Accuracy of the angiography-based quantitative flow ratio in intermediate left main coronary artery lesions and comparison with visual estimation.

BACKGROUND: Revascularization of left main coronary artery (LMCA) stenosis is mostly based on angiography. Indices based on angiography might increase accuracy of the decision, although they have been scarcely used in LMCA. The objective of this study is to study the diagnostic agreement of QFR (quantitative flow ratio) with wire-based fractional flow reserve (FFR) in LMCA lesions and to compare with visual severity assessment. METHODS: In a series of patients with invasive FFR assessment of intermediate LMCA stenoses we retrospectively compared the measured value of QFR with that of FFR and the estimate of significance from angiography. RESULTS: 107 QFR studies were included. The QFR intra-observer and inter-observer agreement was 87% and 82% respectively. The mean QFR-FFR difference was 0.047 ± 0.05 with a concordance of 90.7%, sensitivity 88.1%, specificity 92.3%, positive predictive value 88.1% and negative predictive value 92.3%. All these values were superior to those observed with the visual estimation which showed an intra- and inter-observer agreement of 73% and 72% respectively, besides 78% with the FFR value. The low diagnostic performance of the visual estimation and the acceptable performance of the QFR index measurement were observed in all subgroups analysed. CONCLUSIONS: QFR allows an acceptable estimate of the FFR obtained with intracoronary pressure guidewire in intermediate LMCA lesions, and clearly superior to the assessment based on angiography alone. The decision to revascularize patients with moderate LMCA lesions should not be based solely on the degree of angiographic stenosis.

Titanium-nitride-oxIde-coated stents multicenter registry in diaBEtic patienTs: the TIBET registry.

We sought to explore the immediate clinical and angiographic results of the Titan(®) stent implantation in diabetic patients, as well as the major adverse cardiac events (MACE) at 6-month follow-up. We enrolled 156 consecutive diabetic patients admitted to undergo percutaneous intervention for at least one significant (50%) coronary lesion. All lesions were treated with the Titan(®) stent implantation according to the contemporary interventional techniques. Patients were prospectively followed-up for at least 6 months. The primary endpoint was MACE at 6-month follow-up [cardiac death, myocardial infarction (MI), or target lesion revascularization (TLR)]. Secondary endpoints included angiographic and clinical procedural success, in-hospital MACE, TLR at 6-month follow-up, and stent thrombosis. The mean age was 66.7 ± 9.6 years, (68.4% males). A total of 197 Titan(®) stents were implanted in 163 lesions. Direct stenting was performed in 45.2% of the cases. The mean stent diameter was 3.1 ± 0.61 mm, and the mean length was 18.0 ± 8.9 mm. Average stent deployment pressure was 13.9 ± 4.2 bars. Angiographic procedural success was achieved in 154 (98.7%) cases, and clinical procedural success was achieved in 153 (98.1%) cases. One patient developed in-hospital non-Q-wave MI following the procedure. Clinical follow-up was completed in 155 (99.4%) patients. Three patients (1.9%) died of a cardiac or unknown cause, and two (1.3%) developed MI. TLR was performed in 11 patients (7.1%). Cumulative MACE at 6-month follow-up occurred in 16 (10.3%) patients. No patient suffered stent thrombosis. Titan(®) stent implantation in diabetic patients achieves an excellent immediate clinical and angiographic outcome, with a low incidence of MACE at mid-term follow-up.

Percutaneous coronary intervention with rotational atherectomy for severely calcified unprotected left main: immediate and two-years follow-up results.

