Stent thrombosis is a major concern in clinical practice: a single Saudi center experience

Drug-eluting stents [DES] are used in the majority of patients who undergo percutaneous coronary intervention [PCI], and have reduced the rate of in-stent restenosis and repeated revascularization in comparison to bare metal stents. However, stent thrombosis [ST] is an uncommon but serious complication of coronary artery stents that is mostly fatal or presents as a large non-fatal myocardial infarction [MI], usually with ST elevation. To study the incidence of stent thrombosis in Middle Eastern Saudi patients who underwent PCI using both drug-eluting stents [DES] and bare metal stents [BMS]. ST can occur acutely [within 24 h], sub acutely [within 30 days], or as late as one year [late] or even more than one year [very late]. In an observational, single center study in catheterization [cath] lab a total of 1386 patients underwent PCI between January 2008 and September 2010. The study included all patients in that period who had acute coronary syndrome and stable coronary artery disease [CAD]. A total of 1386 patients had PCI and stent deployments; 19 [1.3%] patients had stent thrombosis, four patients [21%] received BMS and 15 patients [79%] received DES. Four patients had acute ST; five had subacute ST; eight patients had late ST; while two patients had very late ST. Nine patients [47%] had DM and eight patients [42%] had hypertension. The incidence of ST in Saudi patients who received DES at our center is similar to internationally reported numbers. Almost half of ST patients are diabetics and there is increasing concern that the risk for late stent thrombosis is slightly higher with DES than BMS.

High bolus tirofiban vs abciximab in acute stemi patients undergoing primary PCI - the tamip study

Primary percutaneous coronary intervention [PCI] has been shown to be an effective therapy for patients with acute myocardial infarction [Ml]. Glycoprotein [GP] llb/llla receptor blockers reduce thrombotic complications in patients undergoing PCI. Most available data relate to Reopro, which has been registered for this indication. GP llb/llla reduce unfavorable outcome in U/Aand non ST-elevation myocardial infarction [STEMI] patients. Only few studies focused on high dose Aggrastat for STEMI patients in the emergency department [ED] before PCI. The aim is to increase the patency during the time awaiting coronary angioplasty in patients with acute Ml. To study the effect of upfront high bolus dose [HDR] of tirofiban on the extent of residual ST segment deviation 1 hour after primary PCI and the incidence of TIMI 3 flow of the infarct-related artery [IRA]. A randomized, open label, single center study in the ED. A total of 90 patients with acute ST-elevation Ml, diagnosed clinically by ECG criteria [ST segment elevation of >2 mm in two adjacent ECG leads] and with an expectation that a patient will undergo primary PCI. Patients were aged 21-85 years and all received heparin 5000 u, aspirin 160 mg, and Plavix 600 mg. Patients were divided in two groups [group I: triofiban high bolus vs group II: Reopro] with 45 patients in each group. In group I, high bolus triofiban 25 meg/kg over 3 min was started in the ED with maintenance infusion of 0.15 meg/kg/ min continued for 12 hours and transferred to cath lab for PCI. Patients in group II were transferred to cath lab, where a standard dose of Reopro was given with a bolus of 0.25 meg/kg and maintenance infusion of 0.125 mcg/kg/min over 12 hours. Results: ST segment resolution and TIMI flow were evaluated in both groups before and after PCI. Thirty-five patients [78%] enrolled in group I and 29 patients [64%] in group II had resolution of ST segment [P-value 0.24]. Twenty-one patients [47% group I] vs 23 patients [51% group II] with P-value 0.83 achieved TIMI 0 flow. Twenty-four patients [53% group I] compared with 22 patients [49% group II] with P-value 0.83 had TIMI 1 to 3 flow before PCI. TIMI 3 flow was achieved in 40 patients [89% group I] compared with 38 patients [84% group II] with P-value 0.76. In this study there was a trend toward better ST segment resolution and patency of IRA [i.e., improved TIMI flow] in patients given high bolus dose Aggrastat in the ED. Larger studies are needed to confirm this finding

Baseline characteristics, management practices, and in-hospital outcomes of patients with acute coronary syndromes: Results of the Saudi project for assessment of coronary events [SPACE] registry

The Saudi Project for Assessment of Coronary Events [SPACE] registry is the first in Saudi Arabia to study the clinical features, management, and in-hospital outcomes of acute coronary syndrome [ACS] patients. We conducted a prospective registry study in 17 hospitals in Saudi Arabia between December 2005 and December 2007. ACS patients included those with ST-elevation myocardial infarction [STEMI], non-ST elevation myocardial infarction and unstable angina; both were reported collectively as NSTEACS [non-ST elevation acute coronary syndrome]. 5055 patients were enrolled with mean age +/- SD of 58 +/- 12.9 years; 77.4% men, 82.4% Saudi nationals; 41.5% had STEMI, and 5.1% arrived at the hospital by ambulance. History of diabetes mellitus was present in 58.1%, hypertension in 55.3%, hyperlipidemia in 41.1%, and 32.8% were current smokers; all these were more common in NSTEACS patients, except for smoking [all P < 0.0001]. In-hospital medications were: aspirin [97.7%], clopidogrel [83.7%], beta-blockers [81.6%], angiotensin converting enzyme inhibitors/angiotensin receptor blockers [75.1%], and statins [93.3%]. Median time from symptom onset to hospital arrival for STEMI patients was 150 min [IQR: 223], 17.5% had primary percutaneous coronary intervention [PCI], 69.1% had thrombolytic therapy, and 14.8% received it at less than 30 min of hospital arrival. In-hospital outcomes included recurrent myocardial infarction [1.5%], recurrent ischemia [12.6%], cardiogenic shock [4.3%], stroke [0.9%], major bleeding [1.3%]. In-hospital mortality was 3.0%. ACS patients in Saudi Arabia present at a younger age, have much higher prevalence of diabetes mellitus, less access to ambulance use, delayed treatment by thrombolytic therapy, and less primary PCI compared with patients in the developed countries. This is the first national ACS registry in our country and it demonstrated knowledge-care gaps that require further improvements

In-hospital adverse clinical outcomes of ST elevation myocardial infarction patients with renal dysfunction

To explore the prognostic value of baseline estimated glomerular filtration rate [eGFR] in Saudi patients presenting with ST elevation myocardial infarction [STEMI], and its impact on hospital therapies. The STEMI patients with a baseline serum Creatinine enrolled in the SPACE [Saudi Project for Assessment of Coronary Events] registry were analyzed. This study was performed in several regions in Saudi Arabia between December 2005 to December 2007. Based on eGFR levels, patients were classified into: more than 90.1 ml/min [normal renal function], 90-60.1 [borderline/mildly impaired renal function], 60-30 [moderate renal dysfunction], and less than 30 ml/ min/1.73 m[2] [severe renal dysfunction]. Two thousand and fifty eight patients qualified for this study. Of these, 1058 patients had renal dysfunction. Patients with renal dysfunction were older, and had a higher prevalence of risk factors for atherosclerosis. Patients with moderate or severe renal dysfunction were less likely to be treated with beta blockers, angiotensin converting enzymes inhibitors, statins, or reperfusion therapies. Significantly worse outcomes were seen with lower eGFR in a stepwise fashion. The adjusted odds ratio of in-hospital death in patients with eGFR less than 30ml/min was 5.3 [95% CI, 1.15-25.51,p=0.0383]. A low baseline eGFR in STEMI patients is an independent predictor of all major adverse cardiovascular outcomes, and a marker for less aggressive in-hospital therapy