Biomedical subjects

Alexandra J Lansky

Publications and source records attributed to Alexandra J Lansky.

At least 73 records · Page 4Linked to original sources

PubMed2004

Impact of intravenous beta-blockade before primary angioplasty on survival in patients undergoing mechanical reperfusion therapy for acute myocardial infarction.

OBJECTIVES: We sought to examine the effect of intravenous beta-blockers administered before primary percutaneous coronary intervention (PCI) on survival and myocardial recovery after acute myocardial infarction (AMI). BACKGROUND: Studies of primary PCI but not thrombolysis have suggested that beta-blocker administration before reperfusion may enhance survival. Whether oral beta-blocker use before admission modulates this effect is unknown. METHODS: The Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial randomized 2082 AMI patients to either stenting or balloon angioplasty, each +/- abciximab. In accordance with the protocol, intravenous beta-blockers were administered before PCI in the absence of contraindications. RESULTS: A total of 1136 patients (54.5%, BB+ group) received beta-blockers before PCI, whereas 946 (45.5%, BB- group) did not. The 30-day mortality was significantly lower in the BB+ group than in the BB- group (1.5% vs. 2.8%, p = 0.03), an effect entirely limited to patients who had not been receiving beta-blockers before admission (1.2% vs. 2.9%, p = 0.007). In contrast, no survival benefit with pre-procedural beta-blockers was observed in patients receiving beta-blockers at home (3.3% vs. 1.9%, respectively, p = 0.47). By multivariate analysis, pre-procedural beta-blocker use was an independent predictor of lower 30-day mortality among patients without previous beta-blocker therapy (relative risk = 0.38 [95% confidence interval 0.17 to 0.87], p = 0.02). The improvement in left ventricular ejection fraction from baseline to seven months was also greater after intravenous beta-blockers (3.8% vs. 1.3%, p = 0.01), an effect limited to patients not receiving oral beta-blockers before admission. CONCLUSIONS: In patients with AMI undergoing primary PCI, myocardial recovery is enhanced and 30-day mortality is reduced with pre-procedural intravenous beta-blockade, effects confined to patients untreated with oral beta-blocker medication before admission.

Adrenergic beta-Antagonists↗

PubMed2004

Six- and twelve-month results from first human experience using everolimus-eluting stents with bioabsorbable polymer.

BACKGROUND: Everolimus, an active immunosuppressive and antiproliferative agent of the same family as sirolimus (rapamycin), has demonstrated significant reduction of neointimal proliferation in animal studies. The First Use To Underscore restenosis Reduction with Everolimus (FUTURE) I trial was the first in-human experience to evaluate the safety and efficacy of everolimus-eluting stents (EES), coated with a bioabsorbable polymer, compared with bare metal stents (BMS). METHODS AND RESULTS: FUTURE I was a prospective, single-blind, randomized trial that enrolled 42 patients with de novo coronary lesions (EES 27, BMS 15). Patient and lesion characteristics were comparable between the groups. Major adverse cardiac event rates were low at 30 days and 6 months, without any early or late stent thrombosis for either group (P=NS). Between 6 and 12 months, there were no additional reports of major adverse cardiac events. The 6-month angiographic in-stent restenosis rate was 0% versus 9.1% (1 patient) (P=NS), with an associated late loss of 0.11 mm versus 0.85 mm (P<0.001), and the in-segment restenosis rate was 4% (1 patient) and 9.1% (1 patient) (P=NS) for EES and BMS, respectively. Intravascular ultrasound analysis revealed a significant reduction of percent neointimal volume in EES compared with BMS (2.9+/-1.9 mm3/mm versus 22.4+/-9.4 mm3/mm, P<0.001). There was no late stent malapposition in either group. The safety and efficacy of the EES appeared to be sustained at 12 months. CONCLUSIONS: In this initial clinical experience, EES with bioabsorbable polymer demonstrated a safe and efficacious method to reduce in-stent neointimal hyperplasia and restenosis.

