested between 18h and 24h after a600mg clopidogrel loading dose using 3 different tests: light transmission aggregometry with 10μmol ADP (LTA, results expressed as platelet inhibition percentage), VerifyNow-P2Y12 (VN, results expressed as PRU) and vasodilatator stimulated phosphoprotein (VASP, results expressed as IRP). Patients under chronic clopidogrel therapy were excluded.ResultsThe mean platelet inhibition percentage, PRU value and IRP value were 38.5±13% by LTA, 178±89 PRU by VN and 52±21% by VASP. When results were analyzed as continuous variables, there was a good correlation between the different tests: LTA/VN (R2=0,642, p<0,001), LTA/VASP (R2=0,409, p<0,001) and VN/VASP (R2=0,616, p<0,001). However, when results were analyzed as pre-specified cut-off points to define patients as “low or good responders” (according to the literature: 50% for LTA, 235 PRU for VN and 50% IRP for VASP), only 47% of the patients were defined as “good” or “low responders” by the 3 tests. Altogether, 33% of the patients were defined as “low responders” by only 1 test, 20% by 2 tests and only 16% by the 3 tests.ConclusionIf the correlation between the different tests is good when results are analyzed as continuous variables, each individual is rarely (less than 50%) defined as “low or good responder” by all the 3 tests when recognized cut-off values are used. In that way, a sole test might not be sufficient to manage antiplatelet therapy in an individual patient

Safety and efficacy of drug-eluting stents and bare metal stents in acute coronary syndrome

Compared with medical therapy, percutaneous coronary intervention has been shown to reduce the rates of death and recurrent ischemia in patients presenting with acute coronary syndromes (ACS). In the current interventional era, both drug-eluting stents (DES) and bare-metal stents (BMS) have been widely used, despite the fact that the use of DES in the context of ACS was initially an “off-label” indication and that ACS has been associated with stent thrombosis (ST). In contrast to the wealth of data available for the use of DES in patients with ST-elevation myocardial infarction, data regarding the performance of DES in non–ST-elevation ACS is restricted to a handful of registries with conflicting data. The aim of this review was to summarize the safety and efficacy of DES in the entire spectrum of ACS

Should we screen for masked hypertension in patient with vascular disease?

Pascal Delsart1, Philippe Marboeuf1, Cedric Delhaye2, Gilles Lemesle2, Claire Mounier-Vehier11Service de M&amp;eacute;decine Vasculaire et Hypertension Art&amp;eacute;rielle, 2Service d&amp;rsquo;h&amp;eacute;modynamique et de Cardiologie B, University Hospital of Lille, FranceBackground: The influence of hypertension on cardiovascular risk is well known. Ambulatory blood pressure measurement (ABPM) is able to identify patients with masked hypertension (MH) underdetected by clinical BP measurement. The benefit of screening for MH in a highrisk population was investigated.Aims: To detect MH in a population with no prior history of hypertension and medically treated for peripheral or coronary arterial disease.Methods: Thirty-eight consecutive patients with peripheral or coronary artery disease documented with arteriography, without a history of hypertension, and with an admission BP &amp;lt; 140/90 mmHg underwent ABPM after discharge. Ambulatory BP &amp;ge; 125/80 mmHg were defined as MH.Results: MH was found in 11 patients (28.9%). The MH group had a mean systolic and diastolic hospitalization BP significantly higher (127 versus 115 mmHg, respectively, P = 0.002 and 76 versus 66 mmHg, P = 0.01), and tended to have a higher admission systolic BP and pulse pressure (127 versus 121 mmHg, respectively, P = 0.07; and 54 versus 46 mmHg, P = 0.06). The first BP measurement on the 24-hour ABPM was significantly higher in the MH group 140 versus 121 mmHg, P = 0.001, for systolic BP and 84 versus 74 mmHg, P = 0.03, for diastolic BP.Conclusions: MH was found in patients with documented and medically treated vascular disease. BP in the prehypertensive range is associated with MH. Systematic screening for MH in this high-risk population requires further investigation.Keywords: blood pressure, monitoring, masked hypertension, vascular diseas

Integrilin in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction

The adjunctive use of eptifibatide in patients undergoing primary percutaneous coronary intervention (PCI) for ST-elevation myocardial infarction (STEMI) remains controversial. We therefore set out to determine the safety and efficacy of eptifibatide in this population

Do patients with drug-eluting stent thrombosis have a similar prognosis to patients presenting with ST-elevation myocardial infarction of de novo lesions?

