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Guido Parodi,
Renato Valenti,
Benedetta Bellandi,
Angela Migliorini,
Rossella Marcucci,
Vincenzo Comito,
Nazario Carrabba,
Alberto Santini,
Gian Franco Gensini,
Rosanna Abbate,
David Antoniucci
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ABSTRACT: OBJECTIVES: This study sought to compare the action of Prasugrel and Ticagrelor in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PPCI). BACKGROUND: It has been documented that prasugrel and ticagrelor are able to provide effective platelet inhibition 2 hours after a loading dose (LD). However, the pharmacodynamic measurements after prasugrel and ticagrelor LD have been provided by assessing only healthy volunteers or subjects with stable coronary artery disease. METHODS: Fifty patients with STEMI undergoing PPCI with bivalirudin monotherapy were randomized to receive 60 mg prasugrel LD (n= 25) or 180 mg ticagrelor LD (n= 25). Residual platelet reactivity was assessed by VerifyNow at baseline and 2, 4, 8 and 12 hours after LD. RESULTS: Platelet Reactivity Units (PRU) 2 hours after the LD (study primary end-point) was 217 (12-279) and 275 (88-305) in prasugrel and ticagrelor group, respectively (p=NS), satisfying pre-specified non-inferiority criteria. High residual platelet reactivity (HRPR; PRU ≥240) was found in 44% and 60% patients (p=0.258) at 2 hours. The mean time to achieve a PRU <240 was 3±2 and 5±4 hours in the prasugrel and ticagrelor group, respectively. The independent predictors of HRPR at 2 hours were morphine use (OR 5.29 [1.44-19.49], p=0.012) and baseline PRU value (OR 1.014 [1.00-1.03], p=0.046). CONCLUSIONS: In patients with STEMI, prasugrel showed to be non-inferior as compared with Ticagrelor in terms of residual platelet reactivity 2 hours after the LD. The 2 drugs provide an effective platelet inhibition 2 hours after the LD in only a half of patients, and at least 4 hours are required to achieve an effective platelet inhibition in the majority of patients. Morphine use is associated with a delayed activity of these agents.
Journal of the American College of Cardiology 03/2013; · 14.16 Impact Factor
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Emanuele Cecchi, Guido Parodi,
Cristina Giglioli,
Silvia Passantino,
Brunella Bandinelli,
Agatina Alessandrello Liotta,
Benedetta Bellandi,
Gabriele Cioni,
Maria Costanzo,
Rosanna Abbate,
Gian Franco Gensini,
Davide Antoniucci,
Lucia Mannini
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ABSTRACT: Takotsubo cardiomyopathy (TC) is characterized by transient hypokinesis of the left ventricular apex or midventricular segments with coronary arteries without significant stenosis. It is often associated with emotional or physical stress; however, its pathophysiology is still unclear. In the present study, we analyzed the alterations in blood viscosity and markers of endothelial damage induced by sympathetic stimulation in patients with previous TC. Seventeen women (mean age 71 years) with previous TC, included and investigated in the TC Tuscany Registry, were compared to a control group of 8 age- and risk factor-matched women with chest pain and coronary arteries free of stenosis. All subjects underwent the cold pressor test (CPT). Before and after the CPT, the hemorheologic parameters (whole blood viscosity at 0.512 s-1 and 94.5 s-1, plasma viscosity, erythrocyte deformability index, and erythrocyte aggregation), catecholamines, plasminogen activator inhibitor-1 (PAI-1), and von Willebrand factor levels were assessed. The patients with TC had significantly greater baseline PAI-1 levels (p <0.01) and lower erythrocyte deformability index values (p <0.01). After CPT, both the patients with TC and the controls had a significant increase in several hemorheologic parameters, catecholamines, and von Willebrand factor levels and a decrease in erythrocyte deformability index. However, the PAI-1 levels were significantly increased only in the patients with TC. Compared to the controls, the patients with TC had significantly greater values of whole blood viscosity at 94.5 s-1 (p <0.05), PAI-1 (p <0.01), von Willebrand factor (p <0.05) and lower erythrocyte deformability index values (p <0.01) after CPT. In conclusion, the results of the present study suggest that in patients with TC, the alterations in erythrocyte membranes and endothelial integrity induced by catecholaminergic storm could determine microvascular hypoperfusion, possibly favoring the occurrence of left ventricular ballooning.
