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1.  Percutaneous coronary intervention strategies and prognosis for graft lesions following coronary artery bypass grafting 
The purpose of this study was to compare the prognosis of graft-percutaneous coronary intervention (PCI) and native vessel (NV)-PCI, drug-eluting stents (DESs) and bare-metal stents (BMSs) for the treatment of graft lesions following coronary artery bypass grafting (CABG), and to determine the risk factors for major adverse cardiac events (MACEs). A total of 289 patients who underwent PCI following CABG between August 2005 and March 2010 were retrospectively analyzed. The effects on survival were compared among patients who underwent NV- and graft-PCI, and DES and BMS implantation. Additionally, the risk factors for MACEs following PCI for graft lesions were analyzed. The findings showed that MACE-free and revascularization-free survival rates were significantly higher in the NV-PCI group compared with those in the graft-PCI group. There were 63 cases (29.0%) of MACEs in the DES group and 25 cases (52.1%) in the BMS group. In patients undergoing NV-PCI, the DES group had significantly fewer MACEs and less target vessel revascularization (TVR) than the BMS group. In patients undergoing graft-PCI, the DES group showed a tendency for fewer MACEs and a lower incidence of cardiac mortality, myocardial infarction and TVR compared with the BMS group. Diabetes, an age of >70 years and graft-PCI were independent risk factors for MACEs in patients post-PCI. It is concluded that NV-PCI has superior long-term outcomes compared with graft-PCI, and should therefore be considered as the first-line treatment for graft disease following CABG. Despite this, graft-PCI remains a viable option. DESs are the first choice for graft-PCI due to their safety and efficacy and their association with reduced mortality and MACE rate. Diabetes, older age and graft-PCI are independent risk factors for MACEs in patients post-CABG who are undergoing revascularization.
PMCID: PMC4471697  PMID: 26136874
coronary artery bypass grafting; percutaneous coronary intervention; multivariate risk factors; prognosis; follow-up
2.  Diagnostic Accuracy of Post Procedural Creatine Kinase, MB Form can Predict Long-Term Outcomes in Patients Undergoing Selective Percutaneous Coronary Intervention? 
Measuring cardiac markers in blood has been the main strategy for the diagnosis of acute myocardial infarction for nearly 50 years. Creatine kinase-MB (CK-MB) has been demonstrated to be a highly specific marker.
The present study aimed to assess the role of CK-MB changes following percutaneous coronary intervention (PCI) to predict one year outcomes of this procedure.
Patients and Methods:
This cohort study was conducted on 138 patients diagnosed with coronary artery disease who underwent PCI. Sixty-nine patients who had a CK-MB elevation ≥ 3 times upper limit of normal (ULN) post procedurally were considered as group I and 69 patients without cardiac enzyme rise after PCI were considered as the control group (group II). The composite end point of major adverse cardiac events (MACE) during one year was assessed by telephone follow-up or presentation at clinical visiting, and compared between the two groups. The MACE was defined as the appearance of at least one of the following events: mortality, repeated revascularization procedures, myocardial infarction, or cerebrovascular events.
Although one year mortality in the group I was 4 (5.8%), about two times greater than the other group 2 (2.9%), the difference was not significantly discrepant (P = 0.57). Moreover, 8 (11.6%) of patients in group I experienced one year MACE, while this rate in the other group was 4 (5.8%), with insignificant difference (P = 0.22). In group I, one case experienced coronary artery bypass surgery, one, exhibited cerebrovascular disease and one reported ST segment elevation myocardial infarction (STEMI), while two patients in the other group were suspicious of having non-ST segment elevation myocardial infarction (NSTEMI) and candidates for repeated PCI. Multivariate analysis revealed that increased post-procedural CK-MB ≥ 3 times UNL could not predict long-term MACE in patients who underwent selective PCI. Area under the curve (AUC) for predicting one year MACE was 0.593 (95% CI: 0.397 - 0.788), indicating inappropriate accuracy for this biomarker (P = 0.290).
It seems that CK-MB ≥ 3 times ULN within 24 hours after PCI cannot independently predict one year MACE in patients undergoing PCI.
PMCID: PMC4253746  PMID: 25478525
Creatine Kinase, MB Form; Angioplasty, Balloon, Coronary; Myocardial Infarction
3.  Immediate Results and Six-Month Clinical Outcome after Percutaneous Coronary Intervention in Patients with Prior Coronary Artery Bypass Surgery 
Redo coronary artery bypass grafting surgery (CABG) is associated with a higher risk of mortality than the first operation. However, the impact of percutaneous coronary intervention (PCI) on the outcome in such patients is currently unclear. We evaluated the in-hospital and six-month clinical outcomes of post-CABG patients who underwent PCI in our center.
Between April 2008 and July 2009, 71 post-CABG patients (16 women and 55 men) underwent 110 stent implantations (74% drug-eluting stents) for 89 lesions. Sixty percent of the PCI procedures were performed on the native coronary arteries, 32% on graft arteries, and 8% on both types of vessels. Major adverse cardiac events (MACE) were recorded in hospital and at six months’ follow-up.
The procedural success rate was 93%, and the in-hospital MACE rate was 5.6 % (1 death, 3 myocardial infarctions). At 6 months, the incidence of MACE was 5.6% (no death or myocardial infarction, but 4 target lesion revascularizations) and 4 (5.6 %) in-stent restenoses. There was no statistically significant difference in the comparison of MACE between the patients treated in either native arteries or in the grafts (15% vs.12%, p value = 0.8). According to the univariate analysis, hypertension and the use of the bare metal stent vs. the drug-eluting stent were the significant predictors of MACE, whereas the multivariate analysis showed that only hypertension (OR = 3.7, 95% CI 3.4–4, p value < 0.048) was the independent predictor of MACE. The mean of the left ventricular ejection fraction had no effect on the incidence of MACE (p value = 0.9). The multivariate analysis showed hypertension (p value < 0.048) and the use of the bare metal stent (p value < 0.018) were the independent predictors of MACE. The chronic total occlusion (CTO) (p value < 0.01) was the independent predictor of the success rate. The prevalence of diabetes had no impact on the incidence of MACE according to the univariate analysis (p value = 0.9). Our multivariate analysis showed that hypertension and the use of the bare metal stent were the independent predictors of MACE and that chronic total occlusion was the independent predictor of the procedural failure rate.
