Restenosis after percutaneous coronary intervention for coronary chronic total occlusion. The central role of an optimized immediate post-procedural angiographic result.

BACKGROUND: Factors of restenosis after percutaneous coronary intervention (PCI) for chronic total coronary occlusion (CTO) have not been fully explored. In particular, although the last ACC/AHA guidelines on PCI suggest that a minimum diameter stenosis of 10% with an optimal goal of as close to 0% as possible should be the new benchmark for lesions treated by stenting, angiographic success of PCI for CTO remains in the literature most often defined as a <30% residual diameter stenosis. Whether an optimized immediate post-PCI angiographic result (OAR) defined by a minimal diameter stenosis as close to 0% is associated with a lower restenosis rate in this subset of coronary lesions remains unknown. METHODS: Therefore, we assessed by quantitative coronary analysis (QCA) both the immediate post-PCI and 6-month follow-up angiographic results of 170 successfully treated true CTO. RESULTS: Post-PCI QCA immediate residual diameter stenosis was <30% in all 170 CTOs and OAR defined as a ≤10% residual stenosis was achieved in 133 (78%). Global binary restenosis rate was 21% in the 170 lesions. Restenosis rates were 46% and 14% in the non-OAR group and in the OAR group, respectively (p<0.0001). Multivariate analysis showed that a non-OAR, a younger age and a retrograde approach were independent factors of restenosis. CONCLUSION: Thus, an optimized immediate angiographic result with a minimal diameter stenosis as close to 0% as possible appears to be associated with a lower rate of restenosis after CTO PCI.

Prevalence of binge drinking and associated behaviours among 3286 college students in France.

BACKGROUND: Studies conducted on characteristics of binge drinking and associated behaviours in college student populations are scarce especially in France. Hence, it is important to identify risk factors for binge drinking at university, especially those which may be changed. The aim of this study was to assess the prevalence of binge drinking and associated behaviours across a large sample of college students in Upper Normandy (France). METHODS: A cross sectional study was performed between November 2009 and February 2013 and data on socioeconomic characteristics and behavioural risk factors were collected: alcohol (consumption and misuse of alcohol, occasional and frequent binge drinking), tobacco, cannabis, cyberaddiction, stress and depression. An anonymous self-administered questionnaire was filled out by college student volunteers from Upper Normandy (France) either online or by paper questionnaire. Analyses were performed using multivariate logistic regression models. RESULTS: A total of 3286 students were included. The mean (Standard Deviation (SD)) age of students was 20.8 years (SD = 2.1) with a male-female ratio of 0.60. The prevalence of binge drinking in the never, occasional and frequent categories was respectively 34.9%, 51.3%, and 13.8%. The mean number of units of alcohol consumed per week (except BD episodes) was 0.78 for never, 3.7 for occasional and 10.5 for frequent binge drinkers (p < 0.0001). A positive relation was observed between frequent binge drinking and the following: male gender (AOR 4.77 95% CI (3.43-6.63); p < 0.0001), living in rented accommodation AOR 1.70 95% CI (1.21-2.40; p < 0.0001), attending business school AOR 4.72 95% CI (2.76-8.08; p < 0.0001), regular practice of sport AOR 1.70 95% CI (1.24-2.34; p = 0.001), smoking AOR 5.89 95% CI (4.03-8.60; p < 0.0001), occasional cannabis use AOR 12.66 95% CI (8.97-17.87;p < 0.0001), and alcohol abuse AOR 19.25 95% CI (13.4-27.72; p < .0001). A negative association was observed between frequent binge drinking and grant holder status, living in couples, and stress. CONCLUSIONS: This study highlights the spread of binge drinking among college students and identifies student populations at risk: male gender, living in rented accommodation, regular practice of sport, and other risk behaviours such as use of tobacco, cannabis and alcohol. These behaviours increase with the frequency of binge drinking.

Eating Disorders and Associated Health Risks Among University Students.

