The elderly are the most rapidly growing population group in the world.Data collected over a 30-year period have demonstrated the increasing prevalence of hypertension with age.The risk of coronary artery disease,stro...The elderly are the most rapidly growing population group in the world.Data collected over a 30-year period have demonstrated the increasing prevalence of hypertension with age.The risk of coronary artery disease,stroke,congestive heart disease,chronic kidney insufficiency and dementia is also increased in this subgroup of hypertensives.Hypertension in the elderly patients represents a management dilemma to cardiovascular specialists and other practioners.During the last years and before the findings of the Systolic Hypertension in Europe Trial were published,the general medical opinion considered not to decrease blood pressure values similarly to other younger patients,in order to avoid possible ischemic events and poor oxygenation of the organs(brain,heart,kidney).The aim of this review article is to highlight the importance of treating hypertension in aged population in order to improve their quality of life and lower the incidence of the cardiovascular complications.展开更多
Context: Atheromatous and thrombotic embolization during percutaneous coronary intervention(PCI) in acute myocardial infarction is common and may result in microcirculatory dysfunction, the prevention of which may imp...Context: Atheromatous and thrombotic embolization during percutaneous coronary intervention(PCI) in acute myocardial infarction is common and may result in microcirculatory dysfunction, the prevention of which may improve reperfusion success, reduce infarct size, and enhance event-free survival. Objective: To determine whether protection of the distal microcirculation from thromboembolic debris liberated during primary PCI results in improved reperfusion and decreased infarct size. Design, Setting, and Patients: Prospective randomized controlled trial at 38 academic and community-based institutions in 7 countries enrolling 501 patients aged 18 years or older with ST-segment elevation myocardial infarction(STEMI) presenting within 6 hours of symptom onset and undergoing primary PCI or rescue intervention after failed thrombolysis. Interventions: Patients were randomized between May 20, 2002, and November 21, 2003, to receive PCI with a balloon occlusion and aspiration distal microcirculatory protection systemvs angioplasty without distal protection. Main Outcome Measures: Coprimary end points were ST-segment resolution(STR) measured 30 minutes after PCI by continuous Holter monitoring and infarct size measured by technetium Tc 99m sestamibi imaging between days 5 and 14. Secondary end points included major adverse cardiac events. Results: Among 252 patients assigned to distal protection, aspiration was performed in 97%(242/251), all angioplasty balloon inflations were fully protected in 79%(193/245), and visible debris was retrieved from 73%(182/250). Complete STR was achieved in a similar proportion reperfused with vs without distal protection(63.3%[152/240] vs 61.9%[148/239], respectively; absolute difference, 1.4%[95%confidence interval,-7.7%to 10.5%; P=.78]), and left ventricular infarct size was similar in both groups(median, 12.0%[n=229] vs 9.5%[n=208], respectively; P=.15). Major adverse cardiac events at 6 months occurred with similar frequency in the distal protection and control groups(10.0%vs 11.0%, respectively; P=.66). Conclusions: A distal balloon occlusion and aspiration system effectively retrieves embolic debris in most patients with acute STEMI undergoing emergent PCI. Nonetheless, distal embolic protection did not resultin improved microvascularflow, greater reperfusion success, reduced infarct size, or enhanced event-free survival.展开更多
Context: Atheromatous and thrombotic embolization during percutaneous coronary intervention (PCI) in acute myocardial infarction is common and may result in m icrocirculatory dysfunction, the prevention of which may i...Context: Atheromatous and thrombotic embolization during percutaneous coronary intervention (PCI) in acute myocardial infarction is common and may result in m icrocirculatory dysfunction, the prevention of which may improve reperfusion suc cess, reduce infarct size, and enhance event-free survival. Objective: To deter mine whether protection of the distal microcirculation from thromboembolic debri s liberated during primary PCI results in improved reperfusion and decreased inf arct size.Design, Setting, and Patients: Prospective randomized controlled trial at 38 academic and community-based institutionsin 7 countries enrolling 501 pa tients aged 18 years or older with ST-segment elevation myocardial infarction(S TEMI) presenting within 6 hours of symptom onset and undergoing primary PCI or r escue intervention after failed thrombolysis. Interventions: Patients were rando mized between May 20, 2002, and November 21, 2003, to receive PCI with a balloon occlusion and aspiration distal microcirculatory protection system vs angioplas ty without distal protection. Main Outcome Measures:Coprimary end points were ST -segment resolution(STR) measured 30 minutes after PCI by continuous Holter mon itoring and infarct size measured by technetium Tc 99m sestamibi imaging between days 5 and 14. Secondary end points included major adverse cardiac events. Resu lts: Among 252 patients assigned to distal protection, aspiration was performed in 97%(242/251), all angioplasty balloon inflations were fully protected in 79 %(193/245), and visible debris was retrieved from 73%(182/250). Complete STR w as achieved in a similar proportion reperfused with vs without distal protection (63.3%[152/240] vs 61.9%[148/239], respectively; absolute difference,1.4%[95 %confidence interval, -7.7%to 10.5%;P = .78]), and left ventricular infarct size was similar in both groups (median, 12.0%[n = 229] vs 9.5%[n = 208],respe ctively; P = .15). Major adverse cardiac events at 6 months occurred with simila r frequency in the distal protection and control groups (10.0%vs 11.0%, respec tively;P = .66). Conclusions: A distal balloon occlusion and aspiration system e ffectively retrieves embolic debris in most patients with acute STEMI undergoing emergent PCI.Nonetheless, distal embolic protection did not result in improved microvascularflow, greater reperfusion suc cess,reduced infarct size, or enhanced event-free survival.展开更多