The American journal of cardiology 02/2013; · 3.58 Impact Factor
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ABSTRACT: There is a lack of clarity concerning the clinical implications of myocardial injury occurring after transcatheter aortic valve implantation (TAVI) procedures. The aim of this study was to determine the incidence, degree, and timing of myocardial injury associated with TAVI procedures and to evaluate its 1-year prognostic value. Among 68 consecutive patients (mean age 80.9 ± 6.4 years) treated with TAVI, 3 patients who died within 24 hours, precluding cardiac biomarker measurements, and 3 patients with major procedural complications were excluded. Cardiac troponin I, creatine kinase-MB, and creatinine levels were determined at baseline and 6, 12, 24, 48, and 72 hours after TAVI. All complications were defined according to the Valve Academic Research Consortium. Myocardial injury was observed in all patients (n = 62), as determined by an increase in cardiac troponin I (median peak at 12 hours 3.8 μg/L, interquartile range 1.8 to 25.67), and a higher degree of myocardial injury was observed in patients (n = 9) who developed acute kidney injury (AKI) (p = 0.026). Periprocedural myocardial infarction was not found. At 1-year follow-up, 5 patients had died, and 7 patients had been hospitalized for heart failure. The development of AKI, not the degree of peak cardiac troponin I (p = 0.348), was identified as the only strong independent predictor of 1-year mortality from any cause (including heart failure) after TAVI (hazard ratio 4.74, 95% confidence interval 1.12 to 20.03, p = 0.034). In conclusion, TAVI was systematically associated with myocardial injury, occurring with a higher degree in patients who developed AKI. However, the simultaneous development of AKI occurring after TAVI is the strongest predictor of 1-year mortality.
The American journal of cardiology 02/2013; · 3.58 Impact Factor
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ABSTRACT: Previous reports have shown that female gender is associated with impaired outcomes among patients with ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, mainly owing to a worst risk profile (more diabetes, more advanced age, and higher Killip class at presentation) compared to men. Still contrasting are data on the effect of gender on the outcome in patients with STEMI undergoing primary angioplasty. In particular, it is still unclear whether a larger infarct size might contribute to the explanation of the worse outcome in women. Therefore, the aim of the present study was to investigate gender-related differences in infarct size as evaluated by myocardial scintigraphy in a large cohort of patients with STEMI undergoing primary percutaneous coronary intervention. We included 830 patients with STEMI undergoing primary percutaneous coronary intervention. The infarct size was evaluated at 30 days using technetium-99m-sestamibi. A logistic regression analysis was performed to determine the relation between gender and infarct size (as percentage of patients above the median) after correction for baseline confounding factors. We also evaluated the presence of a potential age-gender interaction. A total of 183 patients (20.8%) were women. Female gender was associated with more advanced age and a greater prevalence of hypertension; previous infarction and smoking were more frequently observed in men. Female gender was associated with a smaller infarct size (p <0.001) that was confirmed after correction for baseline confounding factors (adjusted odds ratio 0.48, 95% confidence interval 0.33-0.7, p <0.001). No age-gender interaction was observed (p = 0.13). In conclusion, the results of the present study have shown that despite the presence of high-risk features at presentation, female gender was associated with a smaller infarct size than that in men, without any interaction between age and gender.
The American journal of cardiology 01/2013; · 3.58 Impact Factor
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ABSTRACT: OBJECTIVES: This study sought to assess the incidence of reocclusion and identification of predictors of angiographic failure after successful chronic total occlusion (CTO) drug-eluting stent-supported percutaneous coronary intervention (PCI). BACKGROUND: Large registries have shown a survival benefit in patients with successful CTO PCI. Intuitively, sustained vessel patency may be considered as a main variable related to long-term survival. Very few data exist about the angiographic outcome after successful CTO PCI. METHODS: The Florence CTO PCI registry started in 2003 and included consecutive patients treated with drug-eluting stents for at least 1 CTO (>3 months). The protocol treatment included routine 6- to 9-month angiographic follow-up. Clinical, angiographic, and procedural variables were included in the model of multivariable binary logistic regression analysis for the identification of the predictors of reocclusion. RESULTS: From 2003 to 2010, 1,035 patients underwent PCI for at least 1 CTO. Of these, 802 (77%) had a successful PCI. The angiographic follow-up rate was 82%. Reocclusion rate was 7.5%, whereas binary restenosis (>50%) or reocclusion rate was 20%. Everolimus-eluting stents were associated with a significantly lower reocclusion rate than were other drug-eluting stents (3.0% vs. 10.1%; p = 0.001). A successful subintimal tracking and re-entry technique was associated with a 57% of reocclusion rate. By multivariable analysis, the subintimal tracking and re-entry technique (odds ratio [OR]: 29.5; p < 0.001) and everolimus-eluting stents (OR: 0.22; p = 0.001) were independently related to the risk of reocclusion. CONCLUSIONS: Successful CTO-PCI supported by everolimus-eluting stents is associated with a very high patency rate. Successful subintimal tracking and re-entry technique is associated with a very low patency rate regardless of the type of stent used.