Aged↗

PubMed2004

Short- and long-term results after multivessel stenting in diabetic patients.

OBJECTIVES: The present study evaluated clinical outcomes in diabetic patients after multivessel stenting. BACKGROUND: Multivessel angioplasty studies have reported decreased survival in diabetic patients undergoing conventional balloon angioplasty compared with coronary artery bypass graft surgery (CABG). However, several studies have demonstrated excellent procedural success and acceptable clinical outcomes after multivessel stenting. METHODS: Multivessel stenting was performed in 689 patients with 1,639 native coronary lesions. Patients were classified into three groups according to diabetes mellitus (DM) status: 1) no DM (501 patients/1,200 lesions); 2) DM treated with oral agents (102 patients/235 lesions); and 3) DM treated with insulin (86 patients/204 lesions). RESULTS: Procedural success was high overall. In-hospital CABG was higher in diabetics treated with insulin compared with the other two groups (3.5% vs. 0.4% vs. 1.0%, p = 0.02). There were no significant differences in the incidence of in-hospital cardiac death and myocardial infarction. Diabetic patients treated with oral agents or insulin had higher one-year target lesion revascularization rates than non-diabetic patients (25% vs. 35% vs. 16%, p < 0.001). Lower one-year survival was observed in diabetic patients treated with either oral agents or insulin, compared with non-diabetic patients (85% vs. 86% vs. 95%, p < 0.001). On multivariable analysis, DM was an independent predictor of one-year mortality, myocardial infarction, and target lesion revascularization after multivessel stenting. CONCLUSIONS: Despite a high technical success rate of multivessel stenting, diabetic patients, especially those treated with insulin, have higher in-hospital CABG, higher subsequent revascularization rates, and lower one-year survival than non-diabetic patients.

Aged↗

PubMed2004

Importance of mitral regurgitation inpatients undergoing percutaneous coronary intervention for acute myocardial infarction: the Controlled Abciximab and Device Investigation to Lower Late Angioplasty Complications (CADILLAC) trial.

OBJECTIVES: We sought to determine the prognostic importance of mitral regurgitation (MR) in patients undergoing percutaneous coronary intervention for acute myocardial infarction (AMI). BACKGROUND: Mitral regurgitation has been associated with a poor prognosis in patients treated with thrombolytic therapy for AMI. The prognostic significance of MR in patients undergoing mechanical reperfusion therapy for AMI is unknown. METHODS: Left ventriculography was performed during the index procedure in 1,976 (95%) of 2,082 non-shock patients enrolled in a prospective, multicenter, randomized trial of mechanical reperfusion strategies in AMI. The severity of operator-assessed MR was divided into four strata: none (n = 1,726), mild (n = 192), and moderate/severe (n = 58). RESULTS: Patients with progressively more severe MR were older (p < 0.0001), were more often women (p < 0.0001), and had higher Killip class (p = 0.0007). More severe grades of MR correlated with triple-vessel disease (p < 0.0001) and lower left ventricular ejection fraction (LVEF) as measured during the index procedure (p = 0.0004). Increasingly severe MR was strongly associated with a higher mortality at 30 days (1.4% vs. 3.7% vs. 8.6%, respectively; p < 0.0001) and at one year (2.9%, 8.5%, 20.8%, respectively; p < 0.0001). By multivariate analysis, the presence of even mild MR was an independent predictor of long-term mortality (mild MR, relative risk [RR] = 2.40, p = 0.005; moderate/severe MR, RR = 2.82, p = 0.006). CONCLUSIONS: Mitral regurgitation of any degree present on the baseline left ventriculogram during the index procedure is a powerful, independent predictor of mortality in patients undergoing mechanical reperfusion therapy for AMI. The presence of MR identifies high-risk patients in whom close out-patient follow-up is warranted, and who may benefit from aggressive adjunctive medical or surgical therapies.

