Setting Of Acute Coronary Syndrome Research Articles

Disparity in the Under-Utilization of Novel P2Y12 Inhibitors in ST-Elevation Myocardial Infarction Following Percutaneous Coronary Intervention.

The most recent guidelines (European Society of Cardiology (ESC) and American College of Cardiology/American Heart Association (ACC/AHA)) all favor prasugrel/ticagrelor over clopidogrel in the setting of acute coronary syndrome (ACS). We therefore sought to investigate which P2Y12 inhibitors were being prescribed in our community hospital setting upon discharge among patients undergoing percutaneous coronary intervention (PCI) in the setting of ST-elevation myocardial infarction (STEMI). We identified patients presenting to two Metro Detroit Michigan hospitals with STEMI between January 1, 2018, to December 31, 2021 using the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) PCI registry. The primary outcome was the choice of P2Y12 inhibitor prescribed on day of discharge following hospitalization for STEMI, and baseline characteristics were compared including race, sex and type of insurance. A total of 366 patients presented to these two Metro Detroit hospitals from January 1, 2018, to December 31, 2021. Female and non-White patients were more likely to be discharged on clopidogrel than ticagrelor or prasugrel (odds ratio (OR): 1.56, confidence interval (CI): 0.99 - 2.45, and OR: 1.43, CI: 0.91 - 2.25, respectively), however, did not reach statistical significance. Patients without private insurance presenting with STEMI were more likely to be discharged on clopidogrel (OR: 1.83, CI: 1.22 - 2.74), which did reach statistical significance in our cohort. In this retrospective single-center study evaluating BMC2 registry, we demonstrate a clinically significant disparity in prescribing patterns based on insurance, with trends for disparity based on gender and ethnicity.

Cangrelor - Expanding therapeutic options in patients with acute coronary syndrome.

Cangrelor is the only intravenous P2Y12 receptor antagonist. It is an adenosine triphosphate analog that selectively, directly, and reversibly binds to the platelet P2Y12 receptors exerting its antiaggregatory effect. Cangrelor is characterized by linear, dose-dependent pharmacokinetics and rapid onset of action providing potent platelet inhibition exceeding 90%. Cangrelor is rapidly metabolized by endothelial endonucleotidase; thus, its half-life is 2.9 to 5.5 min, and its antiplatelet effect subsides within 60 to 90 min. Data originating from three pivotal cangrelor trials (CHAMPION PLATFORM, CHAMPION PCI, and CHAMPION PHOENIX) indicate that cangrelor reduces the risk of periprocedural thrombotic complications during percutaneous coronary intervention at the expense of mild bleedings. Its unique pharmacological properties allow it to overcome the limitations of oral P2Y12 receptor inhibitors, mainly related to the delayed and decreased bioavailability and antiplatelet effect of these agents, which are often observed in the setting of acute coronary syndrome. Subgroups of patients who could theoretically benefit the most from cangrelor include those in whom pharmacokinetics and pharmacodynamics of oral P2Y12 receptor antagonists are most disturbed, namely patients with ST-segment elevation myocardial infarction, those treated with opioids, with mild therapeutic hypothermia, or in cardiogenic shock. Cangrelor could also be useful if bridging is required in patients undergoing surgery. According to the current guidelines cangrelor may be considered in P2Y12 receptor inhibitor-naïve patients undergoing percutaneous coronary intervention in both acute and stable settings.

Long-Term Percutaneous Coronary Intervention Outcomes in Chronic Versus Acute Coronary Syndromes (TARGET All Comers Trial)

