Is the transradial approach associated with decreased acute kidney injury following percutaneous coronary intervention in patients not complicated by major bleeding and haemodynamic disturbance?

BACKGROUND: The impact of the transradial approach (TRA) on the development of acute kidney injury (AKI) after percutaneous coronary interventions (PCI) has been controversial. METHODS: We retrospectively analysed 463 patients undergoing PCI for either acute or chronic coronary syndrome. Excluded patients were those with missing laboratory or procedural data, acute/decompensated heart failure, major bleeding, haemodynamic instability, long-term dialysis and mortality. The primary endpoint of the study was the incidence of AKI after PCI, which was defined as an increase in serum creatinine (SCr) level of 0.5 mg/dl or 25% from the baseline. Secondary endpoints were change in SCr level, increase in SCr of ≥ 0.3 and ≥ 0.5 mg/dl, and increase in SCr of ≥ 25 and ≥ 50%. We compared the incidence of AKI between the TRA and the transfemoral approach (TFA) in the overall and a propensity score (PS)-matched study population. RESULTS: The study population included 339 patients. After PS matching, we obtained a well-balanced population of 182 patients. The differences between the incidence of AKI in the TRA and TFA were not significant in both the overall (9.0 vs 11.2%, p = 0.503) and PS-matched (9.9 vs 7.7%, p = 0.601) study population. TRA resulted in a significantly lower incidence of SCr increase of ≥ 50% in unmatched patients. However, after PS matching, there was no difference between the TRA and TFA in any variable of secondary post-PCI renal outcomes. Age, female gender, baseline SCr level, baseline estimated glomerular filtration rate and contrast volume were independent predictors of AKI. CONCLUSION: Compared to the conventional TFA, TRA was not associated with a reduced incidence of AKI after PCI in patients not complicated by major bleeding, acute heart failure and haemodynamic disturbances.

Diastolic Dyssynchrony in Acute ST Segment Elevation Myocardial Infarction and Relationship with Functional Recovery of Left Ventricle.

BACKGROUND: Incidence of diastolic dyssynchrony (DD) and its impact on functional recovery of left ventricle (LV) after ST segment elevation myocardial infarction (STEMI) is not known. METHODS: Consecutive patients with STEMI who underwent successful revascularization were prospectively enrolled. Echocardiography with tissue Doppler imaging was performed within 48 hours of admission and at 6 months. LV end-diastolic volume index (EDVI), end-systolic volume index (ESVI), ejection fraction (EF), and left atrial volume index (LAVI) were calculated. Diastolic delay was calculated from onset of QRS complex to peak of E wave in tissue Doppler image and presented as maximal temporal difference between peak early diastolic velocity of 6 basal segments of LV (TeDiff). Study patients were compared with demographically matched control group. RESULTS: Forty eight consecutive patients (55 ± 10 years, 88% male) and 24 controls (56 ± 6 years, 88% male) were included. TeDiff was higher in STEMI than in controls (35.9 ± 19.9 ms vs. 26.3 ± 6.8 ms, p = 0.025). Presence of DD was higher in STEMI than controls (58% vs. 33%, p = 0.046) according to calculated cut-off value (≥ 29 ms). There was no correlation between TeDiff and change in EDVI, ESVI, and LAVI at 6 months, however TeDiff and change in EF at 6 months was positively correlated (r = 0.328, p = 0.023). Patients with baseline DD experienced remodeling less frequently compared to patients without baseline DD (11% vs. 38%, p = 0.040) during follow-up. CONCLUSION: STEMI disrupts diastolic synchronicity of LV. However, DD during acute phase of STEMI is associated with better recovery of LV thereafter. This suggests that DD is associated with peri-infarct stunned myocardium that is salvaged with primary intervention as well as infarct size.

Effectiveness of Left Judkins Catheter as a Single Multipurpose Catheter in Transradial Coronary Angiography From Right Radial Artery: A Randomized Comparison With Conventional Two-Catheter Strategy.