Journal of the American College of Cardiology 12/2012; · 14.16 Impact Factor
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ABSTRACT: The goal of this study was to compare the outcomes of patients treated with everolimus-eluting stents (EES) with outcomes of patients treated with first-generation paclitaxel-eluting stents (PES) for unprotected left main disease (ULMD).
No data exist about the comparison of these 2 types of stents in ULMD.
The primary endpoint of the study was a 1-year composite of cardiac death, nonfatal myocardial infarction, target vessel revascularization, and stroke (MACE). Secondary endpoints were 1-year target vessel failure (TVF) and 9-month angiographic in-segment restenosis >50%.
From 2004 to 2010, a total of 390 patients underwent ULMD percutaneous coronary intervention (224 received PES and 166 EES). The 1-year MACE rate was 21.9% in the PES group and 10.2% in the EES group (p = 0.002). TVF rate was 20.5% in the PES group and 7.8% in the EES group (p < 0.001). The in-segment restenosis rate was 5.2% in the EES group and 15.6% in the PES group (p = 0.002). EES and EuroSCORE were the only variables related to the risk of MACE. EES (odds ratio: 0.32; p = 0.007) was also independently related to the risk of restenosis.
EES implantation for ULMD is associated with a reduced incidence of 1-year MACE, TVF, and restenosis as compared with PES implantation.
Journal of the American College of Cardiology 10/2012; 60(14):1217-22. · 14.16 Impact Factor
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ABSTRACT: BACKGROUND: Several clinical studies have demonstrated that anginal attacks shortly before the onset of STEMI limit infarct size and improve short- and long-term outcomes. However, the clinical significance of preinfarction angina in STEMI patients treated by primary PCI is still controversial. Therefore, the aim of the current study was to evaluate the impact of preinfarction angina on scintigraphic infarct size in STEMI patients undergoing primary PCI. METHODS: Our population is represented by 430 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. RESULTS: Preinfarction angina was associated with more advanced age, a larger prevalence of family history for CAD, smoking, and longer ischemia time. No difference was observed in other clinical or angiographic characteristics. Preinfarction angina did not affect either the rate of postprocedural TIMI 3 flow or infarct size (19 ± 15.5 vs 16 ± 13.9, p = 0.18). Similar results were observed in subanalyses according to infarct location (anterior STEMI: 22.7 ± 14.8 vs 19.2 ± 16.1, p = 0.36; non-anterior STEMI: 16.1 ± 15.7 vs 13.8 ± 11.6, p = 0.36), gender (female gender: 15.6 ± 14.5 vs 11.5 ± 13.2, p = 0.30; male gender 20.4 ± 16 vs 17.2 ± 13.8, p = 0.3) or ischemia time (≤ or > 4 h) (17.6 ± 15.6 vs 15.8 ± 14.1, p = 0.52; 21.6 ± 15.5 vs 16.7 ± 13.3, p = 0.18). The absence of any impact of preinfarction angina on infarct size was confirmed after correction for baseline characteristics, such as age, smoking, family history for CAD and ischemia time (OR [95% CI] = 1.26 [0.66-2.41], p = 0.48). CONCLUSIONS: This study shows that among STEMI patients undergoing primary PCI preinfarction angina does not affect infarct size.
