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Intervention / Peripheral circulation
P5463 | SPOTLIGHT 2013
Long-term survival and prognostic factors of cardiovascular
events in patients treated with percutaneous angioplasty for renal
artery stenosis
D. Rzeznik, T. Przewlocki, A. Kablak-Ziembicka, A. Roslawiecka, A. Kozanecki,
J. Lach, P. Podolec. John Paul II Hospital, Department of Cardiac and Vascular
Diseases, Krakow, Poland
P5464 | BEDSIDE
Vertebral artery in-stent restenosis incidence, risk factors and
treatment methods in the prospective randomized STOVAST
(STenting for Ostial Vertebral Artery STenosis) trial population
P. Paluszek, P. Pieniazek, K. Dzierwa, L. Tekieli, P. Musialek, T. Przewlocki,
A. Kablak-Ziembicka, M. Hlawaty, M. Trystula, P. Podolec. Institute of Cardiology,
John Paul II Hospital, Krakow, Poland
Background: Symptomatic vertebral artery stenosis (VAS) is a well-known risk
factor for vertebrobasilar stroke and carries a 10% to 15% incidence of stroke or
death at 1 year. Vertebral artery stenting has emerged as the treatment of choice,
but this technique is limited by high restenosis rates.
Material/methods: In the STOVAST Trial the outcomes of vertebral artery stenting with a randomized allocation to drug-eluting stents (DES) vs bare-metal
stents (BMS) were prospectively evaluated. From 2008 to 2011, 100 consecutive patients (age 66.1±8 years, 65 men) with neurologist-confirmed diagnosis of
symptomatic ostial VAS were included in the study and 99 stents (49 DES, 50
BMS) were implanted. One-year angiographic follow-up was performed in 85 patients, as 6 patients died and 8 patients withdrew follow-up angiography consent.
Restenosis was defined as an in-stent stenosis (ISR) ≥50% diameter stenosis.
Results from the trial showed no evidence for in-stent restenosis reduction with
DES vs BMS use (20.9% vs 23.8%, p=0.75). At one-year follow-up 63% patients
remained asymptomatic.
Results (table): In a group of 85 angiographically-controlled patients restenosis was observed in 19 (22.3%) stents, in 4 (4.7%) of them total occlusion was
found. Restenosis occured in 1/12 (8.3%) cobalt-chromium BMS, 9/30 (30%)
stainless-steel BMS, 2/15 (13.3%) zotarolimus-, 4/19 (21%) everolimus-, 2/4
(50%) paclitaxel-, 1/5 (20%) sirolimus-eluting stents. Stent fracture was observed
in 2 cases, but only in one case it caused restenosis. 4 patients with stent occlusion were treated conservatively (optimized pharmacotherapy). All 15 patients
with ISR had reangioplasty. Treatment methods included DES-in-BMS placement (3 cases), baloon angioplasty (4 cases), drug-eluting baloon angioplasty
(8 cases). Technical success (residual stenosis <20%) was achieved in 93.3%.
Conclusions: Vertebrobasilar ischemia symptoms recurrence after VAS is the
predictor of restenosis. High restenosis rate remains a concern, however it could
be succesfully treated with reangioplasty in vast majority of cases.
P5465 | BEDSIDE
Treatment of 001 ostial bifurcated lesions with a second generation
of placlitaxel eluting balloon: 6 months outcomes of a multicenter
registry
F. Lezana 1 , B. Vaquerizo 1 , H. Tizon 2 , E. Fernandez 3 , J. Suarez De Lezo 4 ,
I. Oategui 5 , J.R. Rumoroso 6 , F. Miranda 2 , J. Mauri 3 , A. Serra 1 . 1 Hospital de la
Santa Creu i Sant Pau, Barcelona, Spain; 2 Hospital del Mar, Barcelona, Spain;
3
Hospital Trias i Pujol, Barcelona, Spain; 4 Hospital Reina Sofia, Cordoba, Spain;
5
Hospital Vall d’Hebron, Barcelona, Spain; 6 Hospital Galdakao, Bilbao, Spain
Aims: In the DES era, the best strategy to treat ostial lesions (001 Medina Classification)remains debatable and all suggested methodologieshave specific limitations.We sought to assess the efficacy and safety of placlitaxel-coated, drugeluting balloon (PEB) in patients with 001 bifurcated lesions placed in secondary
branches.
