Detection of Myocardial Ischemia in Diabetic Patients: The Limitations of Myocardial Perfusion Imaging

In the study of 286 patients with suspected coronary artery disease and recent exercise single photon emission computed tomography (SPECT) test, we performed coronary angiography with coronary fractional flow reserve (FFR) measurement and tested the differences between diabetic (103) and non-diabetic (183) patients in ischemia detection by this two methods. The diabetic patients had a higher prevalence of hypertension, higher BMI and cholesterol levels, as well as longer duration of hospitalization than non-diabetic patients. There was no difference found between groups according to the exercise SPECT test, but, there were significantly more negative results in the non-diabetic group than in the diabetic group according to the FFR test, also, the percentage of stenosis was higher in diabetic patients. The concordance between the two methods was found, it was fair in diabetic patients (k=0.25, 95% C.I. 0.06–0.45) and moderate in non-diabetic patients (k=0.49, 95 % C.I. 0.36–0.62)

Detection of Myocardial Ischemia in Diabetic Patients: The Limitations of Myocardial Perfusion Imaging

In the study of 286 patients with suspected coronary artery disease and recent exercise single photon emission computed tomography (SPECT) test, we performed coronary angiography with coronary fractional flow reserve (FFR) measurement and tested the differences between diabetic (103) and non-diabetic (183) patients in ischemia detection by this two methods. The diabetic patients had a higher prevalence of hypertension, higher BMI and cholesterol levels, as well as longer duration of hospitalization than non-diabetic patients. There was no difference found between groups according to the exercise SPECT test, but, there were significantly more negative results in the non-diabetic group than in the diabetic group according to the FFR test, also, the percentage of stenosis was higher in diabetic patients. The concordance between the two methods was found, it was fair in diabetic patients (k=0.25, 95% C.I. 0.06–0.45) and moderate in non-diabetic patients (k=0.49, 95 % C.I. 0.36–0.62)

Randomized Comparison of Eptifibatide Versus Abciximab in Primary Percutaneous Coronary Intervention in Patients With Acute ST-Segment Elevation Myocardial Infarction Results of the EVA-AMI Trial

ObjectivesThe aim of this study was to compare eptifibatide and abciximab as adjuncts to primary percutaneous coronary intervention (PCI).BackgroundThe glycoprotein (GP) IIb/IIIa receptor inhibitor abciximab as adjunct to primary PCI in patients with ST-segment elevation myocardial infarctions has been shown to reduce ischemic complications and improve clinical outcomes. So far, no trial has been performed to compare the efficacy of another GP IIb/IIIa receptor inhibitor, eptifibatide, and abciximab in primary PCI.MethodsA total of 427 patients with ST-segment elevation myocardial infarctions <12 h and planned primary PCI were randomized to double-bolus eptifibatide (n = 226) followed by a 24-h infusion or single-bolus abciximab (n = 201) followed by a 12-h infusion. In this noninferiority trial, the primary end point was the incidence of complete (≥70%) ST-segment resolution (STR) 60 min after PCI, a measure of myocardial reperfusion. The assumption was a 60% complete STR rate in the abciximab group. The noninferiority margin was set to 15%.ResultsThe incidence of complete STR at 60 min after PCI in the intention-to-treat analysis was 62.6% after eptifibatide and 56.3% after abciximab (adjusted difference: 7.1%; 95% confidence interval: 2.7% to 17.0%). All-cause mortality 6.2% versus 4.5% (p = 0.50); reinfarction 0.4% versus 3.5% (p = 0.03); target vessel revascularization 4.4% versus 6.5% (p = 0.40); the combined end point of death, nonfatal reinfarction, and target vessel revascularization 10.6% versus 10.9% (p = 0.90); stroke 0.5% versus 0.5% (p = 1.00) after 6 months; and Thrombolysis In Myocardial Infarction major bleeding complications 4.0% versus 2.0% (p = 0.20) after 30 days were observed after eptifibatide and abciximab, respectively.ConclusionsEptifibatide as an adjunct to primary PCI is equally as effective as abciximab with respect to STR. (Efficacy of Eptifibatide Compared to Abciximab in Primary Percutaneous Coronary Intervention [PCI] for Acute ST Elevation Myocardial Infarction [STEMI]; NCT00426751

120 Superiority of CT scan over transthoracic echocardiography in predicting aortic regurgitation after TAVI

BackgroundParavalvular aortic regurgitation (AR) occurs in up to 86% of patients undergoing Transcatheter Aortic Valve Implantation (TAVI). Its prevalence remains unchanged after one year follow-up but its determinants are unclear. We sought to evaluate the impact of annulus measurement by transthoracic echocardiography (TTE) and by CT scan on the occurrence of AR.MethodsThe study included 43 symptomatic patients (83±8 years, 72% in NYHA≥III) with severe aortic stenosis [0.76±0.19cm2, mean gradient 42±14mmHg] who underwent TAVI using CoreValve® LLC Percutaneous Aortic Valve Implantation System, Medtronic, Minneapolis USA. Left ventricular outflow tract (LVOT) area was computed from LVOT diameter (21±2mm) by TTE using a spherical model and from CT using an ellipsoidal model according to the larger (25±3mm) and the smaller outflow tract diameters (22±3mm). These data were compared to the prosthesis area and the occurrence of AR after TAVI.ResultsIn patients with AR greater or equal to 2/4 (32%), LVOT area measured by CT was significantly greater as compared to patients with no or mild AR (478±65mm 2 vs. 411±85mm2, p=0.009). Furthermore, the difference between actual prosthesis area and LVOT area measured by CT scan was significantly smaller (113±55 vs. 171±67, p=0.009) in patients with significant AR (≥2/4) after TAVI. In contrast, LVOT area from TTE did not correlate with AR severity.ConclusionCT scan is more accurate than TTE for calculating LVOT area for prosthesis sizing before TAVI in order to avoid post-implantation AR

