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Massimo Margheri

Publications and source records attributed to Massimo Margheri.

15 recordsLinked to original sources
PubMed2006

Sirolimus-eluting versus uncoated stents in acute myocardial infarction.

BACKGROUND: Sirolimus-eluting stents reduce rates of restenosis and reintervention, as compared with uncoated stents. Data are limited regarding the safety and efficacy of such stents in primary percutaneous coronary intervention (PCI) for acute myocardial infarction with ST-segment elevation. METHODS: We performed a single-blind, multicenter, prospectively randomized trial to compare sirolimus-eluting stents with uncoated stents in primary PCI for acute myocardial infarction with ST-segment elevation. The trial included 712 patients at 48 medical centers. The primary end point was target-vessel failure at 1 year after the procedure, defined as target-vessel-related death, recurrent myocardial infarction, or target-vessel revascularization. A follow-up angiographic substudy was performed at 8 months among 174 patients from selected centers. RESULTS: The rate of the primary end point was significantly lower in the sirolimus-stent group than in the uncoated-stent group (7.3% vs. 14.3%, P=0.004). This reduction was driven by a decrease in the rate of target-vessel revascularization (5.6% and 13.4%, respectively; P<0.001). There was no significant difference between the two groups in the rate of death (2.3% and 2.2%, respectively; P=1.00), reinfarction (1.1% and 1.4%, respectively; P=1.00), or stent thrombosis (3.4% and 3.6%, respectively; P=1.00). The degree of neointimal proliferation, as assessed by the mean (+/-SD) in-stent late luminal loss, was significantly lower in the sirolimus-stent group (0.14+/-0.49 mm, vs. 0.83+/-0.52 mm in the uncoated stent group; P<0.001). CONCLUSIONS: Among selected patients with acute myocardial infarction, the use of sirolimus-eluting stents significantly reduced the rate of target-vessel revascularization at 1 year. (ClinicalTrials.gov number, NCT00232830 [ClinicalTrials.gov].).

Angioplasty, Balloon, Coronary↗
PubMed2006

Predictors of in-hospital mortality after percutaneous coronary intervention for cardiogenic shock.

OBJECTIVES: The mortality of patients with cardiogenic shock (CS) complicating ST elevation acute myocardial infarction (STEMI) remains high, despite early revascularization. Current knowledge of predictors of death is limited. BACKGROUND: The pathophysiologic understanding of CS after acute myocardial infarction has shifted from a mere hemodynamic disorder to a more complex approach including imbalance in metabolic functions. METHODS: In 45 consecutive patients (71.4+/-13 years) with CS complicating STEMI treated with primary percutaneous coronary intervention (PCI) serum levels of lactate, glucose and uric acid on coronary care unit (CCU) admission were measured. The end-point was in-hospital death. RESULTS: The following parameters, on CCU admission, were univariate predictors of in-hospital mortality: serum glucose >200 mg/dl (OR=11.3, p=0.002), serum creatinine >1.5 mg/dl (OR=12.7, p=0.003), uric acid >6.5 mg/dl (OR=6.7, p=0.016), lactate >6.5 mmol/l (OR=54, p<0.0001), age > or =75 years (OR=8.5, p=0.002), history of hypertension (OR=8.3, p=0.003) and TIMI flow post PCI < or = 2 (OR=12.9, p=0.02). At multivariate analysis, after adjustment for sex, age, hypertension and diabetes, lactate >6.5 mmol/l and TIMI flow post PCI < or = 2 were still independent predictors of in-hospital mortality (OR=295, p=0.01; OR=19.5, p=0.04, respectively). CONCLUSIONS: Hyperlactatemia, hyperglycemia and increased levels of uric acid on CCU admission are univariate predictors of in-hospital death. Moreover, at multivariate analysis, hyperlactatemia (>6.5 mmol/l) is an independent indicator of in-hospital death in CS patients complicating STEMI.

Aged↗
PubMed2006

Early discharge after acute myocardial infarction in the current clinical practice. Community data from the AMI-Florence Registry, Italy.

