Comparison of Intracoronary Epinephrine and Adenosine for No-Reflow in Normotensive Patients With Acute Coronary Syndrome (COAR Trial)

Background: Intracoronary epinephrine has been effectively used in treating refractory no-reflow, but there is a dearth of data on its use as a first-line drug in normotensive patients in comparison to the widely used adenosine. Methods: In this open-labeled randomized clinical trial, 201 patients with no-reflow were randomized 1:1 into intracoronary epinephrine as the treatment group and intracoronary adenosine as the control group and followed for 1 month. The primary end points were improvement in coronary flow, as assessed by TIMI (Thrombolysis in Myocardial Infarction) flow, frame counts, and myocardial blush. Secondary end points were in-hospital and short-term mortality and major adverse cardiac events. Results: In all, 101 patients received intracoronary epinephrine and 100 patients received adenosine. Epinephrine was generally well tolerated with no immediate table death or ventricular fibrillation. No-reflow was more effectively improved with epinephrine with final TIMI III flow (90.1% versus 78%, P =0.019) and final corrected TIMI frame count (24±8.43 versus 26.63±9.22, P =0.036). However, no significant difference was observed in final grade III myocardial blush (55.4% versus 45%, P =0.139), mean reduction of corrected TIMI frame count (−25.71±11.79 versus −26.08±11.71, P =0.825), in-hospital and short-term mortality, and major adverse cardiac events. Conclusions: Epinephrine is relatively safe to use in no-reflow in normotensive patients. A significantly higher frequency of post-treatment TIMI III flow grade and lower final corrected TIMI frame count with relatively better achievement of myocardial blush grade III translate into it displaying relatively better efficacy than adenosine. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04699110.

Sarcopenia is a risk factor for major adverse cardiac events after surgical revascularization for critical limb ischemia

Objectives We examined the effect of sarcopenia on early surgical outcomes in patients with critical limb ischemia (CLI) in terms of major adverse cardiac events (MACE) and major adverse limb events (MALE), as well as the value of inflammatory markers of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte ratios (PLR) as indicators of sarcopenia in CLI patients. Methods This was an observational retrospective single-center study. Patients who required surgical revascularization for CLI between October 2015 and December 2020 were identified. Psoas muscle areas were calculated from computed tomography images for psoas muscle index (PMI) calculations. Sarcopenia was defined as PMI < 5.5 cm2/m2 for men and PMI < 4.0 cm2/m2 for women. Risk factors for 30-day major adverse cardiac events (MACE) and major adverse limb events (MALE) were analyzed. NLR and PLR were compared between sarcopenic and non-sarcopenic patients. Results The mean age of 217 study patients was 61.5 ± 10.9, and 16 (7.4%) patients were female. 82 (37.8%) patients were sarcopenic. Patients with sarcopenia were older (65.1 ± 9.3 vs 59.4 ± 11.2, p < .001) and history of myocardial infarction was more frequent (23.2% vs 12.6%, p = 0.042) among sarcopenic patients. Sarcopenic patients more frequently encountered MACE (9.8% vs 0.7%, p = 0.002), but not MALE. Sarcopenia increased early postoperative MACE in our cohort with an odds ratio of 11.925. NLR was not different between the two groups, while PLR was higher (127.16 vs 104.06, p = 0.010) among sarcopenic patients. The platelet-to-lymphocyte ratio of 125.11 had a sensitivity of 53.7% and a specificity of 68.1% for differentiating sarcopenia. Conclusions Sarcopenia was associated with more frequent 30-day MACE and perioperative mortality after revascularization for CLI. 30-day MALE was not increased in patients with sarcopenia. The use of PLR as a simple marker of sarcopenia is limited by its low sensitivity and specificity.

Incidence of postoperative, major, adverse cardiac events in patients undergoing carotid endarterectomy: A single-center, retrospective study

Objective: This study aimed to determine the incidence of postoperative major adverse cardiac events for patients undergoing carotid endarterectomy. Methods: This single-center, retrospective study recruited 171 carotid endarterectomy patients between January 1999 and June 2018. Patients who received a carotid endarterectomy in conjunction with other surgery were excluded. The primary outcomes were the incidences of major adverse cardiac events (comprising myocardial infarction, significant arrhythmias, congestive heart failure, and cardiac death) within 7 days, 7–30 days, and > 30 days–1 year, postoperatively. The secondary outcomes were the factors related to major adverse cardiac events and the incidence of postoperative stroke. The patients’ charts were reviewed, and direct contact was made with them to obtain information on their status post discharge. Results: The incidences of major adverse cardiac events within 7 days, 7–30 days, and >30 days–1 year of the carotid endarterectomy were 3.5% of patients (95% confidence interval: 0.008–0.063), 1.2% (95% confidence interval: 0.004–0.028), and 1.8% (95% confidence interval: 0.002–0.037), respectively. The major adverse cardiac events occurring within 7 days were arrhythmia (2.3% of patients), cardiac arrest (1.8%), myocardial infarction (1.2%), and congestive heart failure (1.2%), while the corresponding postoperative stroke rate was 4.7%. Conclusion: The 7-day incidence of major adverse cardiac events after the carotid endarterectomy was 3.5%. The most common major adverse cardiac event during that period was cardiac arrhythmia.

Effects of colchicine on major adverse cardiac events in next 6-month period after acute coronary syndrome occurrence; a randomized placebo-control trial

Background Cardiovascular disease in particular acute coronary syndrome (ACS) is remained one of the most cause of morbidity and mortality, annually. Considering inflammatory pathway of atherosclerosis, colchicine as an anti-inflammatory drug is introduced to be effective in pathogenesis, prognosis and mortality rate of these patients. So in order to find out the effects of this drug we conducted this trial to know whether it reduces major adverse cardiac events (MACE) in ACS patients or not. Methods In a prospective randomized double-blinded placebo-controlled trial, we enrolled ACS patients (40–70 years) with recent ST-segment elevation myocardial infarction (STEMI) or NSTE-ACS diagnosed by coronary angiography and managed with either medical therapy or percutaneous coronary intervention. Patients were assigned to two groups either receiving colchicine 0.5 mg daily or placebo for 6 months. Both groups simultaneously received standard medical therapy as accessible guidelines. MACE occurrence consists of decompensated heart failure, ACS, stroke and survival rate compared between two groups. Results A total of 249 patients were recruited between October 2019-March 2020 with mean age of 56.89 ± 7.54, 69.5% males; 120 assigned to the colchicine group and 129 assigned to the placebo group. Over the 6 months’ period, 36 MACE occurred that were 8 events in the colchicine group compared with 28 events in the placebo group experiencing the event (P = 0.001). All of four deaths in the colchicine group and two in the placebo group were due to cardiovascular events. Evaluating adverse effects, gastrointestinal symptom was the most with the rate of 15 (12.5%) in the colchicine group and 3 (2.5%) in the controls. (P = 0.002). Conclusion The addition of colchicine to standard medical therapy in ACS patients significantly reduces MACE occurrence and improves survival rate over the time.