ABSTRACT
BACKGROUND: Early reperfusion of the occluded coronary artery during acute myocardial infarction is considered crucial for reduction of infarcted mass and recovery of ventricular function. Effective microcirculation and the balance between protective and harmful lymphocytes may have roles in reperfusion injury and may affect final ventricular remodeling. METHODS/DESIGN: BATTLE-AMI is an open-label, randomized trial comparing the effects of four therapeutic strategies (rosuvastatin/ticagrelor, rosuvastatin/clopidogrel, simvastatin plus ezetimibe/ticagrelor, or simvastatin plus ezetimibe/clopidogrel) on infarcted mass and left ventricular ejection fraction (LVEF) (blinded endpoints) in patients with ST-segment elevation myocardial infarction submitted to fibrinolytic therapy before coronary angiogram (pharmacoinvasive strategy). All patients (n = 300, 75 per arm) will be followed up for six months. The effects of treatment on subsets of B and T lymphocytes will be determined by flow-cytometry/ELISPOT and will be correlated with the infarcted mass, LVEF, and microcirculation perfusion obtained by cardiac magnetic resonance imaging. The primary hypothesis is that the combined rosuvastatin/ticagrelor therapy will be superior to other therapies (particularly for the comparison with simvastatin plus ezetimibe/clopidogrel) for the achievement of better LVEF at 30 days (primary endpoint) and smaller infarcted mass (secondary endpoint) at 30 days and six months. The trial will also evaluate the improvement in the immune/inflammatory responses mediated by B and T lymphocytes. Omics field (metabolomics and proteomics) will help to understand these responses by molecular events. DISCUSSION: BATTLE-AMI is aimed to (1) evaluate the role of subsets of lymphocytes on microcirculation improvement and (2) show how the choice of statin/antiplatelet therapy may affect cardiac remodeling after acute myocardial infarction with ST elevation. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02428374 . Registered on 28 September 2014.
Subject(s)
Anti-Inflammatory Agents/administration & dosage , B-Lymphocytes/drug effects , Hydroxymethylglutaryl-CoA Reductase Inhibitors/administration & dosage , Inflammation Mediators/blood , Platelet Aggregation Inhibitors/administration & dosage , ST Elevation Myocardial Infarction/drug therapy , T-Lymphocytes/drug effects , Thrombolytic Therapy , Adenosine/administration & dosage , Adenosine/analogs & derivatives , Anti-Inflammatory Agents/adverse effects , B-Lymphocytes/immunology , B-Lymphocytes/metabolism , Biomarkers/blood , Brazil , Clinical Protocols , Clopidogrel , Coronary Angiography , Drug Therapy, Combination , Enzyme-Linked Immunospot Assay , Ezetimibe/administration & dosage , Female , Flow Cytometry , Humans , Hydroxymethylglutaryl-CoA Reductase Inhibitors/adverse effects , Magnetic Resonance Imaging , Male , Metabolomics , Platelet Aggregation Inhibitors/adverse effects , Proteomics , Research Design , Rosuvastatin Calcium/administration & dosage , ST Elevation Myocardial Infarction/blood , ST Elevation Myocardial Infarction/diagnostic imaging , ST Elevation Myocardial Infarction/immunology , Simvastatin/administration & dosage , Stroke Volume/drug effects , T-Lymphocytes/immunology , T-Lymphocytes/metabolism , Thrombolytic Therapy/adverse effects , Ticagrelor , Ticlopidine/administration & dosage , Ticlopidine/analogs & derivatives , Time Factors , Treatment Outcome , Ventricular Function, Left/drug effects , Ventricular Remodeling/drug effectsABSTRACT
OBJECTIVES: We sought to assess a new modality of radiofrequency intravascular ultrasound (IVUS) called iMAP-IVUS (Boston Scientific, Santa Clara, California) during the evaluation of patients presenting with high-risk acute coronary syndromes. BACKGROUND: There are limited data on plaque tissue characterization and phenotype classification using iMAP-IVUS. METHODS: In the iWonder study patients presenting with ST-elevation myocardial infarction (STEMI) or non-STEMI underwent three-vessel grayscale IVUS and iMAP-IVUS tissue characterization prior to percutaneous intervention. In total 385 lesions from 100 patients were divided into culprit (n = 100) and nonculprit (n = 285) lesions. Lesion phenotype was classified as (i) thin-cap fibroatheroma (iMAP-derived TCFA); (ii) thick-cap fibroatheroma; (iii) pathological intimal thickening; (iv) fibrotic plaque; and (v) fibrocalcific plaque. RESULTS: Culprit lesions had smaller minimum lumen cross-sectional area (MLA) with greater plaque burden compared to non-culprit lesions. Volumetric analysis showed that culprit lesions had longer length and larger vessel and plaque volumes compared to non-culprit lesions. iMAP-IVUS revealed that culprit lesions presented more NC and fibrofatty volume, both at lesion level and at the MLA site (all P < 0.001). Any fibroatheroma was more frequently identified in culprit lesions compared with non-culprit lesions (93% vs. 78.9%, P = 0.001), anywhere within the lesion 19.0%, P < 0.001) as well as at the MLA site (18.0% vs. 9.5%, P = 0.07). CONCLUSIONS: Three-vessel radiofrequency iMAP-IVUS demonstrated a greater plaque burden and higher prevalence of any fibroatheroma as well as iMAP-derived TCFAs in culprit versus non-culprit lesions in patients presenting with STEMI or non-STEMI undergoing percutaneous coronary intervention. © 2017 Wiley Periodicals, Inc.