In the Targeted therapy with a localised abluminal coated, low-dose sirolimus-eluting, biodegreadable polymer coronary stent (TARGET; NCT02520180) All Comers trial the biodegradable polymer (BP) sirolimus-eluting FIREHAWK stent was noninferior to the durable polymer (DP) everolimus-eluting XIENCE stent with respect to target lesion failure (TLF) at 1 and 5 years; however, the long-term safety and efficacy in the setting of acute coronary syndromes (ACS) are not known. We sought to assess the long-term outcomes in ACS versus chronic coronary syndromes (CCS) with BP sirolimus-eluting stent (SES) versus DP everolimus-eluting stent (EES). The TARGET AC study was a multicenter, open-label, noninferiority trial of all comer patients randomly allocated 1:1 to BP SES or DP EES (stratified by ST-elevation myocardial infarction and study site). In this predefined substudy, the outcomes were compared based on clinical presentation (ACS vs CCS) and treatment allocation. A total of 1,653 patients were enrolled (728 with ACS and 922 with CCS), with 94% completing the 5-year follow-up. The baseline characteristics were well-matched between the 2 stent types; however, co-morbidities were more prevalent in the CCS than in the ACS population. TLF (15.5% vs 17.7%, p = 0.24), patient-oriented outcomes (32.0% vs 34.4%, p = 0.31), and stent thrombosis (4.1% vs 3.3%, p = 0.40) were similar between patients with ACS and patients with CCS. In the ACS cohort, the outcomes at 5 years for BP SES versus DP EES were similar for TLF (16.0% vs 14.9%, p = 0.70), ischemia-driven target lesion revascularization (5.6% vs 8.3%, p = 0.17), and definite/probable stent thrombosis (2.7% vs 4.6%, p = 0.18). The same was true for the CCS cohort, with 5-year outcomes for BP SES versus DP EES for TLF (18.0% vs 17.4%, p = 0.82), ischemia-driven target lesion revascularization (6.4% vs 5.0%, p = 0.37), and definite/probable stent thrombosis (3.0% vs 1.8%, p = 0.26). In conclusion, in the TARGET AC trial, 1 in 3 patients had a major adverse event at 5 years, irrespective of CCS or ACS presentation. Long-term, the BP sirolimus-eluting FIREHAWK stent was as safe and effective as the DP everolimus-eluting XIENCE stent across the spectrum of clinical presentations.

A comprehensive guide on the optimal timing of PCI in the setting of acute coronary syndrome: An updated meta-analysis

BackgroundInvasive revascularization is recommended for cohorts of patients with ST-elevation myocardial infarction (STEMI) and non-ST-elevation acute coronary syndrome (NSTE-ACS). However, the optimal timing of invasive revascularization is still controversial and no defined consensus is established. We aim to give a comprehensive appraisal on the optimal timing of invasive strategy in the heterogenous population of ACS. MethodsRelevant studies were assessed through PubMed, Scopus, Web of science, and Cochrane Library from inception until April 2023. Major adverse cardiovascular events (MACE) and all-cause mortality were our primary outcomes of interest, other secondary outcomes were cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. The data was pooled as odds ratio (OR) with its 95% confidence interval (CI) in a random effect model using STATA 17 MP. ResultsA total of 26 studies comprising 21,443 patients were included in the analysis. Early intervention was favor to decrease all-cause mortality (OR = 0.79, 95% CI: 0.64 to 0.98, p = 0.03), when compared to delayed intervention. Subgroup analysis showed that early intervention was significantly associated with all-cause mortality reduction in only NSTE-ACS (OR = 0.83, 95% CI [0.7 to 0.99], p = 0.04). However, there was no significant difference between early and delayed intervention in terms of MACE, cardiac death, TVR, MI, repeat revascularization, recurrent ischemia, and major bleeding. ConclusionAn early intervention was associated with lower mortality rates compared to delayed intervention in NSTE-ACS with no significant difference in other clinical outcomes.PROSPERO registration: CRD42023415574.

Accuracy of Smartwatch Electrocardiographic Recording in the Acute Coronary Syndrome Setting: Rationale and Design of the ACS WATCH II Study.

