Ionizing radiation exposure in complex percutaneous coronary intervention: Defining local diagnostic reference levels in the catheterization laboratory.

INTRODUCTION AND OBJECTIVES: Concerns regarding the consequences of ionizing radiation (IR) have been increasing in the field of interventional cardiology (IC). There is little information on reported national and local radiation diagnostic reference levels (DRLs) in catheterization laboratories in Portugal. This study was designed to assess the IR dose exposure during complex percutaneous coronary intervention (PCI), and to set the respective DRLs and future achievable doses (ADs). METHODS: This was a retrospective cohort study which took place between 2019 and 2020, including patients who underwent complex PCI. Complex PCI was defined as all procedures that encompass treatment of chronic total occlusions (CTO) or left main coronary artery. DRLs were defined as the 75th percentile of the distribution of the median values of air kerma area product (PKA) and cumulative air kerma (Ka,r). ADs were set at the 50th percentile of the study dose distribution. Multivariate analysis was performed using linear regression to identify predictors significantly associated with radiation dose (Ka,r). RESULTS: A total of 242 patients were included in the analysis. Most patients underwent a CTO procedure (146, 60.3%). Patients were aged 67.9±11.2 years and mostly male (81.4%). DRLs were set in Ka,r (3012 mGy) and PKA (162 Gy cm2) for complex PCI. ADs were also set in Ka,r (1917 mGy) and PKA (101 Gy cm2). Independent predictors of Ka,r with a positive correlation were PKA (0.893, p<0.001), fluoroscopy time (0.520, p<0.001) and PCI time (0.521, p<0.001). CONCLUSIONS: This study reports the results of IR in complex PCI. DRLs were set for IR dose exposure measured in Ka,r (3012 mGy) and PKA (162 Gy cm2). ADs, values to be achieved in future assessment, were set to Ka,r (1917 mGy) and PKA (101 Gy cm2).

Clinical results of percutaneous coronary intervention in chronic total occlusions of the right coronary artery.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTOs) of the right coronary artery (RCA) are a relatively common finding in the context of coronary angiography. However, the benefit of revascularization remains controversial. METHODS: A single-center retrospective cohort analysis prospectively collected outcomes of CTO patients undergoing percutaneous coronary intervention (PCI) in 2019 and 2020. Patients were divided into two groups according to the CTO vessel treated (left coronary artery [LCA]-CTO or RCA-CTO). The primary outcome was defined as the recurrence of angina and/or heart failure (HF) symptoms and secondary outcomes were myocardial infarction (MI) and all-cause mortality. RESULTS: A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome occurred in 28 (16.6%) patients and was significantly more frequent in RCA-CTO patients (19, 24.7%, p=0.010) in a mean follow-up of 18 months. This was mainly driven by recurrence of HF symptoms (12, 15.6%, p=0.013). Treated RCA-CTO was an independent predictor of the primary outcome (p=0.019, HR 2.66, 95% CI 1.17-6.05). MI and mortality rates were no different between groups (RCA-CTO with 1.3%, p=0.361 and 2.6%, p=0.673, respectively, on survival analysis). Left ventricular ejection fraction was an independent predictor of mortality (p=0.041, HR 0.93, 95% CI 0.87-0.99). CONCLUSIONS: Revascularization of CTO lesions by PCI was associated with low rates of symptom recurrence, and clinical outcomes showed no differences regardless of which artery was treated. Recanalization of RCA-CTO was less beneficial in reducing the recurrence of HF symptoms.

Clinical outcomes of percutaneous coronary intervention in chronic total occlusion in patients with type 2 diabetes mellitus.

