Remote ischemic preconditioning for prevention of contrast induced nephropathy-Insights from an Indian study.

OBJECTIVES: To study if four cycles of remote ischemic preconditioning (RIPC) could offer protection against contrast induced nephropathy (CIN) and post procedural renal dysfunction in high risk patients undergoing percutaneous coronary intervention (PCI). METHODS: This was a prospective single blind randomized sham controlled trial where patients undergoing coronary angioplasty with stage III chronic kidney disease were randomized into sham preconditioning and remote ischemic preconditioning. The primary outcome was the reduction in the incidence of CIN. The secondary outcomes were the maximum improvement in eGFR, maximum reduction in serum creatinine and composite of requirement of hemodialysis, death and rehospitalization for heart failure up to 6 weeks after PCI. RESULTS: Eleven out of fifty patients in the study group developed CIN (22%) compared to eighteen out of the fifty control patients (36%) (p=0.123). There was a statistically significant improvement in the post procedure creatinine values at 24h (p=0.013), 48h (p=0.015), 2 weeks (p=0.003), 6 weeks (p=0.003) and post procedure glomerular filtration rate (eGFR) values at 24h (p=0.026), 48h (p=0.044), 2 weeks (p=0.015) and 6 weeks (p=0.011) in study group compared to control group. The secondary outcome composite of requirement of hemodialysis, death and rehospitalization for heart failure was not statistically significant (p: 0.646). CONCLUSION: RIPC does not result in significant reduction of CIN. However RIPC helps in the prevention of post procedural worsening in eGFR and serum creatinine even up to 6 weeks.

Coronary angioplasty in spontaneous coronary artery dissection-Strategy and outcomes.

OBJECTIVE: To study the clinical, angiographic and technical characteristics of patients with spontaneous coronary artery dissection (SCAD) undergoing percutaneous coronary intervention (PCI). METHODS: This was a retrospective single center study where patients with angiographically confirmed SCAD undergoing PCI over a period of 4 years (2013-2017) were analyzed. We also sought to identify the clinical and angiographic predictors of procedural failure during PCI. RESULTS: There were a total of 42 patients with angiographically confirmed SCAD during the study period of which 16 patients (38.1%) underwent PCI. 14 out of the 16 patients (87.5%) taken up for PCI had technical success. In all patients the lesion was initially attempted to cross with a floppy wire and if unsuccessful it was escalated to a hydrophilic wire and finally to a stiff wire The SCAD lesion was crossed with a floppy wire in 71.4% of patients, with a hydrophilic wire in 14.2% and a stiff wire in 7.1% of patients. Wire escalation was required in 5 patients (31.3%) and in 60% of cases there was a technical success after wire escalation. Presence of diabetes mellitus, hypertension, dyslipidemia, smoking, coexisting atherosclerosis, diffuse nature of the lesion, and baseline Thrombolysis in Myocardial Infarction (TIMI)≤2 flow did not predict procedural failure during PCI. CONCLUSION: PCI in SCAD is associated with a fair rate of technical success in our population. Choosing an initial floppy wire and then escalating to a hydrophilic wire followed by a stiff wire is an optimal revascularization strategy.

Predictors of contrast induced nephropathy and the applicability of the Mehran risk score in high risk patients undergoing coronary angioplasty-A study from a tertiary care center in South India.

OBJECTIVE: To study the incidence and predictors of Contrast induced nephropathy (CIN) in high risk patients undergoing coronary angioplasty. To study the applicability of the Mehran Risk Score (MRS) in the prediction of CIN in our population. METHODS: This was a prospective observational study where patients with an estimated glomerular filtration rate (eGFR) between 30 and 60ml/mt undergoing elective percutaneous coronary intervention (PCI) over a period of 15 months were evaluated prospectively for the development of CIN. The patients who developed CIN were then analysed for the presence of specific risk factors. The patients were categorized into the 4 risk groups based on the MRS. RESULTS: 100 high risk patients underwent PCI during the study period. The incidence of CIN was 29%. On multivariate analysis, the presence of anemia (p=0.007), increased contrast volume usage (as defined by >5* B.Wt/S.cr) (p=0.012) and usage of loop diuretics (p=0.033) were independently found to confer a significant risk of CIN. In patients belonging to the high Mehran risk group (MRS10- 15) and very high risk group (MRS >15) the risk of CIN was 3 fold (OR: 3.055, 95% CI: 1.18-7.94, p=0.022) and 24 fold (OR: 24, 95% CI: 2.53-228.28, p=0.006) higher respectively when compared to intermediate and low risk patients (MRS <10). CONCLUSION: The incidence of CIN in high risk patients undergoing PCI is substantially higher in our population compared to similar studies in the west. The MRS risk prediction is pertinent even in an Indian population.

Predictors of no- reflow during primary angioplasty for acute myocardial infarction, from Medical College Hospital, Trivandrum.

BACKGROUND: Primary angioplasty (PCI) for acute myocardial infarction is associated with no-reflow phenomenon, in about 5-25% of cases. Here we analysed the factors predicting no reflow . METHODS: This was a case control study of consecutive patients with acute myocardial infarction who underwent Primary PCI from August 2014 to February 2015. RESULTS: Of 181 patients who underwent primary PCI, 47 (25.9%) showed an angiographic no-reflow phenomenon. The mean age was 59.19±10.25years and females were 11%. Univariate predictors of no reflow were age >60years (OR=6.146, 95%CI 2.937-12.86, P=0<0.001), reperfusion time >6h (OR=21.94, 95%CI 9.402-51.2, P=<0.001), low initial TIMI flow (≤1) (OR=12.12, 95%CI 4.117-35.65, P<0.001), low initial TMPG flow (≤1) (OR=36.19, 95%CI 4.847-270.2, P<0.001) a high thrombus burden (OR=11.04,95%CI 5.124-23.8, P<0.001), a long target lesion (OR=8.54, 95%CI 3.794-19.23, P<0.001), Killip Class III/IV(OR=2.937,95%CI 1.112-7.756,P=0.025) and overlap stenting(OR=3.733,95%CI 1.186-11.75,P=0.017). Multiple stepwise logistic regression analysis predictors were: longer reperfusion time>6h (OR=13.844, 95%CI 3.214-59.636, P=<0.001), age >60 years (OR=8.886, 95%CI 2.145-36.80, P=0.003), a long target lesion (OR=8.637, 95%CI 1.975-37.768, P=0.004), low initial TIMI flow (≤1) (OR=20.861, 95%CI 1.739-250.290, P=0.017). CONCLUSIONS: It is important to minimize trauma to the vessel, avoid repetitive balloon dilatations use direct stenting and use the shortest stent if possible.