OBJECTIVE: To determine the prevalence of eating disorders among university students and its relationship to behavioral characteristics and substance use. DESIGN: Cross-sectional study collected socioeconomic characteristics and behavioral risk. SETTING: University of Upper Normandy, France. PARTICIPANTS: University student volunteers. PHENOMENON OF INTEREST: The Sick, Control, One stone, Fat, Food (SCOFF) screening test was used to identify subjects with eating disorders by a confidential questionnaire self-administered either online or on paper. ANALYSIS: Multivariate logistic regression models with P < .05 considered significant. RESULTS: A total of 3,457 students were included with a male-to-female ratio of 0.57. The prevalence of positive SCOFF screening was 20.5% among students. A positive relation between the positive SCOFF was observed with female gender (adjusted odds ratio [AOR], 2.98; 95% confidence interval [CI], 2.28-3.89; P < .001), stress (AOR, 1.10; 95% CI, 1.09-1.12; P < .001), depression (AOR, 8.62; 95% CI, 3.37-22.10; P < .001) alcohol abuse problems (AOR, 1.52; 95% CI, 1.20-1.95; P = .006), and risk of cyber-addiction (AOR, 5.09; 95% CI, 2.69-9.62; P < .001). CONCLUSIONS AND IMPLICATIONS: Eating disorders are highly prevalent among university students in France and associated with other behavior risks, stress, and depression. It might prove necessary in the future to screen students with the SCOFF questionnaire upon entry to the university to inform student about the risk of eating disorders and advise them to consult with their general practitioner.

Prevalence and association of perceived stress, substance use and behavioral addictions: a cross-sectional study among university students in France, 2009-2011.

BACKGROUND: University students face multiple stressors such as academic overload, constant pressure to succeed, competition with peers as well as concerns about the future. Stress should not be considered on its own, but should be associated with potential risk behaviors leading to onset of substance use and related problems heightened during the university period. The aim of this study was to determine the prevalence of main substance use and behavioral addictions among students in higher education in France and to examine the relationship with perceived stress. METHODS: A self-administered questionnaire was filled out by university student volunteers from Upper Normandy (France) either by anonymous online questionnaire or by paper questionnaire. Data collected included socio-economic characteristics, Perceived Stress Scale (PSS), substance use (tobacco, alcohol, and cannabis) and hazardous behaviors: alcohol abuse problems, smoking, consumption of cannabis, eating disorders, and cyber addiction. RESULTS: A total of 1876 students were included. Mean PSS score was 15.9 (standard deviation = 7.2). Highly stressed students (4th quartile) were compared with lesser stressed students (1st quartile). A positive relation was observed between female gender, regular smokers, alcohol abuse problems, risk of cyberaddiction and especially eating disorders (AOR = 5.45, 95% CI = 3.42-8.69), and increasing PSS score. PSS score however, was not significantly related to the curriculum, regular alcohol use, drunkenness or binge drinking even after additional controlling for use of other substances. We found a significant negative association between stress and practice of sport: students with the most physical activity were less likely to report perceived stress (4th quartile: AOR = 0.57, 95% CI = 0.39-0.80). CONCLUSIONS: This cross-sectional study among university students in France revealed that perceived stress was associated not only with known risks such as alcohol misuse, but also with new risks such as eating disorders and cyber addiction. These results could help to develop preventive interventions focussing on these risk behaviors and subsequently improving stress coping capacity in this high-risk population.

Long-term clinical outcome and routine angiographic follow-up after successful recanalization of complex coronary true chronic total occlusion with a long stent length: a single-center experience.

OBJECTIVES: To evaluate clinical and angiographic outcomes after successful recanalization of chronic total coronary occlusion (CTO) with implantation of a long total stent length (SL). BACKGROUND: Routine follow-up angiogram (RFUA) data after successful recanalization of CTO with a long SL are lacking. METHODS: RFUAs were performed at 6 months after successful recanalization of 106 CTOs using drug-eluting stents (DESs) with a long SL (≥ 20 mm) in 102 consecutive patients. RESULTS: Mean number of stents was 3.9 ± 1.8 and mean total SL was 78 ± 32 mm (range, 23-174 mm). Sirolimus-eluting stents (SESs) were used in 100 lesions. In-stent total reocclusion occurred in 2 cases (1 SES and 1 non-SES DES). Restenosis rate was 18% in the 100 SES subgroup (total SL, 79 ± 33 mm; range, 23-174 mm; mean number of stents, 3.9 ± 1.8); younger age and longer total SL were found to be independent predictors of restenosis (longer age: hazard ratio, 0.939; 95% confidence interval, 0.885-0.996; P=.035; longer total SL: hazard ratio, 1.017; 95% confidence interval, 1.00-1.03; P=.045). Restenosis type was diffuse in only 11% and 89% were successfully treated by repeat percutaneous coronary intervention. During a median follow-up of 2 years (interquartile range, 1-4.3 years), major cardiac events other than those angiographically driven at RFUA occurred in 2 patients. CONCLUSION: Angiographic restenosis rate remains acceptable in patients with complex CTO successfully treated by DES despite a long SL.