Background: The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial. Methods: The CADILLAC trial randomized 2082 patients with acute...Background: The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial. Methods: The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab. Results: Earlier reperfusion(< 3 vs 3-6 vs >6 hours) was associated with lower 1-year mortality(2.6%vs 4.3%vs 4.8%, P=.046 for< 3 vs ≥3 hours), more frequent grade 2 to 3 myocardial blush(55%vs 53%vs 44%, P=.003), more frequent complete ST-segment resolution(64%vs 68%vs 47%, P=.006), and greater improvement in left ventricular function. Early reperfusion(< 3 vs 3-6 vs≥3 hours)was associated with lower mortality in high-risk patients(3.8%vs 6.9%vs 7.0%, P=.051 for< 3 vs ≥3 hours) but not in low-risk patients(1.4%vs 0.6%vs 1.0%, P=.63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms(≤2 hours, hazard ratio 1.24, P=.013) but not late(>2 hours, heart rate 0.88, P=.33). Conclusions: Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.展开更多
Objectives: We sought to determine the relationship between cigarette smoking and outcomes after mechanical reperfusion therapy in acute myocardial infarction(AMI). Background: Prior studies have found that smokers wi...Objectives: We sought to determine the relationship between cigarette smoking and outcomes after mechanical reperfusion therapy in acute myocardial infarction(AMI). Background: Prior studies have found that smokers with AMI have lower mortality rates and a more favorable response to fibrinolytic therapy than nonsmokers. The impact of cigarette smoking in patients undergoing primary percutaneous coronary intervention has not been examined. Methods: In the CADILLAC trial, 2082 patients with AMI were randomized to percutaneous transluminal coronary angioplasty±abciximab versus stenting±abciximab. Data on smoking status were prospectively collected and follow-up continued for 1 year. Results: At the time of presentation, 638(31%) patients had never smoked, 546(26%) were former smokers, and 898(45%) were currently smoking. In comparison to nonsmokers, current smokers were younger, more often men, and less frequently had diabetes, hypertension, prior AMI, and triple-vessel coronary disease. Procedural success rates were unrelated to smoking status. Mortality was lowest in current smokers, intermediate in former smokers, and highest in nonsmokers at 30 days(1.3%vs 1.7%vs 3.5%, respectively, P=.02) and 1 year(2.9%vs 3.7%vs 6.6%, P=.0008). After multivariate correction for differences in baseline variables, however, current smoking status was no longer protective from late mortality(hazard ratio 0.96, 95%CI 0.52-1.76, P=.89). Conclusions: The “smokers paradox”extends to patients undergoing primary PCI for AMI, with increased survival seen in current smokers, an effect entirely explained by differences in baseline risk and not smoking status per se. The deleterious effects of smoking are expressed in the occurrence of AMI nearly a decade earlier than in nonsmokers, with similar age-adjusted risk, mandating intensive primary and secondary cigarette-cessation efforts.展开更多
We determined the outcomes of patients with acute ST-segment elevation(STE) myocardial infarction(STEMI) and non-STEMI(NSTEMI) after primary percutaneous coronary intervention(PCI). The prognosis after primary PCI in ...We determined the outcomes of patients with acute ST-segment elevation(STE) myocardial infarction(STEMI) and non-STEMI(NSTEMI) after primary percutaneous coronary intervention(PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for >30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725(87.8%) and NSTEMI in 239(12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival(2.4 vs 1.8 hours, p=0.0002) and increased door-to-balloon time(3.2 vs 1.9 hours, p< 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline(37.3%vs 19.4%, p< 0.0001) and higher ejection fraction(58.7%vs 55.8%, p=0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality(3.4%vs 4.4%, p=0.40) but higher rates of major adverse cardiac events(24.0%vs 16.6%, p=0.007) that was driven by more frequent ischemic target vessel revascularization(21.8%vs 11.9%, p< 0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.展开更多
Objective We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections and intramural hematomas after drug-eluting stent (DES) implantation. Method...Objective We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections and intramural hematomas after drug-eluting stent (DES) implantation. Methods We studied 887 patients with 1 045 non-in-stent restenosis lesions in 977 native arteries undergoing DES implantation with IVUS imaging, and compared the dissected stent end to the non-dissected stent end. Results Eighty-two dissections were detected; 51.2% (42/82) involved the proximal and 48.8% (40/82) the distal stent edge. When compared to the non-dissected stent end, residual plaque area [(8.0±4.3) mm2 vs (5.2±3.0) mm2, P【0.01], plaque burden [(52±12)% vs (36±15)%, P【0.01], plaque eccentricity (8.4±5.5 vs 4.0±3.4, P【0.01), and stent edge symmetry (1.17±0.11 vs 1.14±0.08, P=0.02) were larger; plaque burden≥50% was more frequent (62% vs 17%, P【0.01) and calcium deposits (52.5% vs 35.6%, P=0.03) more common; and the lumen/stent area (0.86±0.16 vs 1.02±0.18, P【0.01) was smaller in the stent dissected end. Independent predictors of stent edge dissection were residual plaque eccentricity (OR=1.3, P【0.01) and residual plaque burden≥50% (OR=7.3, P【0.01). Intramural hematomas occurred in 34.1% (28/82) of dissections.Independent predictors of intramural hematomas were plaque eccentricity (OR=1.4, P=0.005), plaque burden≥50% (OR=7.1, P=0.02), and mean lumen diameter to stent diameter ratio (OR=0.37, P=0.04).Concluslon IVUS identified edge dissections after 9.4% of DES implantations. Residual plaque eccentricity and significant plaque burden predicted coronary stent edge dissections. Dissections in less diseased reference segments with an arc of normal vessel wall (greater plaque eccentricity) more often evolved into an intramural hematoma.展开更多
