SCIENTIFIC NEWS March 2015 Samir Rafla

1. IVUS plaque regression with high doses of statins
By: SOLACI
Original title: Effect of high-intensity statin therapy on atherosclerosis in non-infarct-
related coronary arteries (IBIS-4): a serial intravascular ultrasonography
study. Reference: Räber L et al. Eur Heart J. 2015 Feb 21;36(8):490-500.
The long-term effect of intensive statin therapy on coronary atherosclerosis in patients
admitted pursuing an ST segment elevation myocardial infarction is unknown. The aim
of this study was to quantify the impact of high doses of statins in the volume and
composition of plaques in the arteries unrelated to the infarction. Between 2009 and
2011, 103 patients admitted pursuing ST segment elevation myocardial infarction were
performed a coronary intravascular ultrasound (IVUS) on the two arteries not
responsible of infarction after successful primary angioplasty to the guilty artery.
These patients were treated with 40 mg of rosuvastatin for 13 months and thereafter a
serial analysis was performed with IVUS. The primary end point was the percentage
change in plaque volume by IVUS. After 13 months a significant decrease in LDL and
a significant increase in the value of HDL were observed. Reduced plaque volume in
arteries unrelated to myocardial infarction 0.9% (IC 95% -1.56 to -0.25, p = 0.007).In
74% of the population regression of plates at least in one artery not infarct-related was
observed. The necrotic core showed no change (-0.05%; CI 95% -1.05 to 0.96%, p =
0.93) as well as the number of plates with thin fibrous cap (124 versus 116, p = 0.15).
Conclusion
After 13 months of high-dose rosuvastatin it was observed by IVUS a regression of
plaques in the arteries unrelated to myocardial infarction.
Editorial comment
While the regression existed and was significant, this did not reach 1% of the volume
of original plaque and this after more than a year of rosuvastatin 40 mg (dose that not
all patients tolerate). The anatomical regression is significant but low impact on
functional compromise that an injury can have.
Shall we change our daily practice to introduce complete revascularization during AMI?
Another study contributes for preventive PCI in AMI.
By: Dres. Santiago Alonso y Pablo Vazquez
Original title: Randomized Trial of Complete Versus Lesion-Only Revascularization in
Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI and
Multivessel Disease: The CvLPRIT Trial. Reference: Gershlick AH et al. J Am Coll
Cardiol. 2015 Mar 17;65(10):963-72.
Recent studies such as the PRAMI and the one we summarize here show complete
revascularization of AMI patients before discharge could be a safe strategy and even a
beneficial. Observational studies have shown the opposite.

2. This study randomized 296 patients after primary PCI. It compared outcomes of 146
patients receiving infarct related artery (IRA) only PCI vs. 150 patients receiving
complete revascularization, either at the time of primary PCI or prior to discharge,
according to the operator’s criterion. The second group included cases when the IRA
was the first lesion treated and all other severe lesions were also treated. Patients with
OCT as only non-culprit lesion were excluded.
Primary end point was a composite of all cause death, recurrent infarction, heart
failure, and ischemia driven revascularization within 12 months. Secondary end points
were any of primary end point outcomes and cardiovascular death. Safety end points
were stroke, major bleeding and contrast induced nephropathy (CIN).
Angiographic and clinical population characteristics were similar. From the CR group, a
7% received IRA only PCI an almost 2% received CABG. 64% of CR group patients
completed revascularization at the time of primary PCI.
Combined end point was significantly lower in the CR arm (10%) compared to the IRA
only arm (21.2%), p = 0.009. Secondary end points were also lower but with no
statistical importance. The rates of stroke, CIN and bleeding were similar. There were
also less events in patients with CR at primary PCI vs those treated in stages.
Conclusion
This study shows the uncomplicated potential benefit of complete revascularization to
treat infarction including non-culprit lesions with a fast separation of combined events
curves (p = 0,055 before 30 days).
Editorial Comment
This is small study supporting the hypothesis that states CR reduces ischemic burden,
which provides short and medium term protection against new ischemic events. This
could be explained partly by the evidence (in the original study) of pan-coronary
inflammation during AMI, increasing risk of events in patients with stable lesions.
Further randomized studies seem necessary to change the daily practice and define
an optimal opportunity (in progress: COMPLETE). SYNTAX scores of both arms would
also be interesting to compare.
Courtesy of Drs. Santiago Alonso and Pablo Vazquez.
Centro Cardiológico Americano. Sanatorio Americano.
Montevideo, Uruguay.
CTO revascularization is beneficial
By: Carlos Fava
Título original: Long-Term Survival Benefit of Revascularization Compared UIT
Medical Therapy in Practice UIT Coronary Chronic Total Occlusion and Well-
Developed Collateral Circulation. Reference: Woo Jin Jan, el at. J Am Coll Cardiol
Interv 2015;8:271-9

3. Multiple studies have shown the benefit of chronic total occlusion (CTO)
revascularization, but for patients presenting Rentrop 3 grade collateral circulation
(CC), such benefit remains unclear.
The study included 738 patients presenting at least one Rentrop 3 grade CTO,
symptomatic and silent ischemia patients, and excluded patients with a history of
revascularization, cardiogenic shock, cardiopulmonary resuscitation or acute ST
elevation myocardial infarction 48hs prior to procedure.
Primary end point was death during follow up and secondary end points were all cause
death, infarction, repeat revascularization and combined events (MACE). 236 patients
(32%) received medical treatment and 502 were treated with revascularization
procedures (170 CABG and 332 with PCI).
Those treated with revascularization were younger, dislipemic, with ACS, higher
ejection fraction and shorter catheterization history. The extent of heart failure was
similar in both groups.
Follow up was 42 months. Multivariable analysis revealed a lower incidence of cardiac
death (HR 0.29; CI 95% 0.15 to 0.58; p<0.01) and MACE (HR 0.32; CI 95% 0.21 to
0.49 p<0.01) in favor of the revascularization group. After propensity score matching,
the incidence of death and MACE still favored the revascularization group. There were
no differences in CABG and PCI, except for the higher rate of repeat revascularization.
Conclusion
In CTO patients and good collateral circulation, revascularization reduce the risk of
cardiac death and combined events.
Editorial Comment
Previous studies had shown that good collateral circulation was beneficial for the
evolution and this analysis shows it is even better when patients are treated with
revascularization procedures, being PCI a valid alternative with a higher rate of repeat
revascularization but with no difference in mortality.
Gentileza del Dr Carlos Fava
Cardiólogo Intervencionista
Fundación Favaloro – Argentina