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ABSTRACT: The benefits of percutaneous coronary intervention (PCI) can be offset by periprocedural complications such as acute vessel closure and stent thrombosis in the absence of adequate antiplatelet and antithrombotic therapy. Additionally, conditions occurring after 30 days post-PCI, such as in-stent restenosis or late stent thrombosis can occur. Excess antithrombotic therapy, on the other hand, carries a risk of major gastrointestinal or intracranial bleeding as well as vascular access site bleeding complications. In this review, evidence related to the various pharmacological agents for reduction of stent thrombosis available to clinicians during and after PCI will be explored.
Expert Review of Cardiovascular Therapy 05/2013; 11(5):567-76.
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ABSTRACT: OBJECTIVES: To characterize non-system reasons for delay in door-to-balloon time (D2BT) and impact on in-hospital mortality. BACKGROUND: Studies have evaluated predictors of delay in D2BT, highlighting system-related issues and patient demographics. Limited data exist for non-system reasons for delay in D2BT. METHODS: We analyzed non-system reasons for delay in D2BT among 82,678 STEMI patients who underwent primary PCI within 24 hours of symptom onset in the CathPCI Registry® from January 1, 2009 to June 30, 2011. RESULTS: Non-system delays occurred in 14.7% of patients (n=12,146). Patients with non-system delays were more likely to be older, female, African American, and have greater comorbidities. The in-hospital mortality for patients treated without delay was 2.5% vs. 15.1% for those with delay (p<0.01). Non-system delay reasons included delays in providing consent (4.4%), difficult vascular access (8.4%), difficulty crossing lesion (18.8%), "other" (31%), and cardiac arrest/intubation (37.4%). Cardiac arrest/intubation delays had the highest in-hospital mortality (29.9%) despite the shortest time delay (median D2BT 84min, 25(th)-75(th) percentile 64-108min), whereas delays in providing consent had a relatively lower in-hospital mortality rate (9.4%) despite the longest time delay (median D2BT 100min, 25(th)-75(th) percentile 80-131min). Mortality for delays due to difficult vascular access, difficulty crossing a lesion, and "other" was also higher (8.0%, 5.6%, and 5.9%, respectively) compared to non-delayed patients (p<0.0001). After adjustment for baseline characteristics, in-hospital mortality remained higher for patients with non-system delays. CONCLUSIONS: Non-system reasons for delay in D2BT in STEMI patients presenting for primary PCI are common and associated with high in-hospital mortality.
Journal of the American College of Cardiology 03/2013; · 14.16 Impact Factor
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ABSTRACT: This study sought to compare short- and long-term (4-year) outcomes in patients with and without peripheral vascular disease (PVD) following non-emergent percutaneous coronary intervention (PCI) in current clinical practice.
Patients with PVD undergoing coronary revascularization have high rates of adverse short-term outcomes. However, the long-term clinical outcomes of patients with PVD undergoing PCI in the contemporary drug-eluting stent (DES) era have not been well characterized.
The 2004/2005 Cornell Angioplasty Registry database was used to evaluate the in-hospital and long-term clinical outcomes in patients undergoing non-emergent (urgent or elective) PCI. A total of 2455 study patients were examined. We excluded patients presenting with an ST-elevation myocardial infarction (MI) ≤24 hours, hemodynamic instability/shock, thrombolytic therapy ≤7 days, or renal insufficiency (creatinine ≥4 mg/dL). Mean clinical follow-up was 4.4 ± 1.1 years.
Of the 2455 patients, a total of 173 (7%) had PVD and 2282 (93%) had no reported history of PVD. DESs were used in 87% of the PCIs. The incidence of in-hospital death (1.8% vs 0.1%; P=.006) was greater in the PVD group, whereas postprocedural MI (6.4% vs 6.8%; P=.810) and major adverse cardiovascular event rates including death, stroke, emergent coronary artery bypass graft/PCI, and MI (8.7% vs 7.0%; P=.360) were similar in the PVD versus no PVD groups. Long-term Kaplan-Meier survival (89.2% vs 76.2%; P<.001) was significantly higher in patients without PVD versus with PVD, respectively. After adjustment with a multivariate Cox regression analysis, long-term all-cause survival was similar in patients with versus without PVD (hazard ratio, 1.16; 95% confidence interval, 0.69-1.93; P=.581).