Objective Angiographic assessment of a left main coronary artery (LMCA) stenosis is often difficult and unreliable. Intravascular ultrasound (IVUS) assessment of absolute lumen dimensions has been shown to correlate w...Objective Angiographic assessment of a left main coronary artery (LMCA) stenosis is often difficult and unreliable. Intravascular ultrasound (IVUS) assessment of absolute lumen dimensions has been shown to correlate with fractional flow reserve (FFR) and to predict clinical outcome in patients with a LMCA stenosis. Methods During 21 months period (October, 2004 to July, 2006), 153 patients (Ostial lesions, n=47; Non-ostial lesion, n=106) underwent IVUS evaluation specifically to assess the severity of an angiographically inconclusive LMCA narrowing. IVUS analysis included plaque morphology; external elastic membrane (EEM), lumen, plaque cross-sectional areas (CSA), plaque burden (plaque CSA/ EEM) and remodeling index (lesion EEM CSA/reference EEM CSA). Results Overall, minimum lumen area (MLA) and diameter (MLD) and plaque burden measured 8.2 mm2, 2.6 mm, and 59.3 %, respectively. An MLA【6.0 mm2 (which has been shown to correlate with a FFR 【0.75) was seen 41.5% in ostial lesions and 44.5% in non-ostial lesions. In particular, ostial LMCA lesions had a larger MLA and a smaller plaque burden than non-ostial lesions (Table). Conclusions Patients referred for LMCA evaluation commonly have insignificant narrowing. Negative remodeling was prominent at the LMCA ostium. These patients deserve IVUS assessment before revascularization.展开更多
Background Current bottleneck of patient-specific coronary plaque model construction is the resolution of in vivo medical imaging.The threshold of cap thickness of vulnerable coronary plaques is 65 microns,while the r...Background Current bottleneck of patient-specific coronary plaque model construction is the resolution of in vivo medical imaging.The threshold of cap thickness of vulnerable coronary plaques is 65 microns,while the resolution of in vivo coronary intravascular ultrasound(IVUS)images is 150-200 microns,which is not enough to identify vulnerable plaques with thin caps and construct accurate biomechanical plaque models.Optical coherence tomography(OCT)with a 15-20μm resolution has the capacity to identify thin fibrous cap.IVUS and OCT images could complement each other and provide for more accurate plaque morphology,especially,fibrous cap thickness measurements.A modeling approach combining IVUS and OCT was introduced in our previous publication for cap thickness quantification and more accurate cap stress/strain calculations.In this paper,patient baseline and follow-up IVUS and OCT data were acquired and multimodality image-based Fluidstructure interaction(FSI)models combining 3D IVUS,OCT,angiography were constructed to better quantify human coronary atherosclerotic plaque morphology and plaque stress/strain conditions and investigate the relationship of plaque vulnerability and morphological and mechanical factors.Methods Baseline and 10-Month follow-up in vivo IVUS and OCT coronary plaque data were acquired from one patient with informed consent obtained.Co-registration and segmentation of baseline and follow-up IVUS and OCT images were performed for modeling use.Baseline and follow-up 3D FSI models based on IVUS and OCT were constructed to simulate the mechanical factors which integrating plaque morphology were employed to predict plaque vulnerability.These 3D models were solved by ADINA(ADINA R&D,Watertown,MA,USA).The quantitative indices of cap thickness,lipid percentage were classified according to histological literatures and denoted as Cap Index and Lipid Index.Cap Index,Lipid Index and Morphological Plaque Vulnerability Index(MPVI)were chosen to quantify plaque vulnerability,respectively.Random forest(RF)which was based 13 extracted features including morphological and mechanical factors was used for plaque vulnerability classification and prediction.Over sampling scheme and a 5-fold crossvalidation procedure was employed in all 45 slices for training and testing sets.Single and all different combinations of morphological and mechanical risk factors were used for plaque progression prediction.Results When Cap Index was used as the measurement,minimum cap thickness(MCT)was the best single predictor which area under curve(AUC)is 0.782 0;the combination of MCT,critical plaque wall strain(CPWSn),critical wall shear stress(CWSS)and cap wall shear stress(CapWSS)was the best predictor with ACU=0.868 6.When Lipid Index was used as the measurement,the lipid percentage(LP)was the best single predictor which AUC value is 0.857 8;the combination of Mean cap thickness(MeanCT),LP,CWSS and cap plaque wall stress(CapPWS)and was the best predictor with ACU=0.9821.When MPVI was used as the measurement,MCT was the best single predictor which AUC value is 0.782 9;the combination of MCT,LP,plaque area(PA),CPWSn and CapWSS was the best predictor with ACU=0.872 9.Conclusions Combinations of morphological and mechanical risk factors had higher prediction accuracy,compared to the prediction of single factors and other combination of morphological factors.展开更多
