A new protocol using sodium bicarbonate for the prevention of contrast-induced nephropathy in patients undergoing coronary angiography.

Contrast-induced nephropathy (CIN) is associated with increased morbidity and mortality rates. Although a previous study reported that pretreatment with sodium bicarbonate is more effective than sodium chloride for prophylaxis of CIN, this has not been a universal finding. We performed a prospective randomized trial to investigate whether CIN can be avoided using sodium bicarbonate. In total 155 patients with a glomerular filtration rate (GFR) <60 ml/min/1.73 m(2) who were undergoing coronary angiography were enrolled. We assigned patients to sodium chloride plus sodium bicarbonate (bicarbonate group, n = 78) or sodium chloride alone (chloride group, n = 77). Infusion of sodium bicarbonate at 1 ml/kg/hour continued from 3 hours before to 6 hours after coronary angiography. CIN was defined as a 25% increase in serum creatinine from baseline value or an absolute increase of ≥0.5 mg/dl, which appeared within 2 days of contrast. Baseline GFR was not significantly different between the 2 groups. Patients in the bicarbonate group had a higher GFR than those in the chloride group on day 2 (45.8 ± 13.4 vs 40.9 ± 14.6 ml/min/1.73 m(2), p = 0.031) and at 1 month (49.5 ± 14.7 vs 43.7 ± 15.5 ml/min/1.73 m(2), p = 0.019). CIN occurred in 10 patients (13%) in the chloride group but in only 2 patients (2.6%) in the bicarbonate group (p = 0.012). Sodium chloride plus sodium bicarbonate is more effective than sodium chloride alone for prophylaxis of CIN and can lead to retention of better long-term renal function.

Contrast-induced nephropathy in patients undergoing emergency percutaneous coronary intervention for acute coronary syndrome.

Contrast-induced nephropathy (CIN) is associated with significantly increased morbidity and mortality after coronary angiography and percutaneous coronary intervention (PCI). The aim of the present study was to assess the clinical features and in-hospital outcomes of CIN after emergency PCI. The serum creatinine (SCr) concentration was measured from days 0 to 30 in 338 consecutive patients with acute coronary syndrome undergoing emergency PCI. CIN was defined as an increase in SCr of >25% or >0.5 mg/dl within 2 days after PCI. Overall, 94 patients (28%) developed CIN. The mean SCr on admission was not significantly different between patients with CIN and those without CIN. The CIN group had significantly greater SCr at days 1, 2, and 30 than did the no CIN group. Multivariate analysis showed female gender (odds ratio [OR] 2.38, 95% confidence interval [CI] 1.12 to 5.07, p = 0.025), a culprit lesion in the left anterior descending artery (OR 2.37, 95% CI 1.31 to 4.27, p = 0.0042), contrast agent volume >200 ml (OR 3.60, 95% CI 1.96 to 6.62, p <0.001) and end-diastolic pulmonary arterial pressure >15 mm Hg (OR 2.03, 95% CI 1.02 to 4.04, p <0.01) to all correlate independently with CIN. The in-hospital mortality rate was greater in the CIN group than in the no CIN group (9.6% vs 3.3%, respectively; p = 0.025). In conclusion, CIN is a frequent complication of emergency PCI for acute coronary syndrome and is associated with a greater mortality rate and persistent renal dysfunction.

Nicorandil suppressed myocardial injury after percutaneous coronary intervention.

BACKGROUND: Nicorandil exerts beneficial effects as an adjunctive therapy for patients with ischemic heart disease. This study was designed to assess the effects of nicorandil on the myocardial protective benefits of elective percutaneous coronary intervention (PCI). METHODS: We randomly divided 49 patients scheduled to undergo elective PCI into two groups, nicorandil and control. Before PCI, the former received an intravenous bolus injection of nicorandil (4 mg), followed by continuous infusion at 6 mg/h for 24 h after intervention. Oral administration of nicorandil was continued until follow-up coronary angiography (CAG). Serial venous blood samples, for measurement of creatine kinase (CK), creatine kinase MB isoform (CK-MB), troponin I (TnI) and myoglobin, were obtained before PCI, and at 0 h, 4 h, 24 h and 48 h after PCI. Left ventricular function and left ventricular wall motion were evaluated by means of contrast ventriculography before PCI and follow-up CAG. RESULTS: At 24 h after PCI, elevations of cardiac enzymes were significantly suppressed in the nicorandil as compared to the control group; CK (78.1+/-34.9 versus 117.4+/-137.9 U/l, P=0.0141), CK-MB (1.57+/-1.90 versus 2.67+/-4.50 U/l, P=0.0485) and TnI (0.37+/-0.55 versus 0.86+/-1.65 ng/ml, P=0.0101). Regional left ventricular wall motion was significantly improved at follow-up in the nicorandil as compared to the control group. CONCLUSIONS: Nicorandil suppressed elevations of cardiac enzymes after elective PCI and left ventricular wall motion was also significantly improved at follow-up, suggesting that nicorandil enhances the myocardial protective effect of PCI against angioplasty-related myocardial injury.