PCI is preferable to redo CABG for post-CABG patients. The independent predictors of MACE were hypertension and bare metal stents.
PMCID: PMC3466866  PMID: 23074602
Angioplasty; Coronary artery bypass; Treatment outcome; Reoperation
4.  Neutrophil to Lymphocyte Ratio Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention 
Korean Circulation Journal  2013;43(2):93-99.
Background and Objectives
A higher neutrophil to lymphocyte ratio (NLR) has been associated with poor clinical outcomes in various cardiac diseases. However, the clinical availability of NLR in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not been known. We evaluated the availability of NLR to predict clinical outcomes in patients with STEMI undergoing primary PCI.
Subjects and Methods
We analyzed 326 consecutive STEMI patients treated with primary PCI. The patients were divided into tertiles according to NLR: NLR≤3.30 (n=108), 3.316.53 (n=110). We evaluated the incidence of major adverse cardiac events (MACE), a composite of all causes of death, non-fatal MI, and ischemic stroke at the 12-month follow-up.
The high NLR group was associated with a significantly higher rate of 12-month MACE (19.1% vs. 3.7%, p<0.001), 12-month death (18.2% vs. 2.8%, p<0.001), in-hospital MACE (12.7% vs. 2.8%, p=0.010) and in-hospital death (12.7% vs. 1.9%, p=0.003) compared to the low NLR group. In the multivariable model, high NLR was an independent predictor of 12-month MACE {hazard ratio (HR) 3.33 (1.09-10.16), p=0.035} and death {HR 4.10 (1.17-14.46), p=0.028} after adjustment for gender, left ventricular ejection fraction, creatinine clearance, angiographic parameters and factors included in the Thrombolysis in Myocardial Infarction risk score for STEMI. There was a significant gradient of 12-month MACE across the NLR tertiles with a markedly increased MACE hazard in the high NLR group (log rank test p=0.002).
The NLR is a useful marker to predict 12-month MACE and death in patients with STEMI who have undergone primary PCI.
PMCID: PMC3596670  PMID: 23508782
Neutrophils; Lymphocytes; Myocardial infarction
5.  Development and validation of a Bayesian index for predicting major adverse cardiac events with percutaneous transluminal coronary angioplasty 
Heart  2001;85(1):69-72.
OBJECTIVE—To create a risk model for predicting major adverse complicating events of percutaneous transluminal coronary angioplasty (PTCA), and to test the accuracy of the model on a prospective cohort of patients
SETTING—Tertiary cardiac centre
METHODS—Available software can predict probabilities of events using Bayes's theorem. To establish the accuracy of these predictive tools, a Bayes table was created to evaluate major adverse complicating events (MACE)—death, emergency coronary artery bypass grafting (CABG), or Q wave infarct occurring during the in-patient episode—on the first 1500 patients in the department PTCA database (development group); the predictive value of this model was then tested with the subsequent 1000 patients (evaluation group). The following probabilities were assessed to determine their association with MACE: age, sex, left ventricular function, American Heart Association lesion morphology classification, cardiogenic shock, previous CABG, diabetes, hypertension, multivessel PTCA.
MAIN OUTCOME MEASURES—To establish the discriminatory ability of the predictive index, calibration plots and receiver operating characteristic (ROC) curves were obtained to compare the development and evaluation groups.
RESULTS—The ROC curve plotted to determine the discriminatory value of the Bayesian table created from the development group (n = 1500) in predicting MACE in the evaluation group (n = 1000) showed a moderately predictive area under the curve of 0.76 (SEM 0.07). This predictive accuracy was confirmed with separately constructed calibration plots.
CONCLUSIONS—Accurate predictions of MACE can be identified in populations undergoing percutaneous intervention. The database used allows operators to obtain consent from patients appropriately from their own experience rather than from other published data. If a national PTCA database existed along similar lines, individual operators and interventional centres could compare themselves with nationally available data.

Keywords: percutaneous transluminal coronary angioplasty; Bayesian risk; outcome prediction
PMCID: PMC1729571  PMID: 11119467
6.  Mean Platelet Volume as a Predictor of One-Year Major Adverse Cardiac Events following Elective Percutaneous Coronary Interventions 
Mean platelet volume (MPV) correlates with platelet activity. The relation between MPV and long-term outcome in patients undergoing percutaneous coronary intervention (PCI) has been investigated in several studies. The aim of the present study was to investigate the utility of MPV in prognosticating the long-term outcome after elective PCI.
The study cohort included 2627 patients undergoing elective PCI between September 2008 and June 2010, whose baseline MPV measurements before PCI were available. The patients were divided into three groups of MPV < 9.1 fL, MPV = 9.1 to 10 fL, and MPV > 10 fL, and they were assessed for developing major adverse cardiac events (MACE), comprising death, myocardial infarction (MI), target vessel revascularization (TVR), and target lesion revascularization (TLR) over a one-year follow-up.
Of 2539 patients, major adverse cardiac events (MACE) at one year occurred in 77 (3.0%) patients, including mortality in 26 (1.0%). The patients in the highest tertile (MPV > 10 fL) had no increased frequency of MACE compared to those in the mid (9.1 to 10 fL) and lowest (< 9.1 fL) tertiles (3.3%, 2.2%, and 3.8%, respectively; p value = 0.14).
No significant differences were found for each of the primary endpoints among the MPV tertiles. In multivariate logistic regression, we investigated the association between high MPV and total MACE (OR = 1.10, 95%CI: 0.69–1.77; p value = 0.68), death (OR = 1.14, 95%CI: 0.51–2.54; p value = 0.74), and non-fatal MI (OR = 1.85, 95%CI: 0.73–4.67; p value = 0.19) at one year's follow-up but MPV did not remain in the model in any of the cases.
