Setting Of Acute Coronary Syndrome Research Articles

Use of sirolimus-coated balloon in de novo small vessel coronary lesions; Long-term follow-up from a single centre registry

Abstract Background Drug coated balloons (DCBs) in Europe are mainly used in restenotic lesions as endorsed by the European Society of Cardiology, with a class IA recommendation. However, some of the recent data suggest, it can also be considered in a subset of denovo lesions, especially in small vessels. Most DCBs used, are coated with Paclitaxcel. There is no data on the efficacy of Sirolimus in DCBs, the drug of choice in drug eluting stents. In this study, we report outcomes from the use of a Sirolimus coated balloon (SCB) in de novo small-vessel coronary lesions, from a single high yield centre. Methods A retrospective analysis was conducted on all patients treated with an SCB between March 2018 and October 2020. Follow-up was achieved with clinic visits, telephone calls and admission records. The outcomes measured include cardiac death, target-vessel myocardial-infarction (TVMI), target lesion revascularisation (TLR) and MACE (combination of cardiac death, target-vessel MI and TLR). Results During the study period, 279-patients (with 332-lesions) with de novo lesions were treated with an SCB. The mean age of patients was 65±12 years, 219 (79%) were male, 36% (n=100) had diabetes, 16% (n=45) had chronic kidney disease and 61% were in the setting of acute coronary syndrome (n=169). Predilatation was performed in 96% (320-lesions). Bailout stenting (with DES) was required in 5% of lesions (n=18) of which 16 were due to dissections and 2 were due to recoil >30% following DCB use. The mean diameter and length of DCBs were 2.35 mm and 26 mm respectively. During a median follow-up of 584-days (19-months) cardiac death was reported in 8 patients (3%). Target vessel MI was in 3% (n=9), TLR per lesion was 8% (n=26) and the MACE rate was 11% (n=31). There were no documented cases of acute vessel closure. Conclusion The long-term outcome from the first ever study on sirolimus eluting balloons in de novo small vessel lesions appears promising with low rates of hard endpoints, and acceptable repeat rates of TLR despite a complex group of patients (50% ACS, 36% diabetics and 19% CKD) and lesion subsets (small vessel and diffuse disease). Implanting stents in these subsets renders them vulnerable to restenosis, making treatment challenging and resulting in high rates of recurrence. Funding Acknowledgement Type of funding sources: None.

Clinical outcomes following use of sirolimus coated balloon in side-branches during provisional stent technique in true bifurcations

Abstract Introduction Provisional stenting is the preferred strategy even in true bifurcations, however, to minimise the need for repeat revascularization of side-branches, the use of drug coated balloons has been suggested. Most of the data available in the literature are on Paclitaxel coated balloons, a drug which is almost obsolete in stents due to its cytotoxic properties. There is limited data on Limus coated balloons (SCB), a drug which is the default for all the currently available drug eluting stents. In this study, we explore the clinical outcomes following use of SCB in side-branches during provisional stent technique in true bifurcations. Methods and results We evaluated all de novo lesions treated with DCB for true bifurcations between March 2018 and October 2020 at our centre. The results are reported as cardiac death, target vessel myocardial infarction (TVMI), target lesion revascularisation (TLR) and MACE (combination of cardiac death, target vessel MI and TLR). During the study period 110 patients with de novo lesions were treated with SCB for bifurcation lesions. Of them; 66 were in true bifurcations. The mean age of patients were 66.3±10.7 years, 75% (n=50) were male, 40 (61%) were in the setting of acute coronary syndrome, 52% (n=34) had diabetes and 32% (n=21) had CKD. Pre-dilatation was performed in all cases and none of them needed bailout stenting. Small vessels (<3.0 mm) accounted for 72% (n=48) of cases. Non-compliant balloons and scoring balloons to prepare the lesion was used in 51% (n=34) and 13% (n=9) of cases respectively. The mean diameter and length of SCBs were 2.6±0.4 mm and 23.2±7.3 mm respectively. During a median follow-up of 729 days (2-years); there were no cardiac deaths, TVMI occurred in one case (2%), TLR in 3% (n=2) and the overall MACE rate was 3% (n=2). There were no documented cases of acute vessel closure Conclusion The results from long term follow-up with this relatively new technology of DCB in treatment of side-branch in true bifurcation is encouraging. We have demonstrated low rates of hard endpoints, TLR and MACE rates despite complex group of patients (61% ACS, 52% diabetics and 32% CKD). These results are encouraging, but going forward, we need more data from larger patient trials. In the meanwhile our data should instil confidence to adopt this technology in clinical practice. Funding Acknowledgement Type of funding sources: None.