Despite significant advances in stent technology and pharmacotherapy, drug-eluting stent thrombosis (DES-ST) remains a major complication of percutaneous coronary intervention (PCI) and commonly presents as ST-elevation myocardial infarction (STEMI). There are currently little data comparing the in-hospital outcomes of patients presenting with STEMI due to DES-ST with those due to de novo coronary artery disease (CAD)

Impact of drug-eluting stent type on periprocedural myocardial necrosis

The relationship between stent design and periprocedural myocardial infarction is unclear. The newest type of drug-eluting stent (DES), the everolimus-eluting stent (EES), has thinner strut and polymer thickness and a small amount of drug. EES use, therefore, could be related to less myocardial necrosis post-percutaneous coronary intervention (PCI). This study was undertaken to compare the amount of myocardial necrosis associated with implantation of the four DES types currently approved in the U.S

Transcarotid transcatheter aortic valve replacement

International audienceOBJECTIVES: The purpose of this study was to assess the feasibility and safety of transcarotid transcatheter aortic valve replacement (TAVR). BACKGROUND: Many candidates for TAVR have challenging vascular anatomy that precludes transfemoral access. Transcarotid arterial access may be an option for such patients. METHODS: The French Transcarotid TAVR Registry is a voluntary database that prospectively collected patient demographics, procedural characteristics, and clinical outcomes among patients undergoing transcarotid TAVR. Outcomes are reported according to the updated Valve Academic Research Consortium criteria. RESULTS: Among 96 patients undergoing transcarotid TAVR at 3 French sites (2009 to 2013), the mean age and Society of Thoracic Surgeons predicted risk of mortality were 79.4 +/- 9.2 years and 7.1 +/- 4.1%, respectively. Successful carotid artery access was achieved in all patients. The Medtronic CoreValve (Medtronic, Inc., Minneapolis, Minnesota) (n = 89; 92.7%) and Edwards SAPIEN valves (Edwards Lifesciences, Irvine, California) (n = 7; 7.3%) were used. Procedural complications included: valve embolization (3.1%), requirement for a second valve (3.1%), and tamponade (4.2%). There were no major bleeds or major vascular complications related to the access site. There were 3 (3.1%) procedural deaths and 6 (6.3%) deaths at 30 days. The 1-year mortality rate was 16.7%. There were 3 (3.1%) cases of Valve Academic Research Consortium-defined in-hospital stroke (n = 0) or transient ischemic attack (TIA) (n = 3). None of these patients achieved the criteria for stroke and none manifested new ischemic lesions on cerebral computed tomography or magnetic resonance imaging. At 30 days, a further 3 TIAs were observed, giving an overall stroke/TIA rate of 6.3%. CONCLUSIONS: Transcarotid vascular access for TAVR is feasible and is associated with encouraging short- and medium-term clinical outcomes. Prospective studies are required to ascertain if transcarotid TAVR yields equivalent results to other nonfemoral vascular access routes

Outcomes after unrestricted use of everolimus-eluting stent compared to paclitaxel- and sirolimus-eluting stents

Compared to paclitaxel-eluting stents (PESs) and sirolimus-eluting stents (SESs), a paucity of data exists regarding the clinical outcome of everolimus-eluting stents (EESs) in unselected patients with the entire spectrum of obstructive coronary artery disease. The present study cohort included 6,615 consecutive patients at Washington Hospital Center who underwent coronary artery stent implantation with EESs (n = 519), PESs (n = 2,036), or SESs (n = 4,060). Patients who received bare metal stents, zotarolimus-eluting stents, or 2 different drug-eluting stent types were excluded. The analyzed clinical end points were death, death or Q-wave myocardial infarction, target lesion revascularization (TLR), target vessel revascularization, definite stent thrombosis, and major adverse cardiac events, defined as the composite of death, Q-wave myocardial infarction, or TLR at 1 year. The groups were well matched for the conventional risk factors for coronary artery disease, except for systemic hypertension, which differed among the groups. The unadjusted end points for EESs and PESs were death (4.5% vs 7.1%; p = 0.03), TLR (3.4% vs 4.6%; p = 0.24), target vessel revascularization (5.6% vs 7.1%; p = 0.46), death or Q-wave myocardial infarction (4.5% vs 7.4%; p = 0.02), and definite stent thrombosis (0.0% vs 0.7%; p = 0.09). The unadjusted end points for EES and SES were death (4.5% vs 5.2%; p = 0.45), TLR (3.4% vs 5.8%; p = 0.3), target vessel revascularization (5.6% vs 8.6%; p = 0.05), death or Q-wave myocardial infarction (4.5% vs 5.4%; p = 0.39), and definite stent thrombosis (0.0% vs 1.08%; p = 0.003). The rates of major adverse cardiac events were similar among the 3 groups. After multivariate analysis, the rate of death or Q-wave myocardial infarction between the EES and PES groups was no longer significant (hazard ratio 1.14, 95% confidence interval 0.59 to 2.20, p = 0.70). In conclusion, the results of the present study suggest the use of EES in routine clinical practice is both safe and effective but offers no clinically relevant advantage in terms of hard end points compared to PES or SES