In the diabetic patients, the one-way analysis of variance demonstrated that mortality was 1.6% (4 patients) in the highest tertile, 0.8% (2 patients) in the mid tertile, and 0.5% (one patient) in the lowest tertile.
There was no direct correlation between pre-procedural MPV and MACE in elective PCI. MPV can only be considered as an appropriate factor for predicting mortality in diabetic patients undergoing elective PCI.
PMCID: PMC4389194  PMID: 25861321
Coronary artery disease; Angioplasty; Mean platelet volume; Treatment outcome
7.  Early and Midterm Major Adverse Cardiac Events in Patient With Saphenous Vein Graft Using Direct Stenting or Embolic Protection Device Stenting 
The treatment of an occluded saphenous vein graft (SVG) with percutaneous coronary intervention may encounter major adverse cardiac events (MACE). MACE rates have been reduced significantly by using the embolic protection device (EPD).
The aim of this study was to clarify the risks and the benefits of embolic protection devices.
Patients and Methods:
In a prospective, non-randomized observational study, patients aged 33 to 85 years old who underwent elective percutaneous coronary intervention due to SVG stenosis at our tertiary care center were enrolled between 2009 and 2011. The incidence rates of adverse events, including MACE, were obtained during the patients’ hospitalization and at 30-day and 6-month follow-up. MACE included death, Q-wave and non-Q-wave myocardial infarction, in-stent thrombosis, target lesion revascularization, and target vessel revascularization.
From 150 patients enrolled to the study, 128 (85.3%) patients underwent direct stenting and the rest underwent the EPD procedure. In-hospital MACE occurred in 17.2% of the patients in the direct stenting group versus only 9.1% in the EPD group (P = 0.530). MACE incidence was gradually increased at one and 6-month follow-up periods in the direct stenting group (19.5% and 21.9%, respectively), and remained unchanged in the EPD group (9.1% at six-month follow-up). Multivariate logistic regression model showed that the stenting procedure type could not predict early and midterm MACE with the presence of baseline characteristics as cofounders.
Despite the considerable lower early and midterm MACE rates, numerically following the EPD procedure compared to direct stenting, the difference in the MACE rates between the two groups was not significant.
PMCID: PMC4253743  PMID: 25478526
Lesion; Blood Vessels; Saphenous Vein; Transplants; Embolic Protection Devices; Coronary Artery Bypass
8.  Percutaneous Coronary Intervention to Treat Chronic Total Occlusion: Predictors of Technical Success and One-Year Clinical Outcome 
Texas Heart Institute Journal  2014;41(1):40-47.
We investigated the overall success rate of percutaneous coronary intervention (PCI) as a treatment for coronary chronic total occlusion and sought to determine the predictive factors of technical success and of one-year major adverse cardiac events (MACE). These factors have not been conclusively defined.
Using data from our single-center PCI registry, we enrolled 269 consecutive patients (mean age, 56.13 ± 10.72 yr; 66.2% men) who underwent first-time PCI for chronic total occlusion (duration, ≥3 mo) from March 2006 through September 2010. We divided them into 2 groups: procedural success and procedural failure. We compared occurrences of in-hospital sequelae and one-year MACE between the groups, using multivariate models to determine predictors of technical failure and one-year clinical outcome.
Successful revascularization was achieved in 221 patients (82.2%). One-year MACE occurred in 13 patients (4.8%), with a predominance of target-vessel revascularization (3.7%). The prevalence of MACE was significantly lower in the procedural-success group (1.8% vs 18.8%; P <0.001). In the multivariate model, technical failure was the only predictor of one-year MACE. The predictors of failed procedures were lesion location, multivessel disease, the occurrence of dissection, a Thrombolysis In Myocardial Infarction flow grade of 0 before PCI, the absence of tapered-stump arterial structure, and an increase in serum creatinine level or lesion length.
In our retrospective, observational study, PCI was successful in a high percentage of chronic total occlusion patients and had a low prevalence of complications. This suggests its safety and effectiveness as a therapeutic option.
PMCID: PMC3967487  PMID: 24512398
Angioplasty, balloon, coronary/methods; chronic disease/therapy; coronary occlusion/therapy; disease-free survival; heart diseases/prevention & control; multivariate analysis; myocardial revascularization; patient selection; retrospective studies; treatment outcome
9.  Long term outcomes of saphaneous vein graft intervention in elderly patients with prior coronary artery bypass graft 
To investigate the procedure characteristics and long term follow-up of percutaneous coronary intervention (PCI) for saphaneous vein graft (SVG) lesions in the elderly patients.
From December 2005 to December 2011, 84 graft lesions were treated percutaneously. Seventeen were located at proximal anastomosis, 48 were located at SVG body, 19 were located at distal anastomosis. Primary endpoint was defined as major adverse cardiovascular events (MACE, composite of cardiac death, target vessel revascularization, acute myocardial infarction).
The graft age was 6.7 ± 4.0 years. Most anastomosis lesions (80.0%) presented within one year post coronary artery bypass grafting (CABG). Proximal anastomosis lesion had the lowest successful rate for PCI compared with graft body and distal anastomosis lesions (70.6% vs. 91.7%, 79.0%, P < 0.05). The distal embolic protection device was used in 19.1% of patients, most frequently used in body graft PCI (29.2%, P < 0.01). The diameter of the stent was smallest in distal anastomosis group (2.9 ± 0.4 mm, P < 0.05). The highest post dilatation pressure was required in the proximal anastomosis (17.8 ± 2.7 atm, P < 0.05). The patients were followed up for 24.3 ± 16.9 months. MACE occurred in 18.57% of patients. Incidence of MACE was highest among proximal anastomosis PCI (47.1% vs. body graft PCI 16.7%, distal anastomosis PCI 21.1%; P < 0.05). Old myocardial infarction was the predictive factor for the poor clinical outcomes (P = 0.04).
PCI of SVG lesions is feasible with lower success rate. PCI of ostial graft anastomosis lesions had the lowest procedure success rate and highest MACE rate compared with graft body and distal anastomosis lesions. Old myocardial infarction was a predictive factor of poor outcomes.