Methods and results: 45 patients with 001 bifurcated lesion treated by using
the second generation Dior (EurocorGm), PEB (3.0μg/m2 balloon surface area),
were included in this prospective multicenter (9 center) registry. After optimal dilatation, a PEB was inflated for a minimum of 45 seconds. Repeat angiography
was planned at 6-8 months in all patients. Dual antiplatelet therapy was recommended at standard doses for at least 4 weeks. Left main bifurcated lesions,
severe calcification and cardiogenic shock, were the only exclusion criteria. Patients were 62±11 years old, 45% diabetic, 48% ACS as clinical presentation,
83% had LVEF >50%, and 19% had 3-vessel disease. The most frequent lesion
treated was first diagonal (45%). In 35% of patients a stent was implanted outside
the target lesion. Pre-dilatation was done in all the cases, with cutting balloon in
61%. Angiographic success was 88% (in 12% of lesions a BMS was implanted
because of significant acute recoil (4) or coronary dissection more that type B (1)).
At 1 month (follow-up completed in all the patients) there was no adverse event
(MACE). At 6 months (follow-up completed in 70% of patients) there was 12%
cumulative and non-hierarchical MACE (3 MI, 0 cardiac deaths, 4 TLR). There
was no subacute thrombosis or occlusion. At 6 months, angiographic follow-up
was completed in 10 patients; reference diameter was 2.18±0.3 mm with a late
loss of 0.31 mm.
Conclusion: We report the largest serie of patients with 001 bifurcated lesion
treated with PEB. In this complex setting, the optimal treatment is unknown. PEB
is a safe strategy (0% acute occlusion/thombosis) and it seems effective at 6
months follow up with a 12% TLR. Angiographic follow-up will be available at the
time of the meeting.
P5466 | BEDSIDE
Quality of life in patients with symptomatic multivessel coronary
artery disease: ten-year follow-up of a comparative post hoc
analyses of medical, angioplasty or surgical strategies-MASS II
trial
A.L.O. Carvalho, M.E. Takiuti, P. Girardi, M.F. Silva, C.L. Garzillo, E.G. Lima,
P.C. Rezende, W. Hueb, J.A.F. Ramires, R. Kalil Filho on behalf of MASS Study
Group. Heart Institute (InCor) - University of Sao Paulo Clinics Hospital, Sao
Paulo, Brazil
Background: The effects of coronary interventions on quality of life (QoL) among
patients with CAD are still scarcely studied. We evaluated the impact of CABG,
PCI or Medical Therapy (MT) on self-perceived QoL among stable CAD patients,
participants of MASS II trial.
Methods: The Short-Form Health Survey (SF-36 QoL) was applied and the analysis was made at baseline, 5 and 10 years. The questionnaire was administered
to 611 patients randomized to 3 treatment options at baseline, 401 patients after
5 years and 334 after 10 years (110 were initially assigned to CABG, 126 to PCI,
and 98 to MT). Multiple comparisons were carried out. The data was presented
by dimensions and also separated in mental and physical parameters.
Results: In this study, after ten years of follow-up, 148 patients (47.3%) had AMI,
97 (25.9%) underwent CABG or PCI, 16 (4.8%) had stroke, and 293 (87%) had
angina. At baseline, the physical component of CABG patients presented the
worst condition compared with PCI or MT. Regarding the mental component,
there was no statistical difference between treatment groups at baseline, five and
ten years. On the other hand, in MT patients they scored in the mental component 63, 75 and 78, and in the physical component 54, 73 and 72, respectively
at baseline, 5 and 10 years. In CABG patients, the mental component was 59,
79 and 74, and in the physical component 46, 77 and 69, respectively. In the PCI
arm, the mental component scored 64, 68 and 76 and in the physical component
scored 57, 71 and 77, at baseline, 5 and 10 years.
