Carotid sinus reactions (CSR), defined as asystole >/= 3 sec and hypotension (systolic blood pressure = 90 mm Hg), are frequent events during carotid artery stenting (CAS). Factors predisposing a patient to CSR as well as the impact of CSR on periprocedural complications have not yet been investigated in a prospective manner. The relationship between various clinical, morphologic, and procedural variables and the occurrence of CSR was examined among 105 consecutive patients undergoing successful CAS. After predilatation with a compliant balloon, tubular-slotted stents were used in all patients. No CSR occurred in 63 (60%) patients, whereas CSR developed in 42 (40%) patients. The most common type of CSR was asystole in combination with short-term hypotension without clinical symptoms. The most important predictor of CSR was bifurcation location of carotid stenosis (bifurcation > ostial > isolated internal carotid artery; P < 0.001). The other independent predictors were presence of contralateral stenosis (P < 0.02), length of stenosis (P < 0.03), and balloon-to-artery ratio (P < 0.02). Occurrence of CSR was unrelated to periprocedural cerebral or cardiovascular complications (7.1% vs. 9.5%; NS). We conclude that CSR occurs frequently (40%) during CAS. Bifurcation location of stenosis is the most important predictor of CSR. CSR does not increase the risk of periprocedural complications.
Background and Purpose-Routinely available independent risk factors for the peri-interventional outcome of patients undergoing elective carotid artery stenting (CAS) are lacking. The rationale of the study was to create a risk score identifying high-risk patients. Methods-We prospectively enrolled 606 consecutive patients assigned to CAS at a secondary care hospital. Various biochemical, clinical, and lesion-related risk factors were prospectively defined. The primary end point reflecting periprocedural complications encompassed minor and major stroke, nonfatal myocardial infarction and all-cause mortality within 30 days. Results-Three percent of patients (nϭ18) experienced a nonfatal minor (nϭ13) or major (nϭ5) stroke. 1.3% of patients (nϭ8) died from fatal stroke (nϭ4) or other causes (nϭ4). No myocardial infarction was observed within 30 days after stenting. Multivariable analysis revealed diabetes mellitus with inadequate glycemic control (HbA 1c Ͼ7%), age Ն80 years, ulceration of the carotid artery stenosis, and a contralateral stenosis Ն50% as independent risk factors. A risk score formed with these variables showed a superior predictive value (C-statisticϭ0.73) compared with single risk factors. The presence of 2 or more of these risk factors identified patients with a risk of 11% for a periprocedural complication compared with 2% in patients with a score of 0 or 1. Conclusions-In patients undergoing elective CAS, a risk score based on routinely accessible variables was able to identify patients at high-risk for atherothrombotic events and all-cause death within 30 days after the intervention.
BackgroundGrowing evidence suggests that poor coronary blood flow after primary percutaneous coronary intervention (PCI) is associated with unfavorable clinical out-come. We retrospectively evaluated data from our single center “real world patients” database of patients undergoing primary PCI to determine differences in clinical and angiographic patterns in patients with or without restoring thrombolysis in myocardial infarction (TIMI) flow 3.Methods and resultsBetween 2001 and 2006, 500 patients underwent primary PCI for STEMI. In 430 patients, post-interventional TIMI flow 3 could be established. In this group, in-hospital mortality was significant lower (6.4% Vs. 32.9%; P < 0.0001), left ventricular ejection fraction was better (51.3 Vs. 44.2%; P < 0.0001), and prehospital fibrinolytic therapy (6.3% Vs. 14.3%; P = 0.015), cardiogenic shock (10.9% Vs. 24.3%; P = 0.002) and use of intra-aortic balloon pump were all more unlikely (5.8% Vs. 11.4%; P = 0.045) compared to patients with TIMI flow ≤ 2. In patients with post-interventional TIMI flow ≤ 2 the left anterior descending coronary artery (LAD) was significantly more often seen as the target vessel (54.3% Vs. 44.6%; P = 0.039). A regressions analysis showed that predictors leading to such flow patterns are diabetes (P = 0.013), pre-hospital fibrinolytic therapy (P = 0.017), cardiogenic shock (P = 0.002) and a 3-vessel disease (P = 0.003). After 6 months, patients without restored normal TIMI flow had worse New York Heart Association functional class (NYHA), and had to undergo repeat coronary angiography more often.ConclusionPost-interventional TIMI flow ≤ 2 is strongly associated with adverse out-come during hospitalization and after 6 months following hospitalization.
AIMS Pre-treatment with clopidogrel results in a reduction of ischaemic events in non-ST-elevation acute coronary syndromes. Data on upstream clopidogrel in the setting of primary percutaneous coronary intervention (PCI) are limited. The aim of this study was to investigate whether clopidogrel loading before arrival at the PCI centre may result in an improved outcome of primary PCI for ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS In a multicentre registry of acute PCI, 5955 patients undergoing primary PCI in Austria between January 2005 and December 2009 were prospectively enrolled. The patients consisted of two groups, a clopidogrel pre-treatment group (n = 1635 patients) receiving clopidogrel before arrival at the PCI centre and a peri-interventional clopidogrel group (n = 4320 patients) receiving clopidogrel at a later stage. Multiple logistic regression analysis including major confounding factors stratified by the participating centres was applied to investigate the effect of pre-treatment with clopidogrel on the in-hospital mortality. Additionally, two subgroups, with or without the use of GP IIb/IIIa antagonist therapy in the catheterization laboratory, were analysed. On univariate analysis, clopidogrel pre-treatment was associated with a reduced in-hospital mortality (3.4 vs. 6.1%, P< 0.01) after primary PCI. On multivariate analysis, clopidogrel pre-treatment remained an independent predictor of in-hospital mortality [odds ratio (OR) = 0.60, 95% confidence interval (CI) 0.35-0.99; P =0.048], especially in patients receiving additional GP IIb/IIIa antagonist therapy in the catheterization laboratory (OR = 0.40, 95% CI 0.19-0.83; P =0.01). CONCLUSION Clopidogrel pre-treatment before arrival at the PCI centre is associated with reduced mortality in a real world setting of primary PCI. These results strongly support the recommendation of clopidogrel treatment 'as soon as possible' in patients with STEMI undergoing pimary PCI.
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