PMCID: PMC3981980  PMID: 24748878
Graft; Anastomosis; Percutaneous coronary intervention; Coronary artery bypass grafting
10.  Contemporary outcomes in vascular patients who require pre-operative coronary stent 
Annals of vascular surgery  2013;27(5):646-654.
The documented risks of pre-operative coronary revascularization prior to vascular surgery have led to a marked reduction in the role of percutaneous coronary intervention (PCI) during pre-operative risk stratification. However, many patients with peripheral arterial disease are first identified immediately after a PCI for an acute coronary syndrome. We sought to determine the risks associated with these patients who then go on to have a peripheral arterial intervention (open operation or endovascular procedure). We hypothesized that there was no difference in outcomes in patients whose medical condition required PCI with coronary stent placement prior to a vascular operation compared to a control cohort of non-stented patients who underwent a vascular operation alone. We report the vascular operative outcomes in a contemporary cohort of vascular patients who had PCI with coronary stent placement for an acute event.
We performed a retrospective cohort analysis utilizing administrative data, of 3,678 vascular patients from 2005 to 2010 at a tertiary care hospital. Two groups were defined: patients with preoperative PCI and coronary stent placement within one year prior to vascular operation (N=101, mean age 66±1.22 years, 51.5% male) and patients with no PCI prior to vascular operation (N=3,577, mean age 60±.27 years, 46.37% male). Cardiovascular risk factors and complications derived from ICD-9 codes were used to parse data following open peripheral vascular surgery, endovascular repair, or amputation. Primary outcomes were death, non-fatal myocardial infarction, major adverse cardiac event (MACE, defined as death, MI or subsequent coronary revascularization) or bleeding.
Univariate analysis showed significant differences in both demographic and outcome analysis in patients with and without prior coronary stent. Patients with a recent PCI followed by a vascular procedure were more likely to undergo an endovascular procedure (75.3% vs 64.5%, OR = 1.67, p = 0.028). These patients also had 11 of 20 cardiovascular risk factors significantly greater than those without a prior PCI. Multivariate sub-group analysis indicated that patients with a prior coronary stent were more likely to have an episode of congestive heart failure (CHF) after 1 year of surgery (16.8%, p= 0.045). Additionally, an acute cardiac ischemic event was more likely within 1 year (2.0%, p= 0.036) and beyond 1 year (4.0%, p= 0.022) of surgery. Importantly, there was no significant increase in death, MI, MACE, or bleeding in patients with pre-operative coronary stent.
Patients who underwent PCI with coronary stent and then went on to require a vascular procedure had significantly more CV risk factors and were more likely to have an endovascular procedure than those patients without preoperative PCI. When controlling for CV risk factors and procedure type, there was no significant difference in death, MI, MACE or bleeding complications between the groups.
PMCID: PMC3700602  PMID: 23541775
11.  Fractional flow reserve versus angiography for guiding percutaneous coronary intervention: a meta-analysis 
Heart  2015;101(6):455-462.
The purpose of this study was to investigate whether fractional flow reserve (FFR) should be performed for patients with coronary artery disease (CAD) to guide the percutaneous coronary intervention (PCI) strategy.
PCI is the most effective method to improve the outcomes of CAD. However, the proper usage of PCI has not been achieved in clinical practice.
A meta-analysis was performed on angiography-guided PCI and FFR-guided PCI strategies. Prospective and retrospective studies were included when research subjects were patients with CAD undergoing PCI. The primary endpoint was the rate of major adverse cardiac events (MACE) or major adverse cardiac and cerebrovascular events (MACCE). Secondary endpoints included death, myocardial infarction (MI), repeat revascularisation and death or MI.
Four prospective and three retrospective studies involving 49 517 patients were included. Absolute risks of MACE/MACCE, death, MI, revascularisation and death or MI for angiography-guided PCI and FFR-guided PCI were 34.8% vs 22.5%, 15.3% vs 7.6%, 8.1% vs 4.2%, 20.4% vs 14.8%, and 21.9% vs 11.8%, respectively. The meta-analysis demonstrated that FFR-guided PCI was associated with lower MACE/MACCE (OR: 1.71, 95% CI 1.31 to 2.23), death (OR: 1.64, 95% CI 1.37 to 1.96), MI (OR: 2.05, 95% CI 1.61 to 2.60), repeat revascularisation (OR: 1.25, 95% CI 1.09 to 1.44), and death or MI (OR: 1.84, 95% CI 1.58 to 2.15) than angiography-guided PCI strategy.
This meta-analysis supports current guidelines advising the FFR-guided PCI strategy for CAD. PCI should only be performed when haemodynamic significance is found.
PMCID: PMC4413679  PMID: 25637372
12.  The SYNTAX Score Can Predict Major Adverse Cardiac Events Following Percutaneous Coronary Intervention 
The SYNTAX score is a grading system that evaluates the complexity and prognosis of patients undergoing percutaneous coronary intervention (PCI). We investigated the association between the incidence of major adverse cardiac events (MACE) following PCI and the SYNTAX score in patients with three-vessel disease.
We consecutively enrolled 381 patients with three-vessel disease undergoing PCI and stenting. The SYNTAX score was divided into tertiles as low (≤16), intermediate (16-22) and high (>22). The endpoint was the incidence of MACE defined as cardiac death, in-hospital mortality, nonfatal myocardial infarction (MI), or target vessel revascularization. Then, the incidence of MACE was compared among the SYNTAX score tertile groups.
The median follow-up was 14 months, and the rate of MACE was 12.6%. The rates of MACE were 7.5%, 9.9%, and 21.6% in patients with low, intermediate, and high SYNTAX score tertiles, respectively. Higher SYNTAX scores significantly predicted a higher risk of MACE (hazard ratio = 2.36; P = 0.02) even after adjustment for potential confounders. The main predictors of MACE were SYNTAX score, advanced age, hyperlipidemia, presentation as recent ST-elevation MI, number of total lesions, and history of renal failure.