Clinical outcomes in percutaneous coronary interventions with polymer-free vs. durable-polymer stents: a metanalysis of randomized clinical trials

Abstract Background Polymer-free (PF) stents were designed as an alternative to durable-polymer (DP) drug-eluting stents to minimize the time on dual antiplatelet treatment for patients at high-risk of bleeding. Nonetheless, the efficacy and safety of PF vs. DP stents in patients undergoing percutaneous coronary intervention (PCI) remain controversial. Methods We performed a metanalysis with currently available studies that assessed the effect of PF-stents vs. DP-stents after performing a systematic search. The endpoints analyzed were all-cause death, myocardial infarction, target lesion revascularization (TLR) and probable or definite stent thrombosis. The raw numbers of incident end-points reported in each study were used. We performed analyses in short and long term (<1 or >1 year follow-up) studies. Results We included 12464 patients from 8 studies (5 short-term and 3 long-term): 6723 treated with PF-stents and 5741 with DP stents. Females represented 23.3% (n=3284) and 33.7% (n=4202) were included in the setting of acute coronary syndromes. As shown in the figure, PF-stents were associated to lower incidence of all-cause mortality (HR: 0.91 95% CI 0.84–0.98; p=0.016) and TLR (HR: 0.88 95% CI 0.80–0.96; p=0.003). No differences were observed in the risk of cardiovascular death (HR: 0.96 95% CI 0.86–1.06 p=0.415), myocardial infarction (HR: 0.90 95% CI 0.80–1.01; p=0.061) or probable-definite stent thrombosis (HR: 0.92 95% CI 0.74–1.14; p=0.447). Finally, no differences in the primary end-point (HR: 0.92 95% CI 0.83–1.03; p=0.143) were detected with PF-stents vs. DP-stents. No significant heterogenicity was observed in any of the endpoints, except for the incidence of stent thrombosis. Conclusions Under current PCI techniques the use of PF-stent might be associated to better outcomes, especially in terms of all-cause mortality and TLR. Funding Acknowledgement Type of funding sources: None.

Long term clinical outcomes from use of Sirolimus coated balloon in coronary intervention; data from a real-world population

Abstract Background The use of drug coated balloons (DCBs) in coronary intervention is escalating. There are two drugs of choice for coating either DCBs or drug eluting stents: Paclitaxel or Sirolimus. Most available DCBs are coated with Paclitaxcel, due to pre-existing, extensive data that support good clinical outcomes. With drug eluting stents both the literature and hence clinical practice favour Sirolimus over Paclitaxcel. This is due the cytostatic properties and wide therapeutic window of Sirolimus. However, there is very limited data on Sirolimus coated balloons (SCBs). We report a long-term follow-up with this relatively new technology from our centre. Methods A retrospective analysis was conducted on all patients treated with an SCB between March 2018 and October 2020. Follow-up was achieved with clinic visits, telephone calls and admission records. The outcomes measured include cardiac death, target-vessel myocardial-infarction (TVMI), target lesion revascularisation (TLR) and MACE (combination of cardiac death, target-vessel MI and TLR). Results 533 patients (690-lesions) with a mean age of 65.4 (range; 37–90) were treated with an SCB. 79% (n=419) were male, 314 (59%) were in the setting of acute coronary syndrome, 40% (n=211) had diabetes and 60% (n=414) had DCB in de-novo lesions. Small vessels accounted for 59% of cases (n=406). Pre-dilatation was performed in 97% (n=670) of cases. Bailout stenting (with a drug eluting stent) was required in 6.5% lesions (n=45), of which 11 were due to dissections and 34 were due to >50% recoil following DCB use. The mean diameter and length of DCBs were 2.8 mm and 26.3 mm respectively. During a median follow-up of 572 days (IQR: 381 - 868); cardiac death occurred in 15 patients (3%). Target vessel MI was in 4%; n=21, TLR per lesion and per patient were 10% (n=72 and n=55 respectively). The overall MACE rate was 12%. There were no documented cases of acute vessel closure. Conclusions The results from long term follow-up with this relatively new technology DCB are encouraging with low rates of hard endpoints and acceptable rates of TLR and MACE despite complex group of patients (59% ACS and 40% diabetics) and lesion subsets (40% restenotic lesions and 59% small vessels). However, in order to further inform clinical practice, more longer-term data on SCBs compared with Paclitaxel coated balloons is needed. Funding Acknowledgement Type of funding sources: None.

ATRIAL FIBRILLATION PATIENTS' EXPERIENCES WITH COMBINATION ANTITHROMBOTIC THERAPY POST-PERCUTANEOUS CORONARY INTERVENTION