Thrombocytopenia that develops after percutaneous coronary intervention(PCI) may result in hemorrhagic complications, requirement for blood product transfusions, and potentially thrombotic or ischemic complications. T...Thrombocytopenia that develops after percutaneous coronary intervention(PCI) may result in hemorrhagic complications, requirement for blood product transfusions, and potentially thrombotic or ischemic complications. The incidence and prognostic significance of thrombocytopenia, in patients with acute myocardial infarction(AMI) who undergo primary PCI have not been evaluated. In the CADILLAC trial 2,082 patients who had AMI within 12 hours of onset without shock were prospectively randomized to receive balloon angioplasty with or without abciximab versus stenting with or without abciximab. Acquired thrombocytopenia, defined as a nadir platelet count<100×109/L in patients who did not have baseline thrombocytopenia, developed in 50 of 1,975 qualifying patients(2.5%) after primary PCI. By multivariate analysis, acquired thrombocytopenia developed more frequently in patients who had non-insulin-requiring diabetes mellitus(odds ratio 3.88[OR], p=0.0002), previous statin administration(OR 3.28, p=0.002), and use of abciximab(OR 2.06, p=0.02) and less frequently in patients who had previous aspirin use(OR 0.26, p=0.002), a higher baseline platelet count(OR 1.20, p< 0.0001), and greater body mass index(OR 0.90, p=0.006). Patients who developed thrombocytopenia versus those who did not had higher in-hospital rates of major hemorrhagic complications(10.0%vs 2.7%, p=0.01), greater requirement for blood transfusions(10.0%vs 3.9%, p=0.05), longer hospital stay(median 4.8 vs 3.6 days, p=0.008), and increased costs(median ＄14,466 vs ＄11,629, p=0.001). All-cause mortality was markedly increased at 30 days(8.0%vs 1.6%, p=0.0008) and at 1 year(10.0%vs 3.9%, p=0.03) in patients who developed thrombocytopenia. In conclusion, thrombocytopenia that develops after primary PCI for AMI, although uncommon, is associated with increased hemorrhagic complications and decreased survival.展开更多
Background-Biological age is a strong determinant of prognosis in patients with acute myocardial infarction(AMI). We sought to examine the impact of age after primary percutaneous coronary intervention in AMI and to d...Background-Biological age is a strong determinant of prognosis in patients with acute myocardial infarction(AMI). We sought to examine the impact of age after primary percutaneous coronary intervention in AMI and to determine whether routine coronary stent implantation and/or platelet glycoprotein IIb/IIIa inhibitors improve clinical outcomes in elderly patients after primary angioplasty. Methods and Results-In the CADILLAC trial, 2082 patients with AMI were randomized to balloon angioplasty,angioplasty plus abciximab,stenting alone, or stenting plus abciximab. No patient was excluded on the basis of advanced age; patients ranging from 21 to 95 years of age were enrolled. One-year mortality increased for each decile of age, exponentially after 65 years of age(1.6%for patients< 55 years, 2.1%for 55 to 65 years, 7.1%for 65 to 75 years, 11.1%for patients >75 years; P< 0.0001). Elderly patients also had increased rates of stroke and major bleeding compared with their younger counterparts. Among elderly patients (≥65 years), 1-year rates of ischemic target revascularization (7.0%versus 17.6%; P< 0.0001) and subacute or late thrombosis (0%versus 2.2%; P=0.005)were reducedwith stenting comparedwith balloon angioplasty. Routine abciximab administration, although safe,was not of definite benefit in elderly patients. Rates of mortality, reinfarction, disabling stroke, and major bleeding in the elderly were independent of reperfusion modality. Conclusions-Despite contemporary mechanical reperfusion strategies,mortality, major bleeding, and stroke rates remain high in elderly patients undergoing primary percutaneous coronary intervention, outcomes that are not affected by stents or glycoprotein Ⅱb/Ⅲa inhibitors. By reducing restenosis, however, stent implantation improves clinical outcomes in elderly patients with AMI.展开更多
Background: The filter-based FilterWire EX(Boston Scientific, Natick, MA) embolic protection system and the GuardWire(Medtronic, Santa Rosa, CA) balloon occlusion and aspiration device have been previously shown to re...Background: The filter-based FilterWire EX(Boston Scientific, Natick, MA) embolic protection system and the GuardWire(Medtronic, Santa Rosa, CA) balloon occlusion and aspiration device have been previously shown to reduce periprocedural complication rates of percutaneous coronary intervention for saphenous vein graft(SVG) disease and are considered the standard of care in this setting. The lateclinical course after treatment with these devices has not been reported. Methods: In the FIRE trial, 651 patients undergoing SVG intervention were randomized to either the FilterWire EX or GuardWire. Six-month rates of the primary end point(composite major adverse cardiac events[MACE]) and its components(death, myocardial infarction[MI], or target vessel revascularization)were studied. Results: MACE at 30 days occurred in 9.9%of patients randomized to the FilterWire EX compared with 11.6%with the GuardWire, P=.53. By 6 months, MACE had increased to 19.3%and 21.9%in FilterWire EX and GuardWire groups, respectively,(relative risk 0.88, 95%CI 0.65-1.19; P=.44). All-cause 6-month mortality in the entire population was 3.5%(3.0%with FilterWire EX vs 4.1%with GuardWire, P=.53, with all deaths occurring after hospital discharge). MI occurred in 12.0%of patients at 6 months(12.1%vs 11.9%with the FilterWire EX and GuardWire, respectively, P=.99), and target vessel revascularization was required in 9.1%(8.2%vs 10.0%, respectively, P=.42). Conclusions: SVG intervention with the FilterWire EX and GuardWire distal protection devices resulted in similar outcomes at 6 months, although the clinical course after hospital discharge was not benign, with significant rates of death, MI, and repeat intervention.展开更多
文摘The elderly are the most rapidly growing population group in the world.Data collected over a 30-year period have demonstrated the increasing prevalence of hypertension with age.The risk of coronary artery disease,stroke,congestive heart disease,chronic kidney insufficiency and dementia is also increased in this subgroup of hypertensives.Hypertension in the elderly patients represents a management dilemma to cardiovascular specialists and other practioners.During the last years and before the findings of the Systolic Hypertension in Europe Trial were published,the general medical opinion considered not to decrease blood pressure values similarly to other younger patients,in order to avoid possible ischemic events and poor oxygenation of the organs(brain,heart,kidney).The aim of this review article is to highlight the importance of treating hypertension in aged population in order to improve their quality of life and lower the incidence of the cardiovascular complications.