Abciximab↗

PubMed2004

Minimally invasive coronary artery bypass grafting versus stenting for patients with proximal left anterior descending coronary artery disease.

The purpose of this study was to compare the clinical outcomes of stenting and minimally invasive coronary artery bypass grafting (MIDCAB) in patients with proximal left anterior descending (LAD) coronary artery disease. The Patency, Outcome, Economics of Minimally invasive direct coronary bypass (POEM) study demonstrated that MIDCAB had similar safety and long-term efficacy for LAD revascularization compared with conventional coronary artery bypass grafting. Although LAD stenting is superior to conventional balloon angioplasty, whether it is comparable to MIDCAB is not known. We identified a matched population of 429 consecutive patients with 1-vessel disease who underwent elective proximal LAD stenting and compared their clinical outcomes with those of the 152 patients in the MIDCAB group of the POEM study. The in-hospital event rate was similar in both groups, except for a shorter length of hospital stay with LAD stenting compared with MIDCAB (2.68 vs 4.07 days, p <0.0001). At 6-month follow-up, the incidence of death and Q-wave myocardial infarction or that of cerebrovascular accident was not significantly different between these 2 groups. However, target vessel revascularization was significantly higher with LAD stenting than MIDCAB (13.3% vs 6.6%, p = 0.045). In the subgroup of patients without diabetes, all clinical events were similar in both groups, and the benefit of a shorter hospital stay associated with stenting was maintained. Compared with MIDCAB, LAD stenting is associated with higher repeat revascularization rates but offers the advantage of shorter hospitalization. For nondiabetics with proximal LAD disease, stenting may be the revascularization strategy of choice.

Coronary Artery Bypass↗

PubMed2004

Relation of final lumen dimensions in saphenous vein grafts after stent implantation to outcome.

Larger final lumen dimensions after percutaneous coronary interventions in native coronary arteries lead to lower restenosis rates. We sought to determine the impact of stent expansion, as assessed by intravascular ultrasound, on clinical results of stent implantation in saphenous vein grafts (SVGs). We identified 226 consecutive patients who underwent intravascular ultrasound-guided stenting of 234 de novo SVG lesions. Patients were divided into 2 groups based on the final stent cross-sectional area (CSA): group I (stent CSA <100% of the reference lumen CSA, n = 176 patients, 182 lesions) and group II (stent CSA >/=100% of the reference lumen CSA, n = 50 patients, 52 lesions). Baseline patient characteristics were similar between the 2 groups with the exception of smaller lesions in group II. More aggressive stent expansion (group II) was associated with (1) increased rates of in-hospital non-Q-wave myocardial infarction (29% vs 17%, p = 0.05), (2) any myocardial infarction (26% vs 8%, p = 0.003) at 1-year follow-up, and (3) no improvement in target vessel revascularization at 1 year (31% vs 26%, p = 0.3). Aggressive stent expansion in SVG lesions resulted in higher myocardial infarction rates and, unlike native arteries, no improvement in target vessel revascularization rate at 1 year. A less aggressive stent implantation strategy in SVGs than in native coronary lesions appears prudent.

Aged↗

PubMed2004

Non-polymer-based paclitaxel-coated coronary stents for the treatment of patients with de novo coronary lesions: angiographic follow-up of the DELIVER clinical trial.

