A prospective study evaluating efficacy of polymer free Pronova XR stent in treatment of denovo coronary artery stenosis.

BACKGROUND: Drug eluting stents have remarkably improved results of percutaneous coronary angioplasty. Most of the currently available drug eluting stents uses a durable polymer as drug carrier which has been implicated in local inflammatory response and continued incidence of late and very late stent thrombosis. The Pronova XR stent is one from those new generation polymer free sirolimus eluting stents in which pharmaceutical excipient is used for the timed release of sirolimus from the XR stent platform instead of a polymeric coating. METHODOLOGY: We consecutively recruited 121 patients undergoing elective or urgent PCI at our center. All the patients were followed up clinically and mandatory follow up angiogram at 6 months was done for one third of the total patients. An independent core lab analyzed paired angiograms. RESULTS: The primary efficacy endpoint was death, MI, TVR at 6 months which occurred in 6.66% patients. The QCA analysis showed reference vessel diameter of 2.5 + 0.44 mm at baseline and the minimal luminal diameter was 0.88 + 0.43 mm giving baseline diameter stenosis of 65.26 + 15.89%. The immediate post procedure in-segment diameter stenosis assessed was 23.68 + 8.96% which increased to 36.02 + 24.48% at follow up with a late lumen loss of 0.25 + 0.76 mm at mean of 191 days. CONCLUSION: Coronary angioplasty with polymer free Pronova XR stents results in acceptable late lumen loss and very low target lesion revascularisation at short and intermediate term in unselected patients.

Use of sclerotherapy for treatment of vascular malformation in a young girl.

Vascular malformations are difficult to treat because of poor results of treatment and recurrence of symptoms. Percutaneous and/or transluminal embolisation has refined the treatment of surface vascular lesions; especially with availability of variety of sclerosants.We report a case of a young girl with vascular malformation of right foot, which was treated with percutaneous sclerotherapy with sodium tetradecyl sulphate (STS). Result was excellent and so far the patient is free of her symptoms.

Recent advances in the management of acute myocardial infarction.

Recently the reperfusion therapy in the form of Primary Percutaneous Coronary intervention (PPCI) has become the gold standard for the treatment of Acute Myocardial Infarction. In spite of rapid revascularization either with PPCI or thrombolytic therapy, the significant number of patients develops decreased left ventricular function leading to heart failure which can increase long-term mortality and morbidity. The number of strategies are being evolved and evaluated to reduce this post infarct heart failure. They are being developed at the level of optimizing the outcomes of PPCI, protection against the reperfusion injury, and novel therapies like cardiac repair and regeneration and sonothrombolysis. Thrombus aspiration using simple aspiration catheters during PPCI are getting established as a useful adjunct tool to reduce distal embolisation and consequently improving myocardial salvage. The newer antiplatelet drugs like Prasugrel and Ticagrelor may replace the Clopidogrel to reduce ischemic complications. The reduction in reperfusion injury using drugs has shown mixed results. The newer modalities like cardiac repair and regeneration using stem cell therapy looks promising but are yet to be established.

Indo Heart Survey on latent abnormal glucose regulation in patients with coronary artery disease without diabetes across India.

BACKGROUND: The Euro Heart Survey on diabetes and heart has demonstrated high prevalence of latent glucose abnormalities in non-diabetic patients with coronary artery disease (CAD) in the European population. The aim of our survey was to assess the prevalence of latent abnormal glucose regulation in adult non-diabetic CAD patients in India. METHODS AND RESULTS: Seven centers distributed across India recruited 350 patients. The diagnosis of CAD was done by coronary angiography showing >50% stenosis in any major epicardial coronary artery or its branches. Oral glucose tolerance test (OGTT) and fasting glucose levels were used to characterize glucose metabolism. Venous plasma glucose was measured before (fasting) and 2 hours after ingestion of glucose. Impaired fasting glucose (IFG) was defined as OGTT (0 minute)>or=100 mg/dl but <126 mg/dl and OGTT (2 hours)<140 mg/dl. Impaired glucose tolerance (IGT) was defined as OGTT (0 minute)<126 mg/dl and OGTT (2 hours)>or=140 mg/dl but <200 mg/dl. Of the 350 patients studied, 176 (50.28%) had impaired glucose regulation (IFG-28 [8%]; IGT-148[42.28%]) and 75 (21.42%) had newly detected Diabetes. In all 251 (71.7%) patients with CAD had previously undetected abnormal glucose regulation. CONCLUSION: This survey demonstrates the presence of abnormal glucose regulation in almost three quarters of the non-diabetic Indian CAD patients. OGTT should be recommended as routine screening test for detecting latent glucose abnormalities in all CAD patients.