INTRODUCTION: According to current practice guidelines, coronary bypass surgery is the standard care option for unprotected left main (ULM) stenosis. However, a group of high surgical risk patients who are not eligible for coronary bypass surgery could benefit from percutaneous coronary intervention (PCI). Severe calcification hampers PCI in this setting, and rotational atherectomy (RA) could be of great help. METHODS: We retrospectively analyzed a cohort of 40 patients with severely calcified ULM stenosis, not eligible for coronary artery bypass grafting, who underwent RA in our center. RESULTS: Forty patients (mean age, 73 ± 8 years; 26 males) with ULM stenosis were treated with RA. Twenty-seven (67%) had distal stenosis. The mean number of treated vessels was 2.38 ± 0.74, with a mean lesion length of 30 ± 18 mm. Abciximab was used in 12 (30%) cases and an intra-aortic balloon pump in three cases. One patient died during the procedure and another two patients died in the first 24 hr after the procedure. The major events registered after the procedure included one significant branch loss, and two minor and one major case of bleeding (the latter requiring transfusion) at the puncture point. After a median of 24.7 (IQR 19.6-34.3) months of follow-up, 12 cardiac deaths were recorded. Survival free of cardiac death was 71 ± 7% and clinical guided target vessel revascularization 19.3 ± 7% at 2 years. CONCLUSION: In a group of high surgical risk patients, RA on severely calcified left main stenosis is feasible and, in spite of high mortality rates, could pose the only possible effective treatment.

The EXTREME registry: titanium-nitride-oxide coated stents in small coronary arteries.

OBJECTIVES: We sought to explore the immediate results of Titan2 stent implantation in small coronary arteries, as well as the incidence of major adverse cardiac events (MACE) at six months follow-up. BACKGROUND: The safety of Titan2 stent has been confirmed in several studies in real-life unselected populations. METHODS: We enrolled 311 consecutive patients admitted for percutaneous intervention for at least one significant (50%) de novo lesion in a native small coronary artery (2.0-2.75 mm). All lesions were treated with Titan2 stent implantation. Patients were prospectively followed up for at least six months. The primary endpoint was MACE at six months follow-up [death, myocardial infarction (MI), or target vessel revascularization (TVR)]. Secondary endpoints included angiographic and clinical procedural success, in-hospital MACE, target lesion revascularization (TLR) during follow-up, and stent thrombosis. RESULTS: The mean age was 67.3 +/- 10.9 years (65.9% males). A total of 356 Titan2 stents were implanted in 353 lesions. Angiographic and clinical procedural success was achieved in 344 (97.5%) patients. No case of in-hospital MACE or acute stent thrombosis was reported. Clinical follow-up was completed for an average of 8 +/- 2 months. Two patients (0.7%) died, and 6 (2.1%) developed MI. TLR was performed in 12 (4.2%) and TVR in 16 (5.5%) patients, all were clinically driven. Cumulative MACE occurred in 20 (6.9%) patients. One patient suffered subacute stent thrombosis, but no late stent thrombosis. CONCLUSIONS: Titan2 stent implantation in small coronary arteries achieves excellent immediate outcome, with a low incidence of MACE at mid-term follow-up.

Percutaneous coronary intervention in heavily calcified lesions using rotational atherectomy and paclitaxel-eluting stents: outcomes at one year.

Heavily calcified lesions present a challenge for percutaneous coronary intervention. With rotational atherectomy, it is possible to treat these lesions and paclitaxel-eluting stents (PESs) reduce the risk of restenosis over the long term. This retrospective study investigated clinical outcomes with rotational atherectomy and PESs in 50 consecutive patients with heavily calcified lesions. Mortality and target lesion revascularization at 1 year (median, 14 months; interquartile range, 8.75-25.5 months) were recorded. Some 52% of patients were aged over 70 years, 68% were male, 52% had acute coronary syndrome, 80% had multivessel disease and 44% were receiving abciximab. Two patients died in hospital, three died during follow-up (one cardiac death) and 3 (6%) underwent target lesion revascularization. At 1 year, the survival rate free of cardiac death was 94% and the survival rate free of target lesion revascularization was 94%. These findings demonstrate that the combination of rotational atherectomy and PESs gives excellent results in heavily calcified lesions.

Intervencionismo coronario en lesiones severamente calcificadas mediante aterectomía rotacional y stent liberador de paclitaxel: resultados tras un año de seguimiento / Percutaneous coronary intervention in heavily calcified lesions using rotational atherectomy and paclitaxel-eluting stents: outcomes at one year