BACKGROUND: Clinical trials suggested feasibility and safety of early discharge after ST-segment elevation acute myocardial infarction (STEMI) for selected patients. Current United States and European guidelines recommend early discharge for uncomplicated AMI. The present study was aimed to assess early discharge in the current clinical practice for STEMI patients. METHODS: Patients enrolled in the AMI-Florence Registry (Italy), a prospective, observational, population-based study performed in the early 2000s, were analysed. The proportion of STEMI patients eligible for early discharge and of those actually discharged early, patient features influencing early discharge and outcomes (mortality, reinfarction or urgent revascularization during the first year of follow-up) were assessed. RESULTS: Of 751 STEMI patients, 59% were classified as eligible for early discharge, according to previously established criteria. Among patients considered eligible, those actually discharged early dropped from 33.1% in age <70 years to 15.9% in age 70-79 years and to 11.7% in age 80+ years. Of eligible patients, 26% were actually discharged within 4 days. Age 70+ years (reference: 69 years or younger; 70-79 years: OR: 0.40, 95% CI: 0.22-0.73; 80+ years: OR: 0.33, 95% CI: 0.14-0.76) and diabetes (OR: 0.48, 95% CI: 0.24-0.98) were negative independent predictors; and coronary reperfusion (OR: 2.92, 95% CI: 1.54-5.53) or firstly admitted to teaching hospital (OR: 1.68, 95% CI: 1.03-2.74) were positive predictors, of the multivariate probability of being early discharged. Among patients eligible for early discharge, 1-year and 3-year mortality did not differ significantly between patients actually, and not, early discharged. After 1 year of follow-up, no deaths were observed among patients early discharged. CONCLUSION: This study confirms, in a setting of current clinical practice, the reliability of criteria for identifying patients eligible for early discharge. Besides, the results confirmed the safety of this practice in selected patients. About 1/4 of eligible patients are actually early discharged, confirming the existence of important opportunities to improve the efficiency in STEMI management.

Aged↗
PubMed2006

Effect of comorbidity on coronary reperfusion strategy and long-term mortality after acute myocardial infarction.

BACKGROUND: Chronic comorbidity is a prognostic determinant in ST-segment elevation myocardial infarction (STEMI). This study was aimed at determining to what extent this effect is independent or derives from adoption of different therapeutic strategies. METHODS: Seven hundred forty patients with STEMI hospitalized within 12 hours of symptom onset were enrolled in a population-based registry, in a health district comprising 1 teaching hospital with and 5 district hospitals without percutaneous coronary intervention (PCI) facilities. Three categories of increasing chronic comorbidity score (CS-1, n = 259; CS-2, n = 235; CS-3, n = 246) were identified from age-adjusted associations of comorbidities with 1-year survival. RESULTS: Higher CS was associated with lower direct admission or transferal rates to hospital with PCI. Coronary reperfusion therapy (PCI in 91.5% of 470 cases) was adopted less frequently (P < .001) in CS-3 (41.9%) than CS-2 (69.4%) or CS-1 (78.8%). Compared with conservative therapy (n = 270), reperfusion therapy reduced 1-year mortality in the whole series not significantly (P = .816) in CS-1 but significantly in CS-2 (P = .012) and CS-3 (P = .001). This trend persisted after adjusting for age, Killip class, and acute myocardial infarction location (hazard ratio [HR] = 0.63 [95% CI 0.14-2.80], HR = 0.62 [95% CI 0.31-1.25], and HR = 0.47 [95% CI 0.26-0.86] in CS-1, CS-2, and CS-3, respectively). By hypothesizing an extension of coronary reperfusion therapy utilization rate in CS-2 and CS-3 to that in CS-1, from 21 (crude analysis) to 20 (adjusted analysis) deaths were classified as potentially avoidable. CONCLUSION: Increased mortality in patients with chronic comorbidity and STEMI derives, at least in part, from underutilization of coronary reperfusion therapy, and might be reduced with a more aggressive therapeutic approach.

Aged↗
PubMed2006

Timing, setting and incidence of cardiovascular complications in patients with acute myocardial infarction submitted to primary percutaneous coronary intervention.