Optimal platelet inhibition in patients undergoing PCI: data from the Multicenter Registry of High-Risk Percutaneous Coronary Intervention and Adequate Platelet Inhibition (MR PCI) study.

BACKGROUND: Optimal inhibition of platelet aggregation (IPA) may afford greater protection against ischemic events during percutaneous coronary intervention (PCI). The objective of this study was to test several antiplatelet regimens in elective high-risk PCI patients by comparing different combinations of glycoprotein IIb/IIIa inhibitors and clopidogrel. METHODS: The study was a randomized open-label study at 3 heart centers in India. One hundred twenty patients were enrolled between July 2006 and September 2006. Patients were randomized to 1 of the 4 groups: group A--tirofiban, group B--eptifibatide, group C--tirofiban + clopidogrel 600-mg loading dose, and group D--eptifibatide + clopidogrel 600-mg loading dose. All patients received a clopidogrel maintenance dose after PCI. The primary outcome measure was the IPA assessed at 10 minutes, at 6 to 8 hours, and at 24 hours. RESULTS: The IPA was higher with high-dose tirofiban compared with eptifibatide at 10 minutes (95.88 +/- 5.85% vs 91.22 +/- 7.52%, P = .003) and at 6 to 8 hours (93.11 +/- 7.6% vs 85.45 +/- 11.03, P < .001). Significantly more patients achieved >95% IPA with the high-dose tirofiban regimen. CONCLUSIONS: This head-to-head study comparing high-dose tirofiban with double-bolus eptifibatide demonstrated higher degree of platelet inhibition with high-dose tirofiban at 10 minutes and at 6 to 8 hours in patients undergoing elective high-risk PCI. The addition of clopidogrel did not acutely extend the IPA from intravenous glycoprotein IIb/IIIa inhibitors, but did so at 24 hours.

Outcome from balloon induced coronary artery dissection after intracoronary beta radiation.

OBJECTIVE: To evaluate the healing of balloon induced coronary artery dissection in individuals who have received beta radiation treatment and to propose a new intravascular ultrasound (IVUS) dissection score to facilitate the comparison of dissection through time. DESIGN: Retrospective study. SETTING: Tertiary referral centre. PATIENTS: 31 patients with stable angina pectoris, enrolled in the beta energy restenosis trial (BERT-1.5), were included. After excluding those who underwent stent implantation, the evaluable population was 22 patients. INTERVENTIONS: Balloon angioplasty and intracoronary radiation followed by quantitative coronary angiography (QCA) and IVUS. Repeat QCA and IVUS were performed at six month follow up. MAIN OUTCOME MEASURES: QCA and IVUS evidence of healing of dissection. Dissection classification for angiography was by the National Heart Lung Blood Institute scale. IVUS proven dissection was defined as partial or complete. The following IVUS defined characteristics of dissection were described in the affected coronary segments: length, depth, arc circumference, presence of flap, and dissection score. Dissection was defined as healed when all features of dissection had resolved. The calculated dose of radiation received by the dissected area in those with healed versus non-healed dissection was also compared. RESULTS: Angiography (type A = 5, B = 7, C = 4) and IVUS proven (partial = 12, complete = 4) dissections were seen in 16 patients following intervention. At six month follow up, six and eight unhealed dissections were seen by angiography (A = 2, B = 4) and IVUS (partial = 7, complete = 1), respectively. The mean IVUS dissection score was 5.2 (range 3-8) following the procedure, and 4.6 (range 3-7) at follow up. No correlation was found between the dose prescribed in the treated area and the presence of unhealed dissection. No change in anginal status was seen despite the presence of unhealed dissection. CONCLUSION: beta radiation appears to alter the normal healing process, resulting in unhealed dissection in certain individuals. In view of the delayed and abnormal healing observed, long term follow up is indicated given the possible late adverse effects of radiation. Although in this cohort no increase in cardiac events following coronary dissections was seen, larger populations are needed to confirm this phenomenon. Stenting of all coronary dissections may be warranted in patients scheduled for brachytherapy after balloon angioplasty.