文摘Context: Atheromatous and thrombotic embolization during percutaneous coronary intervention(PCI) in acute myocardial infarction is common and may result in microcirculatory dysfunction, the prevention of which may improve reperfusion success, reduce infarct size, and enhance event-free survival. Objective: To determine whether protection of the distal microcirculation from thromboembolic debris liberated during primary PCI results in improved reperfusion and decreased infarct size. Design, Setting, and Patients: Prospective randomized controlled trial at 38 academic and community-based institutions in 7 countries enrolling 501 patients aged 18 years or older with ST-segment elevation myocardial infarction(STEMI) presenting within 6 hours of symptom onset and undergoing primary PCI or rescue intervention after failed thrombolysis. Interventions: Patients were randomized between May 20, 2002, and November 21, 2003, to receive PCI with a balloon occlusion and aspiration distal microcirculatory protection systemvs angioplasty without distal protection. Main Outcome Measures: Coprimary end points were ST-segment resolution(STR) measured 30 minutes after PCI by continuous Holter monitoring and infarct size measured by technetium Tc 99m sestamibi imaging between days 5 and 14. Secondary end points included major adverse cardiac events. Results: Among 252 patients assigned to distal protection, aspiration was performed in 97%(242/251), all angioplasty balloon inflations were fully protected in 79%(193/245), and visible debris was retrieved from 73%(182/250). Complete STR was achieved in a similar proportion reperfused with vs without distal protection(63.3%[152/240] vs 61.9%[148/239], respectively; absolute difference, 1.4%[95%confidence interval,-7.7%to 10.5%; P=.78]), and left ventricular infarct size was similar in both groups(median, 12.0%[n=229] vs 9.5%[n=208], respectively; P=.15). Major adverse cardiac events at 6 months occurred with similar frequency in the distal protection and control groups(10.0%vs 11.0%, respectively; P=.66). Conclusions: A distal balloon occlusion and aspiration system effectively retrieves embolic debris in most patients with acute STEMI undergoing emergent PCI. Nonetheless, distal embolic protection did not resultin improved microvascularflow, greater reperfusion success, reduced infarct size, or enhanced event-free survival.
文摘Context: Atheromatous and thrombotic embolization during percutaneous coronary intervention (PCI) in acute myocardial infarction is common and may result in m icrocirculatory dysfunction, the prevention of which may improve reperfusion suc cess, reduce infarct size, and enhance event-free survival. Objective: To deter mine whether protection of the distal microcirculation from thromboembolic debri s liberated during primary PCI results in improved reperfusion and decreased inf arct size.Design, Setting, and Patients: Prospective randomized controlled trial at 38 academic and community-based institutionsin 7 countries enrolling 501 pa tients aged 18 years or older with ST-segment elevation myocardial infarction(S TEMI) presenting within 6 hours of symptom onset and undergoing primary PCI or r escue intervention after failed thrombolysis. Interventions: Patients were rando mized between May 20, 2002, and November 21, 2003, to receive PCI with a balloon occlusion and aspiration distal microcirculatory protection system vs angioplas ty without distal protection. Main Outcome Measures:Coprimary end points were ST -segment resolution(STR) measured 30 minutes after PCI by continuous Holter mon itoring and infarct size measured by technetium Tc 99m sestamibi imaging between days 5 and 14. Secondary end points included major adverse cardiac events. Resu lts: Among 252 patients assigned to distal protection, aspiration was performed in 97%(242/251), all angioplasty balloon inflations were fully protected in 79 %(193/245), and visible debris was retrieved from 73%(182/250). Complete STR w as achieved in a similar proportion reperfused with vs without distal protection (63.3%[152/240] vs 61.9%[148/239], respectively; absolute difference,1.4%[95 %confidence interval, -7.7%to 10.5%;P = .78]), and left ventricular infarct size was similar in both groups (median, 12.0%[n = 229] vs 9.5%[n = 208],respe ctively; P = .15). Major adverse cardiac events at 6 months occurred with simila r frequency in the distal protection and control groups (10.0%vs 11.0%, respec tively;P = .66). Conclusions: A distal balloon occlusion and aspiration system e ffectively retrieves embolic debris in most patients with acute STEMI undergoing emergent PCI.Nonetheless, distal embolic protection did not result in improved microvascularflow, greater reperfusion suc cess,reduced infarct size, or enhanced event-free survival.
