Non Surgical Management of Unprotected Isolated Ostial Left Main Coroner Artery Disease

Prevalence of Left Main Coroner Artery (LMCA) stenosis inpatients undergoing coronary angiography was 2.5 to 10 %, almosrt all patients suffer from concomitantatherosclerotic disease of other coronary branches. Incontrast, an isolated atherosclerotic lesion of LMCA is very rare. with iscidences 0.07 to 0.15 %. Coroner artery by pass graft surgery (CABG) has been recommended as the standard treatment in LMCA disease, however, percutaneous coronary interventions (PCI) on the LMCA remained in scope, as some patients with high risk or contra indications of CABG and very limited life expectancy, still had no other option than PCI. A 58th years old man with factor; smoker, dyslipidemia and hypertention, complain of chest discomfort, he was referred with diagnosis of APS CCS III and MSCT coroner revealed mild plaque burden with critical subtotal occlusion i n in LMCA, calcified plaque in LAD and other vessels were normal. He refuse CABG and went for PCI, angiography revealed significant isolated unprotected LMCA disease. Successful PCI using anchor wire technique and implantation of BMS in the lesion was done. Patient discharged on day 6 of hospitalization with no complication

Jakarta Cardiovascular Care Unit Network System

A tremendous progress has been made in the management of patients with ST elevation myocardial infarction (STEMI) over the last 20 years. Primary percutaneous coronary intervention (PPCI) is the preferred option for treating STEMI patients, but offering an easy, direct and fast access to this procedure is still difficult due to geographic and structural medical services differences, especially in developing countries such as Indonesia. Analysis of Jakarta Acute Coronary Syndrome registry 2010 showed a proportion of patients not recieving acute repercusion therapy of 59% from 654 STEMI patients and majority of them (52%) were from inter-hospital referral. The time from onset of infarction to hospital admission was more than 12 hours in almost 80% cases. Network organization is central to optimize patient care at the acute stage of an MI and there is a strong need to build a cardiovascular care unit network system that is well organized in Jakarta. This involves a multidisciplinary approach that should give an appropriate diagnosis and initial treatment with rapid and safe transport to a PCI capable hospital. Thus, harmonizing the activities of all hospitals in Jakarta that will give the best cardiovascular services to the community by providing two acute reperfusion therapy options (PPCI or pharmaco-invasive strategy) depending on the time needed for the patient to reach the cath-lab

Vacular Complication Comparison between Radial versus Femoral Approach of Primary Percutaneous Coronary Intervention using Eptifibatide

Background.The transfemoral approach for percutaneous coronary intervention (PCI) has the complications in vascular access site more than transradial approach. Risk of vascular complications will increase in using eptifibatide. Methods.. This is a prospective cross sectional study involving 52 STEMI patients qualified to primary PCI. 26 patients in transfemoral approaches and 26 patients in transradial approaches. In these two groups, we compare the incidence of vascular complications such as bleeding, arteriovenous fistula, pseudoaneurysm and artery occlusion. Results. From the 52 subjects of this study, found 94.2% men and 5.8% women, mean age 54.3 9.9 years with the highest risk factors were smoking (67.3%), hypertension (51.9%), dyslipidemia (34.6%), diabetes (30.8%) and family history (11.5%). There were no significantly statistic relationship between duration of puncture and PCI procedures between the two groups. Incidence of vascular complications occurred in the femoral group (19.1% vs. 0), consist of arteriovenous fistula (11,5%), pseudoan-eurysm (3,8%), and minor bleeding (3,8%). Minor bleeding occurred in female subject with age 77 years. Conclusion. There was no significant difference in vascular complications between transfemoral approaches with transradial approaches on the Primary PC

Relation of Level of Platelet Inhibition after Eptifibatide with Major Cardiovascular Events in ST-Segment Elevation Acute Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

Background: Eptifibatide, an inhibitor of glycoprotein IIb/IIIa administered as adjunctive therapy to reperfusion therapy Primary PCI in STEMI patients. Persistently high platelet reactivity was found in patients who experienced recurrent atherothrombotic events during antiplatelet therapy. Objective: To evaluate the level of platelet inhibition after eptifibatide therapy and to assess the relation between level of platelet inhibition and Major Cardiaovascular event (MACE). Methods: Platelet function test by Multiplate analyzer was performed in STEMI Patients who undergone Primary-PCI, 10 minutes after a bolus of eptifibatide. MACE were prospectively monitored during hospitalization and the incidence of MACE correlated with the measured level of platelet inhibition. Results: From 99 subjects, approximately 55% of the subjects were non-responders (high platelet reactivity). 18 patients experienced MACE, most were heart failure (8 people), malignant arrhythmias (3 people), recurrent angina (2 people), stroke (2 people) and reinfarction, infections and major bleeding each 1 person. 12 subjects experienced MACE was from the non-responder group and 8 subjects from the responder grup. The study was found that the level of platelet inhibition wasnt an independent predictor for the risk of MACE. Conclusion: Less achieved therapeutic effects of platelet Inhibition (non-responders) was found in the majority (55%) subjects. Different level of platelet inhibition wasnt an independent predictor for the risk of MACE