BACKGROUND: At the Istituto di Clinica Medica Generale e Cardiologia (Florence, Italy), the widespread use of percutaneous coronary intervention (PCI) has markedly changed the hospital course of patients with acute myocardial infarction (AMI). These patients are typically transferred to the coronary care unit (CCU) only after primary PCI, whereas during the thrombolytic era, patients were first admitted to CCU before reperfusion. OBJECTIVES AND METHODS: The incidence, timing and setting of complications from symptom onset to hospital discharge in 689 consecutive AMI patients undergoing PCI were evaluated. RESULTS: Ventricular fibrillation occurred in 11% of patients, and most episodes (94.7%) occurred before or during PCI. Of all patients, 6.3% developed complete atrioventricular block (CAVB), and in 86.3% of these cases, the CAVB occurred before or during PCI; in 94.5%, a CAVB resolution occurred in the catheterization laboratory (CL). Thirty-one patients (4.5%) had impending shock on admission to the CL. Cardiogenic shock developed in 2 9 patients (4.2%), mostly in the prehospital phase or in the CL. Only four patients (less than 1%) developed cardiogenic shock later during their hospital course. Similarly, circulatory and ventilatory support, as well as temporary pacing and cardiac defibrillation, were used mostly in the prehospital phase or in the CL. During the CCU stay, 45 patients (6.5%) had hemorrhagic or vascular complications, and the incidence of post-PCI ischemia and early reocclusion of the culprit vessel were low (2.1% and 0.6%, respectively). Thus, cardiac complications usually associated with AMI were observed mainly before hospital admission or in the CL during the reopening of the target vessel. These complications were rarely observed after a successful PCI. CONCLUSIONS: For AMI patients, the CL is not only the site of PCI, it is also where most life-threatening cardiac complications are observed and treated.

Aged↗
PubMed2006

Contrast-induced nephropathy in urgent coronary interventions.

OBJECTIVES: Patients submitted to urgent percutaneous coronary interventions (PCIs) are quite often at high risk for contrast-induced nephropathy (CIN) since they exhibit several predisposing factors such as electrical and haemodynamic instability together with the lack of time to undergo adequate prophylaxis. This was a not blinded, non-randomized study whose aims were (i) to evaluate the incidence of CIN after urgent PCI in a high-volume cardiovascular referral practice (patients with acute myocardial infarction or with acute coronary syndromes enrolled in a single centre), and (ii) to assess the prognostic implications of CIN during hospitalization and at 1-month follow-up. METHODS: Between 1 October 2003 and 1 April 2004, 194 consecutive patients undergoing urgent coronary angiography and PCIs at our catheterization laboratory were enrolled in the study: 67 patients (34.5%) received the iso-osmolar contrast medium iodixanol (group A) and 127 patients (65.5%) received the hypo-osmolar contrast medium iopromid (group B). RESULTS: The overall incidence of CIN was 10.82%. Patients of group A showed a higher incidence of CIN than patients of group B (22.3 vs. 4.7%, P < 0.05). On univariate logistic analysis, age, pre-existing renal insufficiency, intra-aortic balloon pump (an indirect indicator of haemodynamic instability), dyslipidaemia, and postprocedural hypotension were risk indicators for the development of CIN after primary PCI. On multivariate logistic analysis, age and postprocedural hypotension remained significant independent correlates of CIN. CONCLUSIONS: In emergency PCIs, CIN is a frequent complication mainly related to haemodynamic instability and pre-existing renal dysfunction. Since CIN is associated with a high in-hospital mortality rate, our data stress the need for the development and validation of new preventive strategies for renal protection during emergency PCIs.

Acute Kidney Injury↗
PubMed2005

Incidence, predictors, and outcomes of coronary dissections left untreated after drug-eluting stent implantation.

