Urgent Percutaneous Coronary Intervention Research Articles

EXPLORATORY ANALYSIS OF URINE PO2 PERI-PROCEDURAL KINETICS AND CI-AKI PROGNOSTIC ABILITIES IN PATIENTS UNDERGOING PCI.

Novel contrast-induced acute kidney injury (CI-AKI) biomarkers are needed to detect earlier and with greater precision the pathophysiological changes in renal medulla associated with kidney damage. We prospectively assessed the kinetics of urine oxygen tension (PO2) in control healthy individuals, and its prognostic ability for CI-AKI in patients undergoing percutaneous coronary intervention (PCI). We enrolled 202 consecutive patients (78% men, mean age 66±10 years) treated with elective or urgent PCI. PO2 was measured using a point-of-care (POC) standard blood gas analyzer at 3 time points (baseline, post -within 3 hours- PCI and at 24 hours post PCI) in urine samples. CI-AKI was defined as an increase of ≥25% or ≥0.5 mg/dl in pre-PCI serum creatinine at 48 hours post PCI. Between baseline and post-PCI measurements, patients without CI-AKI showed a decrease of -37 (36) mmHg in PO2 urine levels whereas patients with CI-AKI showed a decrease of only -23 (38) mmHg. (P=0.014). Using ROC analysis, percentage change in urine PO2 immediately after PCI relative to baseline levels, significantly predicted CI-AKI (AUC 0.804 95%CI 0.717-0.892). A significant drop in urine oxygen tension appears as a normal response of the kidney medulla to an acute insult (contrast media) immediately post PCI with a recovery to baseline levels 24 hours later. Absence or attenuation of this drop in urine oxygen tension could predict CI-AKI earlier and more precisely.

SEPTAL COLLATERAL PERFORATION COMPLICATED BY INTRAVENTRICULAR SEPTAL HEMATOMA: RESOLUTION BY COIL EMBOLIZATION

Abstract A 76–year–old man with effort angina was admitted to our cardiology department for an elective coronary angiography (CA). Diagnostic CA revealed severely calcified three–vessel coronary artery disease (CAD) with chronic total occlusions (CTO) of the right dominant coronary artery (RCA) and left circumflex artery (LCX), and severe calcific stenosis of the left descending artery (LAD). An urgent percutaneous coronary intervention (PCI) to treat the LAD was carried out because of ECG modifications and chest pain immediately after CA. During the procedure a septal collateral perforation occurred leading to abrupt development of a large intraventricular septal hematoma (IVSH). Urgent embolization of the culprit vessel with coils was performed using block and deliver (BAD) technique. Rapid hematoma expansion involved another proximal septal collateral. A prompt second coil embolization was carried out arresting the growth of the septal hematoma. The patient was discharged in stable condition and complete resolution of IVSH was confirmed by transthoracic echocardiogram two months later. Timely management of the septal perforation and close echocardiographic monitoring resulted in complete hematoma resolution and a satisfactory outcome.

Broken Heart! Surprised to Know Why!

A 70-year-old female attended the emergency department with cardiac sounding chest pain, cough, new concerning ECG changes and recent history of long flight. Her cardiac enzymes were elevated raising the suspicion of Acute Coronary syndrome. She was taken for urgent percutaneous coronary intervention which did not reveal any significant obstructive coronary artery disease however, ventriculogram revealed severe left ventricular systolic dysfunction (LVSD) with typical apical akinesis resembling takatsubo. A transthoracic echocardiogram confirmed severely reduced left ventricular ejection fraction. In addition, she was also treated for pneumonia which was the possible trigger of the event.

Impact of a Nationwide Medication History Sharing Program on the Care Process and End-User Experience in a Tertiary Teaching Hospital: Cohort Study and Cross-Sectional Study.

