Periprocedural Myocardial Injury in High-Risk Patients With NSTEMI Pretreated With Ticagrelor for Less or More Than 6 Hours Before PCI.

We assessed the impact on periprocedural myocardial injury of a ticagrelor loading dose given <6 or >6 hours before percutaneous coronary intervention (PCI) in non-ST-elevation myocardial infarction (NSTEMI) patients at high risk. All consecutive patients pretreated with ticagrelor and undergoing PCI for a high-risk NSTEMI have been included in the present analysis. Propensity-score matching was performed to compare the outcomes between patients pretreated with ticagrelor for >6 hours or ≤6 hours. The primary outcome was the rate of periprocedural myocardial injury after PCI. We also recorded clinical outcomes, including major adverse cardiovascular events and major bleedings at 1 month. A total of 1216 patients with NSTEMI were deemed eligible for the study: 481 received a ticagrelor loading dose ≤6 hours (mean time, 4.3 ± 1.2 h) and 735 >6 hours (16.1 ± 8.4 hours) before PCI. Patients pretreated with ticagrelor for >6 hours presented more risk factors and comorbidities compared to others. In patients pretreated with ticagrelor for >6 hours, the rate of periprocedural myocardial injury was significantly lower compared to the other group, in the overall population (19.6% vs 37.8%; P < .0001) and in the matched cohort of 644 patients (18.9% vs 33.5%; P < .0001). The rate of major adverse cardiovascular events and major bleeding events did not differ between the two groups, in both unmatched and matched populations. The present study suggests that ticagrelor pretreatment reduces periprocedural myocardial injury in high-risk patients with NSTEMI undergoing PCI with expected time intervals >6 hours.

One-year clinical outcome of patients with left ventricular thrombus after acute myocardial infarction discharged on triple or dual antithrombotic therapy.

In patients with left ventricular thrombus (LVT) after acute myocardial infarction (MI), both anticoagulant and antiplatelet therapies are needed. It is unknown whether dual antithrombotic therapy (DAT) is able to reduce the incidence of bleeding complications without significantly increasing the number of thromboembolic events, compared to triple antithrombotic therapy (TAT). We retrospectively evaluated all post-MI patients with LVT discharged on TAT or DAT from our tertiary hospital in the last decade. The primary outcome was the occurrence of all-cause mortality, thromboembolic events, hospitalizations for re-MI or heart failure and any bleeding at 1 year. A propensity-score matching was performed in order to compare the primary outcome between TAT and DAT. Out of 2564 acute MI patients, 83 (3.2%) had an LVT at echocardiography: 51 (61.4%) discharged on TAT and 32 (38.6%) on DAT. At clinical follow-up, completed in 93% of cases, the incidence of the primary outcome was 18.2% (25.5% in TAT and 6.7% in DAT group; p = 0.04). More than 2/3 of the events included in the primary outcome were related to bleeding complications and occurred during the first month from hospital discharge. In the matched cohort of 42 patients with follow-up data available, the primary outcome occurred in 9 (42.9%) patients in the TAT and 2 (9.5%) in the DAT group (p = 0.03). In post-MI patients with LVT, DAT seems more effective than TAT in reducing clinical outcome, especially early bleeding complications. A randomized study is warranted to confirm this hypothesis.

Current management and prognosis of patients with recurrent myocardial infarction.

Recurrent myocardial infarction (re-MI) is a common event following acute coronary syndrome (ACS), especially during the first year. According to epidemiological studies, patients who experience re-MI are at higher risk of all-cause cardiovascular events and mortality. The cornerstones of re-MI prevention include complete functional coronary revascularization, effective dual antiplatelet therapy and secondary prevention strategies. Notwithstanding this, some controversy still exists on the definition and management of re-MI, and no dedicated studies have been designed or conducted so far in this setting. We here provide an overview of epidemiological and prognostic data on ACS patients experiencing re-MI, along with current available treatment and preventive options.

Fondaparinux During Intra-Aortic Balloon Pump Counterpulsation in Acute Myocardial Infarction Patients Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Although anticoagulation with unfractionated heparin (UFH) is commonly used during intra-aortic balloon pump (IABP) counterpulsation to prevent thromboembolic events, no data or guidelines exist to support this strategy, especially in the setting of acute myocardial infarction (AMI). This study sought to compare the short-term outcome of UFH vs fondaparinux in AMI patients who underwent successful percutaneous coronary intervention (PCI) and IABP insertion. METHODS: The anticoagulation therapy of revascularised AMI patients who received IABP counterpulsation and admitted to a tertiary hospital in the last decade was retrospectively evaluated. The primary outcome was the occurrence of all-cause mortality, stroke or transient ischaemic attack, reinfarction, unplanned revascularisation, major or minor limb ischaemia, and any bleeding at 1 month. Propensity score matching was performed to compare the primary outcome between UFH and fondaparinux. RESULTS: Of 1,355 AMI survivors at 2 days after hospital admission and who underwent successful PCI, an IABP was inserted in 197 (14.5%): 72 (36.5%) were treated with UFH and 125 (63.5%) with fondaparinux (2.5 mg o.d.). At clinical follow-up, completed in 98.5% of cases, the incidence of the primary outcome was 22.5% in UFH and 5.7% in fondaparinux groups (p=0.0009). More than two-thirds of the events included in the primary outcome were related to early bleeding complications. In the matched cohort of 62 patients, the primary outcome occurred in 14 (45.2%) patients in the UFH and two (6.5%) in the fondaparinux group (p=0.01). CONCLUSIONS: This study suggested that fondaparinux is safer, by reducing early bleeding complications at one month, than UFH in the management of IABP.