BACKGROUND: Paclitaxel, a microtubule-stabilizing compound with potent antitumor activity, has been shown to inhibit smooth muscle cell proliferation and migration. The DELIVER trial was a prospective, randomized, blinded, multicenter clinical evaluation of the non-polymer-based paclitaxel-coated ACHIEVE stent compared with the stainless steel Multi-Link (ML) PENTA stent. METHODS AND RESULTS: A total of 1043 patients with focal de novo coronary lesions, <25 mm in length, in 2.5- to 4.0-mm vessels were randomized (ACHIEVE n=524; ML PENTA n=519). Angiographic follow-up was performed in a subset of 442 patients (ACHIEVE n=228; ML PENTA n=214). Prespecified end points were a 40% reduction in target-vessel failure at 9 months (primary clinical end point) and a 50% reduction in binary restenosis at 8 months (major secondary end point). Baseline clinical characteristics were comparable between the groups. Patients in ACHIEVE had more type C lesions and a larger reference diameter. At follow-up, stent late loss was 0.81 versus 0.98 mm (P=0.003), stent binary restenosis was 14.9% versus 20.6% (P=0.076), and target-vessel failure was 11.9% versus 14.5% (P=0.12) for ACHIEVE and ML PENTA, respectively. CONCLUSIONS: The ACHIEVE paclitaxel-coated stent decreased neointimal proliferation compared with the bare-metal PENTA stent; however, this reduction was insufficient to meet the prespecified primary end point of target-vessel failure and the secondary end point of binary restenosis.

Combined Modality Therapy↗

PubMed2004

Comparison of differences in outcome after percutaneous coronary intervention in men versus women <40 years of age.

We evaluated the outcomes of 177 consecutive patients (43 women, 134 men) <40 years of age with premature atherosclerosis who underwent percutaneous coronary intervention. Women were younger, had more diabetes mellitus (37% vs 10%; p <0.001), but less hyperlipidemia (58% vs 75%; p <0.001) compared with men. In-hospital vascular complications and 1-year mortality rate or Q-wave myocardial infarction (7.9% vs 0.08%, p <0.01) were higher in women. By multivariable regression analysis, female gender was the only independent predictor of vascular complications (odds ratio, 14.1; 95% confidence intervals, 1.59 to 125, p = 0.01) and of 1-year mortality rate or nonfatal myocardial infarction (odds ratio, 12.5; 95% confidence interval, 1.14 to 111, p = 0.03). Women with premature coronary disease had a distinctive risk factor profile relative to men, with a predominance of diabetes and hypercholesterolemia, and were at higher risk of developing vascular and ischemic complications after percutaneous coronary intervention, warranting aggressive risk factor modification and vigilance in this population.

Adult↗

PubMed2004

Contribution of stent underexpansion to recurrence after sirolimus-eluting stent implantation for in-stent restenosis.

BACKGROUND: We used intravascular ultrasound (IVUS) to evaluate recurrence after sirolimus-eluting stent (SES) implantation treatment of in-stent restenosis (ISR). METHODS AND RESULTS: Forty-eight ISR lesions (41 patients with objective evidence of ischemia) were treated with SES. Recurrent ISR was identified in 11 lesions (all focal); repeat revascularization was performed in 10. These were compared with 16 patients (19 lesions) without recurrence as documented by angiography. Nine of 11 recurrent lesions had a minimum stent area (MSA) <5.0 mm2 versus 5 of 19 nonrecurrent lesions (P=0.003); 7 of 11 recurrent lesions had an MSA <4.0 mm2 versus 4 of 19 nonrecurrent lesions (P=0.02); and 4 of 11 recurrent lesions had an MSA <3.0 mm2 versus 1 of 19 nonrecurrent lesions (P=0.03). A gap between SESs was identified in 3 of 11 recurrences versus 1 of 19 nonrecurrent lesions. CONCLUSIONS: Stent underexpansion is a significant cause of failure after SES implantation treatment of ISR.

Combined Modality Therapy↗

PubMed2004

Comparison of frequency of hemorrhagic stroke in patients <75 years versus > or =75 years of age among patients receiving glycoprotein IIb/IIIa inhibitors during percutaneous coronary interventions.

We identified 1,369 consecutive patients who received glycoprotein IIb/IIIa inhibitors during 1,461 stenting procedures (2,382 lesions); of these, 240 (17.5%) were aged > or =75 years (253 procedures, 430 lesions). Very elderly patients (> or =75 years) had similar in-hospital outcomes but a higher hemorrhagic stroke rate than patients aged <75 years.

