Editorial 1

To image or not to image; to protect or not to protect Gary S. Mintz Coronary Artery Disease 2014, 25:1–3 Cardiovascular Research Foundation, New York, New York, USA

Correspondence to Gary S. Mintz, MD, 111 East 59th Street, 11th Floor, New York, NY 10022, USA Tel: + 1 646 434 4133; fax: + 1 646 434 4715; e-mail: [email protected] Received 8 October 2013 Accepted 13 October 2013

Predictors of periprocedural myocardial infarction (MI) during stent implantation are a large grayscale intravascular ultrasound (IVUS)-attenuated plaque (‘shadowing’ in the absence of calcification), as discussed by Wu et al. [1], especially when shadowing begins closer to the lumen than to the adventitia [2–5], a large virtual histology–IVUS necrotic core (or lipidic plaque by integrated backscatter–IVUS or necrotic core by iMAP) [6–9], a large amount of optical coherence tomography lipidic plaque [10–15], a large lipid core plaque by nearinfrared spectroscopy [16–18], and the presence of plaque rupture [11,19–22]. The common denominator is the presence of a thin cap fibroatheroma that is responsible both for the imaging findings and the myonecrosis during stent implantation [23–25]. Besides confirming the relationship between attenuated plaque and periprocedural MI, Wu and colleagues suggest that the procedural link is the amount of embolic-prone plaque that prolapses through stent struts. The incidence of periprocedural MI ranges from 2 to 50% depending on presentation, procedure, and the biomarker threshold used for the diagnosis [26]. In part, because of this heterogeneity, the prognostic implications are controversial [27], although several studies have demonstrated that periprocedural MI is associated with worse in-hospital, short-term, and long-term clinical outcomes including death and recurrent MI [28–32]. To cite just one study, Harrison et al. [32] analyzed 291 380 acute MI patients from the American College of Cardiology National Cardiovascular Data Registry. Angiographic no-reflow developed in 2.3% and was associated with an in-hospital mortality of 12.6% compared with 3.8% in patients without no-reflow. Should routine invasive imaging be performed to prevent periprocedural MI? On one hand and while the absence of these findings indicates a low probability of an event, all of these modalities have a low specificity. Conversely, angiography and clinical characteristics are poor predictors of periprocedural MI, therefore it is not surprising that routine use of embolic protection does not improve outcomes [33]. In the randomized Enhanced Myocardial Efficacy and Recovery by Aspiration of Liberated Debris (EMERALD) trial, embolic protection did not improve microvascular flow, reperfusion success, infarct size, or event-free survival [34]. One possibility is that embolic c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins 0954-6928

protection should not be used in all patients, but only in patients with a high likelihood of periprocedural MI. The ongoing Coronary Assessment by Near-infrared of Atherosclerotic Rupture-prone Yellow (CANARY, NCT01268319) trial is a prospective study randomizing patients with large near-infrared spectroscopic lipid core plaques in native coronary arteries to an embolic protection device versus standard of care in an attempt to answer this question. Of course, there are other reasons to perform invasive imaging during stent implantation. Two meta-analyses of the randomized IVUS versus angiographic-guided bare metal stent implantation trials have showed a reduction in restenosis, repeat revascularization, and major adverse cardiac events, but not in death or MI [35,36]. Although there are few randomized trials in the drug-eluting stent era, two meta-analyses (the latter involving three randomized trials and 12 observational studies with 24 849 patients) show that IVUS guidance reduces early and late stent thrombosis, MI, repeat revascularization, and mortality [37,38]. One optical coherence tomography study has shown similar results [39]. Although previous studies have questioned the value of IVUS guidance in the setting of ST-elevation MI [40,41], the ADAPT-DES study suggests the opposite – that IVUS guidance had its greatest impact in this group, patients with the greatest frequency of attenuated plaque [42] and, perhaps, the most to lose if a periprocedural MI should occur.

Acknowledgements Conflicts of interest

Dr Mintz is a consultant for and receives grant or fellowship support from Volcano Corporation, Boston Scientific, and InfraReDx.

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