ECG analysis in patients with acute coronary syndrome undergoing invasive management: rationale and design of the electrocardiography sub-study of the MATRIX trial.

BACKGROUND: The twelve­lead electrocardiogram (ECG) has become an essential tool for the diagnosis, risk stratification, and management of patients with acute coronary syndromes (ACS). However, several areas of residual controversies or gaps in evidence exist. Among them, P-wave abnormalities identifying atrial ischemia/infarction are largely neglected in clinical practice, and their diagnostic and prognostic implications remain elusive; the value of ECG to identify the culprit lesion has been investigated, but validated criteria indicating the presence of coronary occlusion in patients without ST-elevation are lacking; finally, which criteria among the multiple proposed, better define pathological Q-waves or success of revascularisation deserve further investigations. METHODS: The Minimizing Adverse hemorrhagic events via TRansradial access site and systemic Implementation of AngioX (MATRIX) trial was designed to test the impact of bleeding avoidance strategies on ischemic and bleeding outcomes across the whole spectrum of patients with ACS receiving invasive management. The ECG-MATRIX is a pre-specified sub-study of the MATRIX programme which aims at analyzing the clinical value of ECG metrics in 4516 ACS patients (with and without ST-segment elevation in 2212 and 2304 cases, respectively) with matched pre and post-treatment ECGs. CONCLUSIONS: This study represents a unique opportunity to further investigate the role of ECGs in the diagnosis and risk stratification of ACS patients with or without ST-segment deviation, as well as to assess whether the radial approach and bivalirudin may affect post-treatment ECG metrics and patterns in a large contemporary ACS population.

Optimizing the Outcomes of Percutaneous Coronary Intervention in Patients with Chronic Kidney Disease.

Percutaneous coronary intervention (PCI) is one of the most common procedures performed in medicine. However, its net benefit among patients with chronic kidney disease (CKD) is less well established than in the general population. The prevalence of patients suffering from both CAD and CKD is high, and is likely to increase in the coming years. Planning the adequate management of this group of patients is crucial to improve their outcome after PCI. This starts with proper preparation before the procedure, the use of all available means to reduce contrast during the procedure, and the implementation of modern strategies such as radial access and drug-eluting stents. At the end of the procedure, personalized antithrombotic therapy for the patient's specific characteristics is advisable to account for the elevated ischemic and bleeding risk of these patients.

Fibrosis after Myocardial Infarction: An Overview on Cellular Processes, Molecular Pathways, Clinical Evaluation and Prognostic Value.

The ischemic injury caused by myocardial infarction activates a complex healing process wherein a powerful inflammatory response and a reparative phase follow and balance each other. An intricate network of mediators finely orchestrate a large variety of cellular subtypes throughout molecular signaling pathways that determine the intensity and duration of each phase. At the end of this process, the necrotic tissue is replaced with a fibrotic scar whose quality strictly depends on the delicate balance resulting from the interaction between multiple actors involved in fibrogenesis. An inflammatory or reparative dysregulation, both in term of excess and deficiency, may cause ventricular dysfunction and life-threatening arrhythmias that heavily affect clinical outcome. This review discusses cellular process and molecular signaling pathways that determine fibrosis and the imaging technique that can characterize the clinical impact of this process in-vivo.

Diagnosis of type 2 Brugada pattern: insights from a pilot survey.

BACKGROUND: Differentiation of Type 2 Brugada Pattern (BP) from incomplete right bundle branch block or normal rSr' pattern can be insidious. The aim of this study was to assess interobserver and intraobserver agreement in the diagnosis of type 2 BP in a cohort of cardiologists with different skills. METHODS: We collected 14 ECGs with a positive terminal deflection of the QRS complex in lead V1 and V2 at the 4th intercostal space. We proposed these ECGs, specifying to use 2012 Consensus conference criteria for diagnosis of type 2 BP, to 42 participants: 14 arrhythmologists, 14 general cardiologists and 14 electrophysiology (EP) fellows. The same 14 ECGs, with a different order, were proposed fifteen days later to the same cohort to assess intraobserver variability. Authors analyzed all 14 ECGs in order to assess whether 2012 Consensus Conference criteria for BP were fulfilled. All patients underwent provocative test with IC antiarrhythmics drugs (flecainide) in order to exclude or confirm the diagnosis of Brugada Syndrome (BrS). RESULTS: Slight interobserver agreement (Fleiss K<0.20) in the diagnosis of type 2 BP was observed in all three categories of cardiologists. Considering five operators per class, intraobserver agreement is variable (k ranging from 0.000 to 0.857), with a slight superiority of arrhytmologists (k minimum value 0.276; k maximum value 0.857). CONCLUSIONS: This study demonstrated, for the first time, a low interobserver agreement in diagnosis of type 2 BP in categories of cardiologists with different abilities. Reproducibility of type 2 BP diagnosis (intraobserver agreement) is poor, even among experts. These findings highlight the difficulties in analysis of ECG with BrS suspicion and, therefore, underscore the key role of clinical and anamnestic data.

Access-Site Crossover in Patients With Acute Coronary Syndrome Undergoing Invasive Management.