Las lesiones severamente calcificadas dificultan el intervencionismo coronario. La aterectomía rotacional permite tratar estas lesiones y los stents liberadores de paclitaxel (SLP) reducen la reestenosis a largo plazo. Se evaluó retrospectivamente el resultado de la aterectomía rotacional y los SLP en lesiones severamente calcificadas en 50 pacientes consecutivos. Se estudió la mortalidad y la revascularización de la lesión tratada tras 1 año (mediana, 14 meses; intervalo intercuartílico, 8,75-25,5). El 52% eran mayores de 70 años; el 68%, varones; el 52% tenía síndrome coronario agudo; el 80%, enfermedad multivaso y un 44% recibió abciximab. Hubo 2 muertes intrahospitalarias, 3 en el seguimiento (una cardiaca) y 3 (6%) casos de revascularización de la lesión tratada. A 1 año, la supervivencia libre de muerte cardiaca fue del 94% y la supervivencia libre de revascularización de la lesión tratada, del 94%; esto muestra que la estrategia de SLP y aterectomía rotacional en lesiones severamente calcificadas proporciona excelentes resultados (AU)

Heavily calcified lesions present a challenge for percutaneous coronary intervention. With rotational atherectomy, it is possible to treat these lesions and paclitaxel-eluting stents (PESs) reduce the risk of restenosis over the long term. This retrospective study investigated clinical outcomes with rotational atherectomy and PESs in 50 consecutive patients with heavily calcified lesions. Mortality and target lesion revascularization at 1 year (median, 14 months; interquartile range, 8.75-25.5 months) were recorded. Some 52% of patients were aged over 70 years, 68% were male, 52% had acute coronary syndrome, 80% had multivessel disease and 44% were receiving abciximab. Two patients died in hospital, three died during follow-up (one cardiac death) and 3 (6%) underwent target lesion revascularization. At 1 year, the survival rate free of cardiac death was 94% and the survival rate free of target lesion revascularization was 94%. These findings demonstrate that the combination of rotational atherectomy and PESs gives excellent results in heavily calcified lesions (AU)

Arteriopatía periférica en el contexto de la angiografía coronaria: abriendo camino / Peripheral arterial disease and coronary angiography: forging a path

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[In-hospital and long-term mortality in women with acute myocardial infarction treated by primary angioplasty]. / Mortalidad a corto y largo plazo en mujeres con infarto de miocardio tratado con angioplastia primaria.

INTRODUCTION AND OBJECTIVES: Mortality and morbidity after ST-elevation myocardial infarction (STEMI) are higher in women than men. It is not clear whether reperfusion by elective treatment with primary angioplasty can improve the poor prognosis in women with this condition. The objective of this study was to determine the effect of sex on clinical characteristics, and on in-hospital and long-term outcomes in patients with STEMI undergoing reperfusion by primary angioplasty. METHODS: A prospective observational study was performed in 838 consecutive patients with STEMI treated by primary angioplasty at a single hospital. Of these, 183 (22%) were women. RESULTS: Women were older (70 years vs 62 years; P<.01), were less frequently smokers (8% vs 53%; P<.01), more frequently had diabetes (45% vs 27%; P<.01) or hypertension (59% vs 36%; P<.01), presented later for angioplasty (4.1 h vs 3.6 h; P=.05), and experienced cardiogenic shock more frequently during the procedure (21% vs 12%; P<.01). There were no differences in the culprit vessel most often responsible for the infarction, in the procedural success rate, or in stent or glycoprotein IIb/IIIa inhibitor use. The total in-hospital mortality rate was higher in women (22% vs 9%; P<.01), as was the adjusted in-hospital rate (odds ratio 2.5, 95% confidence interval 1.2-5.2). During long-term follow-up after discharge (median 35.4 months), there was no significant difference in age-adjusted survival rate (relative risk 1.2, 95% confidence interval 0.7-1.9). CONCLUSIONS: Despite recent advances in the treatment of STEMI, women experience greater in-hospital mortality, even after adjustment for baseline clinical characteristics. However, the long-term age-adjusted mortality rate in women discharged from hospital was similar to that in men.

[Right versus left radial artery approach for coronary angiography. Differences observed and the learning curve]. / Vía radial derecha o izquierda en la coronariografía. Importancia en la curva de aprendizaje.

