207Special Feature / Cardiovascular Revascularization Medicine 11 (2010) 199–215

Conclusion: There are no in-hospital outcome differences in STEMIaccording to the time of presentation.

doi:10.1016/j.carrev.2010.03.054

Cardiovascular pharmacology

Adverse outcomes in patients prescribed a proton pump inhibitorfollowing percutaneous coronary intervention with drug-eluting stentsMichael A. Gaglia Jr, Rebecca Torguson, Nicholas Hanna, Zhenyi Xue,Manuel A. Gonzalez, Itsik Ben-Dor, Sara D. Collins, Asmir I. Syed,Gabriel Maluenda, Cedric Delhaye, Kohei Wakabayashi,Kimberly Kaneshige, William O. Suddath, Kenneth M. Kent,Lowell F. Satler, Augusto D. Pichard, Ron WaksmanWashington Hospital Center, Washington, DC, USA

Background: Recent evidence shows that clopidogrel and proton pumpinhibitors (PPI) are metabolized by the same pathway, and patients takingboth drugs have higher levels of platelet reactivity and more adverseoutcomes than patients taking only clopidogrel.Methods: Following percutaneous coronary intervention (PCI) with drug-eluting stents (DES), we compared 502 patients not prescribed a PPI atdischarge to 318 patients prescribed a PPI; all patients were on clopidogrel.Patients were followed for 1 year for major adverse cardiac events (MACE),including death, Q-wave myocardial infarction, stent thrombosis, and targetvessel revascularization. We performed multivariable Cox regression toadjust for confounders, including compliance with clopidogrel, to assess theeffect of a PPI at discharge upon 1-year outcomes.Results: Baseline characteristics of patients discharged with a PPI weresimilar to patients discharged without a PPI. The most common PPI wasesomeprazole (58%); there were no differences in outcome by individualPPI. Univariable survival analysis showed a higher rate of MACE (13.8%vs. 8.0%, P=.008) and overall mortality (4.7% vs. 1.8%, P=.02) in the PPIgroup. After multivariable analysis, the adjusted hazard ratio for MACE inthe PPI group was 1.8 (95% CI 1.1–2.7, P=.01).Conclusion: In patients undergoing PCI with DES and receivingclopidogrel, prescription for a PPI at discharge was associated with a higherrate of MACE at 1 year. Recommendations for PPI therapy in all patients ondual antiplatelet therapy should be revisited.

doi:10.1016/j.carrev.2010.03.055

Relationship between platelet reactivity inhibition and major bleedingin patients undergoing percutaneous coronary interventionGilles Lemesle a, Omar Ait Mokhtarb, Sebastien Armerob, Julien Mancinic,Caroline Bonellod, Iliassou Tahiroub, Paul Barragane, FrançoiseDignat-George f, Laurence Camoin-Jau f, Franck Paganellib, Laurent BonellobaCardiology Hospital, University Hospital of Lille, Lille, FrancebPôle de cardiologie, Service de cardiologie interventionnelle,Hôpital universitaire nord, Faculté de médecine, Université Aix-Marseille II,France, Marseille, France

cAix-Marseille Université, Faculté de médecine, LERTIM (EA 3283),France, Marseille, FrancedAssistance Publique, Hôpitaux de Marseille, Hôpital de la Timone, SSPIM,France, Marseille, FranceeService de Cardiologie, Clinique des Fleurs, Ollioules, France, Marseille,FrancefUnité INSERM UMRS 608, UFR Pharmacie, Université Aix-Marseille II,France, Marseille, France