Timely and comprehensive collection of a patient's medication history in the emergency department (ED) is crucial for optimizing health care delivery. The implementation of a medication history sharing program, titled "Patient's In-home Medications at a Glance," in a tertiary teaching hospital aimed to efficiently collect and display nationwide medication histories for patients' initial hospital visits. As an evaluation was necessary to provide a balanced picture of the program, we aimed to evaluate both care process outcomes and humanistic outcomes encompassing end-user experience of physicians and pharmacists. We conducted a cohort study and a cross-sectional study to evaluate both outcomes. To evaluate the care process, we measured the time from the first ED assessment to urgent percutaneous coronary intervention (PCI) initiation from electronic health records. To assess end-user experience, we developed a 22-item questionnaire using a 5-point Likert scale, including 5 domains: information quality, system quality, service quality, user satisfaction, and intention to reuse. This questionnaire was validated and distributed to physicians and pharmacists. The Mann-Whiteny U test was used to analyze the PCI initiation time, and structural equation modeling was used to assess factors affecting end-user experience. The time from the first ED assessment to urgent PCI initiation at the ED was significantly decreased using the patient medication history program (mean rank 42.14 min vs 28.72 min; Mann-Whitney U=346; P=.03). A total of 112 physicians and pharmacists participated in the survey. Among the 5 domains, "intention to reuse" received the highest score (mean 4.77, SD 0.37), followed by "user satisfaction" (mean 4.56, SD 0.49), while "service quality" received the lowest score (mean 3.87, SD 0.79). "User satisfaction" was significantly associated with "information quality" and "intention to reuse." Timely and complete retrieval using a medication history-sharing program led to an improved care process by expediting critical decision-making in the ED, thereby contributing to value-based health care delivery in a real-world setting. The experiences of end users, including physicians and pharmacists, indicated satisfaction with the program regarding information quality and their intention to reuse.

Cost-Effectiveness of Fractional Flow Reserve–Guided Treatment for Acute Myocardial Infarction and Multivessel Disease

Complete revascularization by non-infarct-related artery (IRA) percutaneous coronary intervention (PCI) in patients with acute myocardial infarction is standard practice to improve patient prognosis. However, it is unclear whether a fractional flow reserve (FFR)-guided or angiography-guided treatment strategy for non-IRA PCI would be more cost-effective. To evaluate the cost-effectiveness of FFR-guided compared with angiography-guided PCI in patients with acute myocardial infarction and multivessel disease. In this prespecified cost-effectiveness analysis of the FRAME-AMI randomized clinical trial, patients were randomly allocated to either FFR-guided or angiography-guided PCI for non-IRA lesions between August 19, 2016, and December 24, 2020. Patients were aged 19 years or older, had ST-segment elevation myocardial infarction (STEMI) or non-STEMI and underwent successful primary or urgent PCI, and had at least 1 non-IRA lesion (diameter stenosis >50% in a major epicardial coronary artery or major side branch with a vessel diameter of ≥2.0 mm). Data analysis was performed on August 27, 2023. Fractional flow reserve-guided vs angiography-guided PCI for non-IRA lesions. The model simulated death, myocardial infarction, and repeat revascularization. Future medical costs and benefits were discounted by 4.5% per year. The main outcomes were quality-adjusted life-years (QALYs), direct medical costs, incremental cost-effectiveness ratio (ICER), and incremental net monetary benefit (INB) of FFR-guided PCI compared with angiography-guided PCI. State-transition Markov models were applied to the Korean, US, and European health care systems using medical cost (presented in US dollars), utilities data, and transition probabilities from meta-analysis of previous trials. The FRAME-AMI trial randomized 562 patients, with a mean (SD) age of 63.3 (11.4) years. Most patients were men (474 [84.3%]). Fractional flow reserve-guided PCI increased QALYs by 0.06 compared with angiography-guided PCI. The total cumulative cost per patient was estimated as $1208 less for FFR-guided compared with angiography-guided PCI. The ICER was -$19 484 and the INB was $3378, indicating that FFR-guided PCI was more cost-effective for patients with acute myocardial infarction and multivessel disease. Probabilistic sensitivity analysis showed consistent results and the likelihood iteration of cost-effectiveness in FFR-guided PCI was 97%. When transition probabilities from the pairwise meta-analysis of the FLOWER-MI and FRAME-AMI trials were used, FFR-guided PCI was more cost-effective than angiography-guided PCI in the Korean, US, and European health care systems, with an INB of $3910, $8557, and $2210, respectively. In probabilistic sensitivity analysis, the likelihood iteration of cost-effectiveness with FFR-guided PCI was 85%, 82%, and 31% for the Korean, US, and European health care systems, respectively. This cost-effectiveness analysis suggests that FFR-guided PCI for non-IRA lesions saved medical costs and increased quality of life better than angiography-guided PCI for patients with acute myocardial infarction and multivessel disease. Fractional flow reserve-guided PCI should be considered in determining the treatment strategy for non-IRA stenoses in these patients. ClinicalTrials.gov Identifier: NCT02715518.

Quantitative Flow Ratio to Predict Non-Target-Vessel Events Before Planned Staged Percutaneous Coronary Intervention in Patients With Acute Coronary Syndrome.