Atherosclerosis 09/2012; · 3.79 Impact Factor
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ABSTRACT: BACKGROUND: Several reports have shown that in patient with ST-segment elevation acute myocardial infarction (STEMI) longer ischemia time is associated with impaired reperfusion and higher mortality. However, there is still some doubts with regards time to reperfusion role in patients treated with primary percutaneous coronary intervention (PCI). Therefore, the aim of the current study was to evaluate the impact of time-to-treatment on infarct size as evaluated by myocardial scintigraphy in a large cohort of STEMI patients undergoing primary PCI. METHODS: Our population is represented by 830 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30days by technetium-99m-sestamibi. RESULTS: Time-to-treatment was significantly associated with age and dyslipidemia. Time-to-treatment linearly affected the rate of postprocedural TIMI 3 flow (p<0.0001) and scintigraphic infarct size (p<0.001). The impact of time-to-treatment on infarct size persisted in the analysis restricted to patients with postpocedural TIMI 3 flow, and after correction for confounding factors such as age, dyslipidemia, postprocedural TIMI 3 flow (OR [95% CI]=1.26 [1.14-1.39], p<0.001). CONCLUSIONS: This study shows in a large population of STEMI patients undergoing primary PCI that time-to-treatment is linearly associated with infarct size.
International journal of cardiology 05/2012; · 7.08 Impact Factor
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ABSTRACT: BackgroundStress-induced Tako-tsubo cardiomyopathy (TTC) is an acute cardiac syndrome, mimics ST elevation myocardial infarction (STEMI),
largely confined to postmenopausal women, frequently precipitated by a stressful event. The pathogenesis of TTC is still unknown.
Some authors hypothesized a possible connection between TTC and anxiety disease, but no previous study analyzed the relationship
between anxiety trait and TTC. This study sought to assess the potential role of anxiety trait in the development and clinical
course of TTC.
MethodsWe included in the present prospective case–control study 50 consecutive patients admitted to our Hospital with a diagnosis
of TTC according to the Mayo Clinic criteria. Fifty control patients with anterior STEMI matched for clinical characteristics
such as age, gender, and hypertension were selected. During the hospitalization, all patients were asked to complete the Spielberger
Trait Anxiety Inventory (STAI) scale for measuring self-reported trait anxiety (Trait-A). Outcome measures at follow-up were
death, TTC recurrence, and rehospitalization.
ResultsThe mean value of STAI scale was 46±12 in TTC patients and 45±14 in STEMI patients (p=0.815). High-anxiety trait (STAI scale value≥40) was documented in 30 (60%) TTC patients and in 26 (52%) STEMI patients
(p=0.387). At multivariate analysis, predictors of TTC were lower peak creatine kinase value (HR 0.999; 95% CI 0.998–0.999;
p=0.018) and an antecedent stressful trigger event (HR 45.487; 95% CI 6.471–319.759; p=0.001), but anxiety trait was not. There were no differences in outcome measures between TTC patients with or without high-anxiety
trait.
ConclusionIn TTC patients, high-anxiety trait is a common finding but it is not significantly more frequent than in patients with STEMI.
Moreover, a high-anxiety trait seems to be neither associated with a worse clinical outcome nor a predictor of TTC. Our study
do not support the routine evaluation of anxiety trait in patients with TTC.
KeywordsStress-induced Tako-tsubo cardiomyopathy–Anxiety trait–Coronary artery disease
Clinical Research in Cardiology 04/2012; 100(6):523-529. · 2.95 Impact Factor
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International journal of cardiology 03/2012; 161(1):e10-1. · 7.08 Impact Factor
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Rossella Marcucci,
Betti Giusti,
Rita Paniccia,
Anna Maria Gori,
Claudia Saracini,
Serafina Valente,
Cristina Giglioli, Guido Parodi,
David Antoniucci,
Gian Franco Gensini,
Rosanna Abbate
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ABSTRACT: High on-treatment platelet reactivity (HPR) by ADP, which primarily reflects the effect of thienopyridines, has been found to be an independent predictor of ischemic events in patients with acute coronary syndrome (ACS) on dual antiplatelet therapy. CYP2C19*2 is associated with HPR by ADP. The aim of our study was to evaluate if high on-clopidogrel platelet reactivity (HPR) by ADP is associated with an increased risk of major adverse coronary events (MACE) after ACS independent of CYP2C19*2 allele, i.e. whether genotyping patients for CYP2C19*2 polymorphism is sufficient to identify those to be switched to novel antiplatelets. A total of 1187 patients were included (CYP2C19 *1/*1 n = 892; *1/*2 n = 264; *2/*2 n = 31); 76 MACE (CV death and non-fatal MI) were recorded in non-carriers of CYP2C19*2 (8.5%) and 39 in carriers of CYP2C19*2 (13.2%). At the landmark analysis in the first 6 months, HPR by ADP and CYP2C19*2 allele were both significantly and independently associated with MACE [HPR by ADP: HR = 2.0 (95% CI 1.2-3.4), p = 0.01; CYP2C19*2 allele: HR = 2.3 (95% CI 1.3-3.9), p = 0.003]. At the land mark analysis from 7 to 12 months, only HPR by ADP remained significantly associated with the risk of MACE [HPR by ADP: HR = 2.7 (95% CI 1.4-5.3), p = 0.003; CYP2C19*2: HR = 0.8 (95% CI 0.2-1.1), p = ns]. CYP2C19*2 allele and HPR by ADP are both independently associated with an increased risk of MACE in the first 6 months after ACS. HPR by ADP is associated with an increased risk until 12 months of follow-up. Therefore, both phenotype and genotype are clinically relevant for the evaluation of the antiplatelet effect of clopidogrel and for the prognostic stratification of ACS patients.
