Randomised comparison of coronary stenting with and without balloon predilatation in selected patients

BACKGROUND—The SWIBAP (stent without balloon predilatation) prospective randomised trial was designed to compare direct coronary stenting with stenting preceded by lesion predilatation with an angioplasty balloon.
OBJECTIVE—To determine the feasibility and safety of direct stenting in non-complex coronary lesions in a prospective study.
PATIENTS AND DESIGN—All patients < 76 years of age scheduled to undergo angioplasty of a non-complex, non-calcified lesion in a coronary artery of > 3.0 mm, who granted their informed consent, were randomised into the trial. In group I, the stent was placed without balloon predilatation, while in group II stent implantation was preceded by balloon predilatation. The primary end point was the angiographic result according to procedure assigned by randomisation. An intravascular ultrasound substudy was performed in 60( )patients.
RESULTS—Stent implantation was successful without predilatation in 192 of the 197 group I patients (97.5%), and with predilatation in 197 of the 199 group II patients (99%) (NS). No in-hospital stent thrombosis or death occurred. Overall procedural times, fluoroscopy times, and volumes of contrast agent given (mean (SD)) in group I v group II were 23.50 (13.54) min v 27.96 (15.23) min (p = 0.002), 6.04 (4.13) min v 6.67 (3.65) min (NS), and 135 (65) ml v 157 (62) ml (p < 0.001), respectively. No major adverse cardiovascular events had occurred by 30( )days.
CONCLUSIONS—The feasibility and safety of direct stenting of selected and non-complex coronary lesions is confirmed. This technique was as successful as the conventional approach and was associated with a minor reduction in fluoroscopic exposure and procedure time and the administration of less contrast agent.


Keywords: coronary artery angioplasty; stent; coronary artery ultrasoun

Incidence, timing, predictors and impact of acute heart failure complicating ST-segment elevation myocardial infarction in patients treated by primary percutaneous coronary intervention

International audienceBackground Acute heart failure (AHF) complicating ST-segment elevation myocardial infarction (STEMI) is recognized as an ominous complication. Previous studies mostly reported outcomes of heterogeneous, non-contemporary population. Moreover, few studies assessed the prognosis of AHF according to its timing. This study evaluated incidence, predictors and impact of AHF according to its timing in a homogeneous STEMI patients population treated by primary percutaneous coronary intervention (pPCI). Methods Data from 6282 patients included in a prospective multicenter registry were analyzed. Patients with AHF (Killip class > I) were compared to patients without AHF and patients with admission AHF were compared to patients who developed in-hospital AHF. In-hospital mortality was the primary endpoint of the study. Propensity-score matching and multivariable regression were used to adjust for confounders. Results A total of 1328 patients (21.1%) presented AHF: 739 on admission and 589 during hospitalization. AHF was associated with a markedly increased in-hospital mortality rate (19.9% vs. 0.8%, p < 0.001). There was a gradual excess risk with each Killip class and admission AHF patients displayed the highest crude mortality rate (24.1%). By multivariable analysis, AHF was the strongest independent predictor of in-hospital mortality (HR = 3.852 (2.303–6.442), p < 0.001) without evidence of any difference according to its timing (HR = 0.947 (0.638–1.372), p = 0.767). These results were consistent after extensive adjustment on baseline characteristics in the matched cohorts. Among other predictors, pPCI beyond guidelines-recommended delays and stent thrombosis were independently associated with AHF. Conclusion AHF regardless of its timing remains a common and dreadful complication of STEMI in the contemporary era. © 201

High-degree atrioventricular block complicating ST segment elevation myocardial infarction in the contemporary era

International audienceBackground High-degree atrioventricular block (HAVB) is a common complication of ST segment elevation myocardial infarction (STEMI). HAVB in STEMI is historically considered as a marker of worse outcome but overall data about HAVB in the contemporary era of mechanical reperfusion and potent antiplatelet therapies are scarce. Aim Analysing incidence, clinical correlates and impact on inhospital outcomes of HAVB in a large prospective registry (Observatoire Régional Breton sur l'Infarctus, ORBI) of modern management of STEMI with a special focus on potential differences between patients with HAVB on admission and those who developed HAVB during hospitalisation. Methods All patients enrolled in ORBI between June 2006 and December 2013 were included in the present analysis and were divided into 3 groups: patients without HAVB at any time, patients with HAVB on admission and those who developed HAVB during hospitalisation. Results A total of 6662 patients (age: 62.0 (52.0–74.0) years; male: 76.3%) were included in the present analysis. HAVB was documented in 3.5% of patients, present on admission in 63.7% of patients and occurring during hospitalisation in 36.3%. Patients with HAVB on admission or occurring during the first 24 h of hospitalisation had higher inhospital mortality rates (18.1% and 28.6%, respectively) than patients without (4.5%) or with HAVB occurring beyond the first 24 h of hospitalisation (8.0%). However by multivariable analysis, HAVB was not independently associated with inhospital mortality contrarily to age, presentation as cardiac arrest, anterior STEMI location, reperfusion therapy, cardiogenic shock, mechanical ventilation and occurrence of sustained ventricular tachyarrhythmias or mechanical complication. Conclusions Patients with HAVB had a higher mortality rate than patients without. However HAVB is not an independent predictor of inhospital mortalit

