Use of prasugrel vs clopidogrel and outcomes in patients with acute coronary syndrome undergoing percutaneous coronary intervention in contemporary clinical practice: Results from the PROMETHEUS study.

BACKGROUND AND OBJECTIVES: We sought to determine the frequency of use and association between prasugrel and outcomes in acute coronary syndrome patients undergoing percutaneous coronary intervention (PCI) in clinical practice. METHODS: PROMETHEUS was a multicenter observational registry of acute coronary syndrome patients undergoing PCI from 8 centers in the United States that maintained a prospective PCI registry for patient outcomes. The primary end points were major adverse cardiovascular events at 90days, a composite of all-cause death, nonfatal myocardial infarction, stroke, or unplanned revascularization. Major bleeding was defined as any bleeding requiring hospitalization or blood transfusion. Hazard ratios (HRs) were generated using multivariable Cox regression and stratified by the propensity to treat with prasugrel. RESULTS: Of 19,914 patients (mean age 64.4years, 32% female), 4,058 received prasugrel (20%) and 15,856 received clopidogrel (80%). Prasugrel-treated patients were younger with fewer comorbid risk factors compared with their counterparts receiving clopidogrel. At 90days, there was a significant association between prasugrel use and lower major adverse cardiovascular event (5.7% vs 9.6%, HR 0.58, 95% CI 0.50-0.67, P<.0001) and bleeding (1.9% vs 2.9%, HR 0.65, 95% CI 0.51-0.83, P<.001). After propensity stratification, associations were attenuated and no longer significant for either outcome. Results remained consistent using different approaches to adjusting for potential confounders. CONCLUSIONS: In contemporary clinical practice, patients receiving prasugrel tend to have a lower-risk profile compared with those receiving clopidogrel. The lower ischemic and bleeding events associated with prasugrel use were no longer evident after accounting for these baseline differences

Relationship of mitral valve annulus plane and circumflex-right coronary artery plane: implications for transcatheter mitral v alve implantation

AimTranscatheter mitral valve implantation (TMVI) is a novel technology for patients with severe mitral valve disease but at high surgical risk. Imaging guidance during the procedure is critical for successful device deployment. Identification of the mitral annular plane (MAP) with fluoroscopy during the procedure is limited by lack of clearly defined landmarks. We hypothesized that a plane defined by left circumflex-right coronary arteries (LCX-RCA) would have a consistent relationship to MAP. Methods and resultsWe studied 25 patients with gated cardiac computed tomography. We identified the MAP and the LCX-RCA plane in mid systole and diastole. The distance between the two planes in prespecified four points (anterior, posterior, medial, and lateral) in the apical 2 and 3-chamber views. Alignment of the planes was described by cranial/caudal angulation for both planes in RAO 30 degrees and LAO 90 degrees (lateral) angulation. Mean age was 819 years, 56% of patients had 2+ mitral regurgitation. In mid systole, the distances between the LCX-RCA plane and the MAP in the four points were<5 mm in 92% of patients. In mid diastole, distances were<5 mm in 100% of patients. In mid systole, the correlation between the caudal/cranial orientations of the 2 planes was 0.85 and 0.80 in the LAO 90 degrees and RAO 30 degrees, respectively (P=<0.001). In mid diastole, this was 0.92 and 0.92 in the LAO 90 degrees and RAO 30 degrees, respectively (P=<0.001). Conclusion LCX-RCA plane has a close and consistent relationship to the MAP and can be useful to guide TMVI. Accurate imaging of mitral valve annular plane during TMVI procedure is challenging. MAP guided by fluoroscopy might be crucial to guide successful prosthesis deployment. A plane defined by the left circumflex- right coronary arteries in the atrioventricular grove has a consistent relationship with MAP; this can be used aided by pre-procedural MDCT to guide TMVI procedur

Low molecular weight heparin versus unfractionated heparin in patients with acute non-ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention with drug-eluting stents

SummaryBackgroundWhether low molecular weight heparin (LMWH) enoxaparin is equivalent to unfractionated heparin (UFH) in patients with non-ST-segment elevation myocardial infarction (NSTEMI) undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DES) remains unclear.MethodsA total of 2397 NSTEMI patients who underwent PCI with DES received either LMWH [n=1178, subcutaneous enoxaparin 1mg/kg, b.i.d., initiated after the patient's arrival and continued until 3–5 days after PCI plus reduced dose of UFH (50–70U/kg) during PCI] or UFH (n=1219, 24,000U/day infusion, initiated after the patient's arrival and continued until at least 48h after PCI). The bleeding events and clinical outcomes during in-hospital and at 8 months were compared.ResultsEnoxaparin group had similar incidences of cardiac death, total death, and total major adverse cardiac events (MACE) at 8 months compared with UFH group. The incidences of major and minor bleeding events were also similar between the two groups. Multivariable Cox regression analysis showed that enoxaparin group had similar incidences of cardiac death [adjusted odds ratio (OR) 1.16, 95% confidence interval (CI) 0.64–2.10, p=0.620], total death (adjusted OR 1.08, 95% CI 0.66–1.76, p=0.760), and total MACE (adjusted OR 0.94, 95% CI 0.69–1.28, p=0.692) at 8 months as compared with UFH group.ConclusionsEnoxaparin with reduced dose of UFH only during PCI as an adjunctive antithrombotic therapy in NSTEMI patients undergoing PCI with DES was safe and showed comparable 8-month clinical outcomes as compared with UFH alone