Platelets 03/2012; · 1.85 Impact Factor
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ABSTRACT: Thus far, the prognostic value of reverse left ventricular (LV) remodeling after ST-elevation acute myocardial infarction (STEMI) has not been fully evaluated. We sought to investigate the incidence, major determinants, and long-term clinical significance of reverse LV remodeling in a large series of STEMI patients successfully treated with primary percutaneous coronary intervention (P-PCI).
Serial complete 2D-echocardiograms were obtained within 24h after P-PCI, and at 1 and 6 months in 512 consecutive reperfused STEMI patients. Reverse remodeling was defined as a reduction >10% in LV end-systolic volume (LVESV) at 6 month follow-up. Reverse LV remodeling occurred in 49% of study population. At follow-up (41.6±23 months), late heart failure (HF) rate was significantly higher among patients without reverse LV remodeling as compared with those with it (32% vs. 11%, P<0.0001). At multivariate analysis, independent predictors of reverse LV remodeling were a small infarct size measured as peak creatine kinase value (P<0.0001), a small functional myocardial damage measured as wall motion score index within the infarct zone (P=0.018) and baseline LVESV (P<0.0001). After adjustment for several clinical, echographic and angiographic variables, Cox analysis identified reverse LV remodeling as the only beneficial independent predictor of long-term heart failure-free survival (HR: 0.44, 95% CI: 0.275-0.722).
Reverse LV remodeling occurred in half of successfully reperfused STEMI patients. Small structural and functional myocardial damages within the infarct zone are the major determinants of reverse LV remodeling. As expression of effective myocardial salvage by P-PCI, the reverse remodeling is an important predictor of favorable long-term outcome.
Atherosclerosis 02/2012; 222(1):123-8. · 3.79 Impact Factor
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ABSTRACT: Recent guidelines have recommended the use of aspirin and prasugrel in patients with acute coronary syndromes undergoing percutaneous coronary intervention. However, prasugrel use has been evaluated only in randomized trials. This study sought to evaluate bleeding rates and adherence to treatment in "real-world" patients treated with prasugrel. In total 298 consecutive patients 68 ± 10 years old (31% >75 years old) underwent stent implantation and received prasugrel therapy. Indications to prasugrel therapy were (1) ST-elevation acute myocardial infarction (41%), (2) drug-eluting stent implantation in diabetics (24%), (3) stent thrombosis (3%), (4) left main coronary artery drug-eluting stent implantation (6%), and (5) percutaneous coronary intervention in patients with high residual platelet reactivity on clopidogrel therapy (26%). All patients received a loading of prasugrel 60 mg. Patients ≥75 years old and with body weight ≤60 kg received a maintenance dose of 5 mg/day (10 mg/day for all the other patients). Follow-up data including adherence to prasugrel therapy were collected by telephone interviews or outpatient visits. Minimal follow-up length was 6 months (mean 9 ± 3). Major, minor, and minimal bleedings (Thrombolysis In Myocardial Infarction criteria) occurred in 2.7%, 4.7%, and 15.1% of enrolled patients. Low residual platelet reactivity (p = 0.001) and female gender (p = 0.29) were independent predictors of bleeding events. The most frequent minimal bleeding event was epistaxis. Only 8 patients (2.7%) permanently discontinued prasugrel therapy because of bleeding events (n = 4), possible side effects (n = 2), or medical decisions not associated with bleeding or side effects (n = 2). Fourteen patients (4.7%) temporarily discontinued prasugrel (average 6.5 days) mainly because of surgical procedures. No definite or probable stent thrombosis occurred, although 3 patients develop de novo myocardial infarction and 1 an ischemic stroke. There were 11 deaths because of heart failure or refractory cardiogenic shock in 9, pulmonary embolism in 1, and cancer in 1. In conclusion, in clinical practice, major and minor bleeding event rates associated with prasugrel therapy are comparable to those reported in controlled randomized trials. The minimal bleeding event rate is higher than reported but does not seem to affect adherence to treatment.