INTRODUCTION AND OBJECTIVES: Coronary chronic total occlusions (CTOs) are relatively common findings in patients with type 2 diabetes mellitus (T2DM). However, the indication for percutaneous coronary intervention (PCI) and its clinical benefit in these patients remain controversial. METHODS: A single-center retrospective cohort study with prospectively collected outcomes was carried out with CTO patients undergoing PCI in 2019 and 2020. Patients were divided into two groups according to previous T2DM diagnosis (T2DM and non-T2DM). The primary outcome was recurrence of angina and/or heart failure symptoms and secondary outcomes were myocardial infarction and all-cause mortality. RESULTS: A total of 177 patients (82.5% male) were included in the analysis, with a mean age of 65±11 years. The primary outcome (total symptom recurrence) occurred in 16.6% of the sample, with no difference between groups (non-T2DM 13.6% vs. T2DM 21.2%, p=0.194) in a two-year follow-up. Angina recurrence was significantly more frequent in T2DM patients (15.2%, p=0.043). The presence of T2DM was not an independent predictor of symptom recurrence (p=0.429, HR 1.37, 95% CI 0.62-2.98). Myocardial infarction and all-cause mortality were also not different between groups (T2DM 1.5%, p=0.786 and 4.5%, p=0.352, respectively, on survival analysis). Independent predictors of all-cause mortality were left ventricular function and creatine clearance (p=0.039, HR 0.92, 95% CI 0.85-0.99 and p=0.013, HR 0.96, 95% CI 0.93-0.99, respectively). CONCLUSIONS: T2DM did not influence outcomes in CTO patients undergoing PCI, and its presence should not be a limiting factor in deciding on CTO revascularization.

Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes in contemporaneous clinical practice.

BACKGROUND: Pretreatment antithrombotic strategies in non-ST elevation acute coronary syndromes (NSTE-ACS) during hospitalization is still a matter of contention within the cardiology community. Our aim was to analyze in-hospital and one-year follow-up outcomes of patients with NSTE-ACS pretreated with dual antiplatelet therapy (DAPT) versus single antiplatelet therapy (SAPT). METHODS: A retrospective study was carried out with NSTE-ACS patients planned to undergo an invasive strategy and were included in the Portuguese Registry of ACS between 2018-2021. A composite primary outcome (in-hospital re-infarction, stroke, heart failure, hemorrhage, death) was compared regarding antiplatelet strategy (DAPT versus SAPT). Secondary outcomes were defined as one-year all-cause mortality and one-year cardiovascular rehospitalization. RESULTS: A total of 1469 patients were included, with a mean age of 66±12 years and 73.9% were male. DAPT regime was used in 38.2% and SAPT in 61.8% of patients. NSTE myocardial infarction was the most frequent presentation (88.5%). Revascularization after 24h occurred in 44.8% patients (63% of these after 48h). Enoxaparin was the anticoagulant more frequently used (45.1%). The primary outcome was more frequently observed in the SAPT group (10.4%, p=0.033), mainly driven by more ischemic events. Time until revascularization > 48h and SAPT regime were independent predictors of the primary outcome (OR 1.66, p=0.036 and OR 2.03, p=0.008, respectively). CONCLUSION: NSTE-ACS patients pretreated with SAPT had worse in-hospital outcomes. This difference can be probably explained by a delay in time until revascularization. Pretreatment DAPT strategy and crossover between heparins is still frequently used in clinical practice.

Mob4 is required for neurodevelopment in zebrafish.

Mob4 is an essential evolutionary conserved protein shown to play roles in cell division and neural development. Mob4 is a core component of the macromolecular STRIPAK complex involved in various critical cellular processes, from cell division to signal transduction pathways. However, Mob4 remains relatively poorly understood. Although the consequences of eliminating Mob4 function in Drosophila are described, its function in vertebrate development remains largely unknown. Here we show that knockdown and knockout of Mob4 during zebrafish embryogenesis limits neuronal cell divisions but has little effect on apoptosis, thus arguing a role for mob4 in neurodevelopment.

Care of patients with ST-elevation myocardial infarction: an international analysis of quality indicators in the acute coronary syndrome STEMI Registry of the EURObservational Research Programme and ACVC and EAPCI Associations of the European Society of Cardiology in 11 462 patients.

AIMS: To use quality indicators to study the management of ST-segment elevation myocardial infarction (STEMI) in different regions. METHODS AND RESULTS: Prospective cohort study of STEMI within 24 h of symptom onset (11 462 patients, 196 centres, 26 European Society of Cardiology members, and 3 affiliated countries). The median delay between arrival at a percutaneous cardiovascular intervention (PCI) centre and primary PCI was 40 min (interquartile range 20-74) with 65.8% receiving PCI within guideline recommendation of 60 min. A third of patients (33.2%) required transfer from their initial hospital to one that could perform emergency PCI for whom only 27.2% were treated within the quality indicator recommendation of 120 min. Radial access was used in 56.6% of all primary PCI, but with large geographic variation, from 76.4 to 9.1%. Statins were prescribed at discharge to 98.7% of patients, with little geographic variation. Of patients with a history of heart failure or a documented left ventricular ejection fraction ≤40%, 84.0% were discharged on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and 88.7% were discharged on beta-blockers. CONCLUSION: Care for STEMI shows wide geographic variation in the receipt of timely primary PCI, and is in contrast with the more uniform delivery of guideline-recommended pharmacotherapies at time of hospital discharge.