Age Factors↗

PubMed2004

Relation between late patency of the infarct-related artery, left ventricular function, and clinical outcomes after primary percutaneous intervention for acute myocardial infarction (CADILLAC trial).

The importance of sustained patency of the infarct-related artery after primary percutaneous coronary intervention for acute myocardial infarction is controversial. We examined serial measures of left ventricular function and clinical outcomes in 280 patients with an initially occluded infarct artery in whom Thrombolysis In Myocardial Infarction trial grade 3 flow was achieved and routine follow-up angiography was performed 7 months after percutaneous coronary intervention. Reocclusion of the infarct artery was associated with decreased event-free survival, and the degree of restenosis was an independent predictor of the lack in improvement in left ventricular ejection fraction over time.

Aged↗

PubMed2004

Gamma radiation for in-stent restenosis: effect of lesion length on angiographic and clinical outcomes.

The relation between lesion length and effectiveness of gamma radiation treatment (gamma-RT) has not been well described. We evaluated the acute and long-term outcome according to baseline lesion length in 130 patients treated with (192)Ir in the Washington Radiation for In-Stent Restenosis Trial; 44 (35.5%) had baseline short in-stent restenosis (ISR) lesions (length < 15 mm) and 80 (64.5%) long ISR lesions (length > or = 15 mm). At 6-month follow-up after gamma-RT, the short ISR group had larger lumen dimensions and lower late loss than the long ISR group. Restenosis rate was significantly higher in patients with long ISR for both the placebo (74% vs. 39%; P = 0.01) and the gamma-RT arm (31% vs. 5.3%; P = 0.04). gamma-RT significantly improved the angiographic outcome in the short-lesion groups but had the more pronounced effect on the reduction of clinical events after treatment of long ISR group. Lesion length remains a powerful predictor of recurrent ISR and clinical events after treatment of ISR even with gamma-RT.

Brachytherapy↗

PubMed2004

Favorable effect of gamma-radiation for in-stent restenosis: effect of diabetes on angiographic and clinical outcomes.

The purpose of this study was to examine the effect of vascular brachytherapy with gamma-radiation (gamma-RT) in patients with diabetes mellitus (DM) with coronary in-stent restenosis (ISR). In the Washington Radiation for In-Stent Restenosis (WRIST) trial, 130 patients with ISR were treated with (192)Ir or placebo. Of the patients enrolled, 44 (34%) had DM (18 of them treated with gamma-RT and 26 with placebo). Gamma-radiation therapy of ISR in diabetics resulted in similar procedural success and in-hospital outcome compared to nondiabetics. At 6-month follow-up, both DM and non-DM patients treated with gamma-RT had significantly lower target lesion revascularization (TLR), target vessel revascularization, and major adverse cardiac event rates compared to placebo. DM remains a powerful predictor of TLR and major adverse cardiac events even after treatment of ISR with gamma-RT.

Adult↗

PubMed2004

Coordinated series of studies to evaluate characteristics and mechanisms of acute coronary syndromes in high-risk patients randomly assigned to enoxaparin or unfractionated heparin: design and rationale of the SYNERGY Library.

Clinical trials and accompanying substudies in patients with acute coronary syndromes (ACS) have over the last several years yielded a wealth of knowledge about the pathophysiology and management of this high-risk condition. The Superior Yield of the New strategy of Enoxaparin, Revascularization, and GlYcoprotein IIb/IIIa inhibitors (SYNERGY) trial is a large-scale, randomized, controlled trial evaluating the effect of enoxaparin and unfractionated heparin on death and myocardial infarction in high-risk patients presenting with non-ST-segment elevation ACS. The SYNERGY Library has been designed as a coordinated series of investigations with simultaneous data acquisition on the same cohort of approximately 500 SYNERGY patients at 60 centers in North America. Specifically, electrocardiograms, coronary arteriograms, inflammatory markers, coagulation studies, and genetic samples will be collected and processed at core laboratory facilities, and the results will be stored in a central repository. This novel strategy for substudy investigation is unprecedented in cardiovascular clinical trials. The goal is to gain significant understanding about this patient population, discover new principles of pathophysiology, identify novel pharmacologic targets, and streamline further drug development. It is hoped that the SYNERGY Library will serve as a model for future substudy design to maximize academic insight within the framework of a large-scale, multicenter trial.