The optimal time point of staged percutaneous coronary intervention (PCI) among patients with acute coronary syndrome (ACS) remains a matter of debate. Quantitative flow ratio (QFR) is a novel noninvasive method to assess the hemodynamic significance of coronary stenoses. We aimed to investigate whether QFR could refine the timing of staged PCI of non-target vessels (non-TVs) on top of clinical judgment for patients with ACS. For this cohort study, patients with ACS from Bern University Hospital, Switzerland, scheduled to undergo out-of-hospital non-TV staged PCI were eligible. The primary end point was the composite of non-TV myocardial infarction and urgent unplanned non-TV PCI before planned staged PCI. The association between lowest QFR per patient measured in the non-TV(from index angiogram) and the primary end point was assessed using multivariable adjusted Cox proportional hazards regressions with QFR included as linear or penalized spline (nonlinear) term. QFR was measured in 1093 of 1432 patients with ACS scheduled to undergo non-TV staged PCI. Median time to staged PCI was 28 days. The primary end point occurred in 5% of the patients. In multivariable analysis (1018 patients), there was no independent association between non-TV QFR and the primary end point (hazard ratio, 0.87 [95% CI, 0.69-1.05] per 0.1 increase; P=0.125; nonlinear P=0.648). In selected patients with ACS scheduled to undergo staged PCI at a median of 4 weeks after index PCI, QFR did not emerge as an independent predictor of non-TV events before planned staged PCI. Thus, this study does not provide conceptual evidence that QFR is helpful to refine the timing of staged PCI on top of clinical judgment. URL: https://www.clinicaltrials.gov; Unique identifier: NCT02241291.

Рrevention of contrast-induced nephropathy during interventional treatment of acute coronary syndrome

The aim of the work was to determine the risk factors of contrast-induced nephropathy in patients with acute coronary syndrome and to evaluate the effectiveness of methods of its prevention. There were examined 62 patients admitted to the interventional cardiology department during 9 months of routine practice with a diagnosis of acute coronary syndrome and concomitant chronic kidney disease. Among them, 56.45% have diabetic nephropathy, 21% – hypertensive nephro­pathy, 19.35% – chronic pyelonephritis, 3.2% – gouty nephropathy. According to the stages of chronic kidney disease: I stage – 8.1%, II stage – 46.8%, III A stage – 30.6%, III B stage – 14.5% of patients. The control group consisted of 32 patients with acute coronary syndrome without kidney pathology. All patients underwent urgent percutaneous coronary intervention using a water-soluble low-osmolarity radiocontrast medium. The risk of contrast-induced nephropathy was determined according to the Mehran scale. Contrast-induced nephropathy was diagnosed by an increase in serum creatinine over 24-48 hours by >25%. Prevention of contrast-induced nephropathy according to existing recommendations was carried out by prescribing early statin therapy and diuresis-controlled combined hydration in 22 patients with concomitant chronic kidney disease. Mathematical processing was performed using Statistica 8.0 software (StatSoft Inc, USA). Patients with chronic kidney disease had a high and very high risk of contrast-induced nephropathy in 19.4% and 3.2% of cases, among them in 91.6% of high and in 100% very high-risk contrast-induced nephropathy developed. Patients in the control group had a low to moderate risk, none of them developed contrast-induced nephropathy. It has been shown that the risk of contrast-induced nephropathy depends on the stage of chronic kidney disease and is associated with a decrease in the ejection fraction of the left ventricle (≤40%), acute left ventricle failure of the III and IV classes according to Killip, a decrease in diuresis in the first 12-24 hours after urgent percutaneous coronary intervention up to ≤0.6 ml/h/kg; in patients with diabetic nephropathy taking metformin 6-12 hours before the administration of the X-ray contrast medium and the glomerular filtration rate ≤45 ml/min./1.73 m2. In patients who underwent prevention of contrast-induced nephropathy in its entirety, its development was not registered.

STEMI patients after out-of-hospital cardiac arrest: should we cool?