BACKGROUND Up to 30% of patients with atrial fibrillation (AF) have coronary artery disease (CAD). Many undergo percutaneous coronary intervention (PCI), requiring antithrombotic therapy (ATT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor to prevent stent thrombosis, combined with warfarin or a direct oral anticoagulant (DOAC) for stroke prevention (triple therapy). In the setting of acute coronary syndrome (ACS) with PCI, or elective PCI with high-risk features, Canadian AF guidelines recommend limiting ASA to 30 days post-PCI, as continuation of triple therapy beyond 30 days results in increased bleeding without reduction in ischemic outcomes. They also recommend 1-12 months of clopidogrel, and oral anticoagulation with doses that may change through the 12 months post-PCI. The complexity of these regimens may contribute to unintended modifications, increasing the risk of thrombosis and/or bleeding. Our goal was to describe patient experiences with combination ATT, including unplanned modifications, after discharge from acute care. METHODS AND RESULTS This is a prospective, observational study of patients with documented AF requiring OAC, who underwent PCI and were discharged on combination ATT. Patients were contacted at 1-, 3-, 6-, and 12-months post-PCI. Fifty-eight patients have been enrolled (January 2020-April 2021) with data from at least 1 time point available for 55 patients (Table 1). Of these, 31 (56.4%) experienced at least one unplanned modification to ATT and 15 (27.3%) experienced more than one. Forty-five (81.8%) of the 55 patients were discharged with a plan for triple therapy. In 18 patients (40.0%), the original plan was to stop ASA at 1-month post-PCI; 7 (38.9%) did not stop as directed. Nine patients (20.0%) had ASA stopped prior to the intended stop date by a prescriber. Of the 31 patients with at least one modification, 9 (29.0%) experienced a modification to clopidogrel which was a prolonged duration in 5 patients; prescriber-driven in 2. Eighteen (58.1%) patients experienced modifications related to oral anticoagulants; 4 in 10 (40.0%) warfarin-treated patients and 14 in 45 (31.1%) DOAC-treated patients. Of all patients with at least one modification, 15 (48.4%) experienced a bleeding event that was either a reason for, or due to, an unplanned ATT modification. CONCLUSION More than 1 in 2 patients with AF undergoing PCI experienced an unplanned modification to their ATT and half of those were associated with bleeding. This underscores the challenges of managing combination ATT for patients and clinicians alike and emphasizes the need for follow up and patient support after discharge. Up to 30% of patients with atrial fibrillation (AF) have coronary artery disease (CAD). Many undergo percutaneous coronary intervention (PCI), requiring antithrombotic therapy (ATT) with acetylsalicylic acid (ASA) and a P2Y12 inhibitor to prevent stent thrombosis, combined with warfarin or a direct oral anticoagulant (DOAC) for stroke prevention (triple therapy). In the setting of acute coronary syndrome (ACS) with PCI, or elective PCI with high-risk features, Canadian AF guidelines recommend limiting ASA to 30 days post-PCI, as continuation of triple therapy beyond 30 days results in increased bleeding without reduction in ischemic outcomes. They also recommend 1-12 months of clopidogrel, and oral anticoagulation with doses that may change through the 12 months post-PCI. The complexity of these regimens may contribute to unintended modifications, increasing the risk of thrombosis and/or bleeding. Our goal was to describe patient experiences with combination ATT, including unplanned modifications, after discharge from acute care. This is a prospective, observational study of patients with documented AF requiring OAC, who underwent PCI and were discharged on combination ATT. Patients were contacted at 1-, 3-, 6-, and 12-months post-PCI. Fifty-eight patients have been enrolled (January 2020-April 2021) with data from at least 1 time point available for 55 patients (Table 1). Of these, 31 (56.4%) experienced at least one unplanned modification to ATT and 15 (27.3%) experienced more than one. Forty-five (81.8%) of the 55 patients were discharged with a plan for triple therapy. In 18 patients (40.0%), the original plan was to stop ASA at 1-month post-PCI; 7 (38.9%) did not stop as directed. Nine patients (20.0%) had ASA stopped prior to the intended stop date by a prescriber. Of the 31 patients with at least one modification, 9 (29.0%) experienced a modification to clopidogrel which was a prolonged duration in 5 patients; prescriber-driven in 2. Eighteen (58.1%) patients experienced modifications related to oral anticoagulants; 4 in 10 (40.0%) warfarin-treated patients and 14 in 45 (31.1%) DOAC-treated patients. Of all patients with at least one modification, 15 (48.4%) experienced a bleeding event that was either a reason for, or due to, an unplanned ATT modification. More than 1 in 2 patients with AF undergoing PCI experienced an unplanned modification to their ATT and half of those were associated with bleeding. This underscores the challenges of managing combination ATT for patients and clinicians alike and emphasizes the need for follow up and patient support after discharge.

Differential Impact of Type 1 and Type 2 Diabetes Mellitus on Outcomes Among 1.4 Million US Patients Undergoing Percutaneous Coronary Intervention