Premature acute coronary syndrome: understanding the early onset.

INTRODUCTION: Acute coronary syndrome (ACS) is less frequent in young adults, but it has become a significant health problem, associated with the increasing prevalence of modifiable risk factors. OBJECTIVES: To characterize patients admitted with premature ACS, comparing with those with nonpremature ACS. METHODS: We performed a retrospective study encompassing patients of the Portuguese Registry (ProACS), comparing two groups: one composed of men less than 55 and women less than 65 years old; and other with men ≥55 and women ≥65 years old at the ACS admission. The primary endpoint was the composite of in-hospital mortality, stroke and myocardial reinfarction (re-MI). RESULTS: A total of 29 870 patients were enrolled and 25% had premature ACS, with a mean age of 50 ± 7 years old. They had a larger prevalence of smoking habits, obesity and dyslipidemia. ST-segment elevation MI (STEMI) was the main admission diagnosis in young patients and coronary angiogram mainly revealed one vessel disease in this subgroup. They had a lower Killip-Kimball (KK) class and mostly preserved left ventricular ejection fraction (LVEF). Composite endpoint was more frequent in nonpremature ACS patients. Nonpremature age, presentation with syncope or cardiac arrest, KK class >1, multivessel disease and LVEF <40% were independent predictors of the primary endpoint ( P < 0.001). Younger patients had lower rates of in-hospital all-cause mortality, re-MI and stroke. One-year all-cause mortality and 1-year cardiovascular and non-cardiovascular readmissions were also lower. CONCLUSIONS: Premature ACS affects 25% of the ACS population, mostly presenting with STEMI, but generally associated with better clinical evolution. Nevertheless, prevention measures are essential to correct modifiable cardiovascular risk factors and reduce coronary events.

Reperfusion therapies and in-hospital outcomes for ST-elevation myocardial infarction in Europe: the ACVC-EAPCI EORP STEMI Registry of the European Society of Cardiology.

AIMS: The aim of this study was to determine the contemporary use of reperfusion therapy in the European Society of Cardiology (ESC) member and affiliated countries and adherence to ESC clinical practice guidelines in patients with ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: Prospective cohort (EURObservational Research Programme STEMI Registry) of hospitalized STEMI patients with symptom onset <24 h in 196 centres across 29 countries. A total of 11 462 patients were enrolled, for whom primary percutaneous coronary intervention (PCI) (total cohort frequency: 72.2%, country frequency range 0-100%), fibrinolysis (18.8%; 0-100%), and no reperfusion therapy (9.0%; 0-75%) were performed. Corresponding in-hospital mortality rates from any cause were 3.1%, 4.4%, and 14.1% and overall mortality was 4.4% (country range 2.5-5.9%). Achievement of quality indicators for reperfusion was reported for 92.7% (region range 84.8-97.5%) for the performance of reperfusion therapy of all patients with STEMI <12 h and 54.4% (region range 37.1-70.1%) for timely reperfusion. CONCLUSIONS: The use of reperfusion therapy for STEMI in the ESC member and affiliated countries was high. Primary PCI was the most frequently used treatment and associated total in-hospital mortality was below 5%. However, there was geographic variation in the use of primary PCI, which was associated with differences in in-hospital mortality.

P2Y12 inhibitor loading dose before catheterization in ST-segment elevation myocardial infarction: Is this the best strategy? / Dose de carga do inibidor P2Y12 antes do laboratório de hemodinâmica no enfarte agudo do miocárdio com supradesnivelamento do segmento ST ­ Será mesmo a melhor estratégia?