Background: Acute Coronary Syndrome (ACS), with or without ST-segment elevation, is a major contributor to global mortality and morbidity. Swift diagnosis and treatment are vital for mitigating cardiac damage and improving long-term outcomes. The 12-lead electrocardiogram (ECG) currently serves as the gold standard for diagnosis in ACS with ST-segment elevation and may support the diagnosis in ACS without ST-segment elevation. However, the growing prevalence of smartwatches enables the acquisition of electrocardiographic data without traditional ECG equipment. While smaller studies support smartwatch ECG use, larger-scale validation within ACS remains lacking. The ACS WATCH II study aims to validate smartwatch ECG recordings for ACS. Methods: The primary objective is to validate smartwatch-obtained electrocardiographic data in patients presenting with ACS. Two cohorts of 120 patients each, presenting ACS with and without ST-segment elevation, will be assessed. Smartwatches will capture recordings of leads I, III, and V2 alongside standard ECGs. These leads, chosen due to a 97% ACS diagnosis sensitivity in previous studies, will undergo blind evaluation by two experienced external assessors against conventional ECG. Additionally, a control sample of 60 healthy individuals will be included. Conclusions: ACS WATCH II pioneers large-scale prospective validation of smartwatch ECG recordings in ACS patients. Additionally, it indirectly validates a swift diagnostic approach using three leads (I, III, and V2). This could expedite time-critical ACS diagnoses and simplify access through smartwatch-based diagnosis.

Ventricular arrhythmia without acute coronary syndrome as an indication for invasive coronary angiography

Abstract Background In the clinical setting of acute coronary syndrome, ventricular arrhythmia is a validated indication for urgent invasive coronary angiography (ICA). However, the indication for ICA in patients with ventricular arrhythmia but no acute coronary syndrome is less clear. This study aimed to determine the incidence of occlusive coronary artery disease (CAD) in such patients and to evaluate the association of arrhythmia subtypes and ICA findings with survival. Methods This study included 309 patients who underwent ICA due to documented ventricular arrhythmia but no acute coronary syndrome between January 2004 and October 2017. Subtypes of arrhythmia and findings from ICA were correlated to outcome. Results Overall, 309 patients [240 male (78%) 69 female (22%), mean age 68 ± 11 y] with the evidence of ventricular arrhythmia were included. The documented ventricular arrhythmia were sustained ventricular tachycardia [VT; N= 140 (45.3%)], non-sustained ventricular tachycardia [nsVT; N= 97 (31.4%)], ventricular extrasystoles [VES; N= 72 (23.3%)]. A history of CAD was documented in 164 (53%) patients. The ICA detected a new CAD [N= 38 (12%)] or significant progression of known CAD [N= 72 (23%)] in 110 (36%) patients. Out of these patients 91 (83%) were treated with percutaneous coronary intervention (PCI), four (4%) were treated with coronary artery bypass grafting (CABG). The other 199 (64%) patients showed no progression of a known CAD [N= 92 (30%)] or no CAD [N= 107 (34%)] without significant progression. During a median follow-up time of 42 months (IQR 18-60), 44 (14.2%) patients died. The subtype of ventricular arrhythmia was associated to prognosis (figure 1). In all subgroups (VT, nsVT, VES), the survival analysis revealed no difference between patients with new CAD or progression of CAD on the one hand and those without CAD or progression on the other (VT: p = 0.70; nsVT: p = 0.65; VES: p = 0.14). Furthermore in all subgroups (VT, nsVT, VES), the survival analysis found no difference between patients with a specific treatment of CAD (PCI or CABG) and those without (VT: p = 0.37; nsVT: p = 0.95; VES: p = 0.07). Conclusion CAD is diagnosed in a relevant proportion of patients with ventricular arrhythmia but no evidence of an acute coronary syndrome. However, neither the successful detection of a new CAD or the progression of a known CAD nor the specific treatment (PCI or CABG) of a detected significant CAD had an impact on survival outcome. This challenges ventricular arrhythmia as an indication for ICA.Figure 1:Survival Curves

48-Month Clinical Outcomes and Prognostic Factors in an All-Comers Population with Acute Coronary Syndrome and Chronic Coronary Syndrome Undergoing Percutaneous Coronary Intervention with a Sirolimus-Eluting Stent.