The SYNTAX score could predict major cardiac outcomes following PCI in patients with three-vessel disease.
PMCID: PMC4348991  PMID: 25774251
Coronary artery disease; major adverse cardiac events; mortality; percutaneous coronary intervention; SYNTAX score
13.  Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients with Coronary Artery Disease and Diabetic Nephropathy: A Single Center Experience 
Patients with diabetic nephropathy (DN) and coronary artery disease (CAD) represent a subset of patients with high cardiovascular morbidity and mortality. The optimal revascularization strategy using either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) remains controversial. The purpose of this study was to compare the clinical outcomes of PCI to CABG in DN patients with CAD.
The clinical and angiographic records of DN patients with CAD who underwent either CABG (n=52) or PCI (n=48) were retrospectively analyzed.
The baseline characteristics were similar in the two groups except for the severity of the CAD. At 30 days, the death rate (PCI: 2.1% vs. CABG: 9.6%, p=0.21) and major adverse cardiac events (MACE) rate (PCI: 2.1% vs. CABG: 9.6%, p=0.21) were similar in comparisons between the PCI and CABG groups. At three years, the death rate (PCI: 18.8% vs. CABG: 19.2%, p=0.94) was similar between the PCI and CABG groups but the MACE rate (PCI: 47.9% vs. CABG: 21.2%, p=0.006) was higher in the PCI group compared to the CABG group. In addition, the repeat revascularization rate was higher in the PCI group compared to the CABG group (PCI: 12.5% vs. CABG: 1.9%, p=0.046).
The CABG procedure was associated with a lower incidence of MACE and repeat revascularization for up to three years of follow-up in DN patients with CAD. However, the overall survival rate was similar in the CABG and PCI groups. Therefore, CABG may be superior to PCI with regard to MACE and repeat revascularization.
PMCID: PMC2687692  PMID: 17939329
Diabetic Nephropathy; Coronary Artery Disease; Coronary Artery Bypass Grafting; Percutaneous Transluminal Coronary Angioplasty
14.  A novel predictor of infarct-related artery patency before percutaneous intervention and in-hospital outcomes for ST-segment elevation myocardial infarction patients: serum bilirubin level 
Previous studies have reported a relationship between serum bilirubin levels and coronary artery disease (CAD). However, data are rare up to now regarding the relation of bilirubin levels with infarct-related artery (IRA) patency in the setting of ST-segment elevation myocardial infarction (STEMI). Moreover, previous studies reported that increased bilirubin was related to impaired post-intervention coronary flow. To our knowledge, the association between serum total bilirubin (TB) levels and pre-primary percutaneous coronary intervention (PCI) with patency of IRA flow in STEMI patients has not been investigated.
To evaluate the association of TB with pre-primary PCI, coronary flow and in-hospital major adverse cardiac events (MACE) in patients with STEMI.
Material and methods
A total of 360 consecutive patients with STEMI (mean age = 61.4 ±13.7 years) admitted within 12 h from the time of symptom onset were enrolled. Patients were divided into 2 groups based on the serum TB levels. We defined normal flow as pre-PCI TIMI 3 flow, while impaired flow was defined as pre-PCI TIMI ≤ 2 flow.
Pre-PCI impaired flow was higher in the TB group than pre-PCI normal flow (p < 0.001). In-hospital mortality and MACE were significantly higher in the high TB group (p = 0.002, p < 0.001 respectively). In the receiver operating characteristic curve analysis, TB > 0.825 mg/dl predicted impaired IRA flow before p-PCI with a sensitivity of 79% and specificity of 71%.
The TB is an inexpensive and readily available marker for STEMI patients undergoing PCI. It can be used for risk stratification in this patient population.
PMCID: PMC4108732  PMID: 25061454
bilirubin; percutaneous coronary intervention; novel predictor
15.  Clinical Significance of On-Treatment Triglyceride Level in Patients Treated by Percutaneous Coronary Intervention for Non-ST-Segment Elevation Acute Coronary Syndrome 
The use of statins in patients with acute coronary syndrome (ACS) has increased, and reduced levels of low-density lipoprotein cholesterol (LDL-C) lead to lower coronary event rates. We studied the effect of lipid levels during statin treatment on prognosis in patients with ACS and percutaneous coronary intervention (PCI).
Between January 2005 and May 2007, 325 ACS patients who underwent PCI and received statins were evaluated. We measured serum lipid levels at baseline and 4 weeks. The relationships between on-treatment levels of triglyceride (TG) and LDL-C and one-year major adverse cardiac events (MACE) were assessed.
At 4 weeks, the mean LDL-C level was 72.5±23.8 mg/dL and the mean TG was 123.2±62.8 mg/dL. MACE occurred in 41 cases (12.6%). Baseline serum lipid levels were similar between the patients with and those without MACE. However, the patients with MACE showed significantly higher TG level at 4 weeks (149.6±81.4 vs. 119.3±58.9 mg/dL, p=0.026) than those without. High on-treatment TG level (≥150 mg/dL) were associated with increased adverse events compared to lower TG level in a univariate analysis (hazard ratio [HR], 3.3; p<0.001). In a multivariate analysis, high 4-week TG level after statin treatment was an independent predictor for MACE (HR, 4.01; 95% confidence interval, 1.85 to 9.06; p=0.001), however, baseline TG and LDL-C levels were not.
High on-treatment TG level (≥150 mg/dL) was associated with a higher risk of MACE. This finding supports the concept that achieving low TG levels may be an important therapeutic parameter in statin-treated patients following ACS and PCI.