INTRODUCTION AND OBJECTIVES: In ST-segment elevation myocardial infarction (STEMI) the benefit of dual antiplatelet therapy is unequivocal, but the optimal time to administer the loading dose (LD) of a P2Y12 inhibitor is the subject of debate and disagreement. The main aim of this study was characterize current practice in Portugal and to assess the prognostic impact of P2Y12 inhibitor LD administration strategy, before versus during or after primary percutaneous coronary intervention (PCI). METHODS: This multicenter retrospective study based on the Portuguese National Registry on Acute Coronary Syndromes included patients with STEMI and PCI performed between October 1, 2010 and September 19, 2017. Two groups were established: LD before PCI (LD-PRE) and LD during or after PCI (LD-CATH). RESULTS: A total of 4123 patients were included, 66.3% in the LD-PRE group and 32.4% in the LD-CATH group. Prehospital use of a P2Y12 inhibitor was a predictor of the composite bleeding endpoint (major bleeding, need for transfusion or hemoglobin [Hb] drop >2g/dl), Hb drop >2g/dl and reinfarction. There were no differences between groups in major adverse events (MAE) (in-hospital mortality, reinfarction and stroke) or in-hospital mortality. CONCLUSIONS: Prehospital use of a P2Y12 inhibitor was associated with an increased risk of bleeding, predicting the composite bleeding outcome and Hb drop >2g/dl, with no differences in mortality or MAE, calling into question the benefit of this strategy.

One aneurysm and two pseudoaneurysms, same patient.

Ventricular pseudoaneurysms are rare pathological entities that mainly arise in the context of myocardial infarction or post-cardiac surgery. The clinical presentation is usually non-specific, and at times patients are asymptomatic. Mortality is high even with timely surgical intervention.The authors present a case of postoperative recurrence of a left ventricular pseudoaneurysm superimposed on an ischaemic true aneurysm.

CRUSADE: Is it still a good score to predict bleeding in acute coronary syndrome? / Score CRUSADE ­ Será ainda um bom score para prever a hemorragia na síndrome coronária aguda?

INTRODUCTION: Major bleeding is a serious complication of acute coronary syndrome (ACS) and is associated with a worse prognosis. The CRUSADE bleeding score is used to stratify the risk of major bleeding in ACS. OBJECTIVE: To assess the predictive ability of the CRUSADE score in a contemporary ACS population. METHODS: In a single-center retrospective study of 2818 patients admitted with ACS, the CRUSADE score was calculated for each patient and its discrimination and goodness of fit were assessed by the area under the receiver operating characteristic curve (AUC) and by the Hosmer-Lemeshow test, respectively. Predictors of in-hospital major bleeding (IHMB) were determined. RESULTS: The IHMB rate was 1.8%, significantly lower than predicted by the CRUSADE score (7.1%, p<0.001). The incidence of IHMB was 0.5% in the very low risk category (rate predicted by the score 3.1%), 1.5% in the low risk category (5.5%), 1.6% in the moderate risk category (8.6%), 5.5% in the high risk category (11.9%), and 4.4% in the very high risk category (19.5%). The predictive ability of the CRUSADE score for IHMB was only moderate (AUC 0.73). The in-hospital mortality rate was 4.0%. Advanced age (p=0.027), femoral vascular access (p=0.004), higher heart rate (p=0.047) and ticagrelor use (p=0.027) were independent predictors of IHMB. CONCLUSIONS: The CRUSADE score, although presenting some discriminatory power, significantly overestimated the IHMB rate, especially in patients at higher risk. These results question whether the CRUSADE score should continue to be used in the stratification of ACS.

Portuguese Registry of Acute Coronary Syndromes (ProACS): 15 years of a continuous and prospective registry. / Registo Nacional de Síndromes Coronárias Agudas: 15 anos de um registo prospetivo contínuo.

The Portuguese Registry of Acute Coronary Syndromes (ProACS) has completed 15 years of continuous and prospective activity. We present an overall picture of the data from this powerful tool. Up to 2016, 45 141 records were included, mostly male (71%), and with a mean age of 66 years. Baseline characteristics remained stable over the years. Of the overall population, 44% of cases were ST-elevation myocardial infarction (STEMI). Over the years there was a significant improvement in compliance with international guidelines, in terms of both diagnostic and therapeutic procedures, as well as for medication. In particular, the rate of reperfusion in STEMI increased to 84%, mainly by primary percutaneous coronary intervention (only 5.2% were treated by thrombolysis in 2016). By contrast, timings in STEMI did not change significantly. Improvements in treatment were accompanied by a reduction in in-hospital mortality from 6.7% in 2002 to 2.5% in 2016 in the overall population. This registry enables analysis of the management and results of acute coronary syndromes over time in Portugal, and hence assessment of improvements in quality of care.