Abstract Introduction Patients who have been successfully resuscitated after out-of-hospital cardiac arrest (OHCA) due to ST-segment elevation myocardial infarction (STEMI) have a high risk of death and poor neurological outcome. Application of therapeutic hypothermia (TTM) is recommended in addition to the reperfusion strategies in patients who remain comatose after resuscitation. However, data analysis in STEMI patients successfully resuscitated after OHCA who remain comatose are inconsistent and still a subject of discussion. Objective The aim of this research was to examine the impact of TTM on in-hospital survival and neurological outcome in comatose STEMI patients after OHCA. Methods The study was conducted as a retrospective observational analysis of data taken from a hospital OHCA registry. The examined sample consisted of 141 patients hospitalized from January 2007 to December 2021 due to STEMI complicated by OHCA and who remained comatose upon admission. Inclusion criteria for analysis were STEMI of any localisation and unresponsiveness on admission defined as Glasgow Coma Score (GCS) ≤ 8. Favorable neurological outcome was defined as Cerebral Performance Category Score (CPC) ≤ 2. Results Our research included 141 comatose survivors of OHCA due to STEMI, among whom 91 (64.5%) were men, and TTM was applied in 82 (58.2%) patients. Witnessed cardiac arrest (48.7% vs. 23.1%, p = 0.027), duration of resuscitation ≤ 20 minutes (66.1% vs. 28.4%, p < 0.0005), initial shockable rhythm (55.2% vs. 22.9%, p = 0.001) and performed urgent percutaneous coronary intervention (PCI) (56.2% vs. 23.1%, p < 0.0005) had a statistically significant influence on in-hospital survival, while good neurological recovery was influenced only by the duration of resuscitation ≤ 20 minutes (69.2% vs. 36.7%, p = 0.008). TTM was applied more often when the resuscitation lasted ≤ 20 minutes (51.2% vs. 29.3%, p = 0.015), with an initial shockable rhythm (85.4% vs. 14.6%, p < 0.0005) and when urgent PCI was performed (82.9% vs. 35.6%, p < 0.0005). TTM had a statistically significant effect on in-hospital survival (58.5% vs. 23.7%, p < 0.0005), while it had no effect on favorable neurological outcome (54.7% vs. 56.3%, p = 1.000). Conclusion In our examined group of STEMI patients successfully resuscitated after OHCA who remained comatose at admission, TTM significantly improved in-hospital survival, but had no effect on favorable neurological outcome.

Pattern of dual antiplatelet use and 12-month outcomes stratified by bleeding and ischemic risk in acute coronary syndrome patients undergoing percutaneous coronary intervention

Abstract Background There is a need to understand real-world antiplatelet usage in different risk group patients to provide insights into personalised approach to acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Purpose We aimed to evaluate patterns and outcomes of antiplatelet therapy use in ACS patients undergoing PCI according to their bleeding and ischemic risks. Methods We retrospectively analysed 3,577 consecutive ACS patients who underwent urgent or emergent PCI from 16 hospitals in between Jan 2016 to Dec 2020. Patients were stratified according to their (i) bleeding risk using PRECISE-DAPT score ≥25 as high (HBR) and <25 as low bleeding risk (LBR) and further by (ii) ischemic risk if any one of the following: diffuse multi-vessel disease, chronic kidney disease, ≥3 stents implanted or lesions treated, total stented length >60mm, chronic total occlusion and history of STEMI is present as high ischemic risk (HIR) or absent as low ischemic risk (LIR). Pattern of dual-antiplatelet (aspirin plus clopidogrel or ticagrelor) use and 12-month outcomes including major bleeding, recurrent MI and cardiovascular (CV) death were compared between HBR, LBR, HIR and LIR groups. Independent predictors of antiplatelet therapy use and clinical events were identified using multi-variate analysis. Results Of 3,577 patients, 25.6% (n=914) are HBR and 74.4% (n=2663) LBR. 86.5% (793/914) of HBR patients also had HIR. Overall usage of aspirin plus clopidogrel was 48.4% and ticagrelor 48.3%. Usage of ticagrelor was significantly higher in LBR (54.0%) compared to HBR (31.8%) patients (p<0.01) but not significantly different between HIR (30.4%) and LIR (41.3%) patients (p=NS). HBR was an independent predictor against ticagrelor use with odds ratio of 0.48 (95% confidence interval 0.38 to 0.60). Aspirin plus ticagrelor compared to aspirin plus clopidogrel was associated with significantly lower recurrent MI rates in both HBR (9.3% vs. 22.7%) and LBR (3.0% vs. 6.0%, both p<0.01) patients, higher bleeding risk in HBR (1.7% vs. 0.5%, p<0.01) but not in LBR (0.6% vs 0.9%, p=NS) and no significant differences in CV death rates in both HBR (3.4% vs. 5.3%) and LBR (1.0% vs. 0.9%, both p=NS) at 12-months. Conclusions In our cohort of ACS patients undergoing PCI, a quarter have HBR of which majority also have HIR. Patients’ bleeding risk was a stronger determinant of dual-antiplatelet therapy choice than ischemic risk. Aspirin and ticagrelor was associated with significantly lower recurrent MI rates irrespective of bleeding risk but high major bleeding rates in HBR but not LBR patients. Our results support personalised approach to dual-antiplatelet therapy use based on bleeding risk.