BackgroundThe aim was to determine the impact of diabetes mellitus (DM) on outcomes after percutaneous coronary intervention (PCI). There is limited data on the impact of DM and its subtypes among patients who underwent PCI during hospitalization. MethodsAll PCI hospitalizations from the National Inpatient Sample (October 2015–December 2018) were stratified by the presence and subtype of DM. Multivariable logistic regression was performed to determine the adjusted odds ratios (aOR) of in-hospital adverse outcomes in type 1 DM (T1DM) and type 2 DM (T2DM) compared to no-DM. ResultsOut of 1,363,800 individuals undergoing PCI, 12,640 (0.9%) had T1DM and 539,690 (39.6%) had T2DM. T1DM patients had increased aOR of major adverse cardiovascular and cerebrovascular events (MACCE) (1.26, 95%CI 1.17–1.35), mortality (1.56, 95%CI 1.41–1.72), major bleeding (1.63, 95%CI 1.45–1.84), and stroke (1.75, 95%CI 1.51–2.02), while T2DM patients had only increased aOR of MACCE (1.02, 95%CI 1.01–1.04), mortality (1.10, 95%CI 1.08–1.13) and stroke (1.22, 95%CI 1.18–1.27), compared to no-DM patients. However, both T1DM and T2DM had lower aOR of cardiac complications (0.87, 95%CI 0.77–0.97 and 0.87, 95%CI 0.85–0.89, respectively), in comparison to no-DM patients. When accounting for the indication, both DM subgroups had higher aOR of MACCE, mortality, and stroke compared to no-DM patients in the acute coronary syndrome setting (p < 0.001, for all), while only increased aOR of stroke (1.59, 95%CI 1.17–2.15 for T1DM and 1.12, 95%CI 1.05–1.20 for T2DM) persisted in the elective setting. ConclusionsPatients with DM who have undergone PCI during hospitalization are more likely to experience adverse in-hospital outcomes, and T1DM patients are a particularly high-risk cohort.

Cardiogenic Shock in the Setting of Acute Coronary Syndrome: Predictive Factors and Outcomes in a Moroccan population

Introduction: Cardiogenic shock (CS) is a life-threatening complication in patients with acute coronary syndrome (ACS), and its development can be unpredictable. The aim of this study was to find independent predictive factors of CS in a Moroccan cohort of ACS patients. Methods: This was a retrospective, comparative, and analytical monocentric study, including 319 ACS patients admitted between January 2018 to April 2021 in MVMIH’s cardiology center. Patients who presented with CS on admission were excluded from the study. This population was divided into two groups: the « shock » group patients eventually developed in-hospital CS and the « no shock » group which did not, and we compared overall patient characteristics and outcomes. Results: 319 ACS patients were included, among them 21 (6,6%) developed CS. Overall, the strongest predictive factors included the presence of acute heart failure on admission (OR = 14,83; 95% CI = 5,45 – 40,32; p &lt; 0,001), GRACE score ≥ 140 (OR = 9,03; 95% CI = 3,20 – 25,46; p &lt; 0,001), left ventricular ejection fraction &lt; 50% (OR = 8,94; 95% CI = 3,08 – 19,53; p &lt; 0,001), eccentric left ventricular hypertrophy (OR = 9,78; 95% CI = 2,61 – 36,70; p &lt; 0,001), and right ventricular dysfunction (OR = 12,25; 95% CI = 2,55 – 58,93; p = 0,002). Complications were more prevalent in the « shock » group with a higher mortality rate of 57,1%. Conclusion: CS in the setting of ACS is correlated with poorer prognosis and higher late mortality, justifying adequate and early diagnosis and management in high-risk patients.

Feasibility and safety of minimal-contrast IVUS-guided rotational atherectomy for complex calcified coronary artery disease.

To assess the feasibility and safety of minimal-contrast percutaneous coronary intervention (PCI) using rotational atherectomy (RA) in patients with severe coronary calcification at high-risk of contrast-associated acute kidney injury (AKI). Twenty-six patients with advanced chronic kidney disease undergoing PCI with RA at three high-volume centres were included. Baseline intravascular ultrasound (IVUS) was performed to assess lesion morphology, and to guide burr-, balloon-, and stent-selection. Final result was assessed by IVUS and angiographically. Feasibility and safety were determined by procedural and in-hospital complications, and efficacy was assessed by freedom from contrast-associated AKI after PCI. Procedural and in-hospital outcome was compared to a propensity-matched population of standard RA PCI. Mean glomerular filtration rate was 32 ± 17ml/min/1.73m2. In seven cases PCI was performed in the setting of acute coronary syndrome. The left main coronary artery was treated in 27.8% and a two-stent bifurcation technique in 44.4%. RA was more often performed electively compared to the standard RA cohort (92.3 vs. 50%; p = 0.0016). Angiographic success was achieved in 100% and documented with a median contrast amount of 12.5ml [Range 4-43]. No in-hospital death or myocardial infarction was reported. Contrast-associated AKI occurred in one patient versus five patients in standard RA group (p = 0.19). Shorter fluoroscopy time and lower radiation dose were achieved as compared to standard RA. A minimal-contrast RA approach with IVUS-guidance for treatment of complex calcified coronary lesions is feasible and safe with high success rate.