Angina, Unstable↗

PubMed2004

Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial: study design and rationale.

BACKGROUND: Patients with acute coronary syndromes (ACS; unstable angina and non-ST-segment elevation myocardial infarction) are at significant risk for death and myocardial infarction. Early angiography followed by revascularization is considered the treatment of choice for moderate- to high-risk patients with ACS. However, despite the integration of newer therapies including stents, glycoprotein IIb/IIIa inhibitors, and thienopyridines, the rate of adverse ischemic events still remains unacceptably high, and the intensive pharmacologic regimens used to stabilize the disrupted atherosclerotic plaque and support angioplasty and surgical revascularization procedures elicit a high rate of bleeding complications. Pilot trials suggest that the thrombin-specific anticoagulant bivalirudin may improve clinical outcomes in ACS. STUDY DESIGN: In the Acute Catheterization and Urgent Intervention Triage strategY (ACUITY) trial, 13,800 patients with moderate- to high-risk ACS are being prospectively randomly assigned at up to 600 centers to unfractionated heparin or enoxaparin + IIb/IIIa inhibition, versus bivalirudin + IIb/IIIa inhibition, versus bivalirudin + provisional IIb/IIIa inhibition. All patients undergo cardiac catheterization within 72 hours, followed by percutaneous or surgical revascularization when appropriate. In a second random assignment, patients assigned to receive IIb/IIIa inhibitors are subrandomized to upstream drug initiation, versus IIb/IIIa inhibitor administration during angioplasty only. The primary study end point is the composite of death, myocardial infarction, unplanned revascularization for ischemia, and major bleeding at 30 days. Clinical follow-up will continue for 1 year. CONCLUSIONS: The ACUITY trial is the largest study yet performed in patients with ACS undergoing an invasive strategy. In addition to evaluating the utility of bivalirudin in ACS, this study will also provide important guidance regarding the necessity for and timing of IIb/IIIa inhibitor administration.

Angina, Unstable↗

PubMed2004

Impact of symptomatic peripheral arterial disease on 1-year mortality in patients undergoing percutaneous coronary interventions.

PURPOSE: To determine the impact of symptomatic peripheral arterial disease (PAD) on clinical outcomes in patients treated with percutaneous coronary interventions (PCI). METHODS AND RESULTS: Symptomatic PAD was identified in 1969 (18.9%) of 10440 consecutive patients undergoing PCI. Patients with PAD were older, more frequently female, and had smaller body surface area and more atherosclerotic risk factors, chronic renal insufficiency, and heart failure. Patients with PAD had lower rates of procedural success (94.2% versus 96.2%, p<0.0001) and higher rates of in-hospital complications, including all-cause mortality (2.1% versus 1.1%, p=0.0002), cardiac death (1.5% versus 0.7%, p=0.0009), urgent coronary artery bypass grafting (1.9% versus 1.2%, p=0.01), recurrent ischemia (5.6% versus 2.8%, p<0.0001), re-PCI to the target lesion (2.4% versus 1.1%, p<0.0001), stroke (0.6% versus 0.3%, p=0.0344), transient ischemic attack (0.4% versus 0.1%, p=0.01), femoral hematoma (10.3% versus 8.5%, p=0.01), retroperitoneal hematoma (0.8% versus 0.3%, p=0.009), limb ischemia (3.0% versus 0.7%, p<0.0001), gastrointestinal bleeding (1.9% versus 0.9%, p<0.0001), and blood transfusion (10.1% versus 5.2%, p<0.0001). At 1-year follow-up, patients with PAD had a higher mortality rate (13.6% versus 5.2%, p<0.0001), a higher rate of myocardial infarction (8.3% versus 6.5%, p=0.008), and also more target lesion (21.2% versus 19.8%, p=0.02) or target vessel revascularization (24.6% versus 21.2%, p=0.002). By multivariate analysis, PAD was an independent predictor of 1-year mortality (odds ratio 1.71, 95% confidence interval 1.42 to 2.07, p<0.0001). CONCLUSIONS: Nearly a fifth of patients undergoing PCI have symptomatic PAD. The presence of PAD is associated with lower rates of procedural success, higher rates of in-hospital and 1-year adverse events, and is independently associated with increased 1-year mortality.