Abstract 12184: Non-ST Segment Elevation Myocardial Infarction in Patients Admitted With Sepsis: A Comparison of Ischemia-Guided Strategy and Early Catheterization

Introduction: Sepsis and Non-ST Segment Elevation Myocardial Infarction (NSTEMI) are common medical conditions that often coexist and can cause significant morbidity and mortality. The optimal management strategy for these patients remains unclear. The American Heart Association (AHA) recommends an ischemia-guided approach in patients with stable NSTEMI, but it is unknown if this strategy is beneficial in the setting of sepsis. The aim of this study was to evaluate the outcomes of an ischemia-guided strategy in patients with sepsis and NSTEMI who underwent left heart catheterization (LHC) and percutaneous intervention (PCI). Methods: This study utilized data from the National Inpatient Sample (NIS) from 2016-2020. Patients admitted with a principal diagnosis of sepsis and a secondary diagnosis of NSTEMI were included in the study. Patients with cardiogenic shock or STEMI were excluded from the study due to the necessity of urgent or emergent left heart catheterization. Patients were divided into two groups based on the timing of LHC & PCI, within 24 hours or 48-72 hours of admission. Logistic linear regression was used to adjust for multiple factors including patient demographics, hospital characteristics, and comorbidities. Results: A total of 298,855 patients were included in the analysis, with 48% of them being females and a mean age of 73 years. Patients who received an ischemia-guided strategy had lower mortality rates (OR: 0.45, 95% CI: 0.27-0.74, P=0.002) and a lower risk of heart failure exacerbation (OR: 0.74, 95% CI: 0.56-0.97, P=0.030) compared to those who did not receive this strategy. There was no significant difference in length of stay (Coefficient: 0.33, 95% CI: -0.34 - 1.01, P=0.330), cardiac arrest (OR: 0.08, 95% CI: 0.00-28.0, P=0.401), or gastrointestinal bleed (OR: 0.81, 95% CI: 0.49-1.33, P=0.412) between the two groups. Conclusion: This study suggests that an ischemia-guided strategy may be beneficial in patients with sepsis and NSTEMI compared to urgent percutaneous coronary intervention. The strategy was associated with lower mortality rates and a lower risk of heart failure exacerbation. Further studies are needed to confirm these findings and determine the optimal management strategy for this patient population.

Cost-effectiveness of cardiovascular magnetic resonance imaging compared to common strategies in the diagnosis of coronary artery disease: a systematic review.

Cardiovascular magnetic resonance imaging (CMR) has established exceptional diagnostic utility and prognostic value in coronary artery disease (CAD). An assessment of the current evidence on the cost-effectiveness of CMR in patients referred for the investigation of CAD is essential for developing an economic model to evaluate the cost-effectiveness of CMR in CAD. We conducted a comprehensive search of multiple electronic databases, including PubMed, Scopus, Web of Science core collection, Embase, National Health Service Economic Evaluation Database (NHS EED), and health technology assessment, to identify relevant literature. After removing duplicates and screening the title/abstract, a total of 13 articles were deemed eligible for full-text assessment. We included studies that reported one or more of the following outcomes: incremental cost-effectiveness ratio (ICER), cost per quality-adjusted life year (QALYs), cost per life year gained, sensitivity and specificity rate as the primary outcome, and health utility measures or health-related quality of life as the secondary outcome. The quality of the included studies was assessed using the CHEERS 2022 guidelines. The findings of this study demonstrate that in patients undergoing urgent percutaneous coronary intervention, CMR over a one-year and lifetime horizon leads to higher quality-adjusted life years (QALYs) compared to current strategies in cases of multivessel disease. The systematic review indicates that the CMR-based strategy is more cost-effective when compared to standard methods such as single-photon emission computed tomography (SPECT), coronary computed tomography angiography (CCTA), and coronary angiography (CA) (CMR = $19,273, SPECT = $19,578, CCTA = $19,886, and immediate CA = $20,929). The results also suggest that the CMR strategy can serve as a cost-effective gatekeeping tool for patients at risk of obstructive CAD. A CMR-based strategy for managing patients with suspected CAD is more cost-effective compared to both invasive and non-invasive strategies, particularly in real-world patient populations with a low to intermediate prevalence of the disease.