Antithrombotic Therapy After Percutaneous Coronary Intervention in Patients With Atrial Fibrillation: Findings From the CONNECT AF+PCI Study

BackgroundIn patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), selecting an antithrombotic regimen requires balancing risks of ischemic cardiac events, stroke, and bleeding. MethodsWe studied 467 patients with AF undergoing PCI in the time period from December 2015 to July 2018 identified via a chart audit by 47 Canadian cardiologists in the CONNECT AF+PCI (the Coordinated National Network to Engage Interventional Cardiologists in the Antithrombotic Treatment of Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) study, to determine patterns of initial antithrombotic therapy selection. ResultsThe median (25th, 75th percentile) CHADS2 score was 2 (1, 3), and PCI was performed in the setting of acute coronary syndrome in 62.1%. Triple antithrombotic therapy (TAT) was the initial treatment in 62.7%, dual-pathway therapy in 25.7%, and dual antiplatelet therapy in 11.6%, with a temporal increase in use of dual-pathway therapy during the course of the study; median intended TAT duration was 1 (1, 3) month. Compared with patients selected for TAT, patients selected for dual-pathway therapy were less likely to have prior myocardial infarction (35.8% vs 25.8%, P = 0.045) and prior PCI (33.8% vs 23.3%, P = 0.03), and they received shorter total length of stents (38 [23, 56] vs 30 [20, 46] mm, P = 0.03). Patients selected for dual-pathway therapy had a higher prevalence of prior stroke/transient ischemic attack (13.0% vs 23.3%, P = 0.01). There was no difference in prevalence of anemia (21.5% vs 25.8%, P = 0.30). Use of dual-pathway therapy was similar among patients with acute coronary syndrome and those with stable disease (24.1% vs 28.2%, P = 0.32). ConclusionsApproximately one-quarter of AF patients undergoing PCI are treated with dual-pathway therapy in Canadian practice, with its use increasing during the studied period. Patients selected for dual-pathway therapy have less-complex coronary disease history and intervention.

Feasibility and safety of cangrelor in patients with suboptimal P2Y12 inhibition undergoing percutaneous coronary intervention: rationale of the Dutch Cangrelor Registry

BackgroundDespite the advances of potent oral P2Y12 inhibitors, their onset of action is delayed, which might have a negative impact on clinical outcome in patients undergoing percutaneous coronary intervention (PCI). Trials conducted in the United States of America have identified cangrelor as a potent and rapid-acting intravenous P2Y12 inhibitor, which has the potential of reducing ischemic events in these patients without an increase in the bleeding. As cangrelor is rarely used in The Netherlands, we conducted a nationwide registry to provide an insight into the use of cangrelor in the management of patients with suboptimal platelet inhibition undergoing (primary) PCI (the Dutch Cangrelor Registry).Study designThe Cangrelor Registry is a prospective, observational, multicenter, single-arm registry with cangrelor administered pre-PCI in: (1) P2Y12 naive patients with ad-hoc PCI, (2) patients with STEMI/NSTEMI with suboptimal P2Y12 inhibition including (3) stable resuscitated/defibrillated patients with out-of-hospital cardiac arrest (OHCA) due to acute ischemia and (4) STEMI/NSTEMI patients with a high thrombotic burden. Primary endpoint is 48 h Net Adverse Clinical Events (NACE), which is a composite endpoint of all-cause death, recurrent myocardial infarction (MI), target vessel revascularization (TVR), stroke, stent thrombosis (ST) and BARC 2-3-5 bleeding.SummaryThe Dutch Cangrelor Registry will assess the feasibility and safety of cangrelor in patients with suboptimal P2Y12 inhibition undergoing (primary) PCI in the setting of acute coronary syndrome (ACS) and stable coronary artery disease (CAD) in the Netherlands.

In-hospital outcomes of sustained ventricular tachycardia in the setting of Acute Coronary Syndrome