There are anatomical differences between right and left radial artery approaches for coronary catheterization that could influence application of the technique. We present the results of a randomized study that compared the effectiveness of the two approaches and identified factors associated with failure of the procedure. The study involved 351 consecutive patients: a left radial approach was used in 180, and a right radial approach, in 171. The procedure could not be completed using the initial approach selected in 15 patients (11 right radial vs. 4 left radial; P=.007). Use of a right radial approach, lack of catheterization experience, patient age >70 years, and the absence of hypertension were found to be independently associated with prolonged fluoroscopy duration and failure using the initial approach. Use of the right radial approach in patients aged over 70 years was associated with a 6-fold increase in the risk of an adverse event. Consequently, use of the right radial approach should be avoided in patients aged over 70 years when trainee practitioners are on the learning curve.

Mortalidad a corto y largo plazo en mujeres con infarto de miocardio tratado con angioplastia primaria / In-hospital and long-term mortality in women with acute myocardial infarction treated by primary angioplasty

Introducción y objetivos. Las mujeres presentan, con respecto a los varones, una mayor mortalidad y morbilidad tras un infarto agudo de miocardio con elevación del segmento ST (IAMEST). Hay controversia sobre si la angioplastia primaria (ACTPp) como tratamiento de elección logra contrarrestar el peor pronóstico de las mujeres en esta situación. El objetivo fue determinar la influencia del sexo en las características clínicas y en el pronóstico intrahospitalario y a largo plazo de un grupo de pacientes con IAMEST tratados con ACTPp como método de reperfusión. Métodos. Estudio observacional prospectivo de una cohorte de 838 pacientes consecutivos, de ellos 183 (22%) mujeres, con IAMEST tratados con ACTPp en un único centro. Resultados. Las mujeres fueron mayores (70 frente a 62 años; p < 0,01), menos fumadoras (el 53 frente al 8%; p < 0,01), más diabéticas (el 45 frente al 27%; p < 0,01), hipertensas (el 59 frente al 36%; p < 0,01), se presentaron con mayor retraso (el 4,1 frente al 3,6 h; p = 0,05) y más shock cardiogénico durante el procedimiento (del 21 frente al 12%; p = 0,01). No hubo diferencias en la arteria causante del IAM, en el éxito angiográfico o en el uso de stents o inhibidores de la glucoproteína IIb/IIIa. La mortalidad intrahospitalaria fue mayor en las mujeres, tanto en el análisis bruto (el 22 frente al 9%; p < 0,01) como en el multivariable (odds ratio = 2,5; intervalo de confianza [IC] del 95%, 1,2-5,2). En el seguimiento clínico a largo plazo (mediana de 35,4 meses) no hubo diferencias en los supervivientes tras el alta tras ajustar por la edad (riesgo relativo = 1,2; IC del 95%, 0,7-1,9). Conclusiones. A pesar de los recientes avances en el tratamiento del IAMEST, las mujeres presentan una mayor mortalidad hospitalaria ajustada por características basales. Las mujeres supervivientes tras el alta hospitalaria tuvieron una similar mortalidad a largo plazo cuando se ajustó por la edad

Introduction and objectives. Mortality and morbidity after ST-elevation myocardial infarction (STEMI) are higher in women than men. It is not clear whether reperfusion by elective treatment with primary angioplasty can improve the poor prognosis in women with this condition. The objective of this study was to determine the effect of sex on clinical characteristics, and on in-hospital and long-term outcomes in patients with STEMI undergoing reperfusion by primary angioplasty. Methods. A prospective observational study was performed in 838 consecutive patients with STEMI treated by primary angioplasty at a single hospital. Of these, 183 (22%) were women. Results. Women were older (70 years vs 62 years; P<.01), were less frequently smokers (8% vs 53%; P<.01), more frequently had diabetes (45% vs 27%; P<.01) or hypertension (59% vs 36%; P<.01), presented later for angioplasty (4.1 h vs 3.6 h; P=.05), and experienced cardiogenic shock more frequently during the procedure (21% vs 12%; P<.01). There were no differences in the culprit vessel most often responsible for the infarction, in the procedural success rate, or in stent or glycoprotein IIb/IIIa inhibitor use. The total in-hospital mortality rate was higher in women (22% vs 9%; P<.01), as was the adjusted in-hospital rate (odds ratio 2.5, 95% confidence interval 1.2-5.2). During long-term follow-up after discharge (median 35.4 months), there was no significant difference in age-adjusted survival rate (relative risk 1.2, 95% confidence interval 0.7-1.9). Conclusions. Despite recent advances in the treatment of STEMI, women experience greater in-hospital mortality, even after adjustment for baseline clinical characteristics. However, the long-term age-adjusted mortality rate in women discharged from hospital was similar to that in men