Periprocedural quantitative coronary angiography after Palmaz-Schatz stent implantation predicts the restenosis rate at six months: results of a meta-analysis of the BElgian NEtherlands Stent study (BENESTENT) I, BENESTENT II Pilot, BENESTENT II and MUSIC trials. Multicenter Ultrasound Stent In Coronaries.

OBJECTIVES: We aimed to identify periprocedural quantitative coronary angiographic (QCA) variables that have predictive value on long-term angiographic results and to construct multivariate models using these variables for postprocedural prognosis. BACKGROUND: Coronary stent implantation has reduced the restenosis rate significantly as compared with balloon angioplasty in short de novo lesions in coronary arteries >3 mm in size. Although the postprocedural minimal luminal diameter (MLD) is known to have significant bearing on long-term angiographic results, no practically useful model exists for prediction of angiographic outcome based on the periprocedural QCA variables. METHODS: The QCA data from patients who underwent Palmaz-Schatz stent implantation for short (<15 mm) de novo lesions in coronary arteries >3 mm and completed six months of angiographic follow-up in the four prospective clinical trials (BENESTENT I, BENESTENT II pilot, BENESTENT II and MUSIC) were pooled. Multiple models were constructed using multivariate analysis. The Hosmer-Lemeshow goodness-of-fit test was used to identify the model of best fit, and this model was used to construct a reference chart for prediction of angiographic outcome on the basis of periprocedural QCA variables. RESULTS: Univariate analysis performed using QCA variables revealed that vessel size, MLD before and after the procedure, reference area before and after the procedure, minimal luminal cross-sectional area before and after the procedure, diameter stenosis after the procedure, area of plaque after the procedure and area stenosis after the procedure were significant predictors of angiographic outcome. Using multivariate analysis, the Hosmer-Lemeshow goodness-of-fit test showed that the model containing percent diameter stenosis after the procedure and vessel size best fit the data. A reference chart was then developed to calculate the expected restenosis rate. CONCLUSIONS: Restenosis rate after stent implantation for short lesions can be predicted using the variables percent diameter stenosis after the procedure and vessel size. This meta-analysis indicates that the concept of "the bigger the better" holds true for coronary stent implantation. Applicability of the model beyond short lesions should be tested.

Remodeling of atherosclerotic coronary arteries varies in relation to location and composition of plaque.

The aim of this study was to determine the contribution of morphologic characteristics and location of plaque in remodeling of atherosclerotic coronary arteries. Consecutive intravascular ultrasound studies performed in native coronary arteries before an intervention were included in the study. Total vessel, lumen and plaque + media areas were measured at target lesion, and distal and proximal references. Remodeling index was calculated as target total vessel area/proximal reference total vessel area, and categorized into 3 groups based on relative total vessel-area ratio: (1) > 1.1 (group A, adequate remodeling); (2) 0.9 to 1.1 (group B, failure of compensatory enlargement); and (3) <0.9 (group C, coronary shrinkage). Eighty-nine narrowings were assessed in 80 intravascular ultrasound studies. Thirty-eight lesions (43%) were defined as soft and 51 (57%) as hard. Soft plaques were more prevalent in group A than in groups B and C (p = 0.001). Conversely, the arc of calcium was larger in group C lesions (p = 0.005). At distal segments, group A lesions were more prevalent than those in groups B and C, whereas at proximal segments group C lesions were more prevalent (p = 0.007). Multivariate analysis identified the arc of calcium and the location of plaque at distal segments as independent predictors of compensatory enlargement (odds ratio 0.94, 95% confidence interval 0.90 to 0.99; odds ratio 4.6; 95% confidence interval 1.4 to 15.7, respectively), whereas hard plaques were an independent predictor of coronary shrinkage (odds ratio 4.6; 95% confidence interval 1.7 to 12.5). In conclusion, composition and location of plaque appeared to be major determinants of vessel remodeling during the process of atherosclerosis.