We characterized the performance as well as safety of a second-generation thin-strut sirolimus-eluting stent with a biodegradable polymer, Alex Plus (Balton, Poland), deployed in the acute coronary syndrome (ACS) setting. We enrolled patients who were subjected to percutaneous coronary intervention (PCI) between July 2015 and March 2016 and took into consideration demographics, clinical and laboratory data, and clinical outcomes. We defined the primary endpoint as the 48-month rate of major cardiovascular adverse events (MACE), including cardiac death, myocardial infarction (MI), or target lesion revascularization (TLR). The secondary endpoints were all-cause death, cardiac death, MI, and TLR rates at 12-, 24-, 36-, and 48 months. We enrolled 232 patients in whom 282 stents were implanted, including 88 ACS and 144 chronic coronary syndrome (CCS) patients. The mean age of the ACS population was 67 ± 13 years old, and 32% of it consisted of females. Patients with ACS were characterized by lower rates of arterial hypertension (85.2% vs. 95.8%, p = 0.004), dyslipidemia (67% vs. 81.9%, p = 0.01), prior MI (34.1% vs. 57.6%, p < 0.001), and prior PCI (35.2% vs. 68.8%, p < 0.001). At 48 months, among the ACS patients, the rates of MACE, death, cardiac death, MI, and TLR were 23.9%, 11.4%, 7.9%, 9.1%, and 10.2%, respectively. No stent thrombosis cases were reported. Multivariable Cox regression revealed that the statistically significant MACE predictors were massive calcifications in coronary arteries (HR 9.0, 95% CI 1.75-46.3, p = 0.009), post-dilatation (HR 3.78, 95% CI 1.28-11.2, p = 0.016), prior CABG (HR 6.64, 95% CI 1.62-27.1, p = 0.008), vitamin K antagonist use (HR 5.99, 95% CI 1.29-27.8, p = 0.022), and rivaroxaban use (HR 51.7, 95% CI 4.48-596, p = 0.002). The study findings show that Alex Plus was effective and safe in a contemporary cohort of real-world ACS patients undergoing primary PCI. The outcomes were comparable between the ACS and chronic coronary syndrome patients, with a trend of lower TLR in ACS patients at 4 years.

Covered Stent Herniation into Coronary Aneurysm Sac—A Case-Inspired Review of Neurointerventional Realignment Techniques

Background: Coronary aneurysms are an infrequent finding in diagnostic angiography, with a reported incidence of 0.35–0.7% in the largest contemporary registries. At least half of them have an atherosclerotic etiology and as such they are often diagnosed in the setting of acute coronary syndrome. The wiring of a thrombosed aneurysm is a difficult task and after successful recanalization, the operator has to decide on the optimal method of aneurysm exclusion. Covered stents are commonly deployed, but their use involves the risk of delivery failure as well as device dislodgement and loss due to their stiffness and size. Moreover, proper stent sizing and apposition is difficult in the case of thrombosed aneurysms. Case presentation: We present a case of coronary aneurysm recanalization and exclusion with a covered stent, with a postdilation-induced stent foreshortening. Due to the subsequent stent migration into the aneurysm sac, its repositioning was attempted. The pitfalls of coronary aneurysm stenting and neurointerventional techniques of prolapsed device realignment are discussed. Conclusions: An adequate landing zone is of the utmost importance in aneurysm exclusion with covered stents. In the case of a short stent anchoring in the normal vessel, another covered or conventional stent should be deployed to mitigate the risk of the device migration.

Experiences of Patients With Atrial Fibrillation With Combination Antithrombotic Therapy Post–Percutaneous Coronary Intervention

BackgroundUp to 30% of patients with atrial fibrillation (AF) have coronary artery disease, and many undergo percutaneous coronary intervention (PCI). In the setting of acute coronary syndrome with PCI, or high-risk elective PCI, Canadian AF guidelines recommend 1-30 days of acetylsalicylic acid, 1-12 months of clopidogrel, and oral anticoagulation (OAC) with doses that may change throughout the 12 months post-PCI. The complexity of these regimens may contribute to unplanned modifications (UPMs), increasing the risk of thrombosis and/or bleeding. We describe what happens to these patients and their antithrombotic therapy (ATT) after discharge. MethodsProspective follow-up was conducted of patients with AF requiring OAC who underwent PCI and were discharged on combination ATT. Patients were contacted at 1, 3, 6, and 12 months post-PCI. ResultsSixty-five patients were enrolled, with data at any time point available for 61 of them (94%). Of these, 44 (68%) experienced at least one UPM to ATT. In total, 105 UPMs occurred. The most common UPM was an extended duration of P2Y12 inhibitor (23 instances; 22%). The most common UPM with acetylsalicylic acid was extended (11 instances; 11%) or shortened (11 instances; 11%) duration. Thirty-nine UPMs (37%) were related to OACs; 9 (23%) were related to warfarin, and 30 (77%) were related to direct OACs. Of all patients with at least one UPM, 33 (75%) experienced bleeding. ConclusionsMore than 2 in 3 patients with AF undergoing PCI experienced a UPM to their ATT. This study underscores the challenges of combination ATT for patients and clinicians alike, emphasizing the need for patient support after discharge.