OBJECTIVES: To investigate safety and efficacy of left Judkins (JL) catheter as a single multipurpose catheter in transradial coronary angiography (TRA). BACKGROUND: Most operators use standard femoral catheters instead of special multipurpose transradial catheters during TRA. METHODS: Patients undergoing TRA through right radial artery (RRA) were randomized into single-catheter approach with JL3.5 and two-catheter approach with JL3.5 and right Judkins 4.0 catheters. Primary outcome measures were rate of success in selective and stable engagement of both coronary arteries with JL catheter, procedure and fluoroscopy times. RESULTS: Of 314 patients enrolled, 206 patients (aged 60.3 ± 12.4 years, 36.9% female) were randomized. JL3.5 was successful in 66.0% of patients as a single catheter. Additional catheter was needed more frequently in single-catheter group (34 vs. 0.97%, P < 0.001). Single-catheter approach reduced procedure time significantly (6.7 ± 2.1 vs. 7.9 ± 3.3 minutes, P = 0.002). However on average there was 19.7% relative increase in fluoroscopy time (2.61 ± 1.38 vs. 2.18 ± 1.54 minutes, P = 0.035) with single-catheter approach. Radial artery spasm tended to develop more frequently in two-catheter group (22.3 vs. 12.6%, P = 0.067). In nearly half of the patients, procedure had been completed successfully with JL3.5 catheter within a fluoroscopy time similar to that of two-catheter group. CONCLUSION: In TRA from RRA, JL3.5 catheter can be very effective when dedicated multipurpose catheter is not available. As a single multipurpose catheter, JL works perfectly in nearly half of procedures without prolonging procedure and fluoroscopy times. However insisting on a single-catheter approach with JL could unnecessarily increase fluoroscopy time and, hence, radiation exposure. (J Interven Cardiol 2016;29:257-264).

Inappropriate combination of warfarin and aspirin.

OBJECTIVE: A combination of warfarin and aspirin is associated with increased bleeding compared with warfarin monotherapy. The aim of the study was to investigate the incidence and appropriateness of the combination of warfarin and aspirin in patients with atrial fibrillation (AF) or mechanical heart valve (MHV). METHODS: This cross-sectional study included consecutive patients with AF or MHV on chronic warfarin therapy (>3 months) without acute coronary syndrome or have not undergone a revascularization procedure in the preceding year. Medical history, concomitant diseases, and treatment data were acquired through patient interviews and from hospital records. RESULTS: Three hundred and sixty patients (213 with AF, 147 with MHV) were included. In those with AF, a significantly higher warfarin-aspirin combination was observed with concomitant vascular disease (38.8% vs. 14.6%), diabetes (36.6% vs. 16.3%), statin therapy (40% vs. 16.9%), left ventricular systolic dysfunction (33.3% vs. 17.5%) (p<0.05 for all). The use of combination therapy was similar between different CHADS-VASc scores. In patients with MHV, higher combination therapy was observed in males (41% vs. 26.7% in females; p=0.070), concomitant vascular disease (47.8% vs. 29.8%; p=0.091), and AF (56.3% vs. 29.8%; p=0.033). Independent predictors of warfarin-aspirin combination were concomitant vascular disease, diabetes, and (younger) age in patients with AF and were concomitant AF and male sex in patients with MHV. Interestingly, the incidence of combination therapy was found to increase with a higher HAS-BLED score in both patients with AF and MHV (p<0.001). CONCLUSION: The combination of warfarin and aspirin was found to be prescribed to patients with AF mainly for the prevention of cardiovascular events, for which warfarin monotherapy usually suffices. On the other hand, co-treatment with aspirin appeared to be underused in patients with MHV.

Effectiveness of sublingual nitroglycerin before puncture compared with conventional intra-carterial nitroglycerin in transradial procedures: a randomized trial.

AIM: Sublingual (SL) nitroglycerin administered before radial artery puncture can improve cannulation success and decrease the incidence of radial artery spasm (RAS) compared with intra-arterial (IA) nitroglycerin in transradial procedures. METHODS: Patients undergoing diagnostic transradial angiography were randomized to IA (200 mcg) or SL (400 mcg) nitroglycerin. Primary endpoints were puncture time and puncture attempts. Secondary endpoint was the incidence of RAS. RESULTS: Total of 101 participants (mean age 60±11years, 53% male) were randomized (51 in IA and 50 in SL groups). Puncture time (50 [36-75] vs 50 [35-90] sec), puncture attempts (1.18±0.48 vs 1.20±0.49), multiple punctures (13.7 vs 16.0%) and RAS (19.6 vs 24.0%) were not statistically different between IA vs SL groups respectively. A composite endpoint of all adverse events related to transradial angiography (multiple punctures, RAS, access site crossover, hypotension/bradycardia associated with nitroglycerin and radial artery occlusion) was very similar in IA vs SL groups (39 vs 40%, respectively). However puncture time was significantly longer with SL nitroglycerin in patients <1.65m height (47 [36-66] vs 63 [41-110] sec, p=0.042). Multiple punctures seemed higher with SL nitroglycerin in patients with diabetes (0 vs 30%, p=0.028) or in patients <1.65m height (7.4 vs 25%, p=0.085). Likewise, RAS with SL nitroglycerin seemed more frequent in smokers compared to IA nitroglycerin (0 vs 27%, p=0.089). CONCLUSIONS: SL nitroglycerin was not different from IA nitroglycerin in terms of efficiency and safety in overall study population. However it may be inferior to IA nitroglycerin in certain subgroups (shorter individuals, diabetics and smokers).