The American journal of cardiology 01/2012; 109(2):214-8. · 3.58 Impact Factor
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Benedetta Bellandi,
Claudia Salvadori, Guido Parodi,
Alberto Genovesi Ebert,
Nunzia Petix,
Stefano Del Pace,
Andrea Boni,
Francesco Pestelli,
Massimo Fineschi,
Antonio Giomi,
Alberto Cresti,
Gabriele Giuliani,
Francesco Venditti,
Loreno Querceto,
Gian Franco Gensini,
Leonardo Bolognese,
Francesco Bovenzi
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ABSTRACT: Tako-tsubo (stress) cardiomyopathy (TTC) is a recently described acute cardiac syndrome that mimics ST-segment elevation myocardial infarction. The TTC Tuscany Registry is an observational prospective multicenter registry established to define the prevalence, epidemiology and prognosis of TTC in the Tuscany area.
From January 1 to December 31, 2009, 105 consecutive patients hospitalized in the 14 Cardiology Units of the Tuscany Region with a diagnosis of TTC, were enrolled in the registry. TTC diagnosis was made using the Mayo Clinic modified criteria. Clinical, instrumental, laboratory and 6-month follow-up data were collected. Results. TTC represented 1.2% of all myocardial infarctions in the Tuscany Region during 2009, and it was diagnosed in 0.6% of the angiographic exams performed during the same year. The data collected showed that TTC affects mainly the female gender (91%) in the post-menopausal period (70 ± 11 years), though 5% of patients were ≤50 years old. An antecedent stressful event was frequently detected (74%). The main clinical presentation was chest pain (86%), associated with ST-segment elevation (59%). Mean left ventricular ejection fraction on admission was 40 ± 9%, and was associated with apical (37%), midapical (49%) or midventricular (5%) wall motion abnormalities. Left ventricular ejection fraction recovered to 51 ± 9% in 7 ± 9 days. Heart failure was the most common complication in the acute phase (14%), and 4 patients presented with cardiogenic shock. No patient died during the index hospitalization. At 6-month follow-up, no patient had TTC recurrence, 9 patients were rehospitalized (7 for noncardiac disease) and 2 patients died of noncardiac causes.
Our data, which represent the largest prospective series of patients with a diagnosis of TTC, show that the prevalence of TTC in Tuscany is similar that described in other national and international studies. Moreover, the data highlight that TTC may occur also in male patients and in patients aged <50 years. The mid-term prognosis is good, but the risk of acute complications related to heart failure cannot be neglected.
Giornale italiano di cardiologia (2006) 01/2012; 13(1):59-66.
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ABSTRACT: High residual platelet reactivity (HRPR) in patients receiving clopidogrel has been associated with high risk of ischemic events after percutaneous coronary intervention (PCI).
To test the hypothesis that HRPR after clopidogrel loading is an independent prognostic marker of risk of long-term thrombotic events in patients with acute coronary syndromes (ACS) undergoing an invasive procedure and antithrombotic treatment adjusted according to the results of platelet function tests.
Prospective, observational, referral center cohort study of 1789 consecutive patients with ACS undergoing PCI from April 2005 to April 2009 at the Division of Cardiology of Careggi Hospital, Florence, Italy, in whom platelet reactivity was prospectively assessed by light transmittance aggregometry.
All patients received 325 mg of aspirin and a loading dose of 600 mg of clopidogrel followed by a maintenance dosage of 325 mg/d of aspirin and 75 mg/d of clopidogrel for at least 6 months. Patients with HRPR as assessed by adenosine diphosphate test (≥70% platelet aggregation) received an increased dose of clopidogrel (150-300 mg/d) or switched to ticlopidine (500-1000 mg/d) under adenosine diphosphate test guidance.
The primary end point was a composite of cardiac death, myocardial infarction, any urgent coronary revascularization, and stroke at 2-year follow-up. Secondary end points were stent thrombosis and each component of the primary end point.