文摘Background: The impact of treatment delays on outcomes after primary percutaneous coronary intervention for acute myocardial infarction is controversial. Methods: The CADILLAC trial randomized 2082 patients with acute myocardial infarction to stenting versus percutaneous transluminal coronary angioplasty, each with or without abciximab. Results: Earlier reperfusion(< 3 vs 3-6 vs >6 hours) was associated with lower 1-year mortality(2.6%vs 4.3%vs 4.8%, P=.046 for< 3 vs ≥3 hours), more frequent grade 2 to 3 myocardial blush(55%vs 53%vs 44%, P=.003), more frequent complete ST-segment resolution(64%vs 68%vs 47%, P=.006), and greater improvement in left ventricular function. Early reperfusion(< 3 vs 3-6 vs≥3 hours)was associated with lower mortality in high-risk patients(3.8%vs 6.9%vs 7.0%, P=.051 for< 3 vs ≥3 hours) but not in low-risk patients(1.4%vs 0.6%vs 1.0%, P=.63). Door-to-balloon times were independently correlated with mortality in patients presenting early after the onset of symptoms(≤2 hours, hazard ratio 1.24, P=.013) but not late(>2 hours, heart rate 0.88, P=.33). Conclusions: Early reperfusion results in superior clinical outcomes, enhanced microvascular reperfusion, and better recovery of left ventricular function. Incremental treatment delays impact mortality more in high-risk versus low-risk patients and more in patients presenting early versus late after the onset of symptoms. These data emphasize the importance of minimizing treatment delays and have implications regarding patient triage for primary percutaneous coronary intervention.
文摘Objectives: We sought to determine the relationship between cigarette smoking and outcomes after mechanical reperfusion therapy in acute myocardial infarction(AMI). Background: Prior studies have found that smokers with AMI have lower mortality rates and a more favorable response to fibrinolytic therapy than nonsmokers. The impact of cigarette smoking in patients undergoing primary percutaneous coronary intervention has not been examined. Methods: In the CADILLAC trial, 2082 patients with AMI were randomized to percutaneous transluminal coronary angioplasty±abciximab versus stenting±abciximab. Data on smoking status were prospectively collected and follow-up continued for 1 year. Results: At the time of presentation, 638(31%) patients had never smoked, 546(26%) were former smokers, and 898(45%) were currently smoking. In comparison to nonsmokers, current smokers were younger, more often men, and less frequently had diabetes, hypertension, prior AMI, and triple-vessel coronary disease. Procedural success rates were unrelated to smoking status. Mortality was lowest in current smokers, intermediate in former smokers, and highest in nonsmokers at 30 days(1.3%vs 1.7%vs 3.5%, respectively, P=.02) and 1 year(2.9%vs 3.7%vs 6.6%, P=.0008). After multivariate correction for differences in baseline variables, however, current smoking status was no longer protective from late mortality(hazard ratio 0.96, 95%CI 0.52-1.76, P=.89). Conclusions: The “smokers paradox”extends to patients undergoing primary PCI for AMI, with increased survival seen in current smokers, an effect entirely explained by differences in baseline risk and not smoking status per se. The deleterious effects of smoking are expressed in the occurrence of AMI nearly a decade earlier than in nonsmokers, with similar age-adjusted risk, mandating intensive primary and secondary cigarette-cessation efforts.
文摘We determined the outcomes of patients with acute ST-segment elevation(STE) myocardial infarction(STEMI) and non-STEMI(NSTEMI) after primary percutaneous coronary intervention(PCI). The prognosis after primary PCI in STEMI has been extensively studied and defined. Outcomes of patients who undergo primary PCI for NSTEMI are less well established. In total, 2,082 patients with ongoing chest pain for >30 minutes consistent with acute MI were randomized to balloon angioplasty versus stenting, each with/without abciximab. Of 1,964 patients, STEMI was present in 1,725(87.8%) and NSTEMI in 239(12.2%). Compared with STEMI, those with NSTEMI were more likely to have delayed time-to-hospital arrival(2.4 vs 1.8 hours, p=0.0002) and increased door-to-balloon time(3.2 vs 1.9 hours, p< 0.0001). Patients with NSTEMI were more likely to have Thrombolysis In Myocardial Infarction grade 3 flow at baseline(37.3%vs 19.4%, p< 0.0001) and higher ejection fraction(58.7%vs 55.8%, p=0.001), but similar rates of postprocedural Thrombolysis In Myocardial Infarction grade 3 flow. At 1 year, patients with NTEMI had similar mortality(3.4%vs 4.4%, p=0.40) but higher rates of major adverse cardiac events(24.0%vs 16.6%, p=0.007) that was driven by more frequent ischemic target vessel revascularization(21.8%vs 11.9%, p< 0.0001). In conclusion, patients with acute MI without STE who are treated with primary PCI have marked delays to treatment, similar late mortality, and increased rates of ischemic target vessel revascularization compared with patients with STEMI, despite more favorable angiographic features at presentation and similar reperfusion success. The adverse prognosis of patients with NSTEMI should be recognized and efforts made to decrease reperfusion times.