OBJECTIVES: The aim of this study was to assess the impact of access-site crossover in patients with acute coronary syndrome undergoing invasive management via radial or femoral access. BACKGROUND: There are limited data on the clinical implications of access-site crossover. METHODS: In the MATRIX (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox)-Access trial, 8,404 patients with acute coronary syndrome were randomized to radial or femoral access. Patients undergoing access-site crossover or successful access site were investigated. Thirty-day coprimary outcomes were a composite of death, myocardial infarction, or stroke (major adverse cardiovascular events [MACE]) and a composite of MACE or Bleeding Academic Research Consortium type 3 or 5 bleeding (net adverse clinical events [NACE]). RESULTS: Access-site crossover occurred in 183 of 4,197 patients (4.4%) in the radial group (mainly to femoral access) and 108 of 4,207 patients (2.6%) in the femoral group (mainly to radial access). In multivariate analysis, the risk for coprimary outcomes was not significantly higher with radial crossover compared with successful radial (MACE: adjusted rate ratio [adjRR]: 1.25; 95% confidence interval [CI]: 0.81 to 1.93; p = 0.32; NACE: adjRR: 1.40; 95% CI: 0.94 to 2.06; p = 0.094) or successful femoral access (MACE: adjRR: 1.17; 95% CI: 0.76 to 1.81; p = 0.47; NACE: adjRR: 1.26; 95% CI: 0.86 to 1.86; p = 0.24). Access site-related Bleeding Academic Research Consortium type 3 or 5 bleeding was higher with radial crossover than successful radial access. Femoral crossover remained associated with higher risks for MACE (adjRR: 1.84; 95% CI: 1.18 to 2.87; p = 0.007) and NACE (adjRR: 1.69; 95% CI: 1.09 to 2.62; p = 0.019) compared with successful femoral access. Results remained consistent after excluding patients with randomized access not attempted. CONCLUSIONS: Crossover from radial to femoral access abolishes the bleeding benefit offered by the radial over femoral artery but does not appear to increase the risk for MACE or NACE compared with successful radial or femoral access. (Minimizing Adverse Haemorrhagic Events by Transradial Access Site and Systemic Implementation of Angiox [MATRIX]; NCT01433627).

Myocardial ischemia due to a recanalized chronic coronary thrombus: Angiographic and optical coherence tomography imaging insights.

Chronic organized thrombus as a result of prior untreated myocardial infarction can determine myocardial ischemia. This entity appears as an angiographically irregular and hazy image; optical coherence tomography is useful to evaluate these ambiguous lesions and guide interventional treatment.

Radial Artery Access for Percutaneous Cardiovascular Interventions: Contemporary Insights and Novel Approaches.

Since its introduction, the transradial access for percutaneous cardiovascular procedures has been associated with several advantages as compared to transfemoral approach, and has become the default for coronary angiography and intervention. In the last 30 years, a robust amount of evidence on the transradial approach has been mounted, promoting its diffusion worldwide. This article provides a comprehensive review of radial artery access for percutaneous cardiovascular interventions, including the evidence from clinical trials of transradial vs. transfemoral approach, technical considerations, access-site complications and limitations, alternative forearm accesses (e.g., ulnar and distal radial artery), and ultimately the use of the radial approach for structural interventions.

Trends and outcomes of optical coherence tomography use: 877 patients single-center experience.

BACKGROUND: Optical-coherence-tomography (OCT) is an emerging invasive coronary imaging with still undefined clinical value. Recent data have underlined daily impact of such technique in several clinical settings such as acute coronary syndromes (ACS) and percutaneous coronary intervention (PCI) guidance. We aimed at assessing the trends and outcomes of OCT use in a high-volume percutaneous coronary interventions (PCI)-center. METHODS: Over 6 years, 1025 coronary artery segments in 877 patients underwent OCT evaluation. Clinical and procedural characteristics were prospectively collected. Clinical setting for OCT was: "Diagnostic OCT" (OCT for lesion evaluation after coronary angiography without further PCI); "PCI-guidance OCT" (OCT as a guidance for complex PCI, both by intention or after diagnostic OCT). Primary study end-point was the occurrence of target-vessel-failure (TVF) during the follow-up. RESULTS: Overall, OCT was successful in 99.1% of attempted lesions. Only one complication (coronary dissection requiring urgent PCI) occurred during OCT. After a follow-up of 695 ±â€¯562 days, TVF occurred in 8.2% of cases. Despite similar baseline characteristics, TVF-free survival curves were different in the two populations (5.4% after diagnostic OCT and 9.9% after PCI-guidance OCT). Minimal-lumen-area (MLA) of target lesion was independently associated with TVF (HR 0.7, 95% CI 0.6-0.8). This was mainly driven by a significant impact of MLA in patients not revascularized (HR 0.6, 95% CI 0.4-0.9). TVF did not change according to the study period despite the selection of patients with increasing complexity. CONCLUSIONS: OCT has a good safety profile across a broad spectrum of patients encountered in daily practice. The easy-to-assess MLA parameter may help stratify prognosis of patients undergoing OCT. These data call for further evaluations of OCT clinical impact. SUMMARY: OCT is a light-based imaging tool which had subvert the quite ordinary world of coronary imaging and the present study evaluates OCT use in a high-volume center. Our results suggest that application of OCT in "real world" patients presenting higher risk has a good safety profile. Several factors could predict a worse long-term outcome in patients undergoing OCT evaluation, mostly related to more complex clinical conditions. These findings could encourage even low-to intermediate volume centers to improve their OCT use in daily practice.

Impellent impeller-Switching intra-aortic balloon pump to IMPELLA-CP after ST-segment elevation myocardial infarction and refractory cardiogenic shock.

Cardiogenic shock is a dreadful complication of myocardial infarction. Despite widespread use and availability, intra-aortic balloon pump (IABP) does not reduce mortality nor improves outcomes. Advanced mechanical circulatory support with IMPELLA system can substantially support hemodynamics and improve short-term prognosis in patients with myocardial infarction and cardiogenic shock.