Transfusion thresholds in acute coronary syndromes.

Anemia is prevalent in patients with acute coronary syndromes. In this setting, there is uncertainty and controversy surrounding the optimal transfusion strategy for managing anemia. The goal of this review is to summarize the current clinical evidence, guidelines, and future directions for managing transfusion in acute coronary syndromes. There is limited evidence from randomized trials evaluating restrictive versus liberal transfusion in patients hospitalized with and/or for acute coronary syndromes. The results from these studies suggest clinical equipoise between transfusion strategies for short term outcomes, and a trend toward favoring a liberal strategy for long term major adverse cardiac events. There is inconsistency across clinical practice guidelines with respect to the optimal strategy for managing anemia and transfusion in acute coronary syndromes due to insufficient evidence. More evidence is urgently needed to conclusively establish the optimal strategy for transfusion management in the setting of acute coronary syndromes. These data will directly inform harmonization of clinical practice guidelines. Future investigations should explore alternative strategies to hemoglobin for quantifying the degree of anemic stress for personalizing transfusion therapy, the effects on functional outcomes, and managing anemia following hospital discharge.

Cardiogenic Shock in the Setting of Acute Coronary Syndromes in Argentina: Results from the ARGEN SHOCK 2 Registry

Background: Cardiogenic shock (CS) is a life-threatening complication of acute myocardial infarction (AMI) and constitutes one of the leading causes of death. Objective: The aim of this study was to investigate the clinical characteristics, treatment strategies, hospital outcome and 30-day mortality of CS in Argentina. Methods: We conducted a prospective, and multicenter registry of patients with acute coronary syndromes (ACS) with and without ST-segment elevation complicated with CS that were hospitalized in 23 centers in Argentina for 14 months (between August 1, 2021, and September 30, 2022). Results: The cohort was made up of 114 patients; median age was 64 years (58-73) and 72% were women; 76.3% corresponded to ST-segment elevation ACS, 12.3% to non-ST-segment elevation ACS, 7% had right ventricular infarction and 4.4% had mechanical complications. In 66.6% of cases CS was present on admission. Revascularization: 91.1%, use of inotropic agents: 98.2%, mechanical ventilation (MV): 59.6%, Swan-Ganz catheter: 33.3%, intra-aortic balloon pump: 30.1%. Overall in-hospital mortality was 60.5%, with no differences between ACS with or without ST-segment elevation, and was 62.6% at 30 days. Conclusion: Morbidity and mortality of CS are high despite the high rate of reperfusion therapy used.

Advanced repeated structuring and learning procedure to detect acute myocardial ischemia in serial 12-lead ECGs

Objectives. Acute myocardial ischemia in the setting of acute coronary syndrome (ACS) may lead to myocardial infarction. Therefore, timely decisions, already in the pre-hospital phase, are crucial to preserving cardiac function as much as possible. Serial electrocardiography, a comparison of the acute electrocardiogram with a previously recorded (reference) ECG of the same patient, aids in identifying ischemia-induced electrocardiographic changes by correcting for interindividual ECG variability. Recently, the combination of deep learning and serial electrocardiography provided promising results in detecting emerging cardiac diseases; thus, the aim of our current study is the application of our novel Advanced Repeated Structuring and Learning Procedure (AdvRS&LP), specifically designed for acute myocardial ischemia detection in the pre-hospital phase by using serial ECG features. Approach. Data belong to the SUBTRACT study, which includes 1425 ECG pairs, 194 (14%) ACS patients, and 1035 (73%) controls. Each ECG pair was characterized by 28 serial features that, with sex and age, constituted the inputs of the AdvRS&LP, an automatic constructive procedure for creating supervised neural networks (NN). We created 100 NNs to compensate for statistical fluctuations due to random data divisions of a limited dataset. We compared the performance of the obtained NNs to a logistic regression (LR) procedure and the Glasgow program (Uni-G) in terms of area-under-the-curve (AUC) of the receiver-operating-characteristic curve, sensitivity (SE), and specificity (SP). Main Results. NNs (median AUC = 83%, median SE = 77%, and median SP = 89%) presented a statistically (P value lower than 0.05) higher testing performance than those presented by LR (median AUC = 80%, median SE = 67%, and median SP = 81%) and by the Uni-G algorithm (median SE = 72% and median SP = 82%). Significance. In conclusion, the positive results underscore the value of serial ECG comparison in ischemia detection, and NNs created by AdvRS&LP seem to be reliable tools in terms of generalization and clinical applicability.