Subject(s)
Acute Coronary Syndrome/diagnostic imaging , Coronary Artery Disease/diagnostic imaging , Coronary Vessels/diagnostic imaging , Non-ST Elevated Myocardial Infarction/diagnostic imaging , Plaque, Atherosclerotic , ST Elevation Myocardial Infarction/diagnostic imaging , Ultrasonography, Interventional/methods , Acute Coronary Syndrome/pathology , Acute Coronary Syndrome/therapy , Aged , Coronary Artery Disease/pathology , Coronary Artery Disease/therapy , Coronary Vessels/pathology , Female , Fibrosis , Humans , Image Interpretation, Computer-Assisted , Male , Middle Aged , Non-ST Elevated Myocardial Infarction/pathology , Non-ST Elevated Myocardial Infarction/therapy , Percutaneous Coronary Intervention , Phenotype , Predictive Value of Tests , Prospective Studies , Risk Factors , Rupture, Spontaneous , ST Elevation Myocardial Infarction/pathology , Severity of Illness Index , Vascular Calcification/diagnostic imaging , Vascular Calcification/pathologyABSTRACT
BACKGROUND: Early reperfusion of the occluded coronary artery during acute myocardial infarction is considered crucial for reduction of infarcted mass and recovery of ventricular function. Effective microcirculation and the balance between protective and harmful lymphocytes may have roles in reperfusion injury and may affect final ventricular remodeling. METHODS/DESIGN: BATTLE-AMI is an open-label, randomized trial comparing the effects of four therapeutic strategies (rosuvastatin/ticagrelor, rosuvastatin/clopidogrel, simvastatin plus ezetimibe/ticagrelor, or simvastatin plus ezetimibe/clopidogrel) on infarcted mass and left ventricular ejection fraction (LVEF) (blinded endpoints) in patients with ST-segment elevation myocardial infarction submitted to fibrinolytic therapy before coronary angiogram (pharmacoinvasive strategy). All patients (n = 300, 75 per arm) will be followed up for six months. The effects of treatment on subsets of B and T lymphocytes will be determined by flow-cytometry/ELISPOT and will be correlated with the infarcted mass, LVEF, and microcirculation perfusion obtained by cardiac magnetic resonance imaging. The primary hypothesis is that the combined rosuvastatin/ticagrelor therapy will be superior to other therapies (particularly for the comparison with simvastatin plus ezetimibe/clopidogrel) for the achievement of better LVEF at 30 days (primary endpoint) and smaller infarcted mass (secondary endpoint) at 30 days and six months...