Abstract Funding Acknowledgements Type of funding sources: None. OnBehalf on behalf of the Investigators of " Portuguese Registry of ACS " Introduction Sustained ventricular tachycardia (SVT) complicates up to 20% of acute coronary syndromes (ACS) and it is, therefore, important to access its impact on prognosis and identify patients with higher risk of SVT. Objective To evaluate predictors of early onset (&amp;lt;48h) and late onset (≥48h) SVT. Methods Based on a multicenter retrospective study, data collected from admissions between 1/10/2010 and 4/09/2019. Patients (pts) were divided in two groups (G): A – pts that presented early onset SVT (ESVT), and B – pts that presented late onset SVT (LSVT). Pts without data on previous cardiovascular history or uncompleted clinical data were excluded. Logistic regression was performed to assess predictors of SVT in ACS. Results Between 29851 pts with ACS, 364 (1.2%) presented SVT. ESVT – 251 pts (69%); LSVT – 91 pts (25%). LSVT G was older (74 ± 13 vs 68 ± 14, p = 0.003), was admitted directly to cat lab less frequently (10.1% vs 24.8%, p = 0.003), had longer times from first symptoms to admission (440min vs 261 min, p &amp;lt; 0.001) and had higher rates of previous stroke (14.4% vs 6.8%, p = 0.028). LSVT G had higher rates of non-ST-elevation myocardial infarction (MI) (35.2% vs 23.1%, p = 0.025) and lower rates of ST-elevation MI (53.8% vs 71.7%, p = 0.002), although both G were similar regarding MI location (anterior – p = 0.135, inferior – p = 0.097). LSVT G had higher systolic blood pression (130 ± 33 vs 122 ± 33, p = 0.050), presented more frequently in Killip-Kimball class ≥2 (52.5% vs 35.5%, p = 0.005) and with atrial fibrillation (21.2% vs 12.4%, p = 0.045), and had higher brain-natriuretic peptide (1075 vs 329, p &amp;lt; 0.001). LSVT G was treated more frequently with diuretics (80.0% vs 47.8%, p &amp;lt; 0.001), amiodarone (62.2% vs 48.8%, p = 0.029), digoxin (8.9% vs 2.4%, p = 0.013) and levosimendan (11.1% vs 2.8%, p = 0.004). ESVT G had higher rates of performed coronarography (88.4% vs 79.1%, p = 0.028) but lower rate of 3 vessels disease (58.5% vs 70.8%, p = 0.017). LSVT G had higher rates of severe (&amp;lt;30%) left ventricle dysfunction (32.9% vs 15.4%, p &amp;lt; 0.001) and need to non-invasive ventilation (23.1% vs 6.8%, p &amp;lt; 0.001). Regarding in-hospital complications, ESVT G had higher rates of heart failure (34.7% vs 19.1%, p = 0.006), atrioventricular block (15.7% vs 1.1%, p &amp;lt; 0.001), atrial fibrillation (20.4% vs 7.7%, p = 0.006) and major haemorrhage (5.2% vs 0.0%, p = 0.024). LSVT G had higher rates of in-hospital death (44.4% vs 20.9%, p &amp;lt; 0.001) and in-hospital stay (14 days vs 7 days, p &amp;lt; 0.001). The G were similar regarding re-infarction (p = 0.216), shock (p = 0.179), mechanical complications (p = 1.00), cardiac arrest (p = 0.097) and stroke (0.348) rates. Logistic regression confirmed ESVT was predictive in-hospital heart failure (p = 0.010, OR 2.67) and de novo AF (p = 0.001, OR 5.56), whether LSVT was predictive of in-hospital death (p = 0.002, OR 2.70). Conclusion LSVT was associated with higher rates of in-hospital complications, but ESVT was associated with higher in-hospital mortality.

Catheter Selection and Angiographic Views for Anomalous Coronary Arteries: A Practical Guide.

Although congenital coronary artery anomalies are relatively rare, they are the second most common cause of sudden cardiac death among young athletes. When encountered in the cardiac catherization laboratory, they are often challenging to selectively engage, requiring multiple catheters, plus increased contrast volume and radiation exposure. In the setting of acute coronary syndromes, it is not infrequent that percutaneous intervention is delayed because of the inability to engage an anomalous coronary artery. The aim of this review is to provide a comprehensive and concise overview of coronary artery anomalies, with particular attention to diagnostic and guide catheter selection for each type of anomaly and recommendations on how to recognize the vessel course angiographically.

IN-HOSPITAL BLOOD PRESSURE VARIABILITY AS A PREDICTOR OF CARDIOVASCULAR EVENTS AND RENAL DYSFUNCTION IN THE SETTING OF ACUTE MYOCARDIAL INFARCTION

Abstract Objective: Recent data have associated blood pressure variability (BPV) with cardiovascular morbidity and renal dysfunction but not in the setting of acute coronary syndrome (ACS). The aim of this study is to determine the impact short-term BPV on in-hospital cardiovascular outcomes and renal function in patients suffering a myocardial infarction (MI). Design and method: A total population of 250 MI patients (79.6% male; mean age 62.5 years;68.4% hypertensives)underwent 24-h ambulatory BP measurement during their hospitalization. The parameters of BPV analyzed were: a) 24-h standard deviation (SD), b) coefficient of variation (CV) and c) average real variability (ARV) of systolic and diastolic BP. The study population was divided intoa STEMI (n = 127) and a non-STEMI (n = 123) group. Cardiovascular outcomes included: new onset of ACS, pulmonary edema, hypertensive emergency, life threatening arrhythmias,whereas worsening of renal function (WRF) was defined as a reduction of GFR &gt; or = 25% according to the RIFLE criteria. No deaths or strokes occurred. Results: In the total population a significant association was demonstrated between SBP CV andthe incidence of cardiovascular outcomes (OR = 1.136; 95% CI: 0.452–1.819; P = 0.001). After separate analysis for each MI group, SBP CV remained a predictor in the STEMI group (OR = 1.825; 95% CI: 0.814–2.835; P = 0.001). Regarding WRF CV SBP demonstrated a prognostic role (OR = 1.946; 95% CI:0.923–2.969; P &lt; 0.001)in the entire population. Results for STEMI group were similar (OR = 3.769; 95% CI:2.056–5.481; P &lt; 0.001). However, non-STEMI group failed to demonstrate any significant associations. We therefore, conducted multivariate regression models for STEMI group, in which the CV SBP retained predictive value of cardiovascular outcomes (OR = 1.502; 95% CI:0.470–2.534; P = 0.005) and WRF (OR = 4.139; 95% CI:2.423–5.962; P &lt; 0.001)independently of age, gender, history of hypertension, diabetes mellitus (DM), smoking and low-density lipoprotein (LDL-C). Conclusions: In the setting of STEMI, assessment of BPV using CV could have a prognostic role of in-hospital cardio-renal outcomes suggesting a clinical need for further individualization of BP regulation in the integrative ACS management.