Prevalence of Depression or Depressive Symptoms in Females Who Receive Urgent Percutaneous Coronary Interventions (PCI): Implications on Acute Coronary Syndrome (ACS) Time-Period, Risk Stratification and Readmissions

Prevalence of Depression or Depressive Symptoms in Females Who Receive Urgent Percutaneous Coronary Interventions (PCI): Implications on Acute Coronary Syndrome (ACS) Time-Period, Risk Stratification and Readmissions

Prognostic implications of non-infarct-related territory unrecognized myocardial infarction in patients with non-ST-segment-elevation acute coronary syndrome

BackgroundPrognostic value of non-infarct-related territory (non-IR) unrecognized myocardial infarction (UMI) in patients with non-ST-elevation acute coronary syndrome (NSTE-ACS) remains to be elucidated. We sought to evaluate the prognostic impact of non-IR UMI in patients with first NSTE-ACS presentation. MethodsThis retrospective single-center analysis was conducted in patients with NSTE-ACS without prior history of coronary artery disease, who underwent uncomplicated urgent percutaneous coronary intervention (PCI) within 48 h of admission between August 2014 and January 2018. All patients underwent postprocedural cardiac magnetic resonance imaging (CMR) within 30 days after PCI. Non-IR UMI was defined as the presence of non-IR delayed gadolinium enhancement with an ischemic distribution pattern. We investigated the association of non-IR UMI, other CMR findings and baseline clinical characteristics with major adverse cardiac events (MACE), defined as death, non-fatal myocardial infarction, stroke, late revascularization, and hospitalization for congestive heart failure. ResultsA total of 168 NSTE-ACS patients were included [124 men (73.8 %); 66 ± 11 years]. Non-IR UMI was detected in 28 patients (16.7 %). During a median follow-up of 32 (15–58) months, MACE occurred in 10 (35.7 %) patients with non-IR UMI, and 20 (14.3 %) patients without (p = 0.013). Cox's proportional hazards analysis showed that the presence of non-IR UMI was an independent predictor of MACE (hazard ratio [HR], 2.37, 95 % confidence interval [CI], 1.09–5.18, p = 0.030). In patients with NSTE-ACS undergoing urgent PCI, the prevalence of non-IR UMI was 16.7 %. ConclusionsNon-IR UMI provided prognostic information independent of conventional risk factors and the extent of myocardial injury caused by NSTE-ACS.

In vitro evaluation of anticoagulant therapy management when urgent percutaneous coronary intervention is required in rivaroxaban-treated patients.

We investigated in vitro the management of intraprocedural anticoagulation in patients requiring immediate percutaneous coronary intervention (PCI) while using regular direct oral anticoagulants (DOACs). Twenty-five patients taking 20 mg of rivaroxaban once daily comprised the study group, while five healthy volunteers included the control group. In the study group, a beginning (24 h after the last rivaroxaban dose) examination was performed. Then, the effects of basal and four different anticoagulant doses (50 IU/kg unfractionated heparin (UFH), 100 IU/kg UFH, 0.5 mg/kg enoxaparin, and 1 mg/kg enoxaparin) on coagulation parameters were investigated at the 4th and 12th h following rivaroxaban intake. The effects of four different anticoagulant doses were evaluated in the control group. The anticoagulant activity was assessed mainly by anti-factor Xa (anti-Xa) levels. Beginning anti-Xa levels were significantly higher in the study group than in the control group (0.69 ± 0.77 IU/mL vs. 0.20 ± 0.14 IU/mL; p < 0.05). The study group's 4th and 12th-h anti-Xa levels were significantly higher than the beginning level (1.96 ± 1.35 IU/mL vs. 0.69 ± 0.77 IU/mL; p < 0.001 and 0.94 ± 1.21 IU/mL vs. 0.69 ± 0.77 IU/mL; p < 0.05, respectively). Anti-Xa levels increased significantly in the study group with the addition of UFH and enoxaparin doses at the 4th and 12th h than the beginning (p < 0.001 at all doses). The safest anti-Xa level (from 0.94 ± 1.21 to 2.00 ± 1.02 IU/mL) was achieved 12 h after rivaroxaban with 0.5 mg/kg enoxaparin. Anticoagulant activity was sufficient for urgent PCI at the 4th h after rivaroxaban treatment, and additional anticoagulant administration may not be required at this time. Twelve hours after taking rivaroxaban, administering 0.5 mg/kg of enoxaparin may provide adequate and safe anticoagulant activity for immediate PCI. This experimental study result should confirm with clinical trials (NCT05541757).

