Clinical impact of in-stent late loss after drug-eluting coronary stent implantation.

AIMS: Controversy exists about the clinical significance of in-stent late loss (ISLL) after drug-eluting stent (DES) implantation. We sought to clarify whether ISLL after DES implantation is related to a potential clinical impact. METHODS AND RESULTS: We included in a meta-regression analysis 21 trials (8641 patients) that randomly compared DES with bare-metal stents (BMS). We evaluated the relationship between angiographic behaviour of DES and the clinical impact of using DES instead of BMS in each trial using meta-regression techniques, weighting by the number of patients included in each trial. Mean ISLL in patients allocated to DES and DeltaISLL (difference in ISLL in patients allocated to BMS and DES) were used as angiographic parameters of efficacy of DES. The number of patients needed to be treated (NNT) to prevent one target lesion revascularization (TLR) was used to quantify the clinical impact of using DES instead of BMS. There was a significant relationship between mean ISLL in patients allocated to DES and the clinical benefit of using DES instead of BMS, as measured with the NNT for TLR: NNT for TLR = 6.2 + 18.4 [ISLL-DES] (R = 0.62; P = 0.007). Therefore, a 0.1 mm increase in mean ISLL-DES was associated with a 1.8 increase in NNT for TLR. There was also a significant association between the degree of inhibition of neointimal hyperplasia of DES in comparison with BMS with the NNT for TLR: NNT for TLR = 17.1-11.8 [DeltaISLL] (R = 0.61; P = 0.008). Therefore, a 0.1 mm reduction in ISLL by using DES instead of BMS was associated with a 1.2 decrease in mean NNT for TLR. CONCLUSION: There is a strong and significant association between the degree of inhibition of neointimal formation with the use of DES and the clinical impact of using DES instead of BMS.

Transient left ventricular apical ballooning.

We describe the case of an elderly woman patient referred for primary angioplasty for acute anterior myocardial infarction, which developed after intense emotional stress. The coronary angiogram was surprisingly normal, but left ventriculography showed severe apical dilatation and dyskinesia, confirmed by echocardiography. By this time we suspected a syndrome of transient apical ballooning without coronary stenosis, which mimics acute myocardial infarction. She underwent medical therapy and subsequent clinical evolution was favorable, with complete recovery of left ventricular systolic function. We discuss the clinical setting and the pathophysiologic mechanisms of this syndrome.

Percutaneous coronary intervention for cardiac arrest secondary to ST-elevation acute myocardial infarction. Influence of immediate paramedical/medical assistance on clinical outcome.

BACKGROUND: Patients with cardiac arrest have been excluded from most randomized trials on percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). OBJECTIVE: The aim of the study was to evaluate the outcome of patients undergoing primary PCI for acute myocardial infarction who suffered from cardiac arrest prior to the procedure, focusing the study on the influence of immediate paramedical-medical assistance on the outcome. METHODS AND RESULTS: Sixty-three patients with ST-elevation AMI and previous cardiac arrest underwent primary PCI within 12 hours after symptom onset. Three groups of patients were defined: Group 1: Cardiac arrest before hospital admission, without immediate (< 1 minute) initiation of resuscitation maneuvers (n = 13); Group 2: Pre-hospital cardiac arrest with immediate initiation of resuscitation maneuvers (n = 14); Group 3: Cardiac arrest after hospital admission. The proportion of patients with ventricular tachycardia or fibrillation as documented initial rhythm was similar among the groups (77%, 79% and 83%, respectively), as well as the rate of angiographic success (92%, 93% and 86%, respectively). However, the incidence of cardiac events at 30 days was significantly higher in Group 1 than in Groups 2 or 3 (54%, 29% and 17%, respectively; p = 0.03), as well as the mortality rate at 30 days (46%, 21% and 18%, respectively; p = 0.06). Interestingly, the outcomes were not statistically different between Groups 2 and 3. In multivariate analysis, the independent predictors for mortality at 30 days for Group 1 were: multivessel disease, angiographic failure and cardiogenic shock. CONCLUSIONS: Combining immediate initiation of resuscitation maneuvers and primary PCI yields a very good clinical outcome in patients with AMI suffering from cardiac arrest.

Prognostic impact of a chronic occlusion in a noninfarct vessel in patients with acute myocardial infarction and multivessel disease undergoing primary percutaneous coronary intervention.

BACKGROUND: Among patients with acute myocardial infarction (AMI) referred for primary percutaneous coronary intervention (PCI), those with multivessel disease have worse clinical outcomes. This study sought to elucidate the impact of a chronic occlusion in a noninfarct vessel among patients with multivessel disease undergoing PCI for AMI. METHODS AND RESULTS: We studied 630 patients with AMI treated with PCI within 12 hours of symptom onset. Three groups of patients were defined: Group 1 (single-vessel disease; n = 345); Group 2 (multivessel disease with no chronic coronary occlusion in another vessel; n = 201); and Group 3 (chronic coronary occlusion in another vessel; n = 84). The probability of being free from events was lower in patients with multivessel disease than in Group 1 (84 +/- 2% vs. 92 +/- 1% at 30 days; 71 +/- 3% vs. 81 +/- 3% at 2 years; Log-Rank: p = 0.001; Breslow: p < 0.001 ), and in Group 3 than in Group 2 (76 +/- 5% vs. 87 +/- 2% at 30 days; 63 +/- 6% vs.75 +/- 4% at 2 years; Log-Rank: p = 0.014; Breslow: p = 0.008 ). Freedom from cardiac death was lower in patients with multivessel disease than in Group 1 (88 +/- 2% vs. 94 +/- 1% at 30 days; 84 +/- 2% vs. 91 +/- 2% at 2 years; Log-Rank: p = 0.003; Breslow: p = 0.002), and in Group 3 than in Group 2 (82 +/- 4% vs. 90 +/- 2% at 30 days; 77 +/- 5% vs. 88 +/- 3% at 2 years; Log-Rank and Breslow: p = 0.020). Among patients with multivessel disease, the presence of cardiogenic shock, left main disease and anterior location, but not the presence of a chronic occlusion in another vessel, were independent predictors of mortality. CONCLUSION: Among patients with AMI and multivessel disease, those with a chronic occlusion in a noninfarct-related vessel constitute a subgroup with very poor clinical outcomes.