Effectiveness of fondaparinux vs unfractionated heparin following percutaneous coronary intervention in survivors of out-of-hospital cardiac arrest due to acute myocardial infarction.

AIM: There is no specific evidence on the antithrombotic management of survivors of out-of-hospital cardiac arrest (OHCA) due to acute myocardial infarction (AMI). We sought to compare the short-term outcome of unfractioned heparin (UFH) vs fondaparinux in OHCA survivors due to AMI admitted in our Institution in the last decade. METHODS: We performed a retrospective cohort study on survivors of OHCA due to AMI managed with UFH or fondaparinux during the hospitalization. The primary outcome was the occurrence of any bleeding, all-cause mortality, cerebrovascular accidents, re-MI, and unplanned revascularization at 1 month. A propensity-score matching was performed to compare the outcome between UFH and fondaparinux. RESULTS: Out of 2083 AMI patients undergoing successful PCI, OHCA was present in 94 (4.5%): 41 (43.6%) treated with UFH and 53 (56.4%) with fondaparinux. At clinical follow-up, the incidence of the primary outcome was 65.9% in UFH and 35.8% in fondaparinux group (p = 0.007). More than half of the events included in the primary outcome were related to bleeding complications. In the matched cohort of 56 patients, the primary outcome occurred in 46.4% and 25.0% (p = 0.16), while bleeding was present in 32.1% and 7.1% (p = 0.04), in the UFH and fondaparinux group, respectively. CONCLUSIONS: The present analysis suggests that fondaparinux is safer than UFH in the management of OHCA due to AMI by reducing early bleeding complications at one month.

Oral Antiplatelet Therapy for Secondary Prevention of Non-Cardioembolic Ischemic Cerebrovascular Events.

Stroke is the leading cause of disability and mortality worldwide. After an acute cerebrovascular ischemia, recurrent vascular events, including recurrent stroke or transient ischemic accidents (TIA), occur in around 20% of cases within the first 3 months. In order to minimize this percentage, antiplatelet therapy may play a key role in the management of non-cardioembolic cerebrovascular events. This review will focus on the current evidence of antiplatelet therapies most commonly discussed in practice guidelines and used in clinical practice for the treatment of stroke/TIA complications. The antiplatelet therapies most commonly used and discussed are as follows: aspirin, clopidogrel, and ticagrelor.

[Chest pain in women: a multicenter study of the National Association of Hospital Cardiologists (ANMCO) of the Lazio Region]. / Il dolore toracico nella donna: studio multicentrico della Sezione dell'ANMCO della Regione Lazio (progetto 3D).

BACKGROUND: Chest pain is an extremely common symptom in women, but several previous studies have suggested that in women this complaint is more frequently underdiagnosed than in men. The aim of this multicenter study proposed by the National Association of Hospital Cardiologists (ANMCO) was to analyze the clinical regimen adopted for women admitted to a public hospital of the Lazio Region for chest pain during a short period of time (only 30 days). METHODS: Between March 1 and March 31, 2001, 747 women were admitted in the Emergency Department of 20 public hospitals in the Lazio Region for chest pain. The patients' age ranged between 40 to 80 years (mean age 61.4 +/- 12.6 years). An ECG was recorded in 727 (97.5%), 326 (44%) underwent cardiologic examination, blood analysis was performed for 584 (78%) and 66 (8.8%) were submitted to two-dimensional echocardiography. RESULTS: Of the 727 ECGs, 403 (56%) were defined as "normal" by a cardiologist and 324 (44%) "abnormal". Of the 747 women with chest pain, 446 (60%) were discharged from the Emergency Department; 2 died (0.2%), and 298 (40%) were hospitalized. Among the latter, 169 (56%) were submitted to echocardiography, 45 (16%) to the ECG effort test, 22 (6%) to stress echocardiography, 40 (11%) to coronary angiography (3 also to primary coronary angioplasty), 10 (3.3%) to esophagogas-troduodenoscopy, and 68 (23%) to several non-cardiologic exams. The final diagnosis was atypical chest pain in 336 (45%), acute myocardial infarction in 60 (6.7%), paroxysmal atrial fibrillation in 42 (5.6%), typical angina in 60 (10.6%), aortic dissection in 3 (0.4%), pericarditis in 7 (0.9%), hypertensive crisis in 80 (11%), gastritis in 27 (3.6%), anxiety in 15 (2%), and a surgical or orthopedic diagnosis in 107 (14%). Two patients (0.2%) died. During follow-up (6 months) cardiac events occurred in 7.6% of 446 women discharged from the Emergency Department. CONCLUSIONS: This study demonstrated that the diagnostic tests are underutilized in women with chest pain, even compared to previous studies including male and female subjects. For women presenting with chest pain, the use of non-invasive tests with the best prognostic impact should be increased.