Early and late ventricular arrhythmias complicating ST-segment elevation myocardial infarction

International audienceBACKGROUND: Ventricular arrhythmias can be life-threatening complications of ST-segment elevation myocardial infarction (STEMI). AIMS: To describe the incidence, predictors and in-hospital impact of early ventricular arrhythmia (EVA, occurring&lt;day 2 after STEMI) and late ventricular arrhythmia (LVA, occurring≥day 2 after STEMI) in patients with STEMI. METHODS: Data from 13,523 patients enrolled in a prospective registry were analysed. Logistic and Cox regressions were performed to identify predictors of EVA, LVA and in-hospital all-cause mortality. Predictors of LVA were used to build a risk score. RESULTS: EVA occurred in 678 patients (5%), whereas 120 patients (0.9%) experienced LVA, at a median timing of 3days after STEMI. EVA was associated with a significantly higher risk of all-cause mortality (hazard ratio: 1.44, 95% confidence interval: 1.17-1.76; P=0.001), whereas no association was observed with LVA (hazard ratio 0.86, 95% confidence interval 0.57-1.28; P=0.45). Multivariable predictors of LVA were: age≥65years; serum creatinine≥85μmol/L on admission; pulse pressure≤45mmHg on admission; presence of a Q wave on admission electrocardiogram; Thrombolysis In Myocardial Infarction flow grade&lt;3 after percutaneous coronary intervention; and left ventricular ejection fraction≤45%. The score derived from these variables allowed the classification of patients into four risk categories: low (0-21); low-to-intermediate (22-34); intermediate-to-high (35-44); and high (≥45). Observed LVA rates were 0.2%, 0.3%, 0.9% and 2.5%, across the four risk categories, respectively. The model demonstrated good discrimination (20-fold cross-validated c-statistic of 0.76) and adequate calibration (Hosmer-Lemeshow P=0.23). CONCLUSIONS: EVA is 5-fold more common than LVA in the setting of STEMI, and portends a higher risk of in-hospital all-cause mortality. LVA is mainly associated with the patient’s baseline risk profile and surrogate markers of larger infarct size. We developed and internally validated a risk score identifying patients at high risk of LVA for whom early intensive care unit discharge may not be suitable

Stress neuropeptide levels in adults with chest pain due to coronary artery disease: potential implications for clinical assessment

: Substance P (SP) and neuropeptide Y (NPY) are neuropeptides involved in nociception. The study of biochemical markers of pain in communicating critically ill coronary patients may provide insight for pain assessment and management in critical care. Purpose of the study was to to explore potential associations between plasma neuropeptide levels and reported pain intensity in coronary critical care adults, in order to test the reliability of SP measurements for objective pain assessment in critical care

Cohort profile: the ESC EURObservational Research Programme Non-ST-segment elevation myocardial infraction (NSTEMI) Registry

Aims The European Society of Cardiology (ESC) EURObservational Research Programme (EORP) Non-ST-segment elevation myocardial infarction (NSTEMI) Registry aims to identify international patterns in NSTEMI management in clinical practice and outcomes against the 2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without ST-segment-elevation. Methods and results Consecutively hospitalised adult NSTEMI patients (n = 3620) were enrolled between 11 March 2019 and 6 March 2021, and individual patient data prospectively collected at 287 centres in 59 participating countries during a two-week enrolment period per centre. The registry collected data relating to baseline characteristics, major outcomes (inhospital death, acute heart failure, cardiogenic shock, bleeding, stroke/transient ischaemic attack, and 30-day mortality) and guideline-recommended NSTEMI care interventions: electrocardiogram pre- or in-hospital, prehospitalization receipt of aspirin, echocardiography, coronary angiography, referral to cardiac rehabilitation, smoking cessation advice, dietary advice, and prescription on discharge of aspirin, P2Y12 inhibition, angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB), beta-blocker, and statin. Conclusion The EORP NSTEMI Registry is an international, prospective registry of care and outcomes of patients treated for NSTEMI, which will provide unique insights into the contemporary management of hospitalised NSTEMI patients, compliance with ESC 2015 NSTEMI Guidelines, and identify potential barriers to optimal management of this common clinical presentation associated with significant morbidity and mortality