Abstract P5464 – Table 1. Analysis for the prediction of ISR
Restenosis group (n=19)
p
Free from restenosis (n=66)
Age
Gender
Male/Female
Smoking
history
Type 2
diabetes
Coronary artery
disease
Carotid artery
disease
Baseline VAS
severity
Lesion
(mm)
Stent diameter
(mm)
Residual stenosis
after stenting
Symptoms
recurrence
64.7±9.4
0.5
66.2±7.9
14/5
0.49
43/23
11 (58%)
0.98
28 (58%)
4 (21%)
0.31
22 (33%)
15 (79%)
0.87
54 (82%)
12 (63%)
0.66
38 (58%)
70.4±11.7%
0.13
74.6±10.2%
8.3±3
0.48
7.7±3
3.7±0.6
0.46
3.6±0.5
10.7±6.5%
0.39
9.5±5.1%
13 (68.7%)
0.003
20 (30.3%)
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As evidenced, patients with atherosclerotic renal artery stenosis (RAS) are at
high-risk for cardiovascular events (CVE). The impact of PTA of RAS on long
term prognosis and factors associated with unfavorable prognosis are still debated. The present study aimed to evaluate a Kaplan-Meier event-free survival
in patients treated with renal stenting for RAS, as well as to identify independent
risk factors of CVE in long-term follow-up.
Methods: Study group comprised 117 patients (60M) in mean age 64.8±10.3y.,
who underwent PTA for significant RAS exceeding 60% lumen reduction. Prevalence of CVE, including cardiovascular death (CVD), myocardial infarction (MI),
cerebral ischemia (IS) were recorded prospectively. The potential prognostic risk
factors of CVD/MI/IS were analyzed, with inclusion of classic atherosclerosis risk
factors, serum levels of NGAL, TGF β1, creatinine (Cr) and BNP, mean systolic
and diastolic blood pressures (SBP and DBP), and echocardiographic parameters: left ventricle mass (LVM) and diastolic function (E/A, e’ velocity, E/e’ ratio).
Results: During the mean follow-up period of 51.7±28.5 (range 1-106) months,
CVE occurred in 20 (17%) patients (9 CVDs, 6 non-fatal MIs, 5 non-fatal ISs). The
Kaplan-Meier event-free survival were: 94.1%, 87.5%, 73%, 71.9% and 50% in
1-, 2-, 3- 5- and 7-year follow-up, respectively. Initial serum creatinine (RR=1.31;
CI:1.11-1.55, p=0.002) and TGF β1 (RR=1.19; CI:1.01-1.41, p=0.042), as well as
BNP concentration 3 months after PTA (RR=1.26; CI:1.07-1.49, p=0.007), and
SBP 12 months after procedure (RR=1.23; CI:1.04-1.45, p=0.017) were independently associated with CVD/MI/IS risk. While, CVD risk was associated with initial
creatinine level (RR=1.4; CI:1.19-1.65, p<0.001) and 6 month’s LVM index in both
women and men (RR=1.17; CI:0.99-1.38, p=0.063) and (RR=1.25; CI:1.06-1.47,
p=0.008).
Conclusions: During 5-year period following PTA of RAS, the CVE rate was relatively low - 28%. The independent risk factor of CVD/MI/IS occurred pre procedural levels of serum creatinine and TGF β1, as well as BNP level at 3months and
SBP at 12 months following PTA. CVD was associated with initial creatinine level
and LVM index at 6 months after PTA. Long-term prognosis in patients undergoing PTA for RAS is related to postprocedural change in LVM, early BNP and later
SBP values following PTA.
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Intervention / Peripheral circulation
Figure 1
Conclusion: Improvement was observed in all dimensions and in the 3 therapeutic options in 5 years and that persisted in 10 years. Comparatively, CABG
provided a better QoL in the first 5 years and that persisted in 10-year follow-up.
S. Al Suhaim 1 , J. Mcmurray 1 , J. Lewsey 2 , P. Jhund 1 . 1 University of Glasgow,
BHF Glasgow Cardiovascular Research Centre, 2 University of Glasgow,
Department of Public Health and Health Policy, Glasgow, United Kingdom
Background: Prescribing rates of Evidence Based pharmacoTherapy (EBT) for
secondary prevention of Cardiovascular Disease (CVD) are lower in patients with
Peripheral Arterial Disease (PAD) compared to other forms of CVD. We analysed
trends in prescribing rates of EBTs for the secondary prevention of CVD in patients with PAD and Myocardial Infarction (MI). Rates were examined according
to age, sex and socioeconomic status.