Implantasi Drug-eluting Stentatas Indikasi Off-label: Pengalaman dan Luaran Klinis di Pusat Jantung Nasional Harapan Kita

Background. Food and Drug Administration (FDA) of Unites States set the indication of drug-eluting stent (DES) on the product label (on-label indication). In the clinical practice, many patients received DES implantation outside the indication (off-label indication). Several “real-world” register showed off-label implantation reach prevalence of 50-60% with wide-ranging clinical outcomes.Objectives. To report the frequency, procedural complications, stent thrombosis (ST) and major cardiovascular events (MACE) of DES implantation with off-label indication in the National Cardiac Center Harapan Kita.Methods. This retrospective cohort study included patients who underwent coronary intervention with one or more DES (sirolimus or paclitaxel) implantation at 2006. Subjects were grouped into on-label and off-label indication. Subjects were followed-up until mid 2008.Results. 196(59%) of total patients who received DES implantation in 2006 in PJNHK are on off-label indications. The most frequent off-label indication was long-lesion intervention. There were more patients with previous myocardial infarction, PCI and CABG in off-label group. No significant difference of procedural complication rates between on-label and off-label group (2.2% vs. 2.6%, P =0.57). There was no significant difference of stent thrombosis rate. There was higher incident of MACE in off-label than on-labelgroup (17.9% vs. 8.6%, P =0.03). This difference was most contributed by incident of cardiac death. The adjusted hazard ratio of off-label was 1.7 (95% CI 0.8 – 3.6; P = 0.16); with several confounding factors including previous cerebrovascular disease, creatinine clearance <60 mL/min, non-elective PCI and double antiplatelet cessation. Conclusion. Off-label indication was quite frequent but has non-significant difference of TVR and ST rate compared to on-label indication. There was higher incident of MACE in off-label group, but this may be influenced by several clinical confounders.Latar Belakang. Food and drug administration (FDA) Amerika Serikat menetapkan indikasi yang ditera pada label produksi drug-eluting stent (DES) (disebut indikasi on-label). Beberapa register ”real-world” menunjukan implantasi off-label mencapai 50-60% dari seluruh populasi, dengan luaran (outcome) klinis yang sangat bervariasi. Penelitian ini akan melihat karakteristik pasien yang dilakukan implatasi stent atas indikasi off-label. Metode. Penelitian kohor retrospektif pada penderita penyakit  jantung koroner yang menjalani intervensi koroner perkutan (IKP) dengan implantasi satu atau lebih DES (sirolimus atau paclitaxel) selama tahun 2006. Subjek dikelompokkan menjadi kelompok indikasi on-labeldan off-label. Indikasi on-label didefinisikan sebagai lesi de novo yang tidak lebih panjang dari 30 mm pada arteri koroner native dengan diameter arteri 2,5 - 3,5 mm untuk sirolimus dan tidak lebih panjang dari 28 mm pada arteri koroner nativedengan diameter arteri 2,5 - 3,75 mm untuk paclitaxel. Subjek diikuti sejak implantasi DES hingga pertengahan 2008. Sebagai luaran adalah kejadian komplikasi prosedur, kejadian stent thrombosis(ST), dan KKM yang meliputi target vessel revascularization(TVR), IMA dan kematian kardiak. Hasil. Sebanyak 196 (59%) dari total pasien yang mendapatkan implantasi DES pada tahun 2006 di PJNHK adalah atas indikasi off-label. Implantasi off-labelpada lesi panjang adalah yang tersering. Kelompok off-labellebih banyak dengan riwayat IMA, riwayat IKP atau riwayat BPK sebelumnya. Tidak didapatkan perbedaan bermakna pada angka kejadian komplikasi prosedur antara kelompok on-labeldan off-label(2,2% vs 2,6%, p=0,57). Tidak didapatkan perbedaan signifikan pada kejadian ST antara kedua kelompok. Insidens KKM ditemukan lebih tinggi pada kelompok off-labeldaripada on-label(17,9% vs 8,6%, p=0,03). Perbedaan KKM ini terutama terlihat pada perbedaan insiden kematian kardiak antara kedua kelompok (p = 0,02). Hazard ratio indikasi off-label adalah 1,7 (KI 95% 0,8 – 3,6; P = 0,16); dengan beberapa faktor perancu yaitu riwayat penyakit serebrovaskular, bersihan kreatinin < 60 mL/menit, tipe IKP yang non-elektif dan penghentian antiplatelet ganda. Kesimpulan. Implantasi DES atas indikasi off-label cukup sering dan memiliki luaran TVR dan ST yang tidak berbeda bermakna dibandingkan dengan indikasi on-label. Insidens KKM lebih tinggi pada indikasi off-label, namun hal ini masih dipengaruhi oleh beberapa faktor perancu klinis lain

Bleeding Predictor in ST-Elevation Myocardial Infarction Underwent Primary Percutaneous Coronary Infarction: The Indonesian (INA) Bleeding Risk Score

