First-Generation Versus Second-Generation Drug-Eluting Stents in Coronary Chronic Total Occlusions: Two-Year Results of a Multicenter Registry.

BACKGROUND: Limited data are available regarding the long-term clinical outcomes of second-generation drug-eluting stents (DES) versus first-generation DES in patients with coronary chronic total occlusion (CTO) who undergo percutaneous coronary intervention (PCI). The aim of this study was to compare the clinical outcomes of second-generation DES with those of first-generation DES for the treatment of CTO. METHODS AND RESULTS: Between March 2003 and February 2012, 1,006 consecutive patients with CTO who underwent successful PCI using either first-generation DES (n = 557) or second-generation DES (n = 449) were enrolled in a multicenter, observational registry. Propensity-score matching was also performed. The primary outcome was cardiac death over a 2-year follow-up period. No significant differences were observed between the two groups regarding the incidence of cardiac death (first-generation DES versus second-generation DES; 2.5% vs 2.0%; hazard ratio [HR]: 0.86; 95% confidence interval [CI]: 0.37 to 1.98; p = 0.72) or major adverse cardiac events (MACE, 11.8% vs 11.4%; HR: 1.00; 95% CI: 0.67 to 1.50; p = 0.99). After propensity score matching, the incidences of cardiac death (HR: 0.86; 95% CI: 0.35 to 2.06; p = 0.86) and MACE (HR: 0.93; 95% CI: 0.63 to 1.37; p = 0.71) were still similar in both groups. Furthermore, no significant differences were observed between sirolimus-eluting, paclitaxel-eluting, zotarolimus-eluting, and everolimus-eluting stents regarding the incidence of cardiac death or MACE. CONCLUSION: This study shows that the efficacy of second-generation DES is comparable to that of first-generation DES for treatment of CTO over 2 years of follow-up.

Objective Tinnitus Concomitant with Eye Blinking: A Case Report.

Tinnitus is a common auditory phenomenon associated with many otological diseases, and is usually subjective. Objective tinnitus can be generated by para-auditory structures, usually derived from vascular or myogenic sources, or the eustachian tube. We present a rare case of intermittent unilateral tinnitus associated with eye blinking. Otoendoscopic examination showed that the external auditory canals and tympanic membranes were normal; however, rhythmic movements of both tympanic membranes, concomitant with the tinnitus, were evident whenever the patient blinked. The tympanometry and stapedial reflexes measured via impedance audiometry exhibited saw-tooth patterns; movement of the tympanic membrane was associated with eyelid blinking. The patient was managed conservatively, with reassurance and medication, and the condition became well-controlled. Here, we present this educational case and review the literature.

Biodegradable polymer biolimus-eluting stent versus durable polymer everolimus-eluting stent in patients with acute myocardial infarction.

BACKGROUND: There are limited data about long-term outcomes for biodegradable polymer biolimus-eluting stent (BES) versus durable polymer everolimus-eluting stent (EES) in patients undergoing percutaneous coronary intervention (PCI) for acute myocardial infarction (AMI). We sought to compare the two-year efficacy and safety of BES versus EES in AMI patients. METHODS: A total of 707 consecutive patients with ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction who underwent PCI with BES (n=171) or EES (n=536) between July 2008 and June 2012 were enrolled in this study. The efficacy endpoint (target vessel failure; a composite of cardiac death, target vessel-related myocardial infarction, and target vessel revascularization) and the safety endpoint (a composite of all cause death, myocardial infarction, and stent thrombosis) at two years were compared in crude and propensity score-matched cohorts. RESULTS: After two years, target vessel failure occurred in 13 patients treated with BES and 49 patients treated with EES (7.6% versus 9.1%; adjusted hazard ratio [HR], 1.09; 95% confidence interval [CI], 0.58-2.04; p=0.78). The rates of composite safety endpoint at two years were not different between two groups (BES 7.6% versus EES 10.8%; adjusted HR, 0.87; 95% CI, 0.47-1.62; p=0.66). The rates of stent thrombosis did not differ between two groups (BES 0.6% versus EES 1.3%; adjusted HR, 0.63; 95% CI, 0.06-6.20; p=0.69). These findings were substantiated by similar results in the propensity score-matched cohort. CONCLUSIONS: In the treatment of patients with AMI, BES showed similar efficacy and safety compared to those of EES for up to two years.