AIMS: Coronary dissections left untreated after percutaneous coronary intervention are associated with unfavourable outcomes. However, their role after drug-eluting stent (DES) implantation is still undescribed. We assessed incidence, predictors, and outcomes of residual dissections in DES-treated lesions. METHODS AND RESULTS: Consecutive patients undergoing DES implantation were enrolled in four Italian centres, with baseline, procedural, and outcome data entered into a dedicated database. Residual dissections were classified according to the National Heart Lung and Blood Institute criteria. End-points of interest were in-hospital, 1-month, and 6-month major adverse cardiovascular events (MACE, i.e. death, myocardial infarction, or target vessel revascularization), and stent thrombosis (ST). Among the 2418 included patients (4630 lesions), a total of 77 (1.7%) final dissections occurred in 67 (2.8%) subjects. Dissections were more frequent in longer and complex lesions and in the left anterior descending, and were associated with increased rates of in-hospital (11.9 vs. 5.2%, P=0.017) and 1-month MACE (13.4 vs. 6.0%, P=0.013), with similar 6-month trends. Cumulative ST was also greater in patients with dissections (6.3 vs. 1.3%, P=0.011). Even non-obstructive dissections with thrombolysis in myocardial infarction 3 flow conferred a significantly worse prognosis. CONCLUSION: This study, reporting for the first time on incidence, predictors, and outcomes of residual dissections in DES-treated coronary lesions, demonstrates their adverse clinical impact and supports the pursuit of a strategy of sealing dissection flaps with other DES.

Aortic Dissection↗
PubMed2005

Detection and assessment of coronary artery anomalies by three-dimensional magnetic resonance coronary angiography.

BACKGROUND: Coronary artery anomalies (CAAs) are a relatively rare condition usually diagnosed in vivo by conventional angiography. In the past few years Magnetic resonance coronary angiography (MRCA) has been used to detect CAAs and found to be highly accurate. No data is available regarding the ability of MRCA to detect previously not suspected anomalies. METHODS: We prospectively analyzed the origin and course of 336 patients undergoing a diagnostic Cardiovascular magnetic resonance (CMR) study. After the completion of a standard examination a navigator-echo 3D-MRCA low-quality scan was used in all the cases to rule out CAAs. The high-quality MRCA was applied only if an abnormal coronary arterial tree was seen. RESULTS: Nineteen patients with CAAs (12 men, 7 women; mean age, 53+/-18 years) were identified by MRCA. Six out of the 19 CAAs subjects had already been detected by other means (coronary angiography in 5, and transesophageal echocardiography in 1 case). However in none of them a complete anatomical assessment was achieved. In 13 patients CAAs were an unexpected and new finding. MRCA was able to assess the origin and proximal course of the anomalous artery in all the cases. CONCLUSIONS: MRCA is able to detect the presence and anomalous course of CAAs. Besides offering precise information about already suspected CAAs, MRCA can identify anomalies previously not suspected. This study suggests a potential role for MRCA as a screening tool for CAAs in young patients with angina, ventricular arrhythmias, or unexplained syncope as well as in highly competitive athletes.

Adolescent↗
PubMed2005

Validation of predictors of intraprocedural stent thrombosis in the drug-eluting stent era.

Although predictors of acute intraprocedural stent thrombosis (IPST) in the drug-eluting stent era have been proposed, external validation is lacking. We thus analyzed the occurrence of IPST in the RECIPE study and found that, among 1,320 patients who underwent drug-eluting stent implantation, IPST occurred in 6 (0.5%), with in-hospital major adverse events in 4 (67%). IPST was predicted by number and total length of implanted stents, baseline minimal lumen diameter, and, in a pooled analysis that incorporated values from the present study and a previous study, use of elective glycoprotein IIb/IIIa inhibitors. Such results may provide useful information to guide prevention of this complication.

Acute Disease↗
PubMed2005

The incidence and timing of major arrhythmias following successful primary angioplasty for acute myocardial infarction.

BACKGROUND: The potential benefits of direct percutaneous transluminal coronary angioplasty (PTCA) on malignant arrhythmias in the hospital phase of acute myocardial infarction have not yet been established. METHODS: We prospectively investigated the incidence and timing of major arrhythmias occurring during direct PTCA and within 24 hours of mechanical reperfusion in 90 consecutive patients with acute myocardial infarction undergoing successful direct PTCA within 12 hours of symptom onset. RESULTS: Ventricular fibrillation and complete atrioventricular block occurred exclusively during direct PTCA and both resolved in the catheterization laboratory. Holter monitoring showed that ventricular tachyarrhythmias, such as runs of more than 3 extrasystoles, were detectable only during the first 8 hours after direct PTCA. CONCLUSIONS: In our group of patients undergoing successful direct PTCA, no in-hospital life-threatening arrhythmias occurred after this procedure.

Analysis of Variance↗
PubMed2004

Age-related changes in treatment strategies for acute myocardial infarction: a population-based study.