Background: Optimal platelet inhibition is critical to prevent ischemicevents following percutaneous coronary intervention (PCI). However, recentstudies have suggested that excessive inhibition may favor bleedings. Weaimed to investigate the relationship between platelet reactivity inhibitionand bleedings in patients undergoing PCI.Methods: From 2008 to 2009, 710 patients undergoing PCI were includedin this retrospective study. Patients who suffered in-hospital major bleeding(n=20), as defined by non-coronary artery bypass graft (CABG)-relatedThrombolysis In Myocardial Infarction (TIMI) major bleeding, werecompared to patients who did not (n=690). All patients received a 600-mgloading dose of clopidogrel and an intravenous 250–500-mg loading dose ofaspirin. A propensity score matching 5:1 based on age, sex, body massindex, clinical presentation, access site, sheath diameter, and glycoproteinIIb/IIIa use was then performed. Platelet reactivity was assessed using thevasodilator-stimulated phosphoprotein (VASP) index.Results: After propensity score matching, both groups were similaraccording to the usual baseline clinical, biological, and angiographiccharacteristics. Platelet reactivity inhibition assessed by the VASP index wassignificantly higher in the group of patients who experienced a non-CABG-related TIMI major bleeding compared to patients who did not: 32.5±22.4%vs. 51.2±21.9% (P=.003).Conclusion: Recent studies have shown that a good response to clopidogrelloading dose is associated with a significant decrease in ischemic eventsafter PCI. The present study reports that high platelet reactivity inhibition isalso associated with increased rates of major bleeding. In consequence, itsupports the potential clinical impact of platelet reactivity monitoring tooptimize antiplatelet therapy in patients undergoing PCI.

doi:10.1016/j.carrev.2010.03.056

Angiotensin-converting enzyme therapy and the risk of contrast-inducednephropathy after coronary angiography and percutaneouscoronary interventionKalpesh Patel, Peter Danyi, Antonio Abbate, Ion S. JovinVirginia Commonwealth University, Richmond, VA, USA

Background: The effects of angiotensin-converting enzyme inhibitors(ACEI) on the incidence of post-cardiac catheterization contrast-inducednephropathy (CIN) are not well understood. Some studies suggest thatACEI may contribute to CIN, while others report a renoprotectiveeffect of ACEI. We studied the effect of ACEI intake on the incidenceof CIN at 72 h, at 3 months, and on the incidence of dialysisin patients undergoing coronary angiography and percutaneous coronary±intervention.Method and results: We studied 1366 predominantly (98%) malepatients, undergoing cardiac catheterization and PCI at a veterans'administration medical center. The mean age was 68 years. Sevenhundred forty-one patients (54%) were on ACEI prior to the procedureand 625 (46%) were not. CIN occurred in 25 (3%) patients in the ACEIgroup and in 18 patients (3%) in the non-ACEI group at 72 h after theprocedure [odds ratio (OR) 1.17, 95% confidence interval (CI) 0.64–2.18;P=.6]. At 3 months, CIN was seen in 66 (9%) patients of the ACEI groupvs. 41 (7%) of the non-ACEI group (OR 1.39, CI 0.93–2.08; P=.10). Onmultivariate analysis, after adjustment for age, co-morbidities, andbaseline creatinine, ACEI therapy was not significantly associated with

Fig. 1. Transfusion and major bleeding rates according to BMI andanticoagulation use.

208 Special Feature / Cardiovascular Revascularization Medicine 11 (2010) 199–215

CIN at 72 h (OR=1.31, P=.64) or with CIN at 3 months (OR=1.21,P=.36). After a median follow-up of 65 months, 17 patients (2%) of theACEI group were placed on dialysis vs. 19 (3%) of the non-ACEI group(hazard ratio 0.74, CI 0.39–1.45; P=.39).Conclusion: In this cohort of predominantly male patients, ACEI therapywas not associated with an increased risk of developing CIN 72h postprocedure, at 3 months postprocedure, and was not associated witha higher long-term risk of initiation of dialysis.

doi:10.1016/j.carrev.2010.03.057

Safety and efficacy of bivalirudin for percutaneous coronaryintervention with rotational atherectomyCedric Delhaye, Kohei Wakabayashi, Gabriel Maluenda, Loic Belle, ItsikBen-Dor, Manuel Gonzalez, Michael A. Gaglia, Asmir I. Syed, RebeccaTorguson, Zhenyi Xue, William O. Suddath, Lowell F. Satler, Kenneth M.Kent, Joseph Lindsay, Augusto D. Pichard, Ron WaksmanWashington Hospital Center, Washington, DC, USA