Subject(s)
Magnetic Resonance Spectroscopy , Myocardial Infarction , B-Lymphocytes , Metabolomics , ProteomicsABSTRACT
O ultrassom intracoronário (USIC) é o método adjunto mais utilizado na Cardiologia Intervencionista, e sua análise depende de normas para a aquisição, mensuração e interpretação das imagens. Ao associar a caracterização tecidual, o artefato causado pelo fio-guia pode hiperestimaro porcentual de núcleo necrótico em determinadas lesões, levando à classificação equivocada defibroateroma. Descrevemos os efeitos quantitativos e na análise tecidual resultantes da subtração do efeitodo artefato do fio-guia nas lesões ateroscleróticas em pacientes com síndrome coronária aguda. Métodos: Foram avaliados 21 pacientes com infarto do miocárdio pós-trombólise com USIC em escala de cinzas e com a tecnologia iMAP®, totalizando 76 lesões.Resultados: O USIC em escala de cinzas mostrou que as lesões tinham extensão média de 21,01 ± 18,03 mm e apresentavam elevada carga de placa (52,07 ± 7,56%). A análise pelo iMAP® demonstrou que, após a subtração do artefato do fio-guia, houve redução de todos os componentes teciduais (necrótico, calcífico, lipídico e fibrótico), porém de maneira mais acentuada do núcleo necrótico (diferença média de 3,59%). Além disso, após a subtração do artefato, 12,4% das lesões que inicialmente apresentavam núcleo necrótico ≥ 10% passaram a não ser mais classificadas como fibroateroma.Conclusões: A análise da placa de ateroma pela tecnologia iMAP® mostrou que o artefato do fio-guia superestimou o componente tecidual do núcleo necrótico. Essa interferência pode mudar errônea e categoricamente as características fenotípicas de lesões mais benignas e estáveis (fibróticas) para lesões potencialmente instáveis, como os fibroateromas, na relação de um em cada dez pacientes...
Intravascular ultrasound (IVUS) is the most widely used ancillary method in Interventional Cardiology, and its analysis depends on standards for acquisition, measurement and interpretation of the images. By associating tissue characterization, the artifact caused by the guidewire may overestimate the percentage of necrotic core in certain lesions, leading to misclassification of fibroatheroma. In this paper we described quantitative and tissue analysis effects resulting from subtracting the effect of guidewire artifact on atherosclerotic lesions in patients with acute coronary syndrome. Methods: Twenty-one patients with post-thrombolysis myocardial infarction were evaluated with grayscale IVUS and iMAPTM technology, totaling 76 lesions. Results: Grayscale IVUS showed that the lesions had a mean length of 21.01 ± 18.03 mm and revealed highplaque burden (52.07 ± 7.56%). The analysis by iMAPTM demonstrated that, after subtracting the guidewire artifact, there was a reduction of all tissue (necrotic, calcific, lipid and fibrotic) components, but more markedly in necrotic core (mean difference: 3.59%). In addition, after artifact subtraction 12.4% of the lesions that initially exhibited a necrotic core ≥ 10% ceased to be classified as fibroatheroma.Conclusions: An atheroma analysis by iMAPTM technology showed that the guidewire artifact over estimated the tissue component of the necrotic core. This interference may change, in an erroneous and categoric alway, the phenotypic characteristics of more stable and benign (fibrotic) lesions to potentially unstable lesions, for example, fibroatheromas, in a ratio of one out of ten patients...
Subject(s)
Humans , Male , Female , Evaluation Studies as Topic/methods , Patients , Drug Therapy , Acute Coronary Syndrome/therapy , Ultrasonography/methods , Coronary Angiography/methods , Data Interpretation, Statistical , Risk Factors , Myocardial Infarction/therapy , Plaque, Atherosclerotic/diagnosis , Plaque, Atherosclerotic/therapy , Thrombolytic Therapy/methodsABSTRACT
Introdução: Atualmente, existe grande debate acerca da fisiopatologia do infarto agudo do miocárdio e da composição tecidual e morfológica das lesões responsáveis por eventos isquêmicos. Entretanto, poucos estudos investigaram a aplicabilidade da tecnologia iMAP® na caracterização tecidual desses pacientes. Avaliamos pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST pós-fibrinolítico com ultrassom intravascular em escala de cinzas e com a tecnologia iMAP®, a fim de descrever a composição tecidual das lesões culpadas pelo infarto agudo do miocárdio. Métodos: Foram avaliadas três artérias coronárias epicárdicas com ultrassom intravascular em escala de cinzas e com a tecnologia iMAP® de 25 pacientes com infarto agudo do miocárdio com supradesnivelamento do segmento ST pós-trombólise, com critérios de reperfusão. Resultados: A média de idade foi de 51 ± 11,5 anos, com predomínio do sexo masculino (72%). A artéria mais frequentemente envolvida foi a coronária direita (48%). O ultrassom intravascular mostrou que as lesões culpadas eram longas (extensão de 31,0 ± 17,2 mm) e com elevado porcentual de volume de placa (58,5 ± 5,1%). No ponto de maior obstrução, ou seja, na área luminal mínima, a carga de placa foi de 82,5 ± 7,5%. Além disso, o índice de remodelamento médio foi ...
