Background and Objectives: The revascularization strategy for percutaneous coronary intervention (PCI) in patients with multivessel (MV) acute coronary syndrome (ACS) remains controversial. Certain gaps in the evidence are related to the optimal timing of non-culprit lesion revascularization and the utility of instantaneous wave-free ratio (iFR) in the management of MV ACS intervention. The major benefits of iFR utilization in MV ACS patients in one-stage complete revascularization are: (1) the possibility to virtually plan the PCI, both the location and the extension of the necessary stenting to achieve the prespecified final hemodynamic result; (2) the opportunity to validate the final hemodynamic result of the PCI, both in culprit artery and all non-culprit arteries and (3) the value of obliviating the uncomfortable, costly, time consuming and sometimes deleterious effects from Adenosine, as there is no requirement for administration. Thus, iFR use fosters the achievement of physiologically appropriate complete revascularization in MV ACS patients during acute hospitalization. Materials and Methods: This pilot study was aimed to test the feasibility of a randomized trial research protocol as well as to assess patient safety signals of co-registration iFR-guided one-stage complete revascularization compared with that of standard staged angiography-guided PCI in de novo patients with MV ACS. This was a single-center, prospective, randomized, open-label clinical trial consecutively screening patients with ACS for MV disease. The intervention strategy of interest was iFR-guided physiologically complete one-stage revascularization, in which the virtual PCI planning of non-culprit lesions and the intervention itself were performed in one stage directly following treatment of the culprit lesion and other critical stenosis of more than ninety percent. Seventeen patients were recruited and completed the 3-month follow-up. Results: Index PCI duration was significantly longer while the volume of contrast media delivered in index PCI was significantly greater in the iFR-guided group than in the angiography-guided group (119.4 ± 40.7 vs. 47 ± 15.5 min, p = 0.004; and 360 ± 97.9 vs. 192.5 ± 52.8 mL, p = 0.003). There were no significant differences in PCI-related major adverse cardiovascular events (MACE) between the groups during acute hospitalization and at 3-months follow-up. One-stage iFR-guided PCI requires fewer PCI attempts until complete revascularization than does angiography-guided staged PCI. Conclusions: Complete revascularization with the routine use of the virtual planning tool in one-stage iFR-guided PCI is a feasible practical strategy in an everyday Cath lab environment following the protocol designed for the study. No statistically significant safety signals were documented in the number of PCI related MACE during the 3-month follow-up.
Implantace stentů do karotických tepen (carotid artery stenting, CAS) se v současnosti ve velkém měřítku používá v léčbě stenózy karotických tepen. Klinické studie z poslední doby prokázaly nízkou incidenci příhod po CAS. Tato studie hodnotí 30denní a roční výsledky pacientů léčených pro CAS intenzivní farmakoterapií na pracovišti provádějícím vysoké počty perkutánních koronárních intervencí ročně. Metoda: V období od ledna 2011 do prosince 2013 byla CAS provedena celkem u 184 pacientů. Mimo protidestičkové léčby byla prováděna i intenzivní antihypertenzní léčba spolu s vysoce intenzivní terapií statiny a léčbou zaměřenou na normalizaci srdeční frekvence. Pacienti byli stratifi kováni podle věku a symptomů. Výsledky: Většina pacientů (86,4 %) splňovala alespoň jedno kritérium vysokého operačního rizika. Výkon byl úspěšný v 98,4 % případů. Třicetidenní a roční incidence cévních mozkových příhod (CMP) byla 4,1 %, resp. 4,5 %. Po 30 dnech byla kombinovaná incidence CMP/úmrtí z kardiovaskulárních (KV) příčin/infarktu myokardu (IM) 5,8 %; po jednom roce dosáhla hodnoty 10,9 %. Třicetidenní incidence CMP/úmrtí z KV příčin u asymptomatických a symptomatických pacientů byla 5,4 %, resp. 4,2 %. Věk ≥ 80 let zvyšoval riziko vzniku CMP/úmrtí z KV příčin/IM do jednoho roku (OR 4,41; 95% CI 1,(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)36; p = 0,04). Závěry: Studie prokázala přijatelné klinické výsledky pacientů s CAS a vysokou incidencí přidružených onemocnění, kteří byli léčeni intenzivní farmakoterapií. Incidence příhod u symptomatických pacientů nepřesáhla rozmezí uváděné v guidelines jako doporučené, zatímco u asymptomatických pacientů byla incidence zvýšená.
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