Introduction: While bivalirudin use in patients undergoing percutaneouscoronary intervention (PCI) results in less bleeding compared tounfractionated heparin (UFH), its safety in patients undergoing rotationalatherectomy (RA) is unknown. This study attempted to examine the safetyand efficacy of bivalirudin for this population.Methods: A cohort of 503 patients who underwent PCI with RA from 2000to 2009 were studied. Of these, patients receiving bivalirudin (n=322) werecompared to those (n=181) treated with UFH±glycoprotein IIb/IIIa inhibitor(GPI) as PCI anticoagulation. Safety was assessed by the frequency of majorbleeding (hematocrit drop ≥15%, intracerebral or gastrointestinal bleeding)and need for transfusion. Efficacy was assessed by a composite end point ofin-hospital death, Q-wave myocardial infarction (MI), or urgent coronaryartery bypass graft (CABG).Results: Bivalirudin group was older, more hypertensive, and had greaterbody mass index. The UFH group was more likely to have prior MI, priorCABG, and an acute coronary syndrome at baseline. GPI was used in 93patients (52%) of the UFH group. No difference was found between groupsfor the composite of death/Q-wave MI/urgent CABG (1.9% vs. 1.7%,respectively, in bivalirudin vs. the UFH group, P=.2). The frequency ofmajor bleeding (2.2% vs. 1.7%, P=.8) or transfusion (5.6% vs. 8.7%, P=.9)was also similar between the groups. After adjustment, bivalirudin use wasnot associated with a reduction in death/Q-wave MI/urgent CABG, majorbleeding, or transfusion compared to UFH.Conclusion: Bivalirudin use seems to be as safe and as effective as UFH inpatients undergoing RA. These results do not suggest superiority ofbivalirudin over UFH.

doi:10.1016/j.carrev.2010.03.058

Body mass index and bleeding complications after percutaneouscoronary intervention in the “bivalirudin era”Cedric Delhaye, Kohei Wakabayashi, Gabriel Maluenda, Loic Belle,Itsik Ben-Dor, Manuel A. Gonzalez, Michael A. Gaglia Jr, Sara D. Collins,Rebecca Torguson, Zhenyi Xue, William O. Suddath, Lowel F Satler,Kenneth M. Kent, Joseph Lindsay, Augusto D. Pichard, Ron WaksmanWashington Hospital Center, Washington, DC, USA

Background: Little is known about the association between obesity andbleeding complications after percutaneous coronary intervention (PCI). Weinvestigated the impact of body mass index (BMI) on PCI-related bleedingand whether the use of bivalirudin that is known to reduce bleedingcompared to heparin modifies this relationship.

Methods: From 2000 to 2009, 16,783 patients who underwent PCI weredivided according to the BMI level: underweight (b18.5 kg/m2), normalweight (18.5–24.9), overweight (25–29.9), Class I (30–34.9), Class II(35–39.9), and Class III obesity (≥40). Bivalirudin was used in 11,433patients and heparin in 5350 for PCI. In-hospital transfusion and majorbleeding (hematocrit drop ≥15% or gastrointestinal bleeding) weresystematically collected.Results: Baseline characteristics differed between each BMI strata. Afteradjustment for confounding factors, underweight patients had no increasedrisk for bleeding compared to those of “normal” weight. While patients withBMI between 25 and 39.9 had the lowest risk for transfusion [0.68 (0.55–0.84), 0.68 (0.53–0.87), and 0.66 (0.48–0.92), respectively, for overweight,Class I, and Class II obese patients], only Class I obese patients had thelowest risk of major bleeding [0.68 (0.48–0.97)]. Patients with the highestBMI had no increased risk for transfusion (Class III obesity) or majorbleeding (Class II and III obesity). A reverse J-shaped relationship to BMIwas observed for the raw incidence of bleeding as well in patients treatedwith bivalirudin as for those receiving heparin (Fig. 1).Conclusion: The better outcomes for bleeding seen in patients in themiddle of the BMI spectrum confirm the existence of a “bleeding obesityparadox” which cannot be explained by adjustment for confoundingfactors. The bleeding relationship to BMI appears to be similar for boththe anticoagulants.

doi:10.1016/j.carrev.2010.03.059