The primary end point event rate was 14.6% (36/247) in patients with HRPR and 8.7% (132/1525) in patients with low residual platelet reactivity (absolute risk increase, 5.9%; 95% CI, 1.6%-11.1%; P = .003). Stent thrombosis was higher in the HRPR group compared with the low residual platelet reactivity group (6.1% [15/247] vs 2.9% [44/1525]; absolute risk increase, 3.2%; 95% CI, 0.4%-6.7%; P = .01). By multivariable analysis, HRPR was independently associated with the primary end point (hazard ratio, 1.49; 95% CI, 1.08-2.05; P = .02) and with cardiac mortality (hazard ratio, 1.81; 95% CI, 1.18-2.76; P = .006).
Among patients receiving platelet reactivity-guided antithrombotic medication after PCI, HRPR status was significantly associated with increased risk of ischemic events at short- and long-term follow-up.
clinicaltrials.gov Identifier: NCT01231035.
JAMA The Journal of the American Medical Association 09/2011; 306(11):1215-23. · 30.03 Impact Factor
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ABSTRACT: The aim of the present study was to investigate whether right coronary artery chronic total occlusion (CTO) carries prognostic implications in patients undergoing drug-eluting stent-supported percutaneous coronary intervention (PCI) for unprotected left main disease (ULMD).
No data exist on the prognostic implication of CTO in patients undergoing PCI for ULMD.
Prospective registry of consecutive patients undergoing PCI for ULMD. Patients with ST-segment elevation myocardial infarction were excluded. Primary endpoints were 6-month and long-term cardiac mortality.
From January 2004 to December 2009, 330 patients underwent PCI for ULMD. Of the 330 patients, 78 (24%) had CTO of the right coronary artery, 22 (7%) had CTO of the left anterior descending artery, and 16 (5%) had CTO of the left circumflex artery. Patients with right coronary artery CTO had a higher risk profile compared with patients without right coronary artery CTO. The 6-month mortality rate was 12.8% in patients with right coronary artery CTO, and 3.6% in patients without right coronary artery CTO (p < 0.002), and the 3-year cardiac survival rate was 76.4 ± 6.8% and 89.7 ± 2.7% (p < 0.003), respectively. By multivariable analysis, the only 2 independent predictors of 3-year cardiac mortality were right coronary artery CTO (hazard ratio: 2.15, 95% confidence interval: 1.02 to 4.50; p = 0.043) and EuroSCORE (hazard ratio: 1.03, 95% confidence interval: 1.02 to 1.05; p < 0.001).
Right coronary artery CTO occurs frequently and is a significant predictor of mortality in patients with ULMD undergoing PCI.
Journal of the American College of Cardiology 07/2011; 58(2):125-30. · 14.16 Impact Factor
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ABSTRACT: The aim of the present study was the comparison of the everolimus-eluting stent (EES) with the paclitaxel-eluting stent (PES) in patients treated for long chronic total occlusions (CTOs). Previous randomized trials have shown the superiority of EESs over PESs. No data exist about the efficacy and safety of EESs in patients treated for complex CTOs requiring multiple stent implantation. We identified 258 patients treated for CTOs who received multiple EESs (n = 112) or PESs (n = 146), with a total stent length of ≥40 mm. The primary end point was in-segment restenosis, defined as >50% luminal narrowing at the segment site, including the stent and 5 mm proximal and distal to the stent edges of the target vessel, on the follow-up angiogram. The secondary end point was the 9-month composite of major adverse cardiovascular events. The 2 patient groups were similar in all baseline characteristics. The median lesion length was 48 mm in the EES group and 46 mm in the PES group (p = 0.793). The incidence of the primary end point of the study was 11.8% in the EES group and 31.4% in the PES group (p = 0.001). The major adverse cardiovascular event rate was lower in the EES group than in the PES group (8.9% and 22.6%, respectively, p = 0.003). Definite or probable stent thrombosis occurred in 5 patients in the PES group (3.4%), with no stent thrombosis occurring in the EES group (p = 0.048). On multivariate analysis, EES was the only variable independently related to the risk of binary angiographic restenosis with an odds ratio of 0.29 (95% confidence interval 0.14 to 0.62; p = 0.002). In conclusion, in patients treated for long CTOs and requiring multiple stent implantation, EESs performed better than PESs, with a >50% reduction in the risk of restenosis and major adverse cardiovascular events.