Impact of cardiac resynchronization therapy optimization inside a heart failure programme : a real‐world experience

Aims: This study sought to describe and evaluate the impact of a routine in‐hospital cardiac resynchronization therapy (CRT) programme, including comprehensive heart failure (HF) evaluation and systematic echo‐guided CRT optimization. Methods and results: CRT implanted patients were referred for optimization programme at 3 to 12 months from implantation. The program included clinical and biological status, standardized screening for potential cause of CRT non‐response and systematic echo‐guided atrioventricular and interventricular delays (AVd and VVd) optimization. Initial CRT‐response and improvement at 6 months post‐optimization were assessed with a clinical composite score (CCS). Major HF events were tracked during 1 year after optimization. A total of 227 patients were referred for CRT optimization and enrolled (71 ± 11 years old, 77% male, LVEF 30.6 ± 7.9%), of whom 111 (48.9%) were classified as initial non‐responders. Left ventricular lead dislodgement was noted in 4 patients (1.8%), and loss or ≤90% biventricular capture in 22 (9.7%), mostly due to arrhythmias. Of the 196 patients (86%) who could undergo echo‐guided CRT optimization, 71 (36.2%) required VVd modification and 50/144 (34.7%) AVd modification. At 6 months post‐optimization, 34.3% of the initial non‐responders were improved according to the CCS, but neither AVd nor VVd echo‐guided modification was significantly associated with CCS‐improvement. After one‐year follow‐up, initial non‐responders maintained a higher rate of major HF events than initial responders, with no significant difference between AVd/VVd modified or not. Conclusions: Our study supports the necessity of a close, comprehensive and multidisciplinary follow‐up of CRT patients, without arguing for routine use of echo‐guided CRT optimization

Benefit and Risks of Aspirin in Addition to Ticagrelor in Acute Coronary Syndromes:A Post Hoc Analysis of the Randomized GLOBAL LEADERS Trial

Key PointsQuestionWhat are the benefits and risks of continuing aspirin in addition to P2Y12 receptor inhibition with ticagrelor among patients with acute coronary syndrome between 1 month and 12 months after percutaneous coronary intervention? FindingsIn this nonprespecified, post hoc analysis of the GLOBAL LEADERS randomized clinical trial, beyond 1 month after percutaneous coronary intervention in acute coronary syndrome, aspirin was associated with increased bleeding risk and appeared not to add to the benefit of ticagrelor on ischemic events. MeaningThe findings of this hypothesis-generating analysis pave the way for further trials evaluating aspirin-free antiplatelet strategies after percutaneous coronary intervention. ImportanceThe role of aspirin as part of antiplatelet regimens in acute coronary syndromes (ACS) needs to be clarified in the context of newer potent P2Y12 antagonists. ObjectiveTo evaluate the benefit and risks of aspirin in addition to ticagrelor among patients with ACS beyond 1 month after percutaneous coronary intervention (PCI). Design, Setting, and ParticipantsThis is a nonprespecified, post hoc analysis of GLOBAL LEADERS, a randomized, open-label superiority trial comparing 2 antiplatelet treatment strategies after PCI. The trial included 130 secondary/tertiary care hospitals in different countries, with 15991 unselected patients with stable coronary artery disease or ACS undergoing PCI. Patients had outpatient visits at 1, 3, 6, 12, 18, and 24 months after index procedure. InterventionsThe experimental group received aspirin plus ticagrelor for 1 month followed by 23-month ticagrelor monotherapy; the reference group received aspirin plus either clopidogrel (stable coronary artery disease) or ticagrelor (ACS) for 12 months, followed by 12-month aspirin monotherapy. In this analysis, we examined the clinical outcomes occurring between 31 days and 365 days after randomization, specifically in patients with ACS who, within this time frame, were assigned to receive either ticagrelor alone or ticagrelor and aspirin. Main Outcomes and MeasuresThe primary outcome was the composite of all-cause death or new Q-wave myocardial infarction. ResultsOf 15968 participants, there were 7487 patients with ACS enrolled; 3750 patients were assigned to the experimental group and 3737 patients to the reference group. Between 31 and 365 days after randomization, the primary outcome occurred in 55 patients (1.5%) in the experimental group and in 75 patients (2.0%) in the reference group (hazard ratio [HR], 0.73; 95% CI, 0.51-1.03; P=.07); investigator-reported Bleeding Academic Research Consortium-defined bleeding type 3 or 5 occurred in 28 patients (0.8%) in the experimental group and in 54 patients (1.5%) in the reference arm (HR, 0.52; 95% CI, 0.33-0.81; P=.004). Conclusions and RelevanceBetween 1 month and 12 months after PCI in ACS, aspirin was associated with increased bleeding risk and appeared not to add to the benefit of ticagrelor on ischemic events. These findings should be interpreted as exploratory and hypothesis generating; however, they pave the way for further trials evaluating aspirin-free antiplatelet strategies after PCI. Trial RegistrationClinicalTrials.gov identifier: NCT01813435. This secondary analysis of the GLOBAL LEADERS randomized clinical trial evaluates the benefit and risks of aspirin in addition to ticagrelor among patients with acute coronary syndrome beyond 1 month after percutaneous coronary intervention