Contrast layering: late clearance of contrast dye--a novel angiographic phenomenon of early atherosclerosis.

Patients with angiographically normal coronary arteries sometimes exhibit delayed clearance of contrast medium. This contrast layering (CL) was tested with intravascular ultrasound (IVUS) and markers of endothelial dysfunction and oxidative stress. The study group (n = 26) consisted of patients with CL and the control group (n = 32) comprised patients with normal coronary arteries despite angina symptoms. The CL was observed in 36 coronary arteries of 26 patients in the study group. Total antioxidant status and nitric oxide levels were significantly lower; total oxidant status, malondialdehyde plasma levels, and oxidative stress index were significantly higher in patients with CL than in controls. The IVUS studies revealed that atherosclerotic plaque burden, fibrous tissue, dense calcific tissue, and necrotic core ratios were significantly higher in the coronary segments with CL compared with adjacent normal segments. These results support the concept of CL as a new angiographic appearance of early atherosclerosis.

Evaluation of atrial conduction features with tissue Doppler imaging in patients with chronic obstructive pulmonary disease.

BACKGROUND: The electrical activity of atria can be demonstrated by P waves on surface electrocardiogram (ECG). Atrial electromechanical delay (AEMD) measured with tissue Doppler imaging (TDI) echocardiography can be a useful non-invasive method for evaluating atrial conduction features. We investigated whether AEMD is prolonged in patients with chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Study consisted of 41 (15 female, 26 male, mean age 62 + 12 years) patients with COPD and 41 healthy subjects. Pulmonary function tests,12 lead surface ECG and echocardiographic examination were performed and recorded. P wave changes on surface ECG, minimum (P (min)) and maximum (P (max)) duration of P wave and its difference as P wave dispersion (P (wd)) were measured and recorded. Atrial electromechanic delay (AEMD) was calculated from colored-TDI recordings. RESULTS: Pulmonary functions were significantly lower in COPD group than the control group as expected. Right atrial areas and pulmonary arterial systolic pressures (PAP) were significantly higher in COPD group than the controls (right atrial area: 11.9 ± 3.4 cm(2) and 8.2 ± 2.2 cm(2), p < 0.0001 and PAP: 38.4 ± 12.2 and 19.0 ± 3.2 mmHg p < 0.0001, respectively). P wave intervals on surface ECG were significantly increased in COPD patients than the control group (P (max): 105 ± 11 and 90 ± 12 ms, p < 0.0001; P (min): 60 ± 12 and 51 ± 10 ms, p = 0.003 and P (wd): 39 ± 10 and 31 ± 7 ms, p < 0.0001). According to the AEMD measurements from different sites by TDI, there was a significant delay between the onset of the P wave on surface ECG and the onset of the late diastolic wave in patients with COPD when compared with controls measured from tricuspid lateral septal annulus (TAEMD) (COPD: 41.3 ± 9.8 ms, control: 36 ± 4.5 ms; p = 0.005). There was a positive correlation between TAEMD and right atrial area (r = 0.63, p < 0.0001) and also between TAEMD and PASP (r = 0.43, p < 0.0005) and a negative correlation between TAEMD and forced expiratory volume (FEV1) (r = -0.44, p = 0.04). CONCLUSIONS: Right atrial electromechanical delay is significantly prolonged in patients with COPD. The right atrial area, PAP and FEV1 levels are important factors of this prolonged delay. Also the duration of atrial depolarization is significantly prolonged and propagation of depolarization is inhomogeneous in patients with COPD. These may be the underlying mechanisms to explain the atrial premature beats, multifocal atrial tachycardia, atrial flutter and fibrillation often seen in patients with COPD secondary to these changes.