Pentraxin 3 Is Highly Specific for Predicting Anatomical Complexity of Coronary Artery Stenosis as Determined by the Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery Score

BACKGROUND AND OBJECTIVES: The aim of this study was to examine the hypothesis that pentraxin 3 (PTX3) can have a diagnostic value for predicting anatomical complexity of coronary artery stenosis as measured by the Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) score. SUBJECTS AND METHODS: We investigated the association of systemic arterial PTX3 with SYNTAX score among 500 patients with ischemic heart disease assigned to medical treatment (251), percutaneous coronary intervention (PCI) (197), or coronary artery bypass graft (CABG) (52). RESULTS: The clinical judgment of the cardiologists was near-perfectly concordant with the SYNTAX score. Mean {99% confidence intervals (CIs)} SYNTAX scores were 5.8 (5.1-6.6), 18.4 (17.1-19.8), and 33.2 (32.8-33.6) in patients assigned to medical therapy, PCI, and CABG, respectively. The AROC (95% CIs) for discriminating between patients with and without a high SYNTAX score (>23) was 0.920 (0.895-0.946) for systemic arterial levels of PTX3. As the systemic arterial level of PTX3 increased, the SYNTAX scores also increased almost in a curvilinear fashion, with the value corresponding to the SYNTAX score of 23 being 0.29 ng . dL-1. This cutpoint achieved a sensitivity of 0.66 (0.57-0.74), a specificity of 0.94 (0.91-0.96), a positive predictive value of 0.79 (0.70-0.87), and a negative predictive value of 0.89 (0.85-0.92). CONCLUSION: We observed that systemic arterial levels of PTX3 were associated with the SYNTAX score in a curvilinear fashion. The discriminatory power of systemic arterial levels of PTX3 for a high SYNTAX score was excellent. The interesting finding of this study was the near perfect concordance between the decisions made by the cardiologists based on their clinical judgment and the SYNTAX score. The systemic arterial PTX3 level of 0.29 ng . dL-1 was highly specific for diagnosing complex coronary artery stenosis.

Comparison between intracoronary abciximab and intravenous eptifibatide administration during primary percutaneous coronary intervention of acute ST-segment elevation myocardial infarction

Administration of glycoprotein 2b/3a inhibitors is an effective adjunctive treatment strategy during primary percutaneous coronary intervention [PPCI] for ST-segment elevation myocardial infarction [STEMI]. Recent data suggest that an intracoronary administration of these drugs can increase the efficacy of PPCI. This study was done to find any potential difference in terms of efficacy of administering intracoronary Abciximab vs. intravenous Eptifibatide in primary PPCI. A total of 40 STEMI patients who underwent PPCI within 12 hours of symptom onset were randomized to either an intracoronary Abciximab [0.25 microg/kg] bolus or two boluses of intravenous Eptifibatide [0.180 microg/kg] each 10 minutes. The primary end points were enzymatic infarct size, myocardial reperfusion measured as ST-segment resolution [STR], and post-procedural thrombolysis in myocardial infarction [TIMI] grade flow of the infarct-related artery. The secondary end points were intra-procedural adverse effect [arrhythmia] and no-reflow phenomenon, in-hospital mortality, reinfarction, hemorrhage, and post-procedural global systolic function. Post-procedural TIMI grade 3 flow was achieved in 95% and 90% of the intracoronary Abciximab and intravenous Eptifibatide groups, respectively [p value = 0.61]. The infarct size, as assessed by the area under the curve of creatine phosphokinase-MB in the first 48 hours after PPCI [micromol/L/hr], was similar between the intracoronary Abciximab and intravenous Eptifibatide groups: 6591 [interquartile range [IQR], 3006.0 to 11112.0] versus 7,294 [IQR, 3795.5 to 11803.5]; p value = 0.59. Complete STR was achieved in 55% and 45% of the intracoronary Abciximab and intravenous Eptifibatide groups, respectively [p value = 0.87]. No deaths, urgent revascularizations, reinfarctions, or TIMI major bleeding events were observed in either group. The intracoronary administration of Abciximab was not superior to the intravenous administration of Eptifibatide in the STEMI patients who underwent primary PCI

[Prevalence of Clopidogrel resistance in patients candidate for percutaneous coronary intervention]