Effects of intravenous administration of tissue plasminogen activator before thrombectomy in patients with acute myocardial infarction.

BACKGROUND: Myocardial salvage after acute myocardial infarction (AMI) largely depends on the removal of infarct-related thrombus. Although both thrombolysis and thrombectomy are effective strategies to remove thrombus, there is a paucity of reports regarding the benefit of the combination therapy. Therefore, the efficacy of intravenous administration with mutant tissue plasminogen activator (Mt-PA) before thrombectomy and ordinary percutaneous coronary intervention (PCI) was evaluated. METHODS AND RESULTS: Consecutive 44 AMI patients without contraindication of Mt-PA were enrolled in the study and randomly assigned to thrombectomy with Mt-PA pre-administration (group T) or thrombectomy alone (group N). Although Thrombolysis in Myocardial Infarction (TIMI) grade before PCI and TIMI myocardial perfusion grade immediately after PCI were significantly greater in group T (p<0.05), there was no improvement of left ventricular ejection fraction immediately and 6 months after PCI. CONCLUSIONS: These results suggest that intravenous administration with Mt-PA before thrombectomy had no significant benefit in the salvage of infracted myocardium over thrombectomy alone, despite improvement of coronary microcirculation immediately after PCI.

Correlation of angiographic morphology immediately after coronary balloon angioplasty with coronary vasomotion late after angioplasty.

BACKGROUND: Various vasomotor responses to acetylcholine have been observed after coronary angioplasty. However, the relationship between the grade of vascular injury due to balloon angioplasty and vasomotor response to acetylcholine in the chronic stage is unknown. In this study we examined the correlation between the morphology immediately after coronary angioplasty and the vasomotor response to acetylcholine 1 year after angioplasty. METHODS: Thirty nine patients with a total of 45 coronary lesions without restenosis 1 year after angioplasty were studied. The 45 lesions were divided into two groups according to the morphology immediately after angioplasty. Group A comprised smooth-walled dilation and smooth-walled dilation with intraluminal haziness which were considered to be related to injury limited to the intima or the surface of the media. Group B comprised intraluminal and extraluminal haziness and extraluminal type dissection which were considered to be related to extensive medial injury. In the 39 patients, acetylcholine provocation test was performed. RESULTS: Transient total occlusion of angioplasty site was induced by acetylcholine in four lesions only in Group A. Percent change in coronary diameter after acetylcholine injection relative to that after injection of isosorbide dinitrate at the angioplasty site was larger in Group A than that of Group B. CONCLUSION: In the chronic stage, vessels with minor vascular injury exhibited a large vasomotor response to acetylcholine; conversely, the response was low in vessels with severe vascular injury by angioplasty. These observations suggest that severe vascular injury by balloon angioplasty may control coronary vasomotion in the chronic stage.

Balloon coronary angioplasty and long-term survival of non-diabetic patients with isolated severe left anterior descending coronary artery disease.

Although long-term survival of diabetic patients with multivessel coronary disease has been reported to be better in those treated with bypass surgery than with coronary angioplasty, it is unclear if diabetic patients who undergo coronary angioplasty show better long-term survival than those treated medically. Between 1985 and 1994, 667 consecutive patients with isolated severe (> or = 90% diameter stenosis) proximal left anterior descending (LAD) coronary artery disease were divided into 4 groups according to the initial therapeutic choice and their diabetic status: of 225 diabetic patients, 104 were treated medically and 121 underwent coronary angioplasty; of 442 non-diabetic patients, 215 were treated medically and 227 underwent coronary angioplasty. The primary end-point of follow-up was death from any cause, and the secondary end-point was cardiac death. Cox's proportional hazard model was used to assess the relative risk of baseline variables. The mean follow-up interval was 6.5+/-3.0 years. The relative distribution of baseline parameters of medically treated patients to those treated with coronary angioplasty was identical in diabetic and non-diabetic patients. Although non-diabetic patients who underwent coronary angioplasty showed better long-term survival than those treated medically, this survival advantage was not observed in diabetic patients. After adjustment of parameters using Cox's proportional hazard model, age over 65 years, coronary angioplasty and low left ventricular ejection fraction were independent determinants of total death. Long-term survival in non-diabetic patients with severe LAD coronary artery disease is more favorable in patients treated with coronary angioplasty than those treated medically, but this advantage is overridden when the patients are diabetic.