Dual Antiplatelet Therapy: A Concise Review for Clinicians.

Dual antiplatelet therapy (DAPT) combines two antiplatelet agents to decrease the risk of thrombotic complications associated with atherosclerotic cardiovascular diseases. Emerging data about the duration of DAPT is being published continuously. New approaches are trying to balance the time, benefits, and risks for patients taking DAPT for established cardiovascular diseases. Short-term dual DAPT of 3-6 months, or even 1 month in high-bleeding risk patients, is equivalent in terms of efficacy and effectiveness compared to long-term DAPT for patients who experienced percutaneous coronary intervention in an acute coronary syndrome setting. Prolonged DAPT beyond 12 months reduces stent thrombosis, major adverse cardiovascular events, and myocardial infarction rates but increases bleeding risk. Extended DAPT does not significantly benefit stable coronary artery disease patients in reducing stroke, myocardial infarction, or cardiovascular death. Ticagrelor and aspirin reduce cardiovascular events in stable coronary artery disease with diabetes but carry a higher bleeding risk. Antiplatelet therapy duration in atrial fibrillation patients after percutaneous coronary intervention depends on individual characteristics and bleeding risk. Antiplatelet therapy is crucial for post-coronary artery bypass graft and transcatheter aortic valve implantation; Aspirin (ASA) monotherapy is preferred. Antiplatelet therapy duration in peripheral artery disease depends on the scenario. Adding vorapaxar and cilostazol may benefit secondary prevention and claudication, respectively. Carotid artery disease patients with transient ischemic attack or stroke benefit from antiplatelet therapy and combining ASA and clopidogrel is more effective than ASA alone. The optimal duration of DAPT after carotid artery stenting is uncertain. Resistance to ASA and clopidogrel poses an incremental risk of deleterious cardiovascular events and stroke. The selection and duration of antiplatelet therapy in patients with cardiovascular disease requires careful consideration of both efficacy and safety outcomes. The use of combination therapies may provide added benefits but should be weighed against the risk of bleeding. Further research and clinical trials are needed to optimize antiplatelet treatment in different patient populations and clinical scenarios.

Comparative effectiveness of Cangrelor in patients with acute coronary syndrome undergoing percutaneous coronary intervention: an observational investigation from the M.O.Ca. registry

Cangrelor, the first intravenous P2Y12 inhibitor (P2Y12-I), has been approved on the basis of three large RCTs from the CHAMPION program which nevertheless have been criticized for the low bleeding risk of the enrolled patients, the large quote of chronic coronary syndromes, and the use of Clopidogrel as control arm even in the setting of acute coronary syndromes (ACS). We sought to investigate, in the setting of ACS, the comparative performance of Cangrelor in terms of in-hospital ischemic and haemorrhagic outcomes compared with the current gold-standard of oral P2Y12-I. The study retrospectively enrolled 686 consecutive patients admitted to the Divisions of Cardiology of Policlinico of Bari and L. Bonomo Hospital of Andria for ACS and treated with percutaneous coronary intervention. The study population was divided according to the P2Y12-I treatment strategy in two groups: patients given an oral P2Y12-I and patients receiving Cangrelor in the cath lab followed by an oral P2Y12-I. Clinical endpoints included death, ischemic and bleeding events occurring during hospital stay. Cangrelor treated patients presented higher clinical risk profile at presentation and faced higher death rate. However, after PS matching, in-hospital mortality resulted comparable between the groups and Cangrelor use was associated with reduced in-hospital definite stent thrombosis (p = 0.03). Data from our real-world registry highlight that, in the setting of ACS, Cangrelor is prevalently used in patients with very challenging clinical presentations. The adjusted analysis provides for the first time promising data on stent thrombosis reduction associated with Cangrelor use.