Multimodality imaging results of neointimal healing after magnesium scaffold implantation in an acute coronary syndrome setting.

Multimodality imaging results of neointimal healing after magnesium scaffold implantation in an acute coronary syndrome setting.

Feasibility and diagnostic reliability of quantitative flow ratio in the assessment of non-culprit lesions in acute coronary syndrome

Several studies have demonstrated the feasibility and safety of hemodynamic assessment of non-culprit coronary arteries in setting of acute coronary syndromes (ACS) using fractional flow reserve (FFR) measurements. Quantitative flow ratio (QFR), recently introduced as angiography-based fast FFR computation, has been validated with good agreement and diagnostic performance with FFR in chronic coronary syndromes. The aim of this study was to assess the feasibility and diagnostic reliability of QFR assessment during primary PCI. A total of 321 patients with ACS and multivessel disease, who underwent primary PCI and were planned for staged PCI of at least one non-culprit lesion were enrolled in the analysis. Within this patient cohort, serial post-hoc QFR analyses of 513 non-culprit vessels were performed. The median time interval between primary and staged PCI was 49 [42–58] days. QFR in non-culprit coronary arteries did not change between acute and staged measurements (0.86 vs 0.87, p = 0.114), with strong correlation (r = 0.94, p ≤ 0.001) and good agreement (mean difference -0.008, 95%CI -0.013–0.003) between measurements. Importantly, QFR as assessed at index procedure had sensitivity of 95.02%, specificity of 93.59% and diagnostic accuracy of 94.15% in prediction of QFR ≤ 0.80 at the time of staged PCI. The present study for the first time confirmed the feasibility and diagnostic accuracy of non-culprit coronary artery QFR during index procedure for ACS. These results support QFR as valuable tool in patients with ACS to detect further hemodynamic relevant lesions with excellent diagnostic performance and therefore to guide further revascularisation therapy.

Effect of Diabetes on Laboratory Markers in Patients with Non-ST Elevation Acute Coronary Syndromes

Background: Diabetic population are at high cardiovascular risk especially in the setting of acute coronary syndromes. This study aimed to investigate the role of diabetes in affecting the main biochemical and haematological markers in patients with non-ST elevation acute coronary syndromes (NSTE-ACS). Methods: A multicentre cross-sectional study recruited patients who were admitted and diagnosed as NSTE-ACS, data were collected from patients using a prepared printed form that recorded patients′ age, comorbidities and results of investigations. Patients were categorized into diabetics and non-diabetics. Results: Ninety-nine patients were enrolled, 39.4% were diabetic, mean age of diabetics was (61.3±10.9) years vs (57.7±12.6) years in non-diabetics, diabetic patients were more to be females 23.1% vs 21.7%, more to have IHD history 58.97% vs 35%, more be hypertensive 69.2% vs 55%, less to be smokers 33.3% vs 38.3% and hyperlipidaemic 30.8% vs 33.3% when compared to non-diabetic counterparts, however, the differences in baseline characteristics between the two groups did not reach statistical significance apart from the more reported history of IHD in diabetics; p=0.019. Diabetic patients tend to be presented more with dyspnoea compared to non-diabetics 41% vs 26.7%. Positive troponin was more to be positive in diabetics (48.7% vs 40%), diabetic patients tend to have higher urea (46.2±19.2 vs 39.6±23.6) and higher creatinine (1.07±0.37 vs 0.95±0.37). Random blood sugar (268.3±115 vs 125.5±50.2, p<0.001) and serum potassium (4.4±0.63 vs 4.12±0.52, p=0.015) were significantly higher in diabetic patients. Conclusion: Apart from higher blood glucose and serum potassium levels, in the setting of NSTE-ACS; presence of diabetes has no remarkable impact on biochemical and haematological markers when compared to non-diabetic population. This needs larger studies in the future to validate these findings and to assess the prognostic significance of laboratory markers in diabetics with acute coronary syndromes especially in low-resources countries where more sophisticated markers are not feasible.

Managing inpatient hyperglycaemia and initiating sodium-glucose cotransporter 2 inhibitor therapy in the setting of diabetes and acute coronary syndrome.

We previously showed that implementing algorithms for managing diabetes in acute coronary syndrome was associated with improved inpatient glycaemic control and increased sodium-glucose cotransporter 2 (SGLT2) inhibitor prescriptions. The present study performed 1 year later found that inpatient hyperglycaemia had relapsed to pre-intervention rates, although SGLT2 inhibitor prescriptions remained increased. We discuss the challenges of improving inpatient glycaemic control.