In contemporary PCI utilizing DESs, glycoprotein IIb/IIIa inhibitors, and clopidogrel, PVD is associated with a higher in-hospital and 4-year all-cause mortality. In our study, this difference in long-term survival was mainly driven by a higher rate of comorbidities in the PVD population that underwent PCI.
The Journal of invasive cardiology 03/2013; 25(3):132-6. · 1.84 Impact Factor
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ABSTRACT: Periprocedural statin therapy has been shown to decrease the rate of myocardial infarctions (MIs) after percutaneous coronary intervention (PCI). However, the impact of long-term statin therapy on postprocedure MI remains unknown. We examined the impact of long-term statin therapy on cardiac enzyme (cardiac troponin I [cTnI] and creatine kinase-MB [CK-MB]) increases after PCI in patients undergoing nonemergency PCI. Using the 2004/2005 Cornell Angioplasty Registry, we evaluated 1,482 patients undergoing elective or urgent PCI with normal preprocedure cardiac enzymes levels (cTnI and CK-MB). The population was divided into 2 groups: (1) patients on long-term (≥7 days) statin therapy before PCI (n = 1,073) and (2) patients not on long-term statin regimen (n = 409). Cardiac enzyme levels after PCI were assessed at 8, 12, and 18 hours after PCI. An increase in cTnI ≥1 time upper-limit of normal (ULN) was observed in 830 patients (56.1%) and an increase in cTnI ≥3 times ULN was observed in 518 patients (35.0%). There was no difference in incidence of cTnI increases ≥3 times ULN in patients on long-term statin therapy versus those not on long-term statin therapy in the overall group (35.1% vs 34.5%, p = 0.855). There was a trend toward a lower incidence of small cTnI increases ≥1 time ULN in patients on long-term statin therapy versus those not receiving long-term statins (54.6% vs 59.7%, p = 0.090). Incidence of CK-MB increases ≥1 time or ≥3 times ULN and peak cTnI and CK-MB levels were similar between the 2 groups. In a subgroup of patients with unstable angina, long-term statin therapy decreased small cTnI increases (≥1 time ULN) after PCI (54.6% vs 64.3%, p = 0.023). The greatest benefit in decrease of MIs after PCI was seen in patients with unstable angina receiving long-term high-dose statin therapy. In conclusion, long-term statin therapy did not decrease the incidence of periprocedural MI in patients with stable coronary artery disease undergoing nonemergency PCI. In patients with unstable coronary syndromes, long-term statin therapy may be beneficial, particularly at a high dose.
The American journal of cardiology 08/2012; · 3.58 Impact Factor
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ABSTRACT: Advances in antiplatelet therapy have significantly improved outcomes in patients with ischemic heart disease. Thienopyridines remain a cornerstone of therapy along with aspirin. Recently, concerns have been raised about the use of clopidogrel due to its pharmacokinetic and pharmacogenetic interpatient variability. A third-generation thienopyridine, prasugrel, overcomes some of these problems by improving inhibition of platelet aggregation, but increasing the risk of peri-procedural bleeding. Other novel antiplatelet agents, such as ticagrelor, have shown improved efficacy in recent trials and require further investigations. The field of pharmacotherapy continues to rapidly evolve as newer agents, such as thrombin receptor antagonists, along with older agents, such as cilostazol and glycoprotein IIb/IIIa inhibitors, are being explored.
Current Atherosclerosis Reports 11/2011; 14(1):78-84. · 2.66 Impact Factor
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ABSTRACT: A sterile inflammatory reaction at the radial access site has been described in the literature as an adverse local reaction to Cook hydrophilic coated sheaths during transradial catheterization. To date, this reaction has not been observed with non-Cook hydrophilic sheaths. Here, we describe two cases of such a reaction with Glidesheaths™ at our institution.
Catheterization and Cardiovascular Interventions 06/2011; 77(7):1050-3. · 2.29 Impact Factor
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Keigo Kawaji,
Noel C F Codella,
Martin R Prince,
Christopher W Chu,
Aqsa Shakoor,
Troy M LaBounty,
James K Min, Rajesh V Swaminathan,
Richard B Devereux,
Yi Wang,
Jonathan W Weinsaft
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ABSTRACT: Cardiac magnetic resonance (CMR) is established for assessment of left ventricular (LV) systolic function but has not been widely used to assess diastolic function. This study tested performance of a novel CMR segmentation algorithm (LV-METRIC) for automated assessment of diastolic function.