Effect of Vigileo/FloTrac System-Guided Aggressive Hydration in Acute Myocardial Infarction Patients to Prevent Contrast-Induced Nephropathy After Urgent Percutaneous Coronary Intervention

Tailored hydration strategies appear to provide an effective solution for preventing contrast-induced nephropathy (CIN) after percutaneous coronary intervention (PCI). The Vigileo/FloTrac system could predict the patients' fluid responsiveness and tolerance to hydration. This prospective multicenter, randomized controlled, open-label study evaluated the efficacy of aggressive hydration guided by the Vigileo/FloTrac system for CIN prevention in patients with acute myocardial infarction (AMI). This trial enrolled patients with AMI undergoing urgent PCI, and these patients were randomized (1:1) to receive either aggressive hydration guided by Vigileo/FloTrac system (intervention group) or general hydration (control group). Patients with AMI in the intervention group received a loading dose of saline, and the hydration speed was adjusted according to the change of Vigileo/FloTrac index. The primary end point is CIN, which was defined as a >25% or >0.5mg/100ml increase in serum creatinine compared with baseline during the first 72hours after urgent PCI. This trial was registered in ClinicalTrials.gov (NCT04382313). A total of 344 patients with AMI were enrolled and randomized in our trial, and the baseline characteristics, including risk factors of CIN, of the Vigileo/FloTrac-guided hydration group (n=173) and control group (n=171) were well balanced (all p >0.05). The total hydration volume in Vigileo/FloTrac-guided hydration group was significantly much more than control group (1,910 ± 600 vs 440 ± 90ml, p <0.001). The incidence of CIN in the Vigileo/FloTrac-guided hydration group was significantly decreased than that in the control group (12.1% [21/173] vs 22.2% [38/171], p=0.013). There was not significantly different in the incidence of acute heart failure after PCI (9.2% [16/173] vs 7.6% [13/171], p=0.583). The incidence of main adverse cardiovascular events in the Vigileo/FloTrac-guided hydration group was lower than that in the control group but without statistically difference (30 events [17.3%] vs 38 events [22.2%], p=0.256). In conclusion, Vigileo/FloTrac system-guided aggressive hydration could effectivelydecrease the risk of CIN for patients with AMI undergoing urgent PCI and avoid attack of acute heart failure at the same time.

Acute Coronary Syndrome Treated with Percutaneous Coronary Intervention in Hutchinson–Gilford Progeria

Hutchinson-Gilford progeria syndrome is an extremely rare genetic disease caused by a de novo mutation in the LMNA gene, leading to an accumulation of a form of Lamin A, called Progerin, which results in a typical phenotype and a marked decrease in life expectancy, due to early atherosclerosis and cardiovascular disease. We report the case of a fourteen-year-old Chinese boy with Hutchinson-Gilford progeria syndrome admitted to the emergency room because of precordial pain. Physical examination showed tachycardia 130 beats/min and arterial hypertension: 170/120 mmHg, normal respiratory rate, no neurological impairment; ECG evidenced sinus tachycardia, left ventricular hypertrophy, horizontal ST-segment depression in I, aVL, II, III, aVF leads, and V4-V6 and ST-segment elevation in aVR and V1 leads. Echocardiography highlighted preserved global left ventricular function with concentric hypertrophy, altered diastolic flow pattern, mitral valve insufficiency, and minimal aortic regurgitation. Blood tests evidenced an increase in high-sensitivity troponin T level (335 pg/mL). NSTEMI diagnosis was performed, and the patient was admitted to the intensive care unit. A coronary CT angiography showed a severe obstruction of the common trunk of the left coronary artery, for which an urgent percutaneous coronary intervention (PCI) was proposed. A selective coronary angiography imaged complete chronic occlusion of the left main coronary artery as well as severe stenosis at the origin of a very enlarged right coronary artery that vascularized the left coronary artery through collaterals. Afterwards, the right coronary artery was probed using an Amplatz right (AR1) guiding catheter, through which a large 3.5 mm drug-eluting coronary stent (Xience Sierra, Abbott, Abbott Park, IL, USA) was implanted. At the end of the procedure, no residual stenosis was imaged and improved vascularization of the left coronary artery distribution segments was observed. Dual antiplatelet therapy (DAPT) consisting of aspirin (75 mg daily) and clopidogrel (37.5 mg daily) and anti-hypertensive therapy were started. At the one-year follow-up, the patient had not reported any occurrence of anginal chest pain.

Effect of Carvedilol Versus Metoprolol on Contrast-Induced Nephropathy in Patients with Acute Coronary Syndrome Undergoing Percutaneous Intervention Therapy.