Background: Currently, there is a great debate about the pathophysiology of acute myocardial infarction and tissue composition and morphology of lesions responsible for ischemic events. However, few studies have investigated the applicability of tissue characterization using iMAPTM technology in these patients. We evaluated patients with ST-segment elevation myocardial infarction after thrombolytic therapy with grayscale intravascular ultrasound and iMAPTM technology to describe the tissue composition of the culprit lesions. Methods: Twenty-five ST-segment elevation myocardial infarction patients with successful reperfusion had the three major epicardial coronary arteries evaluated by grayscale intravascular ultrasound and iMAPTM technology. Results: Mean age was 51 ± 11.5 years with a prevalence of males (72%). The artery most often involved was the right coronary artery (48%). Intravascular ultrasound showed that the culprit lesions were long (mean extension 31.0 ± 17.2 mm) with a high percent of plaque volume (58.5 ± 5.1%). At the point of highest obstruction (minimal luminal area), the plaque burden was 82.5 ± 7.5%. Furthermore, the mean remodeling index was 1.4 ± 1.0, indicating positive remodeling. iMAPTM analysis of the lesion and minimal luminal area showed a prevalence of fibrotic and necrotic components when compared to other components. Conclusions: In ST-segment elevation myocardial infarction patients, the culprit lesion showed ...
ABSTRACT
Objetivo - Relatar a experiência do Setor de Hemodinâmica do Hospital Säo Paulo (Escola Paulista de Medicina) na retirada percutânea de corpos estranhos intravasculares, analisando as principais técnicas utilizadas. Métodos - No período de 1985 a 1991, 15(0,18//) dos 7.936 procedimentos em nosso serviço relacionaram-se a corpos estranhos intravasulares em dez homens e cinco mulheres. Foram encontrados fragmentos de "intracath" em 9 pacientes (60//) cateteres diagnósticos em quatro (26,8//). Um paciente (6,6//) apresentava um cateter de Swan-Ganz com nó verdadeiro em veia cava superior e outro, um fragmento de fio guia retido no ramo circunflexo da artéria coronária esquerda durante a angioplastia transluminal coronária. Para a retirada dos corpos estranhos intravasculares foram utilizadas a técnica do laço por meio de cateter improvisado em 11 casos, o biótomo endomiocárdio em um caso e uma modificaçäo da técnica do laço para a retirada de fragmento intracoronário. Em dois casos de fragmentos periféricos, optou-se pela conduta expectante. Resultados - Obtivemos um sucesso de 100// nos 13 procedimentos de retirada de corpos estranhos intravasculares. Nos dois casos onde a conduta foi expectante näo ocorreram complicaçöes no seguimento clínico. Conclusäo - A técnica percutânea, principalmente a do laço, pela sua facilidade de execuçäo, alta eficácia, baixo custo e baixa incidência de complicaçöes deve ser o método de escolha para a retirada de corpos estranhos intravasculares. Devido ao inadequado seguimento na literatura, a melhor conduta nos casos periféricos ainda näo está bem estabelecida
Purpose - To report our experience on percutaneos vascular foreigh body retrievel and to analyse current techniques employed. Methods - From 1985 to 1991, 15 (0.18%) of 7.963 procedures performed in the Cardiac Catheterization Laboratory - Hospital São Paulo were intravascular foreign body retrieval: 9 (60%) intracath, 4 (26.8%) diagnostic catheters, one Swan Ganz catheter entrapped at superior cava vein and one fragment of angioplasty guide-wire in the circunflex branch of the left coronary artery. The snare technique was used in 11 cases, a endomyocardial bioptome device in 1 case and modified snare technique for the intracoronary wire fragment retrieval was used in 1 case. In two cases of embolized fragment in peripheral arteries, no attempt was done for retrieval. Results - All (100%) of the 13 attempted procedures were sucessfull. The two foreign bodies not removed had an uneventfull follow-up. Conclusion - The snare technique for percutaneous retrieval of intravascular foreign bodies is sofe and has excellent results. The management peripheral fragments is not well defined yet