文摘Objective We used intravascular ultrasound (IVUS) to assess incidence, predictors, morphology, and angiographic findings of edge dissections and intramural hematomas after drug-eluting stent (DES) implantation. Methods We studied 887 patients with 1 045 non-in-stent restenosis lesions in 977 native arteries undergoing DES implantation with IVUS imaging, and compared the dissected stent end to the non-dissected stent end. Results Eighty-two dissections were detected; 51.2% (42/82) involved the proximal and 48.8% (40/82) the distal stent edge. When compared to the non-dissected stent end, residual plaque area [(8.0±4.3) mm2 vs (5.2±3.0) mm2, P【0.01], plaque burden [(52±12)% vs (36±15)%, P【0.01], plaque eccentricity (8.4±5.5 vs 4.0±3.4, P【0.01), and stent edge symmetry (1.17±0.11 vs 1.14±0.08, P=0.02) were larger; plaque burden≥50% was more frequent (62% vs 17%, P【0.01) and calcium deposits (52.5% vs 35.6%, P=0.03) more common; and the lumen/stent area (0.86±0.16 vs 1.02±0.18, P【0.01) was smaller in the stent dissected end. Independent predictors of stent edge dissection were residual plaque eccentricity (OR=1.3, P【0.01) and residual plaque burden≥50% (OR=7.3, P【0.01). Intramural hematomas occurred in 34.1% (28/82) of dissections.Independent predictors of intramural hematomas were plaque eccentricity (OR=1.4, P=0.005), plaque burden≥50% (OR=7.1, P=0.02), and mean lumen diameter to stent diameter ratio (OR=0.37, P=0.04).Concluslon IVUS identified edge dissections after 9.4% of DES implantations. Residual plaque eccentricity and significant plaque burden predicted coronary stent edge dissections. Dissections in less diseased reference segments with an arc of normal vessel wall (greater plaque eccentricity) more often evolved into an intramural hematoma.
文摘Objective Angiographic assessment of a left main coronary artery (LMCA) stenosis is often difficult and unreliable. Intravascular ultrasound (IVUS) assessment of absolute lumen dimensions has been shown to correlate with fractional flow reserve (FFR) and to predict clinical outcome in patients with a LMCA stenosis. Methods During 21 months period (October, 2004 to July, 2006), 153 patients (Ostial lesions, n=47; Non-ostial lesion, n=106) underwent IVUS evaluation specifically to assess the severity of an angiographically inconclusive LMCA narrowing. IVUS analysis included plaque morphology; external elastic membrane (EEM), lumen, plaque cross-sectional areas (CSA), plaque burden (plaque CSA/ EEM) and remodeling index (lesion EEM CSA/reference EEM CSA). Results Overall, minimum lumen area (MLA) and diameter (MLD) and plaque burden measured 8.2 mm2, 2.6 mm, and 59.3 %, respectively. An MLA【6.0 mm2 (which has been shown to correlate with a FFR 【0.75) was seen 41.5% in ostial lesions and 44.5% in non-ostial lesions. In particular, ostial LMCA lesions had a larger MLA and a smaller plaque burden than non-ostial lesions (Table). Conclusions Patients referred for LMCA evaluation commonly have insignificant narrowing. Negative remodeling was prominent at the LMCA ostium. These patients deserve IVUS assessment before revascularization.
基金supported in part by a Jiangsu Province Science and Technology Agency grant ( BE2016785)
文摘Background Current bottleneck of patient-specific coronary plaque model construction is the resolution of in vivo medical imaging.The threshold of cap thickness of vulnerable coronary plaques is 65 microns,while the resolution of in vivo coronary intravascular ultrasound(IVUS)images is 150-200 microns,which is not enough to identify vulnerable plaques with thin caps and construct accurate biomechanical plaque models.Optical coherence tomography(OCT)with a 15-20μm resolution has the capacity to identify thin fibrous cap.IVUS and OCT images could complement each other and provide for more accurate plaque morphology,especially,fibrous cap thickness measurements.A modeling approach combining IVUS and OCT was introduced in our previous publication for cap thickness quantification and more accurate cap stress/strain calculations.In this paper,patient baseline and follow-up IVUS and OCT data were acquired and multimodality image-based Fluidstructure interaction(FSI)models combining 3D IVUS,OCT,angiography were constructed to better quantify human coronary atherosclerotic plaque morphology and plaque stress/strain conditions and investigate the relationship of plaque vulnerability and morphological and mechanical factors.Methods Baseline and 10-Month follow-up in vivo IVUS and OCT coronary plaque data were acquired from one patient with informed consent obtained.Co-registration and segmentation of baseline and follow-up IVUS and OCT images were performed for modeling use.Baseline and follow-up 3D FSI models based on IVUS and OCT were constructed to simulate the mechanical factors which integrating plaque morphology were employed to predict plaque vulnerability.These 3D models were solved by ADINA(ADINA R&D,Watertown,MA,USA).The quantitative indices of cap thickness,lipid percentage were classified according to histological literatures and denoted as Cap Index and Lipid Index.Cap Index,Lipid Index and Morphological Plaque Vulnerability Index(MPVI)were chosen to quantify plaque vulnerability,respectively.Random forest(RF)which was based 13 extracted features including morphological and mechanical factors was used for plaque vulnerability classification and prediction.Over sampling scheme and a 5-fold crossvalidation procedure was employed in all 45 slices for training and testing sets.Single and all different combinations of morphological and mechanical risk factors were used for plaque progression prediction.Results When Cap Index was used as the measurement,minimum cap thickness(MCT)was the best single predictor which area under curve(AUC)is 0.782 0;the combination of MCT,critical plaque wall strain(CPWSn),critical wall shear stress(CWSS)and cap wall shear stress(CapWSS)was the best predictor with ACU=0.868 6.When Lipid Index was used as the measurement,the lipid percentage(LP)was the best single predictor which AUC value is 0.857 8;the combination of Mean cap thickness(MeanCT),LP,CWSS and cap plaque wall stress(CapPWS)and was the best predictor with ACU=0.9821.When MPVI was used as the measurement,MCT was the best single predictor which AUC value is 0.782 9;the combination of MCT,LP,plaque area(PA),CPWSn and CapWSS was the best predictor with ACU=0.872 9.Conclusions Combinations of morphological and mechanical risk factors had higher prediction accuracy,compared to the prediction of single factors and other combination of morphological factors.