In patients who undergo coronary angioplasty, Clopidogrel resistance is accompanied with increased risk of cardiovascular events [unstable angina, recurrent MI, death, etc]. In different studies resistance to Clopidogrel has been reported to be up to 30%. Identification of these patients and determining the contributing factors can help us to reduce cardiovascular events. This cross-sectional study was carried out on candidates of elective percutaneous coronary intervention [PCI] in Shahid Modarres Hospital. Resistance to Clopidogrel was evaluated by platelet aggregometry in platelet-rich-plasma [PRP] using a routine aggregometer [Helena Biosciences Europe]. The platelet aggregation was measured before and after exposure to 20 micro mol ADP as a reagent. Contributing factors such as age, gender, metabolic factors and medications were examined by Chi-square test. This study was run on 90 candidates for elective PCI. Their mean age was 62.6 +/- 10.2 years and 52.2% were male. 20% were semi-responder and 7.8% was non-responder. Gender, hypertension, obesity, using angiotensin-converting enzyme inhibitors and calcium channel blockers did not have any role in Clopidogrel resistance, but diabetes, hyperlipidemia, using beta blockers and statins were more common in Clopidogrel resistant patients [p<0.005]. Considering both non-responders and semi-responders, prevalence of resistance to Clopidogrel was 27.8%, so we must be worried about it. Further larger studies should be designed to determine and manage the contributing factors

Immediate results and six-month clinical outcome after percutaneous coronary intervention in patients with prior coronary artery bypass surgery

Redo coronary artery bypass grafting surgery [CABG] is associated with a higher risk of mortality than the first operation. However, the impact of percutaneous coronary intervention [PCI] on the outcome in such patients is currently unclear. We evaluated the in-hospital and six-month clinical outcomes of post-CABG patients who underwent PCI in our center. Between April 2008 and July 2009, 71 post-CABG patients [16 women and 55 men] underwent 110 stent implantations [75% drug-eluting stents] for 89 lesions. Sixty percent of the PCI procedures were performed on the native coronary arteries, 32% on graft arteries, and 8% on both types of vessels. Major adverse cardiac events [MACE] were recorded in hospital and at six months' follow-up. The procedural success rate was 93%, and the in-hospital MACE rate was 5.6% [1 death, 3 myocardial infarctions]. At 6 months, the incidence of MACE WAS 5.6% [no death or myocardial infarction, but 4 target lesion revascularizations] and 4 [5.6%] in-stent restenoses. There was no statistically significant difference in the comparison of MACE between the patients treated in either native arteries or in the grafts [15% vs. 12%, p value =0.8]. According to the univariate analysis, hypertension and the use of the bare metal stent vs. the drug-eluting stent were the significant predictors of MACE, whereas the multivariate analysis showed that only hypertension [OR = 3.7, 95% CI 3.44-4, p value < 0.048] was the independent predictor of MACE. The mean of the left ventricular ejection fraction had no effect on the incidence of MACE [p value = 0.9]. The multivariate analysis showed hypertension [p value < 0.048] and the use of the bare metal stent [p value <0.018] were the independent predictors of MACE. The chronic total occlusion [CTO] [p value <0.01] was the independent predictor of the success rate. The prevalence of diabetes had no impact on the incidence of MACE according to the univariate analysis [p value= 0.9]. Our multivariate analysis showed that hypertension and use of the bare metal stent were the independent predictors of MACE and that chronic total occlusion was the independent predictor of the procedural failure rate. PCI is preferable to redo CABG for post-CABG patients. The independent predictors of MACE were hypertension and bare metal stents

Potential role of thermal therapy as an adjunct treatment in congestive heart failure

The clinical and economic importance of heart failure is widely recognized. The incidence of heart failure is on the increase, particularly with the aging of the population around the world. It is time for a paradigm shift in heart failure management. Alternative non-pharmacological strategies to remodel the failing ventricle will shape a major portion of heart failure therapy in the decade ahead. Exposure to heat is widely used as a traditional therapy in many cultures. In this paper, we will review recent data that suggest thermal therapy may be helpful as an adjunctive non-pharmacological treatment for heart failure

Evaluation of underlying coronary stenosis severity in patients with acute MI after thrombus aspiration using export catheter

Early clinical and retrospective angiographic evaluations indicated that in patients with acute myocardial infarction [MI], vulnerable plaques most often represented a mild luminal stenosis. More recent studies drawing upon prospective angiograms, however, have demonstrated that in majority of patients with acute MI, the underlying stenosis is significant. Twenty-eight patients with acute MI candidated for thrombectomy were enrolled in this study. Thrombectomy was performed using export thrombectomy catheters. After the injection of nitroglycerin, the severity of the lesions was determined by two independent operators. Between April 2007 and February 2008, 28 patients, comprised of 26 men and 2 women with acute MI, were evaluated, The underlying stenosis was >/= 50% in 22 [78.6%] patients and <50% in the remaining 6 [20.4%] patients [P value < 0.01]. The right coronary artery was the most common vessel involved in the lesions < 50%. Contrary to the general belief of many cardiologists, the majority cases of myocardial infarction occur in consequence of significant stenosis