Vía radial derecha o izquierda en la coronariografía. Importancia en la curva de aprendizaje / Right versus left radial artery approach for coronary angiography. Differences observed and the learning curve

La vía radial izquierda (RI) presenta diferencias anatómicas con la vía radial derecha (RD) que podrían influir en la técnica del cateterismo coronario. Presentamos un estudio aleatorizado que trata de comparar ambas técnicas para valorar los factores relacionados con su complejidad. Se analizó a 351 pacientes consecutivos (180 RI y 171 RD); no se pudo completar el procedimiento por la vía inicial en 15 pacientes (11 RD y 4 RI; p = 0,007). El uso de RD, la inexperiencia, la edad mayor de 70 años y la ausencia de hipertensión arterial tienen relación independiente con un tiempo prolongado de fluoroscopia o el abandono de la vía inicial. El uso de RD en pacientes mayores de 70 años se relaciona con un riesgo de eventos 6 veces mayor, por lo que en una curva de aprendizaje se debería excluir el uso de RD esos pacientes

There are anatomical differences between right and left radial artery approaches for coronary catheterization that could influence application of the technique. We present the results of a randomized study that compared the effectiveness of the two approaches and identified factors associated with failure of the procedure. The study involved 351 consecutive patients: a left radial approach was used in 180, and a right radial approach, in 171. The procedure could not be completed using the initial approach selected in 15 patients (11 right radial vs. 4 left radial; P=.007). Use of a right radial approach, lack of catheterization experience, patient age >70 years, and the absence of hypertension were found to be independently associated with prolonged fluoroscopy duration and failure using the initial approach. Use of the right radial approach in patients aged over 70 years was associated with a 6-fold increase in the risk of an adverse event. Consequently, use of the right radial approach should be avoided in patients aged over 70 years when trainee practitioners are on the learning curve

Niveles de insulinemia plasmatica en sujetos con hipertension arterial esencial / Insulinemia levels in plasma in subjects with essential hypertension

Se estudiaron 2 grupos de sujetos: el 1, formado por 30 pacientes con hipertension arterial esencial y el 2, por 32 sujetos normales (controles) para determinar la relacion entre la hipertension, la secrecion de insulina y la tolerancia a los carbohidratos. A todos se les realizo una prueba de tolerancia a la glucosa oral y se tomaron muestras de sangre a los 0,30,60,90 y 120 minutos, para determinar glicemia e insulinemia. Se calculo el area bajo la curva de glicemia e insulinemia y el indice insulinogenico. Se preciso la existencia del habito de fumar, practica de ejercicios y se calculo el indice de masa corporal. La prueba de tolerancia a la glucosa evidencio valores de glicemia significativamente mayores en el tiempo 0 (p<0,05), a los 30 (p<0,01), 90(p<0,01) minutos, en los hipertensos tambien sus valores de insulinemia fueron mas elevados a los 60(p<0,05) y a los 90(p<0,01) minutos. Los valores del area bajo la curva de glicemia o insulinemia y el indice insulinogenico fueron significativamente mayores en los hipertensos. Concluimos, que los hipertensos tienen una respuesta glicemica-insulinemica, significativamente mayor que los controles; quizas por una relacion causal entre niveles de insulinemia e hipertension aretial esencial.Los pacientes con HTAE, pudieran constituir una poblacion de riesgo de desarrollar grados de intolerancia a la glucosa

Niveles de insulinemia plásmatica en sujetos con hipertensión arterial esencial / Insulinemia levels in plasma in subjects with essential hypertension