文摘Thrombocytopenia that develops after percutaneous coronary intervention(PCI) may result in hemorrhagic complications, requirement for blood product transfusions, and potentially thrombotic or ischemic complications. The incidence and prognostic significance of thrombocytopenia, in patients with acute myocardial infarction(AMI) who undergo primary PCI have not been evaluated. In the CADILLAC trial 2,082 patients who had AMI within 12 hours of onset without shock were prospectively randomized to receive balloon angioplasty with or without abciximab versus stenting with or without abciximab. Acquired thrombocytopenia, defined as a nadir platelet count<100×109/L in patients who did not have baseline thrombocytopenia, developed in 50 of 1,975 qualifying patients(2.5%) after primary PCI. By multivariate analysis, acquired thrombocytopenia developed more frequently in patients who had non-insulin-requiring diabetes mellitus(odds ratio 3.88[OR], p=0.0002), previous statin administration(OR 3.28, p=0.002), and use of abciximab(OR 2.06, p=0.02) and less frequently in patients who had previous aspirin use(OR 0.26, p=0.002), a higher baseline platelet count(OR 1.20, p< 0.0001), and greater body mass index(OR 0.90, p=0.006). Patients who developed thrombocytopenia versus those who did not had higher in-hospital rates of major hemorrhagic complications(10.0%vs 2.7%, p=0.01), greater requirement for blood transfusions(10.0%vs 3.9%, p=0.05), longer hospital stay(median 4.8 vs 3.6 days, p=0.008), and increased costs(median ＄14,466 vs ＄11,629, p=0.001). All-cause mortality was markedly increased at 30 days(8.0%vs 1.6%, p=0.0008) and at 1 year(10.0%vs 3.9%, p=0.03) in patients who developed thrombocytopenia. In conclusion, thrombocytopenia that develops after primary PCI for AMI, although uncommon, is associated with increased hemorrhagic complications and decreased survival.
文摘Background-Biological age is a strong determinant of prognosis in patients with acute myocardial infarction(AMI). We sought to examine the impact of age after primary percutaneous coronary intervention in AMI and to determine whether routine coronary stent implantation and/or platelet glycoprotein IIb/IIIa inhibitors improve clinical outcomes in elderly patients after primary angioplasty. Methods and Results-In the CADILLAC trial, 2082 patients with AMI were randomized to balloon angioplasty,angioplasty plus abciximab,stenting alone, or stenting plus abciximab. No patient was excluded on the basis of advanced age; patients ranging from 21 to 95 years of age were enrolled. One-year mortality increased for each decile of age, exponentially after 65 years of age(1.6%for patients< 55 years, 2.1%for 55 to 65 years, 7.1%for 65 to 75 years, 11.1%for patients >75 years; P< 0.0001). Elderly patients also had increased rates of stroke and major bleeding compared with their younger counterparts. Among elderly patients (≥65 years), 1-year rates of ischemic target revascularization (7.0%versus 17.6%; P< 0.0001) and subacute or late thrombosis (0%versus 2.2%; P=0.005)were reducedwith stenting comparedwith balloon angioplasty. Routine abciximab administration, although safe,was not of definite benefit in elderly patients. Rates of mortality, reinfarction, disabling stroke, and major bleeding in the elderly were independent of reperfusion modality. Conclusions-Despite contemporary mechanical reperfusion strategies,mortality, major bleeding, and stroke rates remain high in elderly patients undergoing primary percutaneous coronary intervention, outcomes that are not affected by stents or glycoprotein Ⅱb/Ⅲa inhibitors. By reducing restenosis, however, stent implantation improves clinical outcomes in elderly patients with AMI.
文摘Background: The filter-based FilterWire EX(Boston Scientific, Natick, MA) embolic protection system and the GuardWire(Medtronic, Santa Rosa, CA) balloon occlusion and aspiration device have been previously shown to reduce periprocedural complication rates of percutaneous coronary intervention for saphenous vein graft(SVG) disease and are considered the standard of care in this setting. The lateclinical course after treatment with these devices has not been reported. Methods: In the FIRE trial, 651 patients undergoing SVG intervention were randomized to either the FilterWire EX or GuardWire. Six-month rates of the primary end point(composite major adverse cardiac events[MACE]) and its components(death, myocardial infarction[MI], or target vessel revascularization)were studied. Results: MACE at 30 days occurred in 9.9%of patients randomized to the FilterWire EX compared with 11.6%with the GuardWire, P=.53. By 6 months, MACE had increased to 19.3%and 21.9%in FilterWire EX and GuardWire groups, respectively,(relative risk 0.88, 95%CI 0.65-1.19; P=.44). All-cause 6-month mortality in the entire population was 3.5%(3.0%with FilterWire EX vs 4.1%with GuardWire, P=.53, with all deaths occurring after hospital discharge). MI occurred in 12.0%of patients at 6 months(12.1%vs 11.9%with the FilterWire EX and GuardWire, respectively, P=.99), and target vessel revascularization was required in 9.1%(8.2%vs 10.0%, respectively, P=.42). Conclusions: SVG intervention with the FilterWire EX and GuardWire distal protection devices resulted in similar outcomes at 6 months, although the clinical course after hospital discharge was not benign, with significant rates of death, MI, and repeat intervention.