OBJECTIVES: To compare across four age groups (<65, 65-74, 75-84, > or =85) the determinants of coronary reperfusion therapy (CRT) use in ST-segment elevation acute myocardial infarction (STE-AMI). DESIGN: Population-based, observational study. SETTING: Performed in the health district of Florence, Italy, where percutaneous coronary intervention (PCI) is the preferred CRT. PARTICIPANTS: Nine hundred thirty patients with STE-AMI prospectively enrolled in the Florence AMI registry. MEASUREMENTS: Use of CRT, clinical factors associated with CRT use. RESULTS: CRT use was reduced from 71% at younger than 65 to 31% at aged 85 and older (P<.001). After adjusting for chronic comorbidity, Killip class, admission hospital category, hospitalization delay, and AMI location, CRT use was 29% (P=.17) lower at age 75 to 84 and 63% (P<.001) lower at age 85 and older than at younger than 65. Within each age group, the probability of receiving CRT was three to five times greater in patients directly admitted to the hospital with PCI facilities. Acute cardiac failure and chronic comorbidity were associated with lower CRT use only in patients aged 65 and older. Patients aged less than 85 years who received reperfusive therapy had a significantly lower risk of death (-44%, P=.045) at 1 year, whereas it was less evident and nonsignificant (-27%, P=.27) in patients aged 85 and older. CONCLUSION: Results confirm that, although they might substantially benefit from CRT during STE-AMI, older patients are excluded from CRT even when eligible. This further indicates that clinicians are not yet completely prepared to manage most efficiently frail elderly with AMI, a task requiring a specific interdisciplinary training program in geriatric cardiology.

Age Factors↗
PubMed2004

Eluting stents: an effective, promising solution?

Recent studies with eluting stents showed encouraging results in preventing in-stent restenosis. We report a case of a patient in whom the implantation of carbon-coated and eluting stents in two different vessels was associated with different angiographic results. A diabetic hypertensive 67-year-old woman with an acute inferior myocardial infarction underwent direct coronary angioplasty on the right coronary artery with the implantation of two carbon-coated stents. In view of the severity of an additional lesion of the left anterior descending coronary artery and diabetes, coronary angioplasty and stenting with an eluting stent was performed in this vessel. Five months later the patient presented with acute pulmonary edema and an increase in troponin I levels. A new coronary angiography showed a long subtotal in-stent restenosis of the right coronary artery, whereas the left anterior descending coronary artery was normal. Our case report suggests that eluting stents should be considered a precious and effective tool in preventing in-stent restenosis.

Aged↗
PubMed2004

Early outcome after paclitaxel-eluting stents in patients with acute and subacute myocardial infarction. A clinical study.

BACKGROUND: Paclitaxel-eluting stents (PES) have been proven to prevent in-stent restenosis in patients submitted to elective percutaneous coronary intervention. No data are so far available about the safety and efficacy of PES in acute and subacute myocardial infarction. The aim of the present investigation was to evaluate the occurrence of in-hospital adverse events in patients with acute and subacute myocardial infarction submitted to PES implantation. METHODS: From June 1 to July 31, 2003, we implanted 53 PES in 43 consecutive patients with acute (34 patients) and subacute (9 patients) myocardial infarction. RESULTS: In 65.1% of the patients the culprit lesion was located in the left anterior descending artery. Direct stenting was performed in 27.9% and glycoprotein IIb/IIIa inhibitors were used in 74.4%. Before the procedure a TIMI flow 0-1 was present in 46.5% while post-procedural TIMI flow 3 was achieved in all patients. A pre-procedural TIMI thrombus grade 2 to 5 was present in 67.8%. No death, reinfarction, early post-infarction angina or any other episode referable to in-stent thrombosis were observed during hospitalization. No patient was submitted to target lesion revascularization. At short-term follow-up with a mean duration of 118 +/- 75 days from discharge no cardiac or noncardiac death, reinfarction or any other major adverse coronary events were reported in the study population and no target lesion revascularization was performed. CONCLUSIONS: In this study, PES implant in patients with acute and subacute myocardial infarction was safe, with an early outcome comparable to conventional standard stents and no adverse events related to acute or subacute thrombosis.

Age Distribution↗