Patients Living with HIV and Coronary Disease: Are we Using Appropriate Anti platelets as Part of Dual Antiplatelet Therapy?

Background: People living with HIV (PLHIV) have a higher incidence of cardiovascular disease and complications after intervention, including in-stent thrombosis. The frequency of potential drug-drug interactions in the setting of acute coronary syndrome (ACS) with antiretroviral therapy (ART) and dual-antiplatelet therapy (DAPT) regimens remains unclear. We sought to determine the frequency of potential drug-drug interactions in a cohort of people living with HIV who were investigated for coronary disease and initiated on DAPT as per Australian ACS Guidelines. Methods: A retrospective audit was performed in a single tertiary hospital in PLHIV presenting with symptomatic coronary artery disease (CAD) receiving DAPT. Patients were grouped based on exposure to a protease inhibitor or efavirenz and etravirine, given that these were found to have the greatest potential interactions with DAPT. Results: Fifty-three patients received DAPT, of which 31 (58%) had a potential drug-drug interaction. Clopidogrel was the most frequent P2Y12 inhibitor prescribed, accounting for 47 (87%) of the interactions. Twenty-six patients were on a protease inhibitor, of which 21 (81%) had a potential drug-drug interaction. There were 11 instances of efavirenz and 3 of etravirine use, of which all resulted in potential drug-drug interactions (100%, respectively). Conclusion: Potential drug-drug interactions were very common in PLHIV needing DAPT. The widespread use of clopidogrel in DAPT regimens resulted in a high rate of drug-drug interactions. An awareness of interactions and guidelines around P2Y12 inhibitor selection may help reduce the rate of in-stent thrombosis for PLHIV and improve clinical outcomes.

Prevalence, clinical determinants and prognostic implications of coronary procedural complications of percutaneous coronary intervention in non-ST-segment elevation myocardial infarction: Insights from the contemporary multinational TAO trial

Few data are available on procedural complications of percutaneous coronary intervention (PCI) in the setting of acute coronary syndrome in the contemporary era. We sought to describe the prevalence of procedural complications of PCI in a non-ST-segment elevation acute coronary syndrome (NSTE ACS) cohort, and to identify their clinical characteristics and association with clinical outcomes. Patients randomized in TAO (Treatment of Acute coronary syndrome with Otamixaban), an international randomized controlled trial (ClinicalTrials.gov Identifier: NCT01076764) that compared otamixaban with unfractionated heparin plus eptifibatide in patients with NSTE ACS who underwent PCI, were included in the analysis. Procedural complications were collected prospectively, categorized and adjudicated by a blinded Clinical Events Committee, with review of angiograms. A multivariable model was constructed to identify independent clinical characteristics associated with procedural complications. A total of 8656 patients with NSTE ACS who were enrolled in the TAO trial underwent PCI, and 451 (5.2%) experienced at least one complication. The most frequent complications were no/slow reflow (1.5%) and dissection with decreased flow (1.2%). Procedural complications were associated with the 7-day ischaemic outcome of death, myocardial infarction or stroke (24.2% vs. 6.0%, odds ratio 5.01, 95% confidence interval 3.96-6.33; P<0.0001) and with Thrombolysis In Myocardial Infarction major and minor bleeding (6.2% vs. 2.3%, odds ratio 2.79, 95% confidence interval 1.86-4.2; P<0.0001). Except for previous coronary artery bypass grafting, multivariable analysis did not identify preprocedural clinical predictors of complications. In a contemporary NSTE ACS population, procedural complications with PCI remain frequent, are difficult to predict based on clinical characteristics, and are associated with worse ischaemic and haemorrhagic outcomes.

Colchicine Use in Acute Coronary Syndromes: An Update.

Coronary artery disease is the leading cause of death worldwide, and its main pathological substrate is represented by atherosclerosis. Inflammation is a major promoter of the atherosclerotic process and is involved in both the initiation and progression of atherosclerosis, as well as in the occurrence of fatal complications. Until the present moment, Colchicine Cardiovascular Outcomes Trial is the largest trial to demonstrate a major benefit of low-dose colchicine on major adverse cardiac events in patients with recent myocardial infarction (MI), but the mechanisms behind this relation are not completely known. The purpose of this review is to emphasize the possible pathways through which colchicine improves the clinical outcomes in the acute setting of acute coronary syndromes by referring to the results of the studies published in the past 5 years. Aside from its stated systemic anti-inflammatory effect, colchicine could be a valuable addition to the therapeutic approach of acute MI by reducing the infarct size, stabilizing the coronary plaque, as well as reducing platelet aggregation. Moreover, colchicine may improve endothelial function, reduce the transcoronary release of cytokines, and prevent a rise in inflammatory markers after percutaneous coronary intervention, thus diminishing the residual inflammatory risk.