Coronary artery perforation after guidewire removal

Coronary artery perforation is a rare, but potentially serious, complication of percutaneous coronary intervention and is associated with a high incidence of death, Q-wave myocardial infarction, and emergency coronary bypass surgery. Management is different but requires prompt recognition and treatment. We describe a case of coronary perforation only after guidewire removal and also review the management of vessel rupture and perforation

combined approach to severe multi-organ atherosclerosis

Severe coronary artery disease often coexists with peripheral vascular atherosclerosis. The assessment of the supra-aortic circulation is, therefore, of clinical relevance. We herein describe a case of coronary artery disease treated with surgical revascularization using the internal mammary artery and thereafter the progressive atherosclerotic disease of the native coronary arteries as well as the left subclavian and left renal arteries. We also describe and discuss the clinical presentation, the diagnostic procedures, and the therapeutic approach with respect to the percutaneous transluminal angioplasty of the subclavian, renal, and right coronary arteries

Prevention of atrioventricular block during radiofrequency ablation by pace mapping of Koch's triangle

Complete atrioventricular block [AV block] is a serious complication of slow pathway ablation therapy in the treatment of atrioventricular nodal re-entrant tachycardia [AVNRT]. The present study was aimed at determining whether the electroanatomical pace mapping of Koch's triangle could significantly improve the safety, efficiency, and efficacy of selective slow pathway ablation in the treatment of AVNRT. A total number of 124 patients were selected to be studied consecutively for radiofrequency [RF] ablation therapy in the treatment of AVNRT. The subjects were divided into two groups: one, designated Group 1, to serve as the control group, and the other, designated Group 2, to serve as the study group. Conventional fluoroscopic slow pathway ablation was performed on the Group 1 subjects [n=66], with the Group 2 subjects receiving slow pathway ablation therapy guided by pace mapping of Koch's triangle. The slow pathway ablation in Group 2 [n=58] was performed with regard to the pace mapping data obtained on the basis of the St-H interval in the anteroseptal [AS], midseptal [MS], and posteroseptal [PS] regions of Koch's triangle. The anterograde fast pathway [AFP] location was determined based on the shortest St-H interval obtained by stimulating the anteroseptal [AS], midseptal [MS], and posteroseptal [PS] aspects of Koch's triangle. In the Group 2 subjects, AFP location was AS in 50 [86.2%] of the cases, MS in 7 [12%] of the cases, and PS in 1 case [1.7%]. One patient with posteroseptal AFP was administered retrograde fast pathway ablation therapy. One patient in the control group [Group 1], representing 1.5% of the group, developed persistent AV block in the course of the treatment, but none of the subjects in the study group [Group 2] developed any complications. It was concluded that an atypical fast pathway location is conducive to the development of atrioventricular block in the ablation therapy in AVNRT, with pace mapping of Koch's triangle having the capacity to eliminate the risk of any such complication developing. It follows that it helps to identify the AFP location before ablation therapy is administered in AVNRT, thereby improving the safety of the treatment

Randomized, blinded trial comparing enoxparin with unfractionated heparin in patients undergoing contemporary percutaneous coronary intervention

This study was designed to examine a unique and low dose use of intravenous enoxaparin in elective percutaneous coronary intervention [PCI] that would be applicable to an unselected population regardless of age, weight, and renal function. There is limited experience in anticoagulation using intravenous low-molecular-weight heparin in PCI. A total of 100 consecutive patients undergoing elective PCI were treated with a single IV bolus of enoxaparin [0.5mg/kg] in group A of patients [n=50] or with unfractionated heparin in group B of patients [n=50]. Sheaths were removed immediately after the procedure in patients treated with enoxaparin and some hours later in those treated with unfractionated heparin. In group A, ACT was 124.6 +/- 9.3 before PCI and 149.2 +/- 17.1 after that [P<0.05]. In group B, one patient [2.9%] developed groin hematoma. No deaths, MI, or urgent target vessel revascularization were reported. Low- dose [0.5 mg/kg] IV enoxaparin allows a target level of anticoagulation in patients undergoing PCI, appears to be safe and effective, allows immediate sheath removal, and does not require dose adjustment