The American journal of cardiology 06/2011; 107(12):1768-71. · 3.58 Impact Factor
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ABSTRACT: Stress-induced Tako-tsubo cardiomyopathy (TTC) is an acute cardiac syndrome, mimics ST elevation myocardial infarction (STEMI), largely confined to postmenopausal women, frequently precipitated by a stressful event. The pathogenesis of TTC is still unknown. Some authors hypothesized a possible connection between TTC and anxiety disease, but no previous study analyzed the relationship between anxiety trait and TTC. This study sought to assess the potential role of anxiety trait in the development and clinical course of TTC.
We included in the present prospective case-control study 50 consecutive patients admitted to our Hospital with a diagnosis of TTC according to the Mayo Clinic criteria. Fifty control patients with anterior STEMI matched for clinical characteristics such as age, gender, and hypertension were selected. During the hospitalization, all patients were asked to complete the Spielberger Trait Anxiety Inventory (STAI) scale for measuring self-reported trait anxiety (Trait-A). Outcome measures at follow-up were death, TTC recurrence, and rehospitalization.
The mean value of STAI scale was 46 ± 12 in TTC patients and 45 ± 14 in STEMI patients (p = 0.815). High-anxiety trait (STAI scale value ≥ 40) was documented in 30 (60%) TTC patients and in 26 (52%) STEMI patients (p = 0.387). At multivariate analysis, predictors of TTC were lower peak creatine kinase value (HR 0.999; 95% CI 0.998-0.999; p = 0.018) and an antecedent stressful trigger event (HR 45.487; 95% CI 6.471-319.759; p = 0.001), but anxiety trait was not. There were no differences in outcome measures between TTC patients with or without high-anxiety trait.
In TTC patients, high-anxiety trait is a common finding but it is not significantly more frequent than in patients with STEMI. Moreover, a high-anxiety trait seems to be neither associated with a worse clinical outcome nor a predictor of TTC. Our study do not support the routine evaluation of anxiety trait in patients with TTC.
Clinical Research in Cardiology 01/2011; 100(6):523-9. · 2.95 Impact Factor
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ABSTRACT: Left ventricular (LV) remodeling has been shown to occur in a relevant proportion of patients with acute myocardial infarction successfully treated with primary percutaneous coronary intervention. The development of LV remodeling after primary percutaneous coronary intervention is associated with increased mortality and with shorter event-free survival. Therapy to prevent or limit LV remodeling is of paramount importance, and it should be started in the early phase of reperfusion. Early identification of patients at risk for LV remodeling may have important prognostic and therapeutic implications. The pathophysiology, time course, and predictors of LV remodeling, as well as the relevant diagnostic techniques and therapeutic interventions evaluated to date, will be discussed.
American heart journal 12/2010; 160(6 Suppl):S11-5. · 4.65 Impact Factor
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ABSTRACT: Stent thrombosis is a major complication after percutaneous coronary intervention (PCI) for ST-segment elevation acute myocardial infarction (AMI) and is associated with reinfarction and increased risk of death.
Patients treated with the turbostratic carbon-coated stent (CID, Saluggia, Italy) for AMI were identified from a prospective primary PCI database. Primary end-point was stent thrombosis within 6 months. Forward stepwise Cox proportional hazards analysis was used to identify independent predictors of stent thrombosis.
Between 2001 and 2008, 746 patients underwent turbostratic carbon-coated stent implantation for AMI. Patients had a mean age of 65 ± 12 years, 9% had cardiogenic shock on admission, 48% had multivessel coronary disease, 78% had baseline target vessel TIMI grade 0-1. Multiple stent implantation was performed in 26% of patients. The majority of patients (78%) received abciximab treatment and a postprocedural TIMI grade 3 flow was achieved in 98% patients. Definite stent thrombosis occurred in 10 patients (1.3%), while three patients (0.4%) had possible stent thrombosis. No probable stent thrombosis occurred. There were no procedural stent thromboses. In patients who received abciximab stent thrombosis the rate was 1%, while it was 4.3% in patients not receiving abciximab treatment. After adjusting for all clinical, angiographic, and procedural variables, abciximab treatment (HR 0.17; 95% CI 0.05-0.56, P = 0.003) and major bleedings (HR 14.2; 85% CI 2.79-72.44, P = 0.001) were the only two predictors related to stent thrombosis.
Patients with AMI treated with turbostratic carbon-coated stent implantation and abciximab treatment have a low incidence of stent thrombosis. Abciximab treatment along with major bleeding complications are the only predictors related to stent thrombosis.
Journal of Interventional Cardiology 12/2010; 23(6):554-9. · 1.18 Impact Factor