Methods: We used a linked database of primary and secondary care records covering 238,064 individuals in Scotland (6% of the total population). We identified
patients with a first diagnosis (defined as a first hospitalisation or first recording of
the diagnosis in primary or secondary care) of PAD or MI. Data on prescribing of
EBTs within 30 days of diagnosis were obtained from primary care. Differences in
rates of EBT use were examined by logistic regression adjusting for age, sex, socioeconomic status, year, comorbidities and whether EBT was prescribed before
the diagnosis.
Results: Between 1997 and 2005, the prescribing rate of EBTs improved (Table).
For all EBTs, prescription- rates were lower in those with PAD. Older patients were
less likely to receive each of the EBTs (e.g. statins age ≥85 years vs. <55 years,
Odds Ratio [OR] 0.20 95% CI 0.14-0.30 for MI; OR 0.06; 95% CI 0.01-0.26 for
PAD). The only differences in prescribing by sex was found for statins in PAD:
men vs. women OR 0.73; 95% CI 0.57-0.95 and β-blockers after MI: men vs.
women OR 1.18; 95% CI 1.03-1.36. There was no difference in EBT prescription
according to socioeconomic status.
Table 1. 30 day prescribing rates (%) over time in patients with MI and PAD
MI
ACEI/ARBs
β-blockers
Statins
Aspirin
PAD
1997
(%)
2005
(%)
Odds Ratio
(95% CI)
1997
(%)
2005
(%)
12.3
19.2
9.7
29.9
46.5
43.4
54.7
53.3
5.2 (3.6–7.4)
3.6 (2.6–5.0)
11.0 (7.5–16.2)
2.8 (2.1–3.8)
3.5
3.5
1.1
7.8
14.6
8.5
31.2
36.4
Odds Ratio
(95% CI)
1.12
1.16
19.9
4.03
(0.50–2.47)
(0.51–2.65)
(7.02–56.8)
(2.49–6.52)
Conclusion: Prescribing rates of EBT within 30 days after first diagnosis although
improving, remain low. Patients with PAD received less EBT than patients with MI.
P5468 | BEDSIDE
Invasive versus conservative strategies in patients with
non-st-elevation acute coronary syndrome: an updated
meta-analysis
J.-S. Jang, H.Y. Jin, J.S. Seo, T.H. Yang, D.K. Kim, Y.J. Song, U. Kang, D.S. Kim.
Inje University College of Medicine, Busan Paik Hospital, Busan, Korea, Republic
of
Background: Early invasive approach is recommended for non-ST-segment elevation acute coronary syndromes (NSTE-ACS). However, recent guidelines pro-
P5469 | BEDSIDE
Prevalence of percutaneous coronary intervention is a key to
reduce a higher early mortality in female patients with acute
myocardial infarction: the Yamagata AMI registry
S. Nishiyama, T. Watanabe, M. Wanezaki, A. Hirayama, T. Arimoto, H. Takahashi,
T. Shishido, T. Miyashita, T. Miyamoto, I. Kubota. Yamagata University School of
Medicine, Yamagata, Japan
It was reported that female patients with acute myocardial infarction (AMI) had
a higher mortality than males. However, it remains to be determined whether
gender difference in early mortality is still present despite advance in treatments.
The purpose of this study was to examine trend in gender difference in early
mortality and prevalence of percutaneous coronary intervention (PCI).
We investigated clinical characteristics, treatments and early mortality using data
from the Yamagata AMI Registry from 1996 to 2009. Of the 6,379 consecutive
first-ever AMI patients registered in entire Yamagata Prefecture, Japan, we included 6,188 patients aged ≥ 30 years (2,000 females) into this study. The observation period was divided into 2 intervals, 1st period (1996 - 2002), and 2nd
period (2003 - 2009).
