Sixteen patients with angina refractory to medical therapy who were not considered suitable for standard revascularization underwent transmyocardial revascularization with holmium laser. The average age of the patients was 63.2 ± 10.5 years. All of them had angina class 3 or 4, and 9 (56%) had previously undergone an aortocoronary bypass grafting. Four patients died during the 6-month follow-up period (25%). Among the survivors, anginal class decreased to class 2 or 1 at the 6th month (p = 0.002). Ejection fraction did not change. The ischemic burden by Holter decreased from 85.3 ± 656 to 5.5 ± 9.7 min (p = 0.046). Myocardial perfusion with 201Tl single photon emission computed tomography (SPECT) images at rest and after dipyridamole showed a significant improvement among the ischemic treated segments (p = 0.015). Baseline ejection fraction was somehow lower in nonresponsive than in responsive patients (33 ± 13 vs. 49 ± 10, p = 0.052). We conclude that transmyocardial laser revascularization with holmium laser is effective in treatment in ischemic patients not amenable to surgery or percutaneous procedures, as previously reported with CO2 laser. Further investigation is needed to determine which clinical profiles identify the patients for whom this therapy is suitable.
Funding Acknowledgements Type of funding sources: None. INTRODUCTION Acute inferior wall myocardial infarction (AIWMI) is related to Right Coronary Artery (RCA) occlusion in about 80% of cases and to Left Circumflex Artery (LCX) in the rest of them, in most series. However it has not been established yet if there is a difference in prognosis depending on culprit artery. PURPOSE This study compares clinical outcome during hospital stay between RCA-related and LCX-related AIWMI. METHODS We analysed all patients with AIWMI admitted to the Cardiac Care Unit between August 2011 and February 2019, both ST-elevation (STEMI) and non ST-elevation myocardial infarction, and whose culprit artery was either the RCA or the LCX. Basal characteristics and clinical outcome during hospital stay were compared between RCA and LCX. RESULTS Among 2252 patients with acute coronary syndrome, 650 were AIWMI. Among them, the culprit artery was the RCA in 461, the LCX in 149, and other or not defined in 30. The mean age was 61.7 ± 11.6 years, 79% of them were male and 21% female. They had a history of current smoking in 50.7%, diabetes mellitus in 24.4%, hypertension in 52.1%, dyslipemia in 44.3% and obesity in 28.7%, without differences between RCA and LCX. RCA patients presented as STEMI in 93.3% vs 87.2% of LCX patients (p = 0.025). Among those presenting as STEMI, 84.4% of RCA and 90.8% of LCX underwent primary coronary intervention. Mean ejection fraction was 50.8% in RCA and 51.2% in LCX. Three-vessel or left main disease was present in 10.2% of RCA and 10.8% of LCX. There was atrioventricular block in 17.8% of RCA and 3.4% of LCX (p < 0.001); atrial fibrillation in 10.2% of RCA and 11.4% of LCX, ventricular fibrillation in 10.4% of RCA and 7.4% of LCX. Median of peak CPK was 1203 in RCA, vs 1785 in LCX (p < 0.001). There was cardiogenic shock (CS) at admission in 5.4% of RCA vs 1.3% of LCX, (p = 0.038) and CS whenever the hospital stay in 8.4% vs 4.0% (p = 0.072). In-hospital mortality was 3.3% in RCA and 3.4% in LCX. Several models of multivariate logistic regression analysis did not find a predictive value of the culprit artery in the development of CS or in-hospital mortality. CONCLUSION AIWMI related to LCX have greater enzymatic size than those related to RCA. However, RCA infarctions present more often atrioventricular block and cardiogenic shock at admission. Multivariate analysis did not shock significant differences in the development of CS or in-hospital mortality. Abstract Figure. Peak CPK depending on culprit artery
Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): This study was financially by a non conditional grant by Astrazeneca. Background/Introduction The favorable net clinical benefit of ticagrelor over clopidogrel in the PLATO trial has been recently questioned in observational studies. However, these mostly retrospective analyses based on the intention-to-treat (ITT) principle, systematically failed to account for switching between P2Y12 inhibitors, which may indeed have led to biased estimates due to exposure misclassification (incorrect classification of subjects with respect to exposure) Purpose To assess the on-treatment safety and effectiveness of ticagrelor vs clopidogrel among patients with acute coronary syndrome (ACS) in a non-trial scenario. Methods Prospective multicentre cohort study of 2070 ACS patients discharged on ticagrelor or clopidogrel between 2015 and 2019. Major exclusions were previous intracranial bleeding, use of prasugrel or oral anticoagulation. Primary study hypothesis stated safety profile of ticagrelor is not unacceptably worse (not inferior) than that of clopidogrel. Primary outcome was risk of major bleeding (BARC types 3, 5) at 1 year. Secondary outcomes were major adverse cardiac and cerebrovascular events (MACCE), and net adverse clinical event (NACE) at 1-yer. Association of ticagrelor vs clopidogrel with outcomes was evaluated based on the on-treatment principle using fully-adjusted Cox regression models with double robust inverse probability of censoring weighted (IPCW) estimators. Sensitivity analyses included propensity score matching analysis and ITT simulation analysis. Results Among 2070 patients included (mean age 63 years, 73% men), 1035 were discharged on ticagrelor and clopidogrel in each treatment group, respectively. Ticagrelor-treated patients were younger, had less comorbidities and more often underwent percutaneous coronary intervention over coronary artery bypass grafting surgery, as the preferred revascularization choice. After adjust for medication adherence and switching, ticagrelor did not increase the risk for major bleeding compared with clopidogrel (adjusted hazard ratio 1.40, 95% CI 0.96 – 2.05; P = .075). Although there was signal for potential harm with ticagrelor among elderly people and patients with previous bleeding, exploratory analysis suggested consistent reductions in MACCE and NACE risks compared with clopidogrel. PSM analysis was congruent with primary analysis, whereas ITT analysis yielded results in the opposite direction. Conclusion(s) In this on-treatment analysis of an all-comers ACS population, ticagrelor did not pose an increased risk for major bleeding, while resulted in a net clinical benefit compared with clopidogrel. Further studies accounting for drug switching are warranted to confirm these findings in high-bleeding risk populations.
Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): The study project was financially supported by a non-conditional grant by Astrazeneca. Background/Introduction Premature cessation of dual antiplatelet therapy (DAPT) after acute coronary syndrome (ACS) has been associated with increased risk of major adverse cardiovascular events (MACE) Purpose To assess the relationship between premature DAPT discontinuation versus therapy continuation and outcomes in ACS patients discharged on ticagrelor or clopidogrel. Methods Prospective, observational, multicentre all-comers registry of ACS patients who were intended to receive 12-month DAPT with ticagrelor or clopidogrel. Adherence was defined by the medication possession ratio metric (MPA, proportion of days of medication supply within a time interval). Categories for DAPT cessation included: physician-recommended discontinuation, brief interruption (invasive procedures), or disruption due to non-compliance or because of bleeding. Fully-adjusted Cox models with time-varying covariates to account for informative censoring, were used to examine the effect of DAPT cessation on MACE (a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, definite stent thrombosis, or target-lesion revascularization). Moderation analysis was also performed to assess for potential exposure-adherence interaction. Results Among 2070 patients included (mean age 63 years, 73% men), 150 (7.3%) prematurely discontinued DAPT, median (IQR) 214 (101-236) days. Significantly more clopidogrel than ticagrelor users discontinued medication (9.5% vs 5%, respectively; P = .001), though timing of cessation was similar in both groups. At 1 year, MPR was slightly higher, but not significantly different, in the clopidogrel group than in the ticagrelor group (70±30 vs 64±29; P = .06). Overall, physician-guided discontinuation and bleeding were the main reasons for DAPT cessation. These were observed with a similar rate in both groups, while non-compliant disruption was more common among ticagrelor- than clopidogrel-treated patients (8% vs 2%, respectively; P for trend .04). After adjustments, DAPT cessation was associated with significantly increased risk of MACE (adjusted HR 2.94; 95% CI 1.82 – 4.74; P < .0001), regardless of the P2Y12 inhibitor (P interaction = 0.665). Non-compliance related cessation resulted in higher risk of MACE (HR 6.04, 95%CI 2.15 – 16.95; P = .001). Conclusion(s) Overall, approximately 7% of patients discontinued DAPT. Early cessation of either ticagrelor- or clopidogrel-based DAPT portended to a near 3-fold increased risk of MACE. Disruption due to non-compliance resulted in higher risk for ischemic events. These data warrant efforts to focus on patient education in subgroups at high risk of non-compliance.
Funding Acknowledgements Type of funding sources: None. Introduction Coronary embolism (CE) is a rare cause of acute coronary syndrome with current evidence from small case series. In our previous work (n=36), atrial fibrillation was the main risk factor and STEMI the most frequent presentation. Objetives In this analysis we compare severity characteristics, management and in-hospital prognosis between an embolic cohort versus a non-embolic one among patients with left anterior descending artery as culprit vessel. Methods Observational, retrospective descriptive study of patients admitted in our unit from July 2011 to march 2021 for ACS. The diagnosis of CE was established according to the National Cerebral Cardiovascular Center Criteria. Data were obtained from the ARIAM Andalucia Registry. Results 646 Patients were analysed (19 embolic vs 627 non-embolic). There were no differences in ejection fraction (EF) (43±9% vs 44±10%, p>0.05) or Killip-Kimbal (KK) stage at admission moment (stage I more frequent in both groups) or use of inotropes or vasoactive drugs. Embolic cohort had more in-hospital complications: worse KK stage (p=0.001; KKII 23.5% vs 15.3%; KKIII 23.5% vs 5.9%), more thrombocytopenia (5.3% vs 0.8%, p=0.046) and higher hsTnT levels (p=0.000). There was more use of non-invasive mechanical ventilation in embolic group (21.1% vs 4.9%, p=0.002). Without differences in incidence of cardiac arrest, mechanical complications, bradycardia, hemorrhage or in-hospital dead. Conservative management was more frequent in the embolic group. Percutaneous coronary intervention was the most frequent strategy in both cohorts (14.3% vs 3%; 85.6% vs 92.3%; p<0.05). At discharge, there were not significant differences in antithrombotic or anticoagulant therapy. Conclusions In our series the embolic group had worse KK stage and more need of non-invasive mechanical ventilation. They had no significant differences in EF, other mayor complications nor in-hospital mortality.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.