PMCID: PMC2784976  PMID: 19949731
Lipids; Triglycerides; Acute coronary syndrome; Hydroxymethylglutaryl-CoA reductase inhibitor
16.  Impact of SYNTAX score on 1-year clinical outcomes in patients undergoing percutaneous coronary intervention for unprotected left main coronary artery 
SYNTAX score is an angiographic scoring system that was developed to quantify the number, complexity, and location of lesions in patients undergoing coronary revascularization. Up to now, the impact of SYNTAX score on clinical outcomes in patients undergoing percutaneous coronary intervention (PCI) for unprotected left main coronary artery (LMCA) lesions has not been fully examined. Therefore, we evaluate the usefulness of the SYNTAX score and identify the cutoff value of this score to predict 1-year clinical outcomes in patients undergoing PCI for unprotected LMCA lesions. This was a single-center retrospective study that included 49 consecutive patients undergoing elective PCI for unprotected LMCA lesions. We calculated the SYNTAX score and examined the correlations between this score and 1-year clinical outcomes. Major adverse cardiac events (MACE) occurred in 12 patients (24%): target lesion revascularization in 9 patients (18%), myocardial infarction in 2 (4%), and cardiac death in 1 (2%). The frequency of MACE was significantly higher in the intermediate (47%) or high score group (50%) than in the low score group (4%). Furthermore, the SYNTAX score was significantly higher in the MACE group than in the non-MACE group (31 vs. 22, p = 0.008). Receiver-operating characteristic curve showed that the SYNTAX score exhibited 83% sensitivity and 76% specificity for predicting the development of MACE at a cutoff value 26. These results demonstrate that the SYNTAX score could be a useful tool to predict 1-year clinical outcomes in patients undergoing elective PCI for unprotected LMCA lesions.
PMCID: PMC3427976  PMID: 22937491
Coronary artery disease; left main coronary artery; percutaneous coronary intervention; SYNTAX score
17.  Usefulness of Hyperemic Microvascular Resistance Index as a Predictor of Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction 
Korean Circulation Journal  2015;45(3):194-201.
Background and Objectives
Microvascular function is a useful predictor of left ventricular functional changes in patients with ST-segment elevation myocardial infarction (STEMI). We evaluated the usefulness of the hyperemic microvascular resistance index (hMVRI) for predicting long-term major adverse cardiovascular events (MACEs) in patients with STEMI assessed immediately after primary percutaneous coronary intervention (PCI).
Subjects and Methods
hMVRI were evaluated in 145 patients with first acute STEMI treated with primary PCI using an intracoronary Doppler wire. hMVRI was defined as the ratio of mean aortic pressure over hyperemic averaged peak velocity of infarct-related artery. Major adverse cardiovascular events (MACEs) included cardiac death and re-hospitalization for congestive heart failure.
During the mean follow-up of 85±43 months, MACEs occurred in 17.2% of patients. Using a receiver-operating characteristics analysis, hMVRI >2.82 mm Hg·cm-1·sec (sensitivity: 87%; specificity: 69%; and area under curve: 0.818) was the best cut-off values for predicting future cardiac events. The Cox proportional hazard analysis showed that hMVRI was an independent predictor for long-term MACEs (hazard ratio 1.741, 95% confidence interval 1.348-2.264, p<0.001). The Kaplan-Meier survival analysis showed a higher incidence of MACEs in patients with hMVRI >2.82 mm Hg·cm-1·sec (p<0.001).
hMVRI was a strong predictor of long-term MACEs in patients with STEMI treated with primary PCI.
PMCID: PMC4446813  PMID: 26023307
Myocardial infarction; Microcirculation; Percutaneous coronary intervention
18.  Combination therapy reduces the incidence of no-reflow after primary per-cutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction 
No-reflow is associated with an adverse outcome and higher mortality in patients with ST-segment elevation acute myocardial infarction (STEMI) who undergo percutaneous coronary intervention (PCI) and is considered a dynamic process characterized by multiple pathogenetic components. The aim of this study was to investigate the effectiveness of a combination therapy for the prevention of no-reflow in patient with acute myocardial infarction (AMI) undergoing primary PCI.
A total of 621 patients with STEMI who underwent emergency primary PCI were enrolled in this study. Patients with high risk of no-reflow (no-flow score ≥ 10, by using a no-flow risk prediction model, n = 216) were randomly divided into a controlled group (n = 108) and a combination therapy group (n = 108). Patients in the controlled group received conventional treatment, while patients in combination therapy group received high-dose (80 mg) atorvastatin pre-treatment, intracoronary administration of adenosine (140 µg/min per kilogram) during PCI procedure, platelet membrane glycoprotein IIb/IIIa receptor antagonist (tirofiban, 10µg/kg bolus followed by 0.15 µg/kg per minute) and thrombus aspiration. Myocardial contrast echocardiography was performed to assess the myocardial perfusion 72 h after PCI. Major adverse cardiac events (MACE) were followed up for six months.
Incidence of no-reflow in combination therapy group was 2.8%, which was similar to that in low risk group 2.7% and was significantly lower than that in control group (35.2%, P < 0.01). The myocardial perfusion (A × β) values were higher in combination therapy group than that in control group 72 h after PCI. After 6 months, there were six (6.3%) MACE events (one death, two non-fatal MIs and three revascularizations) in combination therapy group and 12 (13.2%) (four deaths, three non-fatal MIs and five revascularizations, P < 0.05) in control group.
Combination of thrombus aspiration, high-dose statin pre-treatment, intracoronary administration of adenosine during PCI procedure and platelet membrane glycoprotein IIb/IIIa receptor antagonist reduce the incidence of no-reflow after primary PCI in patients with acute myocardial infarction who are at high risk of no-reflow.
PMCID: PMC4394328  PMID: 25870616
Acute myocardial infarction; Myocardial contrast echocardiography; No-reflow phenomenon; Percutaneous coronary intervention; ST-elevation myocardial infarction
19.  Multivessel revascularisation versus infarct-related artery only revascularisation during the index primary PCI in STEMI patients with multivessel disease: a meta-analysis 
Netherlands Heart Journal  2015;23(4):224-231.
There are controversial data regarding infarct-related artery only (IRA-PCI) revascularisation versus multivessel revascularisation (MV-PCI) in ST-elevation myocardial infarction (STEMI) patients with multivessel disease undergoing primary percutaneous coronary intervention (PCI). We performed a meta-analysis comparing outcome in same stage MV-PCI versus IRA-PCI in STEMI patients with multivessel disease.