Background Acute myocardial infarction still become one of the leading mortality cause in the world. Among these patients, ST elevation myocardial infartion (STEMI) has the greatest mortality rate among other type of Myocardial Infarction. When a myocard infarct patient have bleeding events, mortality rate greatly increased. Up until now, there is no specific bleeding risk assessment tool to predict bleeding events in STEMI patient. Methods A retrospective cohort study, done in National Cardiovascular Center Harapan Kita, Jakarta in STEMI patients underwent Primary Percutaneous Coronary Intervention (PPCI). Bleeding event was defined according to definition by Bleeding Academic Research Consortium (BARC) European Society of Cardiology, 2011. Categories for data obtained was basic characteristics, clinical examinations, initial therapies, lab results, x-ray, PPCI procedures, and in hospital treatments. Statistical analysis was done using multivariat analysis using logistic regression method and then converted to a scoring system. Results 579 sampels fit the inclusion and exclusion criteria. Bleeding event occured in 42 patients (7.3%). Indonesia bleeding score (Range 1-100) was created by assignment of variables that included in the final model according to their Odds Ratio (OR) values. Those variables are: female gender (OR 2.91, CI 1.23-6.91), Killip class 3 / 4 (OR 5.64, CI 2.27-14.03), Age ? 62 y.o (OR 2.19, CI 1.00-4.83), White blood cell >12.000 (OR 2.12, CI 0.95-4.73), Creatinine >1.5 (OR 2.17, CI 0.95-4.96), Body Mass Index ? 25 (OR 1.71, CI 0.83-3.51), Multiple coronary lesion (OR 1.95, CI 0.83- 4.54), Femoral access (OR 2.33, CI 0.77-7.01), and TPM implantation (OR 3.21, CI 1.28-8.07). These variabels was converted into two type of scoring system. The INA-1 contains all of the variables, and INA-2 minus variables related to interventional result and procedures. Conclusion Indonesia bleeding score quantifies risk for in-hospital bleeding event in STEMI patients underwent PPCI, which enhances baseline risk assessment for STEMI care

Association of Ebtifibatide Administration Timing and TIMI Flow of Infarct Related Artery During Primary PCI

Background. Optimal administration timing of Glicoprotein IIb/IIIa inhibitor in STEMI patients undergoing Primary PCI is controversial. Several stud -ies have shown that early administration of eptifibatide, which is given to patients with pain awitan of 3 hours. This study was aimed to evaluated effect of eptifibatide administra-tion timing to TIMI grading flow in first angiographic IRA during primary PCI in patients with STEMI. Methods and result. Of 116 consecutive STEMI patients who underwent primary PCI, 79 patients received ebtifibatide 90 minutes (Group 2) before first angiographic of IRA. There were no significant differences of TIMI 3 flow proportion after PCI between the groups (86.1% vs 83.8% for Group 1 and 2 respectively, p = 0.745). Group 2 showed more frequent TIMI 2 flow (18.9% vs 5.1%, p = 0.036) but tend to have less frequent TIMI 0 flow (56.8 % vs 67.1%, p = 0.281). Conclusion. Patients who received eptifibatide > 90 minutes before first angiographic IRA during primary PCI achieved more appropriate TIMI flow as compare to that received eptifibatide < 90 minutes

Myeloperoxidase as a Predictor for Subsequent Cardio-vascular Events in Patients with Acute Myocardial Infarction

Background. Inflammation has been linked to all stages of the develop-ment of vulnerable plaque which not only causes platelet activation but also proceeded by activation of polymorphonuclear neutrophils (PMNs). Myeloperoxidase (MPO), a hemoprotein abundantly expressed by PMNs and secreted during activation, possesses potent proinflammatory prop-erties and may contribute directly to tissue injury. Among predictors of major adverse cardiovascular events (MACE) that we have been widely used and known, such as hs-CRP and Troponin T, it still unknown whether MPO also provides prognostic information in patients with acute myocar-dial infarction (AMI). Objectives. The aim of our study is to search predictive value of MPO and to compare MPO with hs-CRP and Troponin T as a predictor of MACE in patients with AMI. Methods.Cohort-prospective study was done, conducted from April to June 2006 in the emergency department of National Cardiovascular Cen-tre - Harapan Kita, (NCVC-HK), Jakarta. MPO, hs-CRP, and troponin T serum levels were assessed in 93 patients with AMI. It recorded death, re-infarctions, angina, revascularization, and heart failure during 6 months of follow-up. Results.Patients with MPO serum level > 204,9 g/l have increased risk of cardiovascular events (HR 6.76; 95% CI 3.37-13.56, P < 0.001). In statistical analysis, MPO (sensitivity 83.1%; specificity 82.4%) is a stronger independent predictor for subsequent cardiovascular events than Tropo-nin T (sensitivity 59.8%; specificity 71.6%) and hs-CRP (sensitivity 48.5%; specificity 46.1%). Conclusions.MPO serum levels powerfully predict an increased risk for subsequent cardiovascular events in patients with acute myocardial infarction