Immediate and long-term results of a modified simultaneous kissing stenting for percutaneous coronary intervention of coronary artery bifurcation lesions.

OBJECTIVES: We propose a modified simultaneous kissing stenting technique (MSKS) based on systematic implantation of a protective stent in the proximal main vessel (PMV) proximally to the bifurcation before simultaneous kissing stenting (SKS). BACKGROUND: SKS has been proposed in large-size coronary vessel bifurcation lesions (BLs) when the PMV can accommodate two stents. SKS implies, however, low-pressure simultaneous final balloon inflations to avoid retrograde PMV dissection or rupture and therefore may not ensure optimal final stent apposition. METHODS: From January 2005 to May 2008, a total of 97 patients with 100 BLs (true bifurcation in 92%) who underwent MSKS were enrolled in a prospective registry. Drug-eluting stents were used for distal main vessel and side branch. Drug-eluting or large-size bare-metal stents were used as proximal protective stents. RESULTS: Immediate procedural success rate was 100%. Global restenosis rate was 10% (5% in the main vessel and 8% in the side branch) at follow-up angiogram performed at 7 months in all patients (100%). No patient had early or late stent thrombosis. Two cases of non-fatal very late stent thrombosis occurred at 46 and 64 months. Over a mean 4.5-year follow-up period, target lesion revascularization rate was 11%, with only 3% driven by clinical ischemia. CONCLUSION: Protective stent systematic implantation in the PMV represents a newly modified SKS technique that allows safe finalization of the procedure by high-pressure kissing balloon final inflation, ensuring optimal stent apposition with high immediate procedural success and low rates of long-term events.

Simultaneous dual vascular access site for the treatment of coronary artery bifurcation lesions by complex 2-stent technique.

OBJECTIVES: To propose an original approach based on simultaneous dual vascular access site (DAS) using 2 small-size guiding catheters to easily perform complex 2-stent techniques for bifurcation coronary lesions (BL). BACKGROUND: Simultaneous kissing stenting and classic crush technique require large 7 or 8Fr guiding catheters leading to large amounts of contrast medium, vascular access site complications, and sometimes frictions or criss-cross of the 2-stent delivery systems. METHODS: DAS was used in 30 patients with BL (11 radio-radial, 16 radio-femoral, and 3 femoro-femoral). Among 60 guiding catheters, the size was 5Fr in 28, 6Fr in 30, and 7Fr in 2 cases of double adjacent BL. When 2 different size catheters were used, contrast medium injections were done using the smallest size catheter. DAS patients were compared with a group of 30 BL patients treated using a single femoral vascular access site (SAS) with 7 or 8Fr catheters. RESULTS: Success rate was 100% in all patients. Contrast volume used was smaller in DAS than in SAS patients (277 ± 156 cc vs. 380 ± 165 cc,P = 0.01). No vascular access site complication occurred in the sub-group of the 11 DAS radio-radial patients. Postintervention hospitalization duration was shorter in DAS than in SAS (1.9 ± 2 vs. 2.8 ± 2 days,P = 0.048). CONCLUSION: DAS allows to successfully perform complex stenting technique of BL using small-size guiding catheters leading to decreased contrast medium volume, decreased vascular access site complications rates, and shortened hospitalization duration.

Return to work after acute ST-segment elevation myocardial infarction in the modern era of reperfusion by direct percutaneous coronary intervention.