Isolated T wave Inversion in Lead aVL as an early sign of Inferior Wall Myocardial Infarction

Electrocardiogram (ECG) is instrumental in identifying acute myocardial infarction (AMI). ST-segment elevation in a region of specific coronary vessels in an acute coronary syndrome (ACS) setting is the hallmark of AMI. Reciprocal ST depression and T wave inversion (TWI) are well-recognized changes that could accompany ST segment elevations. Reciprocal changes may represent the only early manifestation of AMI and may be present in specific leads such as lead aVL as early and sensitive markers of AMI. Abnormalities in the ST segment and T wave can result from non-ACS causes, but early recognition and appropriate intervention are paramount for patients with ACS. We report a case of a 55-year-old male with acute IWMI with early reciprocal and dynamic ECG changes with a literature review.

Incidental Finding of Interrupted Aortic Arch in an Adult Patient Who Underwent Urgent Percutaneous Coronary Intervention

Different vascular abnormalities have been reported concerning congenital anomalies of the aortic arch. We report a case of Interrupted Aortic Arch (IAA) discovered in the setting of acute coronary syndrome.

Magnesium Bioresorbable Scaffold (BRS) Magmaris vs Biodegradable Polymer DES Ultimaster in NSTE-ACS Population-12-Month Clinical Outcome.

Percutaneous coronary intervention (PCI) in the acute coronary syndrome (ACS) setting is associated with a greater probability of device failure. The currently ongoing development of new scaffold technologies has concentrated an effort on improving the PCI outcomes, including the use of new biodegradable materials. This pilot study evaluates the performance of a magnesium bioresorbable scaffold (Magmaris, Biotronik, Germany) in comparison to the sirolimus-eluting bioresorbable polymer stents (BP-SES) (Ultimaster, Terumo, Japan) in the NSTE-ACS setting. The population of this pilot comprised 362 patients assigned to one of two arms (193-Magmaris vs 169-Ultimaster). The data regarding the primary outcome comprised of death from cardiac causes, myocardial infarction, and stent thrombosis, along with target-lesion failure (TLF) and other clinical events was collected in the 1-yearfollow-up. There were no statistically significant differences in clinical outcomes in the short term (30 days) or in the 1-yearfollow-up between both groups. At 12 months, there were no statistically significant differences between the Magmaris and Ultimaster for composed endpoints or the TLF.

386 IMPACT OF REVASCULARIZATION COMPLETENESS ON ONE-YEAR OUTCOMES OF IMPELLA-SUPPORTED PCI IN ACUTE CORONARY SYNDROME: A SINGLE-CENTER EXPERIENCE

Abstract Background The use of mechanical circulatory support in high-risk percutaneous coronary intervention (HRPCI) has grown over the past decade. We aimed to evaluate the impact of coronary revascularization extent on one-year outcomes of Impella-supported HRPCI in the setting of acute coronary syndrome (ACS). Methods We performed a single-center retrospective study including all patients who underwent coronary angiography supported by Impella at our institution. Patients undergoing HRPCI in the setting of ACS with Impella-assistance were identified for the analysis. Revascularization extent was assessed using the British Cardiovascular Intervention Society (BCIS) jeopardy score revascularization index (RI). Patients were classified into two groups according to the completeness of revascularization in high RI (RI&amp;gt;0.75) and low RI (RI&amp;lt;0.75). The primary study endpoint was survival free from major adverse cardiac and cerebrovascular events (MACCE: all-cause death, myocardial infarction, stroke, heart failure hospitalization) at one-year follow-up. Results Among fifty patients enrolled in the study, forty ACS patients (mean age 69.2±9 years) were identified for the analysis. At coronary angiography, 76.3% had multivessel disease, and the mean BCIS-JSPRE-PCI score was 10.2±2.1. After Impella-supported PCI, BCIS-JSPOST-PCI score was 2.1±2.0 (p&amp;lt;0.01) and RI&amp;gt;0.75 was reached in 89.2% of cases (mean RI 0.8±0.2). In-hospital mortality was 20.5% without a statistical difference between high and low RI (p=0.1). Within 12 months, time-to-MACCE was statistically higher in patients with high RI as compared to low RI (288.2 vs. 189.8 days, p&amp;lt;0.05) (Figure). Conclusions Our single-center experience suggests a more extensive revascularization, aiming for a positive impact on outcomes, when a Impella-protected strategy is performed in the setting of acute coronary syndromes.

