Clinical Decision Making Staging of Multivessel Percutaneous Coronary Interventions: an Expert Consensus Statement from the Society for Cardiac Angiography and Interventions

and Gregory J. Dehmer, 7 MD, FSCAI Percutaneous coronary interventions (PCIs) to treat multivessel coronary artery disease (MVCAD) may involve single-vessel or multivessel interventions, performed in one or more stages. This consensus statement reviews factors that may influence choice of strategy and includes six recommendations to guide decisions regarding staging of PCI V C 2011 Wiley Periodicals, Inc

Consideration of a New Definition of Clinically Relevant Myocardial Infarction After Coronary Revascularization An Expert Consensus Document From the Society for Cardiovascular Angiography and Interventions (SCAI)

Numerous definitions have been proposed for the diagnosis of myocardial infarction (MI) after coronary revascularization. The universal definition for MI designates post procedural biomarker thresholds for defining percutaneous coronary intervention (PCI)-related MI (type 4a) and coronary artery bypass grafting (CABG)-related MI (type 5), which are of uncertain prognostic importance. In addition, for both the MI types, cTn is recommended as the biomarker of choice, the prognostic significance of which is less well validated than CK-MB. Widespread adoption of a MI definition not clearly linked to subsequent adverse events such as mortality or heart failure may have serious consequences for the appropriate assessment of devices and therapies, may affect clinical care pathways, and may result in misinterpretation of physician competence. Rather than using an MI definition sensitive for small degrees of myonecrosis (the occurrence of which, based on contemporary large-scale studies, are unlikely to have important clinical consequences), it is instead recommended that a threshold level of biomarker elevation which has been strongly linked to subsequent adverse events in clinical studies be used to define a "clinically relevant MI." The present document introduces a new definition for "clinically relevant MI" after coronary revascularization (PCI or CABG), which is applicable for use in clinical trials, patient care, and quality outcomes assessment. Numerous definitions for the diagnosis of MI after coronary revascularization are in use (1). A standardized MI definition would provide uniformity for comparing clinical trial results, for assessing patient outcomes and for guiding quality improvement initiatives. In 2007, a "universal definition" for MI following coronary revascularization was proposed (2) and recently revised in 2012 (3). In this document, a PCI-related MI (type 4a) was defined as an increase in cTn to >5Â the 99th percentile of the URL during the first 48 h following PCI (in patients with normal baseline cTn concentrations), plus either: 1) evidence of prolonged ischemia as demonstrated by prolonged chest pain; or 2) ischemic ST-segment changes or new pathological Q waves; or 3) angiographic evidence of a flow limiting complication; or 4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. MI associated with CABG (type 5) was defined as an increase in cTn to >10Â the 99th percentile URL during the first 48 h following CABG (in patients with normal baseline cTn concentrations), plus either: 1) new pathological Q waves or new LBBB; or 2) angiographically documente

Asymptomatic Carotid Artery Stenosis: A Primer on Risk Stratification and Management

This well-illustrated text reviews the current state of knowledge with regard to the various anatomic and physiologic methods available to identify asymptomatic patients who are at high risk to develop a future stroke. Asymptomatic Carotid Artery Stenosis is particularly targeted towards physicians involved in clinical decision making regarding revascularization of patients with asymptomatic carotid stenosis. Furthermore, the editors and contributors' hopes and objectives are to stimulate the medical community into subjecting these methodologies to rigorous prospective clinical trials to redefine standards of care for these patients

Impact of main branch stenting on endothelial shear stress: role of side branch diameter, angle and lesion

In-stent restenosis and stent thrombosis remain clinically significant problems for bifurcation lesions. The objective of this study is to determine the haemodynamic effect of the side branch (SB) on main branch (MB) stenting. We hypothesize that the presence of a SB has a negative effect on MB wall shear stress (WSS), wall shear stress gradient (WSSG) and oscillatory shear index (OSI); and that the bifurcation diameter ratio (SB diameter/MB diameter) and angle are important contributors. We further hypothesized that stent undersizing exaggerates the negative effects on WSS, WSSG and OSI. To test these hypotheses, we developed computational models of stents and non-Newtonian blood. The models were then interfaced, meshed and solved in a validated finite-element package. Stents at bifurcation models were created with 30° and 70° bifurcation angles and bifurcations with diameter ratios of SB/MB = 1/2 and 3/4. It was found that stents placed in the MB at a bifurcation lowered WSS dramatically, while elevating WSSG and OSI. Undersizing the stent exaggerated the decrease in WSS, increase in WSSG and OSI, and disturbed the flow between the struts and the vessel wall. Stenting the MB at bifurcations with larger SB/MB ratios or smaller SB angles (30°) resulted in lower WSS, higher WSSG and OSI. Stenosis at the SB lowered WSS and elevated WSSG and OSI. These findings highlight the effects of major biomechanical factors in MB stenting on endothelial WSS, WSSG, OSI and suggests potential mechanisms for the potentially higher adverse clinical events associated with bifurcation stenting