Whereas early mortality after AMI was significantly decreased in both genders,
female patients still had twice early mortality of males. Higher proportion of severe
Killip class and higher prevalence of hypertension and hypercholesterolemia were
observed in females than in males. The proportion of patients undergoing PCI
was higher in males than in females, which was significantly increased in both
genders. Multivariate logistic regression analysis revealed that age, severe Killip
class, creatinine level, and PCI were independent risk factors for early mortality.
Adjusted for independent risk factors, there was no significant difference in early
mortality between males and females in 2nd period (1st period, odds ratio 1.44,
95% confidence interval 1.05-1.96; 2nd period, 1.14, 0.85-1.53). There was a
significant increase in the proportion of patients undergoing PCI (1st, 59.3% vs.
2nd, 73.0%, P < 0.01). The early mortality was lower in patients undergoing PCI
compared to those without. Increasing the prevalence of PCI was likely to improve
early mortality in females aged < 80 years in 2nd period. However, there was
a gender difference in early mortality among elderly patients aged ≥ 80 years.
An increase in the prevalence of PCI was lower in elderly females compared to
elderly males.
In conclusion, decreasing gender difference in early mortality after AMI was observed, which may be associated with increasing prevalence of PCI.
P5470 | BEDSIDE
Correlation between arterial stiffness and degree of stenosis in
carotid arteries in patients with carotid atherosclerosis disease
M. Abdelrasoul 1 , C. Vlachopoulos 1 , K. Filis 2 , K. Masoura 1 , K. Aznaouridis 1 ,
A. Aggelakas 1 , A. Synodinos 1 , N. Ioakeimidis 1 , C. Stefanadis 1 . 1 Hippokration
General Hospital, Athens, Greece; 2 Division of Vascular Surgery, First
Department of Propaedeutic Surgery, Athens, Greece
Purpose: Studies of the association between arterial stiffness and atherosclerosis are contradictory. We studied arterial stiffness and central pressures in relation
to carotid atherosclerosis severity assessed by B-mode ultrasound.
Methods: Aortic stiffness and wave reflections were measured in 61 patients
with carotid atherosclerotic plaques and no history of coronary heart disease or
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P5467 | BEDSIDE
Lower prescribing rates of evidence based pharmacotherapy in
patients with a first diagnosis of peripheral arterial disease
compared with myocardial infarction
pose early or deferred angiography within the routine invasive strategy. We sought
to perform an updated meta-analysis to determine whether early invasive therapy
improves clinical outcomes in patients with NSTE-ACS.
Methods: Randomized controlled trials (RCTs) identified through search of MEDLINE, EMBASE, and the Cochrane databases (1991 through December 2012)
and hand searching of cross references from original articles and reviews. Clinical trials that randomized NSTE-ACS patients to early invasive versus delayed
invasive or more conservative approach were included for analysis. Major outcomes of death and myocardial infarction (MI) occurring from index hospitalization
to the end of follow-up were extracted from published results of eligible studies.
Secondary end points included the composite of death or MI; rehospitalization; recurrent angina; and repeat revascularization. The pooled effects were calculated
using fixed-effects model (Mantel-Haenszel method) or random effects models
(Dersimonian and Laird method).
Results: A total of fifteen RCTs including 15,315 patients were included in this
meta-analysis. No statistically significant differences in the risk of death (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.70–1.06, p=0.15) or MI (OR 0.92,
95% CI 0.74–1.13, p=0.41) were detected between early invasive group versus
delayed invasive or conservative approach group. Early invasive strategy significantly reduced the risk of composite of death or MI (OR 0.82, 95% CI 0.70–0.96,
p=0.02), rehospitalization (OR 0.80, 95% CI 0.72–0.89, p<0.001), and recurrent
angina (OR 0.75, 95% CI 0.56–0.99, p=0.04). Stratified analysis by the invasiveness suggested similar odds of mortality in studies comparing invasive versus
conservative strategy (OR 0.87, 95% CI 0.68–1.11, p=0.25) and early versus late
invasive approach (OR 0.81, 95% CI 0.50–1.32, p=0.41).
Conclusions: Management of NSTE-ACS by early invasive strategy does not
decrease the risk of death or MI at long-term follow up. However, early intervention
reduces the risk of recurrent angina and rehospitalization compared with delayed
intervention or conservative management.