Abstract 15767: Association of Invasive Hemodynamic Evaluation With 3- and 6-Months Survival in Patients Treated for Cardiogenic Shock

Introduction: Cardiogenic shock (CS) is a complex spectrum of low output states which can occur in the setting of Acute Coronary Syndrome (ACS) or Acute Decompensated Heart Failure (ADHF). Its management is guided by frequent hemodynamic assessment and prompt treatment without which the mortality rate ranges from 27% to 51%. Contemporary data suggests that the use of right heart catheterization (RHC) improves in-hospital mortality and survival of patients. Our study aims to compare the difference in survival at 3 and 6 months based on RHC. Methods: A single center retrospective analysis was performed on patients admitted with CS secondary to ACS or ADHF from 7/01/2018 till 6/30/2020 at the University of Iowa. Patients were identified by the International Classification of Diseases 10th Revision Clinical Modification (ICD-10 CM) codes and were risk-stratified using the Society of Cardiovascular Angiography &amp; Interventions (SCAI) Shock Classification. 3 and 6 months survival analysis was done with the help of Log Rank test and Kaplan Meier survival curves. RHC was also evaluated as a predictor by Cox Regression analysis among all SCAI groups. Results: 647 patients admitted with CS, 249 patients underwent RHC during their admission. 51 had ACS and 198 had isolated ADHF as the precipitating cause of CS in patients who underwent invasive assessment. Evaluation by RHC showed improved 3 months survival in patients with SCAI 2 (p&lt;0.01), SCAI3 (p=0.01) and SCAI 5 CS (&lt;0.01). The association was significant at 6 months in SCAI 2 (p&lt;0.01), and SCAI 5 CS (&lt;0.01). RHC was a significant predictor of improved survival in SCAI 2 (HR 0.23; p=0.03; 95% CI 0.06 - 0.9), SCAI 3 (HR 0.26; p=0.01; 95% CI 0.08 - 0.8) and SCAI 5 CS (HR 0.20; p=0.04; 95% CI 0.04 - 0.97) at 3 months and SCAI 5 CS at 6 months(HR 0.20; p=0.04; 95% CI 0.46 - 0.9). Conclusion: Our study indicates that invasive hemodynamic evaluation during the treatment of CS favors survival in specially in the SCAI 2, SCAI 3 and SCAI 5 classification groups. In addition, RHC predicts better survival in these patients over 3 and 6 months. We assume that patients in SCAI 4 group may also gain same benefit however, due to limited number of patients our analysis couldn’t reach statistical significance in the SCAI 4 category.

Endothelin System and Ischemia-Induced Ventricular Tachyarrhythmias.

Despite the contemporary treatment of acute coronary syndromes, arrhythmic complications occurring prior to medical attendance remain significant, mandating in-depth understanding of the underlying mechanisms. Sympathetic activation has long been known to play a key role in the pathophysiology of ischemia-induced arrhythmias, but the regulating factors remain under investigation. Several lines of evidence implicate the endothelin system (a family of three isopeptides and two specific receptors) as an important modulator of sympathetic activation in the setting of acute coronary syndromes. Such interaction is present in the heart and in the adrenal medulla, whereas less is known on the effects of the endothelin system on the central autonomic network. This article summarizes the current state-of-the-art, placing emphasis on early-phase arrhythmogenesis, and highlights potential areas of future research.