Adult↗

PubMed2003

Comparison of the angiographic outcomes after beta versus gamma vascular brachytherapy for treatment of in-stent restenosis.

This study was designed to compare the angiographic outcomes of beta versus gamma vascular brachytherapy (VBT). We reviewed the angiographic results of 636 lesions (212 that underwent beta and 212 that underwent gamma VBT, and 212 that received placebo) with native coronary in-stent restenosis matched for lesion length, vessel size, preprocedure minimum lumen diameter (MLD), and time to angiographic follow-up in the various randomized clinical trials and studies. Baseline lesion complexity was similar in these 3 groups. Final MLD was smaller in the beta VBT group than in the gamma VBT or placebo group. At follow-up, beta and gamma VBT significantly reduced both angiographic restenosis (34.4% for beta VBT, 26.4% for gamma VBT, and 50.9% in the placebo group; p <0.0001) and recurrent lesion length (9.2 mm for beta VBT, 8.4 mm for gamma VBT, and 15.5 mm placebo, p <0.0001) compared with placebo. Gamma VBT was associated with a greater reduction in restenosis outside the stent than beta VBT. By multivariable analysis, independent angiographic predictors of treated segment restenosis included beta or gamma VBT, lesion length, and vessel size. In matched lesions, beta and gamma VBT achieved similar reductions in treated segment restenosis and recurrent lesion length compared with placebo.

Adult↗

PubMed2003

Increased CK-MB release is a "trade-off" for optimal stent implantation: an intravascular ultrasound study.

OBJECTIVES: We sought to determine the impact of aggressive stent expansion on creatine kinase-MB isoenzyme (CK-MB) release and clinical restenosis. BACKGROUND: Elevation of CK-MB after percutaneous coronary interventions has been associated with late mortality. METHODS: We identified 989 consecutive patients who underwent intravascular ultrasound-guided stenting of 1,015 coronary lesions. Patients were divided into three groups according to stent expansion, defined as the ratio of final lumen over the reference lumen cross-sectional areas: Group 1 (ratio <70%, n = 117 patients with 126 lesions); Group 2 (ratio 70% to 100%, n = 551 patients with 562 lesions); Group 3 (ratio >100%, n = 321 patients with 327 lesions). RESULTS: The peak CK-MB values increased significantly with increasing stent expansion: CK-MB = 3 to 5x normal occurred 16%, 18%, and 25% in Groups 1, 2, and 3, respectively, p = 0.02; CK-MB >5 times normal occurred 9%, 13%, and 16% respectively, p = 0.02. Conversely, at one year follow-up there was a stepwise decrease in target lesion revascularization (11% vs. 19% and 17%, respectively, p = 0.04) and major adverse cardiac events with increasing stent expansion. In addition, there was a trend toward lower mortality in Group 3 (9% vs. 4.4% vs. 4.0%, p = 0.07). CONCLUSIONS: Intravascular ultrasound-guided stent overexpansion (final lumen greater than reference lumen cross-sectional area) is accompanied by a higher periprocedural CK-MB release but a lower target lesion revascularization and a trend toward lower mortality at one year. Increased periprocedural CK-MB release appears as a trade-off for optimal stent implantation and lower clinical restenosis.

Cineangiography↗