Prognostic value of neutrophil to lymphocyte ratio in patients presenting with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

Atherosclerosis is an inflammatory process, and inflammatory biomarkers have been identified as useful predictors of clinical outcomes. The prognostic value of leukocyte count in patients with ST-segment elevation myocardial infarctions who undergo primary percutaneous coronary intervention is not clearly defined. In 325 patients with STEMIs treated with primary percutaneous coronary intervention, total and differential leukocyte counts, once at admission and 24 hours thereafter, were measured. The neutrophil/lymphocyte ratio (NLR) was calculated as the ratio of neutrophil count to lymphocyte count. The primary end point was all-cause death. Twenty-five patients (7.7%) died during follow-up (median 1,092 days, interquartile range 632 to 1,464). The total leukocyte count decreased (from 11,853 ± 3,946/µl to 11,245 ± 3,979/µl, p = 0.004) from baseline to 24 hours after admission. Patients who died had higher neutrophil counts (9,887 ± 5,417/µl vs 8,399 ± 3,639/µl, p = 0.061), lower lymphocyte counts (1,566 ± 786/µl vs 1,899 ± 770/µl, p = 0.039), and higher NLRs (8.58 ± 7.41 vs 5.51 ± 4.20, p = 0.001) at 24 hours after admission. Baseline leukocyte profile was not associated with outcomes. The best cut-off value of 24-hour NLR to predict mortality was 5.44 (area under the curve 0.72, 95% confidence interval [CI] 0.52 to 0.82). In multivariate analysis, a 24-hour NLR ≥5.44 was an independent predictor of mortality (hazard ratio 3.12, 95% CI 1.14 to 8.55), along with chronic kidney disease (hazard ratio 4.23, 95% CI 1.62 to 11.1) and the left ventricular ejection fraction (hazard ratio 0.94 for a 3% increase, 95% CI 0.76 to 0.93). In conclusion, NLR at 24 hours after admission can be used for risk stratification in patients with STEMIs who undergo primary PCI. Patients with STEMIs with 24-hour NLRs ≥5.44 are at increased risk for mortality and should receive more intensive treatment.

Clinical validity of longitudinal pre-ejectional myocardial velocity for identifying the transmural extent of viable myocardium: early after reperfusion of an infarct-related coronary artery.

BACKGROUND: Positive longitudinal pre-ejectional velocity (+PEVL) was recently reported to be a reliable index of myocardial recovery early after successful revascularization in myocardial infarction (MI); that is, it recognizes the transmural extent of viable myocardium. The applicability of PEVL in the real-world clinical setting for identifying the transmural extent of viable myocardium in reperfused recent MI was assessed. METHODS AND RESULTS: Using tissue Doppler imaging, the resting basal and mid myocardial PEVLs were determined within 3 days after revascularization in 41 consecutive patients with recent MI. Infarct thickness was semi-quantified using delayed gadolinium-enhanced magnetic resonance imaging (MRI) at baseline and at 6-month follow up to differentiate transmural from nontransmural MI. The proportion of segments showing the presence of +PEVL was not significantly changed as infarct thickness increased (p=0.2), with 66.2% having +PEVL even in segments involving >75% transmural infarction. Moreover, +PEVL was found in a large fraction of segments with akinesia (70.4%). Specificity and negative predictive value of +PEVL for assessing infarct nontransmurality were disappointingly low (32.0% and 26.9%, respectively). All of these results were not altered when the 6-month follow-up MRI was done. CONCLUSIONS: +PEVL cannot be regarded as a reliable marker for predicting the transmural extent of viable myocardium in recent MI.