A total of 101 patients with normal LV systolic function underwent CMR and echocardiography (echo) within 7 days. LV-METRIC generated LV filling profiles via automated segmentation of contiguous short-axis images (204+/-39 images, 2:04+/-0:53 minutes). Diastolic function by CMR was assessed via early:atrial filling ratios, peak diastolic filling rate, time to peak filling rate, and a novel index-diastolic volume recovery (DVR), calculated as percent diastole required for recovery of 80% stroke volume. Using an echo standard, patients with versus without diastolic dysfunction had lower early:atrial filling ratios, longer time to peak filling rate, lower stroke volume-adjusted peak diastolic filling rate, and greater DVR (all P<0.05). Prevalence of abnormal CMR filling indices increased in relation to clinical symptoms classified by New York Heart Association functional class (P=0.04) or dyspnea (P=0.006). Among all parameters tested, DVR yielded optimal performance versus echo (area under the curve: 0.87+/-0.04, P<0.001). Using a 90% specificity cutoff, DVR yielded 74% sensitivity for diastolic dysfunction. In multivariate analysis, DVR (odds ratio, 1.82; 95% CI, 1.13 to 2.57; P=0.02) was independently associated with echo-evidenced diastolic dysfunction after controlling for age, hypertension, and LV mass (chi(2)=73.4, P<0.001).
Automated CMR segmentation can provide LV filling profiles that may offer insight into diastolic dysfunction. Patients with diastolic dysfunction have prolonged diastolic filling intervals, which are associated with echo-evidenced diastolic dysfunction independent of clinical and imaging variables.
Circulation Cardiovascular Imaging 11/2009; 2(6):476-84. · 5.94 Impact Factor
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ABSTRACT: The assessment of coronary stents with present-generation 64-detector row computed tomography scanners that use filtered backprojection and operating at standard definition of 0.5-0.75 mm (standard definition, SDCT) is limited by imaging artifacts and noise.
We evaluated the performance of a novel, high-definition 64-slice CT scanner (HDCT), with improved spatial resolution (0.23 mm) and applied statistical iterative reconstruction (ASIR) for evaluation of coronary artery stents.
HDCT and SDCT stent imaging was performed with the use of an ex vivo phantom. HDCT was compared with SDCT with both smooth and sharp kernels for stent intraluminal diameter, intraluminal area, and image noise. Intrastent visualization was assessed with an ASIR algorithm on HDCT scans, compared with the filtered backprojection algorithms by SDCT.
Six coronary stents (2.5, 2.5, 2.75, 3.0, 3.5, 4.0mm) were analyzed by 2 independent readers. Interobserver correlation was high for both HDCT and SDCT. HDCT yielded substantially larger luminal area visualization compared with SDCT, both for smooth (29.4+/-14.5 versus 20.1+/-13.0; P<0.001) and sharp (32.0+/-15.2 versus 25.5+/-12.0; P<0.001) kernels. Stent diameter was higher with HDCT compared with SDCT, for both smooth (1.54+/-0.59 versus1.00+/-0.50; P<0.0001) and detailed (1.47+/-0.65 versus 1.08+/-0.54; P<0.0001) kernels. With detailed kernels, HDCT scans that used algorithms showed a trend toward decreased image noise compared with SDCT-filtered backprojection algorithms.
On the basis of this ex vivo study, HDCT provides superior detection of intrastent luminal area and diameter visualization, compared with SDCT. ASIR image reconstruction techniques for HDCT scans enhance the in-stent assessment while decreasing image noise.
Journal of cardiovascular computed tomography 3(4):246-51.
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ABSTRACT: Pulse pressure provides information beyond systolic and diastolic blood pressures, from which it is calculated. The majority of individuals older than 70 years have a widened pulse pressure resulting from age-related stiffening of the central elastic arteries and systolic hypertension. A widened pulse pressure is associated with cardiovascular risk factors such as diabetes, hypertension, and smoking. It also predicts a higher risk of subsequent cardiovascular events, stroke, renal disease, heart failure, and mortality, particularly in the elderly. The authors review the mechanisms that contribute to pulse pressure and the association between pulse pressure, vascular risk factors, and outcomes.
The American Journal of Geriatric Cardiology 15(4):226-32; quiz 133-4. · 1.04 Impact Factor