Se estudiaron 2 grupos de sujetos: el 1, formado por 30 pacientes con hipertensión arterial esencial y el 2, por 32 sujetos normales (controles) para determinar la relación entre la hipertensión, la secreción de insulina y la tolerancia a los carbohidratos. A todos se les realizó una prueba de tolerancia a la glucosa oral y se tomaron muestras de sangre a los 0,30,60,90 y 120 minutos, para determinar glicemia e insulinemia. Se calculó el área bajo la curva de glicemia e insulinemia y el índice insulinogénico. Se precisó la existencia del hábito de fumar, práctica de ejercicios y se calculó el índice de masa corporal. La prueba de tolerancia a la glucosa evidenció valores de glicemia significativamente mayores en el tiempo 0 (p<0,05), a los 30 (p<0,01), 90(p<0,01) minutos, en los hipertensos también sus valores de insulinemia fueron más elevados a los 60(p<0,05) y a los 90(p<0,01) minutos. Los valores del área bajo la curva de glicemia o insulinemia y el índice insulinogénico fueron significativamente mayores en los hipertensos. Concluimos, que los hipertensos tienen una respuesta glicémica-insulinémica, significativamente mayor que los controles; quizás por una relación causal entre niveles de insulinemia e hipertensión aretial esencial.Los pacientes con HTAE, pudieran constituir una población de riesgo de desarrollar grados de intolerancia a la glucosa (AU)

Comparación farmacocinética de 2 formulaciones de quinidina en voluntarios sanos / Comparison of pharmacokinetics of 2 quinidine formulations in healthy volunteers

Se realizó un estudio comparativo del curso temporal de las concentraciones plasmáticas de quinidina en voluntarios sanos, y se determinaron los parámetros farmacocinéticos fundamentales en tabletas convencionales de quinidina sulfato y tabletas de liberación prolongada elaboradas a partir de un complejo polimetacrilato-quinidina. Se concluyó que resultó adecuado al régimen de dosificación de 2 tabletas de quinidina de liberación prolongada cada 12 horas para lograr un perfil de concentración plasmática vs. tiempo, característico de este tipo de formulación, con el valor de tiempo de vida media de eliminación de 12,8 horas en comparación con 4,5 horas que presentó la tableta convencional de sulfato de quinidina

Comparación farmacocinética de 2 formulaciones de quinidina en voluntarios sanos / Comparison of pharmacokinetics of 2 quinidine formulations in healthy volunteers

Se realizó un estudio comparativo del curso temporal de las concentraciones plasmáticas de quinidina en voluntarios sanos, y se determinaron los parámetros farmacocinéticos fundamentales en tabletas convencionales de quinidina sulfato y tabletas de liberación prolongada elaboradas a partir de un complejo polimetacrilato-quinidina. Se concluyó que resultó adecuado al régimen de dosificación de 2 tabletas de quinidina de liberación prolongada cada 12 horas para lograr un perfil de concentración plasmática vs. tiempo, característico de este tipo de formulación, con el valor de tiempo de vida media de eliminación de 12,8 horas en comparación con 4,5 horas que presentó la tableta convencional de sulfato de quinidina (AU)

Supradesnivel del segmento ST con onda Q¿aneurisma, isquemia o ambas? / ST- segment elevation with Q wave a neurysm, ischemia, or both?

Con el propósito de aclarar la causa del signo electocardiográfico de supradesnivel del segmento ST acompañado de una onda Q patológica, se estudiaron dos grupos de pacientes con acinesia o dicinesia del ventrículo izquierdo detectadas por una ventriculografía nuclear en reposo. El grupo I tenía antecedentes documentados de un infarto del miocardio (n=20), mientras que el grupo 2 tenía una cardiomiopatía dilatada con arterias coronarias normales en una coronariografía(n=10). En el grupo I, 10 pacientes tenían dicinesia y 5 acinesia. En el grupo I. 8 pacientes tenían supradenivel del segmento ST asociado en una onda Q (sensibilidad= 40%) y en el grupo II, 2 tenían supradesnivel en las derivaciones correspondiente a la zona de disfunción (sensibilidad= 20%). La diferencia de sensibilidad fue significativa( p<0,01). A los pacientes del grupo I se le realizó una prueba de esfuerzo y se encontró que 8(100%) de los que tenían supradesnivel con onda Q lo aumentaron =0,1 mV, mientras que de 12 pacientes que no tenían supradesnivel en reposo, 6(50%) lo manifestaron durante el esfuerzo por lo que la sensibilidad aumentó de 40%en reposo a 70%en esfuerzo(p<0,01>. Se infiere que el signo clásico de supradesnivel del segmento ST con onda Q en reposo pude ser debido a una isquemia en el sitio del infarto más que a una disfunción mecánica avanzada