| Part1Baseline coronary intermediate stenosis and acute myocardial infarctionObjective Uncoupling of angiographic coronary stenosis and rupture of a thin-cap fibroatheroma were widely recognized as underlying mechanism of acute myocardial infarction (MI). Previous studies have also demonstrated that acute coronary syndromes predominantly occurred at the site of lesions previously considered insignificant (diameter stenosis<50%) on initial coronary angiography. Currently, relatively little data has been reported the angiographic coronary lesion characteristics a few months or days before MI. We want to evaluate the angiographic stenosis of coronary lesions responsible for acute MI with a focus on determining the impact of intervals from initial angiogram to subsequent clinical event.Methods From2007through2011, we identified104patients with MI and with previous angiogram at our center. Angiograms were reanalyzed with quantitative coronary angiography, and relevant clinical data were obtained from medical records. The patients were divided into three groups based on initial coronary stenosis, group below50%, between50-70%and above70%. The coronary lesion characteristics and time intervals were analyzed. We also analyzed the12months outcomes of the study patients after MI.Results Main clinical characteristics of the3groups of patients were similar, except for more patients in group between50-70%experienced percutaneous coronary intervention (82.5%, P=0.009). Underlying diameter stenosis was significantly larger and minimal lumen diameter was significantly smaller in group above70%. Interestingly, underlying diameter stenosis that led to MI<12months after evaluation were more severe than those in>12months (P=0.002). Baseline lesions in patients with time interval (between baseline angiogram and MI) less than12months presented with more severe stenosis (66.43±23.80vs.50.79±22.38%, P=0.002) and smaller minimal lumen diameter (1.28±0.89vs.1.96±0.77mm, P<0.001), compared with those in patients (76patients) with time interval more than12months. Baseline lesion diameter stenosis was negative correlated with time interval between baseline angiogram and MI (r=-0.421, R2=0.177, P<0.001). However, baseline lesion diameter stenosis progression was positive correlated with time interval between baseline angiogram and MI (r=0.467, R2=0.218, P<0.001). There were no significant differences among groups in the incidence of death, target vessel revascularization (TLR), MI, and total major adverse cardiac events (MACE). Multivariate logistic regression analysis showed that diabetes mellitus was the only independent predictor of TLR (OR=12.547,95%CI:3.538-44.491, P<0.001) and MACE (OR=7.016,95%CI:2.514-19.579, P<0.001).Conclusions The progression of mild and intermediate coronary lesions may be another mechanism of acute MI. Myocardial infarctions were more prone to occur at severe coronary lesions, compared with intermediate coronary lesions. However, there were no significant differences among groups in the incidence of death, TLR, MI, and total MACE, and diabetes mellitus was the only independent predictor of TLR and MACE in patients with MI. Randomized comparison of drug-eluting stents versus optimal medical therapy for treatment of intermediate coronary stenosis examined by intravenous ultrasoundObjective Although intermediate coronary lesions are usually not considered severe enough and deferred for percutaneous coronary interventions (PCI), studies have demonstrated the association between mild or intermediate coronary plaques rupture or erosion and potential risk of acute cardiac events. The intermediate atherosclerotic lesions may progress abruptly or keep stable, resulting in therapeutic dilemmas for cardiologists. Currently, optimal management of coronary intermediate lesions still remains unknown and challenging.Methods From January2007to May2009,97patients with intermediate coronary lesions were enrolled in the trial;47were randomly assigned percutaneous coronary interventions with drug-eluting stents (DES) and50medical treatment. The specific entry criteria for the trial were as follows.(1)>18years old and with stable or unstable angina;(2) diameter stenosis of de novo intermediate lesion was from50to70percent by visual;(3) target artery diameter≥2.25mm and<4.0mm;(4) minimal lumen cross-sectional area is≥3.8mm2but≤4.8mm2detected by IVUS. The primary end point was a composite of all-cause death, myocardial infarction and target vessel revascularization (TVR) at3years.Results At3years follow up, TVR was required in2(4.2%) patients treated with DES as compared with6(12%) patients treated with medications (P=0.270). No patients died in the2groups during the follow up time. One (2%) patient in the medication group experienced MI compared with no patients treated with PCI (P=1.000). One patient in the PCI group presented with severe heart failure and accepted with cardiac re synchronization therapy. In terms of overall major adverse cardiovascular events, there was no difference in the composite of death, myocardial infarction and target vessel revascularization (4.2%vs.12%, P=0.270). However, compared with medication group, the recurrent angina rate was much lower in the PCI group (21.3%vs.54%, P=0.001).Conclusions Compared with optimal medical treatments, DES in patients with intermediate coronary lesions and minimal lumen cross sectional area≥3.8mm2but≤4.8mm2appeared safe and results in a non-significant reduction in clinical outcomes. Intermediate lesions in non-culprit coronary arteries prone to progression and revascularizations:risk factors and therapy strategiesObjective Intermediate lesions in non-culprit coronary arteries, defined as≥50%but <70%diameter stenosis by visual estimation, are not uncommon in catheter-based clinical practice, particularly during culprit-lesion stenting, attesting to the diffusion of coronary atherosclerotic nature process. Effective early identification of which patient with intermediate lesions in non-culprit coronary arteries will be a candidate for revascularization over time is of paramount importance, providing the opportunity to implement therapy and prevention strategies.Methods From Fuwai Hospital catheterization laboratory database,1917consecutive patients treated with coronary stents and had at least one intermediate lesions in non-culprit coronary arteries between August2008and March2010were screened. The culprit lesions stents treated were clearly identified by a combination of examinations. Patients were considered eligible if an intermediate lesion located in an artery other than the infarct or symptom related artery. Patients with the presence of an intermediate lesion and previous angioplasty in the same vessel were excluded.Results The study population comprised of465patients (519lesions) with intermediate lesions in non-culprit coronary arteries who underwent culprit-lesion coronary stents implantation on initial admission and angiographic follow-up ((11.02±5.84) months). According to whether intermediate lesion received a necessary revascularization or not during the follow-up, the patients were classified into Revascularization group (1621esions in156patients) and No revascularization group (337lesions in309patients). Risk factors for revascularization of intermediate lesions in non-culprit coronary arteries were assessed. Baseline clinical characteristics were comparable between groups, except for patients in Revascularization group had more type2diabetes and MI history. Multivariate analysis of the risk factors of revascularization of intermediate lesions in non-culprit coronary arteries showed that type2diabetes (OR=1.616,95%CI:1.058-2.470, P=0.026), without using statins (OR-3.355,95%CI:1.455-7.740, P=0.005), complex lesions (OR=2.743,95%CI:1.805-4.168, P<0.001), and proximal lesions (OR=1.635,95%CI:1.056-2.533,P=0.028) were independent predictors.Conclusions These four risk factors should be included into therapy and prevention strategies in patients with intermediate lesions in non-culprit coronary arteries. |
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