BACKGROUND: Previous studies have evaluated return to work after acute ST-segment elevation myocardial infarction (STEMI) treated medically, after bypass surgery or after percutaneous coronary intervention (PCI) for stable coronary artery disease. However, there are few data regarding return to work after acute STEMI treated by direct PCI. AIMS: To analyse the factors influencing return to work after STEMI treated by direct PCI. METHODS: Two hundred consecutive patients who underwent direct PCI for acute STEMI and who were employed at the time of their STEMI were studied. Stents were used in 94% of patients and glycoprotein IIb/IIIa inhibitors in 77%. RESULTS: Among the 200 patients, 152 (76%) patients returned to work and 48 (24%) did not. Patients who did not return to work did not differ from those who returned to work in terms of time from onset of chest pain to PCI, STEMI location, left ventricular function, extent of vessel disease, PCI technique and success, completeness of revascularization, duration of hospital stay, intrahospital complications and performance of cardiac rehabilitation. Multivariable analysis showed that older age, daytime onset of chest pain, manual labour, rapid call-out of the emergency medical team, unmarried status and a limited number of risk factors were independent predictors of non-return to work. CONCLUSION: Age, sociopsychological and occupational factors appear to be the strongest predictors of return to work after STEMI treated by direct PCI. Clinical and procedural factors as well as cardiac rehabilitation appear to have no impact on return to work in this subset of patients.

The value of stress single-photon emission computed tomography imaging performed routinely at 6 months in asymptomatic patients for predicting angiographic restenosis after successful direct percutaneous intervention for acute ST elevation myocardial infarction.

AIMS: The authors tested the value of stress single-photon emission computed tomography (SPECT) imaging performed systematically for detecting angiographic restenosis in asymptomatic patients who underwent direct percutaneous coronary intervention (PCI) for acute ST segment elevation myocardial infarction (STEMI). Angiographic restenosis of the infarct-related artery after direct PCI for STEMI is often silent and the strategy for follow-up evaluation of asymptomatic patients remains debated. METHODS: A total of 149 patients successfully treated by direct PCI (96% stenting) for STEMI with no symptoms during the follow-up systematically underwent both rest thallium 201/stress Tc 99m setamibi myocardial perfusion imaging and coronary angiogram at 6 months. Patients were followed up for 2.5+/-0.5 years after 6 months control for cardiac events. RESULTS: In the 149 patients, the sensitivity, specificity, positive and negative predictive values and accuracy of SPECT imaging were 48, 61, 35, 72 and 57%, respectively, for detecting binary angiographic restenosis defined as > or =50% diameter stenosis. Whether stress testing was maximal or performed after withheld anti-ischemic drugs did not improve the results. Reversible ischemia at SPECT in the infarct territory did not predict long-term cardiac events. CONCLUSION: These data suggest a poor correlation between stress SPECT imaging and angiographic restenosis at 6 months in patients treated by direct PCI for STEMI who remain asymptomatic at follow-up. The long-term clinical prognostic value of SPECT reversible ischemia in the infarct territory appears also limited in this peculiar subset of patients. These findings should be taken into account in the strategy of the clinical follow-up of this population.

A new approach of primary angioplasty for ST-elevation acute myocardial infarction based on minimalist immediate mechanical intervention.

OBJECTIVES: No reflow has been reported in 12-30% of the patients directly revascularized by angioplasty for acute ST elevation myocardial infarction with the highest incidence after primary stenting in patients with initial thrombolysis in myocardial infarction (TIMI) grade 0 flow. We hypothesized that a minimalist immediate mechanical intervention (MIMI) based on the use of very small size balloons to avoid both large dissection and distal embolization may be sufficient to restore flow in emergency and that recanalization may be sustained by maximized antithrombotic regimen (abcximab, clopidogrel, aspirin and heparin) allowing one to postpone stenting in better conditions. METHODS: MIMI was performed in 93 patients for ST elevation myocardial infarction with initial TIMI grade 0 flow. RESULTS: MIMI resulted in a TIMI grade 3 flow in 77/93 patients (83%). Immediate stenting was performed in the 16 patients with failed MIMI and resulted in a TIMI grade 3 flow in nine (56%). The residual stenosis after MIMI was 81+/-11% and ST segment resolution (> or =50%) at 1 h after reperfusion was obtained in 84%. Stenting was performed the following days in 52 patients with a post-stenting TIMI grade 3 flow in 50 (96%; 100% when stenting done beyond 24 h). No reocclusion occurred between MIMI and stenting. Among the 25 patients without stenting, six had mild stenosis at control angiogram and underwent medical treatment whereas 19 had multiple vessel disease and underwent bypass surgery. CONCLUSIONS: MIMI combined with maximized antithrombotic therapy results in immediate and sustained recanalization with a high rate of ST resolution in a majority of patients with ST elevation myocardial infarction. This approach allows one to postpone stenting in more stable conditions with a low rate of TIMI flow deterioration or to schedule more appropriate medical or surgical alternative management.