Systematic searches of studies comparing MV-PCI with IRA-PCI in the MEDLINE and the Cochrane Database of systematic reviews were conducted. A meta-analysis was performed of all available studies. Primary outcome was all-cause mortality. Secondary endpoints were re-infarction, revascularisation, bleeding and major adverse cardiac events (MACE).
A total of 15 studies were identified with a total number of 35,975 patients. Mortality rate was significantly higher in the MV-PCI group compared with the IRA-PCI group, odds ratio (OR): 1.64 (1.46–1.85). Both the incidence of re-infarction and re-PCI were significantly lower in the MV-PCI group compared with the IRA-PCI group: OR 0.54 (0.34–0.88) and OR 0.67 (0.48–0.93), respectively. Bleeding complications occurred more often in the MV-PCI group as compared with the IRA-PCI group: OR 1.24 (1.08–1.42). Rates of MACE were comparable between the two groups.
MV-PCI during the index of primary PCI in STEMI patients is associated with a higher mortality rate, a higher risk of bleeding complications, but lower risk of re-intervention and re-infarction and comparable rates of MACE.
PMCID: PMC4368524  PMID: 25884095
STEMI; Multivessel diseases; Multivessel PCI; Infarct-related artery
20.  Culprit vessel only versus “one-week” staged percutaneous coronary intervention for multivessel disease in patients presenting with ST-segment elevation myocardial infarction 
To explore the impact of a “one-week” staged multivessel percutaneous coronary intervention (PCI) versus culprit-only PCI on deaths and major adverse cardiac events (MACE).
We retrospectively analyzed 447 patients with multivessel disease who experienced a ST-segment elevation myocardial infarction (STEMI) within 12 h before undergoing PCI between July 26, 2008 and September 25, 2011. After completion of PCI in the infarct artery, 201 patients still in the hospital agreed to undergo PCI in non-infarct arteries with more than 70% stenosis for a “one-week” staged multivessel PCI. A total of 246 patients only received intervention for the culprit vessel. Follow-up ended on September 9, 2014. This study examined the differences in deaths from any cause (i.e., cardiac and noncardiac) and MACE between the two treatment groups.
Compared to a culprit-only PCI treatment approach, the “one-week” staged multivessel PCI was strongly associated with greater benefits for 55-month all cause death [41 (16.7%) vs.13 (6.5%), P = 0.004] and MACE [82 (33.3%) vs. 40 (19.9%), P = 0.002] rates. In addition, there were significant differences in the number of myocardial infarctions [43 (17.5%) vs. 20 (10.0%), P = 0.023], coronary-artery bypass grafting [CABG; 20 (8.1%) vs. 6 (3.0%), P = 0.021], and PCI [31 (12.6%) vs. 12 (6.0%), P = 0.018]. Patients undergoing culprit-only PCI compared to “one-week” PCI had the same number of stent thrombosis events [7 (2.8%) vs. 3 (1.5%), P = 0.522].
Compared to a culprit-only PCI treatment approach, “one-week” staged multi-vessel PCI was a safe and effective selection for STEMI and multi-vessel PCI.
PMCID: PMC4460164  PMID: 26089845
ST-segment elevation myocardial infarction; Percutaneous coronary intervention; Multivessel revascularization
21.  Temporal trends in percutaneous coronary intervention outcomes among older patients in the United States 
American heart journal  2013;166(2):273-281.e4.
New percutaneous coronary intervention (PCI) device technologies are often rapidly adopted into clinical practice, yet few studies have examined the overall impact of these new technologies on patient outcomes in community practice.
In hopes of determining temporal trends in PCI outcomes, we used data from the Centers for Medicare & Medicaid Service's Chronic Condition Warehouse (n = 3,250,836) by comparing patient characteristics and rates of 3-year major adverse cardiac events (MACE) across the balloon angioplasty (POBA) era (01/1991-09/1995), the bare metal stent (BMS) era (02/1998-04/2003), and the drug-eluting stent (DES) era (05/2004-10/2006). The adjusted association between era and outcomes was determined with Cox proportional hazards modeling (POBA era as reference).
Compared with the POBA era, patients undergoing PCI were significantly older and had more medical comorbidities, and the risk for 3-year MACE was significantly lower during the BMS and DES eras (BMS vs. POBA adjusted HR [95% CI]: 0.930 [0.926–0.935]; DES vs. BMS: 0.831 [0.827–0.835]). Compared with males, the adjusted risk for 3-year MACE among females was lower during the POBA era, but slightly higher during the BMS and DES eras. Across all three eras, patients ≥75 years of age had higher adjusted risk for MACE compared with younger patients, and the risk for revascularization was lower for both females and older patients.
Despite its application in older and sicker Medicare beneficiaries, there has been a significant decrease in post-PCI MACE over time. The risk for death or myocardial infarction is higher among females and older patients compared with males and younger patients; therefore, future studies should focus on improving clinical outcomes in these high-risk subgroups.
PMCID: PMC4406473  PMID: 23895810
22.  Immediate results and six-month outcomes after percutaneous coronary intervention in a referral heart center in Isfahan, Iran 
ARYA Atherosclerosis  2011;7(1):24-30.
There is a lack of data in our society on the outcomes, complications, and prognostic factors in patients with coronary artery disease who underwent percutaneous coronary intervention (PCI). We evaluated the success rate, early and late outcomes, and prognostic factors in a referral university center in Isfahan, IRAN.
This prospective cohort study was conducted in Chamran University Hospital in Isfahan (IRAN) from March 2010 to February 2011. Patients consequently were included if they have the indication for emergent or elective PCI. Outcomes included procedural success, complications, and major adverse cardiovascular events (MACE) during hospitalization and 6 months follow-up.
