One-year clinical outcomes and relative costs of primary infarct artery stenting versus angioplasty following systemic thrombolysis for acute myocardial infarction.

We investigated the clinical effectiveness and relative cost of two different infarct artery revascularization strategies in patients following systemic thrombolysis for acute myocardial infarction. The clinical efficacy and relative cost of stenting and angioplasty have not been investigated in patients requiring infarct artery revascularization after systemic thrombolysis for myocardial infarction. We prospectively enrolled 220 consecutive patients who received thrombolytic therapy for acute myocardial infarction and were subsequently treated with either angioplasty or primary stenting of the infarct artery. In-hospital and 1-year clinical outcomes, including death, myocardial infarction, and repeat revascularization, and total hospital costs over the 1-year study period were assessed. Compared to angioplasty, primary stenting resulted in lower in-hospital mortality (4% vs. 0%; P = 0.01) and reduced rates of repeat percutaneous or surgical revascularization (7% vs. 0%; P = 0.0009). At 1-year follow-up, stenting was associated with a lower death rate (6.25% vs. 0%; P = 0.002) and reduced repeat infarct artery revascularization (11% vs. 27%; P = 0. 001). Initial hospitalization costs were higher in the stent group ($11,818 +/- $3,377 vs. $9,723 +/- $8,661; P = 0.014) due primarily to catheterization laboratory-related expenditures ($7,346 +/- $2, 395 vs. $3,567 +/- $1,212; P = 0.0001). However, the cumulative 1-year medical cost difference between the two groups was not significant ($13,938 +/- $5,939 vs. $12,914 +/- $9,308; P = 0.33). Following thrombolytic therapy, primary infarct artery stenting reduced in-hospital and 1-year mortality and revascularization rates compared to angioplasty. Stenting was associated with higher initial hospital costs, which were off-set by lower revascularization rates, resulting in comparable total hospitalization costs after 1 year. These findings have important clinical and economic implications in an increasingly cost-conscious health care environment. Cathet. Cardiovasc. Intervent. 49:135-141, 2000.

Clinical predictors of improved long-term blood pressure control after successful stenting of hypertensive patients with obstructive renal artery atherosclerosis.

Despite a high procedural success rate, long-term blood pressure control after successful renal artery stenting of hypertensive patients has been inconsistent. This most likely reflects the absence of clinical guidelines for the selection of patients likely to benefit from renal revascularization. A cohort of 150 consecutive hypertensive patients (mean age, 66.7 years; 86 women) with 180 renal artery lesions (> or =75%) underwent primary Palmaz stent deployment. Mean arterial blood pressure (MAP), serum creatinine, and antihypertensive medication requirements were monitored prospectively. Specific definitions of blood pressure cure, improvement, or treatment failure were followed. Renal artery duplex Doppler or angiography was performed to assess stent patency at a mean 13 months (range, 7-15 months). Multivariate logistic regression analysis was used to select clinical variables that best related to a beneficial blood pressure control at follow-up. The procedural success rate was 97.3% (146 patients) and major in-laboratory complications were infrequent (1.3%). Late MAP values in 127 patients (91%) fell from 110 +/- 13.7 to 97.6 +/- 10.6 mm Hg (P < 0.001); antihypertensive medication requirements decreased from 2.9 +/- 1.2 to 1.9 +/- 1.1 (P < 0.01). The 13-month stent restenosis rate defined by duplex Doppler or angiography was 12%. Multivariate logistic regression analysis identified a preprocedure MAP of >110 mm Hg (odds ratio, 2.9; P = 0.003) and bilateral renal stenoses (odds ratio, 4.6; P = 0.009) as predictors of a beneficial blood pressure response at follow-up. This study provides general preprocedure guidelines for the selection of hypertensive patients with atherosclerotic renal lesions likely to benefit from primary Palmaz stenting and confirms a high procedural success and low stent restenosis rate.