Carvedilol can inhibit inflammation, vasoconstriction, and oxidative stress, which play important roles in the development and progression of contrast-induced nephropathy (CIN). To the best of our knowledge, no studies have investigated the potential effect of carvedilol on the prevalence of CIN after percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). The present study aimed to determine whether carvedilol use is associated with the development of CIN. A total of 319 patients (mean age, 59.2 ± 12.4years; 77.7% male) with ACS who underwent urgent PCI at our institution between May 2019 and May 2022 were included prospectively. Overall, 100 and 219 patients were assigned to the carvedilol and metoprolol groups, respectively. The prevalence of CIN was significantly lower in the carvedilol group (6.0%) than in the metoprolol group (18.3%; P = .003). Multivariate analysis revealed that carvedilol use (odds ratio [OR] .250, 95% confidence interval [CI] .092-.677, P = .006), amount of contrast agent (OR 1.004, 95% CI 1.000-1.008, P = .031), and admission estimated glomerular filtration rate (OR .978, 95% CI 0.960-.995, P = .014) were independently associated with the development of CIN. The use of carvedilol may be a promising option for the prevention of CIN in patients with ACS undergoing urgent PCI.

Acute Coronary Syndrome after Percutaneous Coronary Intervention: State of the Problem and Clinical Practice Data

Aim. To study the prevalence, clinical and endovascular predictors, causes and timing of the development of acute coronary syndrome (ACS) in patients who had previously undergone percutaneous coronary intervention (PCI), as well as the clinical features of the disease and lipid spectrum parameters.Material and methods. The prospective study included 768 patients successively hospitalized from 01.01.2019 to 01.01.2020 in the Regional cardiovascular center, undergoing to emergency coronary angiography.Results. The main group included 768 patients who underwent emergency coronary angiography for ACS. 90 of them had previously undergone PCI (11.7%). Men prevailed (66.7%), the average age was 62 years. 25.5% of patients underwent ACS within a year after coronary stenting, the mean time from PCI to ACS was 43 months. Most often, there was ACS without ST segment elevation (80%). The results of a retrospective analysis of the first PCI showed that 89.7% of patients underwent urgent PCI, 77.8% of patients received bare metal stents. In 67.1% of patients, 1 stent was implanted, the average diameter was 3.2 mm, the average length was 22 mm. Thromboaspiration was performed in 12% of cases, predilatation in 25%, and NC postdilation in 41.3% of cases. Complications of PCI developed in 9% of patients. Stent thrombosis was diagnosed in 7.8% of cases, significant restenosis in 35.6%. Repeated stenting due to ACS was performed in 64.4% of patients, of which 74.6% received 1 stent; average diameter 3.4 mm, average length 24.0 mm. Predilatation was performed in 52.9% of cases, thromboaspiration – in 41.2%, and NC-postdilation – in 86.7% of cases. Complications of PCI developed in 10%. In addition, 99% of patients had significant dyslipidemia. The average cholesterol level was 4.91 mmol/L, the average low-density lipoprotein level was 2.94 mmol/L.Conclusion. Patients after PCI are 12% of group with ACS in clinical practice of the Regional Vascular Center. The most common predictor of recurrent atherothrombotic events is bare metal stent implantation as well as dyslipidemia.

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.

Effect of Ticagrelor Compared to Clopidogrel on Short-term Outcomes of COVID-19 Patients with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention; a Randomized Clinical Trial.

Acute COVID-19 infection is associated with increased adverse clinical outcomes in patients with acute coronary syndromes (ACS). Given that some studies suggested improved pulmonary function with Ticagrelor, this clinical trial aimed to compare the effects of Ticagrelor versus Clopidogrel on the short-term outcomes of these patients. In this multicenter clinical trial, 180 COVID-19 patients with ACS who underwent urgent percutaneous coronary intervention (PCI) were randomized to receive Ticagrelor (180mg loading dose followed by 90mg twice daily, n=90) or Clopidogrel (600mg loading dose with 75mg daily, n=90), and then followed for one month after their procedure. The primary composite endpoint was a combination of all-cause mortality, myocardial infarction, and early stent thrombosis within the first month after stent implantation. After thirty days of follow-up, the primary composite endpoint was non-significantly lower in the Ticagrelor compared to the Clopidogrel group (18.5% vs 23.5% respectively, p = 0.254). Based on the time-to-event analysis, the mean survival rate was 26.8 ±7.7 and 24.7 ±9.9 days, respectively, for the Ticagrelor and the Clopidogrel arms (Log-rank p = 0.275). Secondary endpoints were similar in the two trial arms, except for the mean oxygen saturation, which was higher in the Ticagrelor group (95.28 ±2.68 % vs. 94.15 ± 3.55 %, respectively; p = 0.021). Among COVID-19 patients with concomitant ACS, who were treated with urgent PCI, the composite outcome of death, myocardial infarction, and early stent thrombosis was not different between Ticagrelor and Clopidogrel groups. However, administration of Ticagrelor was associated with a slight but statistically significant increase in oxygen saturation compared to Clopidogrel, but this difference wasn't clinically important.