A total of 282 patients (74.1% females) with mean age of 57.0±3.2 years were studied. Most of the patients (89.7%) underwent elective PCI. Angiographic and procedure success rates were 95.7% and 94.6%, respectively. In-hospital MACE included two cases of death (0.7%) and one MI (0.3%); 2/29 (6.9%) of the emergent PCI and 1/253 (0.4%) of the elective PCI cases. MACE during follow-up included three cases of death (1.0%) and two MI (0.7%); 2/252 (0.8%) of the elective PCI and 1/28 (3.5%) of the emergent PCI cases. The overall MACE was calculated as 8 cases (2.8%) which included 5/29 (17.2%) of the emergent and 3/253 (1.1%) of the elective cases; P<0.001. In multivariate analysis, none of the factors including gender, age, emergency of the procedure, lesion type, number of stenotic vessels, or stent type were associated with total MACE (P>0.05).
PCI is performed with an acceptable success rate in our center in Isfahan and mortality and complications are within the range reported by other highly specialized centers in IRAN. Further studies with larger sample size are needed to find predictive factors.
PMCID: PMC3347842  PMID: 22577441
Percutaneous Coronary Intervention; Myocardial Infarction; Acute Coronary Syndrome; Reperfusion Therapy; Outcome; Mortality
23.  Impact of diabetes on long term follow-up of elderly patients with chronic total occlusion post percutaneous coronary intervention 
The prognosis of elderly patients with chronic total occlusion (CTO) and diabetes mellitus (DM) treated with percutaneous coronary intervention (PCI) is not known.
To investigate the effect of diabetes on long-term follow-up of CTO after PCI in elderly patients.
A total of 153 elderly patients (age > 65 years old) with CTO lesions which were successfully treated with PCI were enrolled. Fifty one patients with diabetes and 102 without diabetes were compared for long-term outcomes (mean follow up: 36 ± 12 months). Major adverse cardiac events (MACE) which include death, myocardial infarction or target lesion revascularization (TLR) were considered as a combined endpoint.
The combined endpoint occurred in 29.4% of diabetes patients, and 11.3% of the patients without diabetes (P < 0.05). The Cox proportional hazards model identified: drug eluting stent (DES) or bare metal stent (BMS) (HR: 0.13, 95% confidence interval (95% CI): 0.03–0.62, P = 0.004), DM (HR: 6.69, 95% CI: 1.62–15.81, P = 0.01) and final minimal lumen diameter (MLD) (HR: 0.37, 95% CI: 0.13–0.90, P = 0.03 ) as independent predictors of MACE, DM with renal impairment (HR: 6.64, 95% CI: 1.32–33.36, P = 0.02), HBA1C on admission (HR: 1.79, 95% CI: 1.09–2.94, P = 0.02), as independent predictors of MACE at long term follow-up.
The study demonstrates that DM is a predictive factor for MACE in elderly CTO patients treated with PCI, type of stent, final minimal lumen diameter and DM with renal impairment, and HBA1C level on admission are predictors of MACE.
PMCID: PMC3627706  PMID: 23610569
Diabetes; Chronic total occlusion; Percutaneous coronary intervention; Elderly patient; Drug eluting stent
24.  Outcomes of Percutaneous Coronary Intervention on Saphenous Vein Graft and Native Coronary Vessels 
The optimal target for revascularization in patients with history of coronary artery bypass graft surgery (CABG) is unclear. This study was designed to compare the outcome of percutaneous coronary intervention (PCI) on saphenous vein grafts (SVG) and that on native vessels in patients with previous CABG in terms of major adverse cardiac events (MACE).
The study drew upon data on consecutive patients hospitalized for PCI and MACE rate during a nine-month follow-up period. The patients were divided according to the target vessel for PCI into two groups: SVG and native vessel.
Between 2003 and 2007, 226 patients underwent PCI 6.57 ± 4.55 years after CABG. Their mean age was 59.52±9.38 years, and 176 (77.9%) were male. PCI was performed on the SVG in 63 (27.9%) patients and on the native coronary artery in the rest. During a nine-month follow-up period, 9 (4%) patients suffered MACE; the prevalence of MACE was not significantly different between the SVG group (4.8%) and the native vessel group (4.9%), (p value = 0.999).
PCI on grafted and native vessels did not affect MACE in patients undergoing PCI after CABG.
PMCID: PMC3466893  PMID: 23074621
Coronary artery bypass; Saphenous vein; Angioplasty; balloon; coronary; Coronary vessels
25.  Evaluation of Clinical Risk Factors to Predict High On-Treatment Platelet Reactivity and Outcome in Patients with Stable Coronary Artery Disease (PREDICT-STABLE) 
PLoS ONE  2015;10(3):e0121620.
This study was designed to identify the multivariate effect of clinical risk factors on high on-treatment platelet reactivity (HPR) and 12 months major adverse events (MACE) under treatment with aspirin and clopidogrel in patients undergoing non-urgent percutaneous coronary intervention (PCI).
739 consecutive patients with stable coronary artery disease (CAD) undergoing PCI were recruited. On-treatment platelet aggregation was tested by light transmittance aggregometry. Clinical risk factors and MACE during one-year follow-up were recorded. An independent population of 591 patients served as validation cohort.
Degree of on-treatment platelet aggregation was influenced by different clinical risk factors. In multivariate regression analysis older age, diabetes mellitus, elevated BMI, renal function and left ventricular ejection fraction were independent predictors of HPR. After weighing these variables according to their estimates in multivariate regression model, we developed a score to predict HPR in stable CAD patients undergoing elective PCI (PREDICT-STABLE Score, ranging 0-9). Patients with a high score were significantly more likely to develop MACE within one year of follow-up, 3.4% (score 0-3), 6.3% (score 4-6) and 10.3% (score 7-9); odds ratio 3.23, P=0.02 for score 7-9 vs. 0-3. This association was confirmed in the validation cohort.
Variability of on-treatment platelet function and associated outcome is mainly influenced by clinical risk variables. Identification of high risk patients (e.g. with high PREDICT-STABLE score) might help to identify risk groups that benefit from more intensified antiplatelet regimen. Additional clinical risk factor assessment rather than isolated platelet function-guided approaches should be investigated in future to evaluate personalized antiplatelet therapy in stable CAD-patients.
PMCID: PMC4370634  PMID: 25799149

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