A randomized controlled trial to investigate the use of acute coronary syndrome therapy in patients hospitalized with COVID-19: the COVID-19 Acute Coronary Syndrome trial.

BACKGROUND: Patients hospitalized with COVID-19 suffer thrombotic complications. Risk factors for poor outcomes are shared with coronary artery disease. OBJECTIVES: To investigate the efficacy of an acute coronary syndrome regimen in patients hospitalized with COVID-19 and coronary disease risk factors. METHODS: A randomized controlled, open-label trial across acute hospitals (United Kingdom and Brazil) added aspirin, clopidogrel, low-dose rivaroxaban, atorvastatin, and omeprazole to standard care for 28 days. Primary efficacy and safety outcomes were 30-day mortality and bleeding. The key secondary outcome was a daily clinical status (at home, in hospital, on intensive therapy unit admission, or death). RESULTS: Three hundred twenty patients from 9 centers were randomized. The trial terminated early due to low recruitment. At 30 days, there was no significant difference in mortality (intervention vs control, 11.5% vs 15%; unadjusted odds ratio [OR], 0.73; 95% CI, 0.38-1.41; p = .355). Significant bleeds were infrequent and were not significantly different between the arms (intervention vs control, 1.9% vs 1.9%; p > .999). Using a Bayesian Markov longitudinal ordinal model, it was 93% probable that intervention arm participants were more likely to transition to a better clinical state each day (OR, 1.46; 95% credible interval [CrI], 0.88-2.37; Pr [beta > 0], 93%; adjusted OR, 1.50; 95% CrI, 0.91-2.45; Pr [beta > 0], 95%) and median time to discharge to home was 2 days shorter (95% CrI, -4 to 0; 2% probability that it was worse). CONCLUSION: Acute coronary syndrome treatment regimen was associated with a reduction in the length of hospital stay without an excess in major bleeding. A larger trial is needed to evaluate mortality.

Machine learning detection of Atrial Fibrillation using wearable technology.

BACKGROUND: Atrial Fibrillation is the most common arrhythmia worldwide with a global age adjusted prevalence of 0.5% in 2010. Anticoagulation treatment using warfarin or direct oral anticoagulants is effective in reducing the risk of AF-related stroke by approximately two-thirds and can provide a 10% reduction in overall mortality. There has been increased interest in detecting AF due to its increased incidence and the possibility to prevent AF-related strokes. Inexpensive consumer devices which measure the ECG may have the potential to accurately detect AF but do not generally incorporate diagnostic algorithms. Machine learning algorithms have the potential to improve patient outcomes particularly where diagnoses are made from large volumes or complex patterns of data such as in AF. METHODS: We designed a novel AF detection algorithm using a de-correlated Lorenz plot of 60 consecutive RR intervals. In order to reduce the volume of data, the resulting images were compressed using a wavelet transformation (JPEG200 algorithm) and the compressed images were used as input data to a Support Vector Machine (SVM) classifier. We used the Massachusetts Institute of Technology (MIT)-Beth Israel Hospital (BIH) Atrial Fibrillation database and the MIT-BIH Arrhythmia database as training data and verified the algorithm performance using RR intervals collected using an inexpensive consumer heart rate monitor device (Polar-H7) in a case-control study. RESULTS: The SVM algorithm yielded excellent discrimination in the training data with a sensitivity of 99.2% and a specificity of 99.5% for AF. In the validation data, the SVM algorithm correctly identified AF in 79/79 cases; sensitivity 100% (95% CI 95.4%-100%) and non-AF in 328/336 cases; specificity 97.6% (95% CI 95.4%-99.0%). CONCLUSIONS: An inexpensive wearable heart rate monitor and machine learning algorithm can be used to detect AF with very high accuracy and has the capability to transmit ECG data which could be used to confirm AF. It could potentially be used for intermittent screening or continuously for prolonged periods to detect paroxysmal AF. Further work could lead to cost-effective and accurate estimation of AF burden and improved risk stratification in AF.

Cardiac MRI of myocardial salvage at the peri-infarct border zones after primary coronary intervention.

The purpose of this study was to use cardiac MRI to define the morphology of the reversibly injured peri-infarct border zone in patients treated with primary percutaneous coronary intervention (PPCI) for acute ST elevation myocardial infarction. In 15 patients, T2-weighted myocardial edema imaging was used to identify the ischemic bed or area at risk (AAR), and late gadolinium enhancement imaging was used to measure infarct size. Images were coregistered, and the boundaries of edema and necrosis were defined using an edge-detection methodology. We observed that infarction always involved the subendocardium but showed variable transmural extension within the AAR. The mean infarct size was 22 +/- 19% (range: 8-48%), and the mean AAR was 34 +/- 12% (range: 20-57%). The infarcted myocardium was always smaller than the ischemic AAR and involved between 34% and 99% (mean 72 +/- 21%) of the ischemic bed primarily due to variation in transmural infarct extension. Although a lateral border zone of potentially viable myocardium was often present, its extent was limited (range: 0-11 mm, mean: 5 +/- 4 mm). As a result of this, infarcts occupied the majority (range: 70-100%, mean: 82 +/- 13%) of the width of the AAR. The mean fractional wall thickening in the infarcted, peri-infarcted, and remote myocardium was 3.6 +/- 16.0%, 40.5 +/- 26.4%, and 88.2 +/- 39.3%, respectively. These findings demonstrate that myocardial salvage is largely determined by epicardial limitation of the infarct within the ischemic AAR after PPCI. The lateral boundaries of necrosis approximate to the lateral extent of the ischemic bed and systolic wall motion abnormalities extend well beyond the infarct border zone.

Reperfusion hemorrhage following acute myocardial infarction: assessment with T2* mapping and effect on measuring the area at risk.

Research ethics committee approval and informed consent were obtained. The purpose of this study was to assess the feasibility of multiecho T2* mapping of the heart for detecting reperfusion hemorrhage following percutaneous primary coronary intervention (PPCI) for acute myocardial infarction, and to measure the effect of hemorrhage on quantifying the ischemic area at risk (IAR) on T2-weighted magnetic resonance images. Fifteen patients (mean age, 59 years; 13 men, two women) were imaged a mean of 3.2 days following PPCI. The mean area of hemorrhage, indicated by a T2* decay constant of less than 20 msec, was 5.0% +/- 4.9 (standard deviation) at the level of the infarct and this correlated with the infarct (r(2) = 0.76, P < .01) and microvascular obstruction (r(2) = 0.75, P < .01) volumes. When 5% or less hemorrhage was present, the IAR was underestimated by 50% at a standard deviation threshold level of five, compared with a boundary detection tool (21.8% vs 44.0%, P < .05). T2* mapping is feasible for quantifying post-reperfusion hemorrhage and boundary detection is required to accurately assess the IAR when hemorrhage is present.

Sirolimus-eluting and paclitaxel-eluting stents for the treatment of coronary bifurcations.

BACKGROUND: The aim of the study was to compare the outcomes of sirolimus-eluting (SES) and paclitaxel-eluting (PES) stent implantation in coronary bifurcations treated with either a 1-stent or 2-stent strategy. METHODS: The study used a retrospective cohort analysis of consecutive de novo bifurcations, excluding left main, treated with SES or PES between April 2003 and June 2005. RESULTS: We identified 170 bifurcations in 161 patients treated with SES and 119 bifurcations in 112 patients treated with PES. During a median follow-up of 1,061 days (interquartile range 814-1,314), 43 patients (26.7%) in the SES group and 28 (25.0%) in the PES group had a major adverse cardiac event (P = .78). The angiographic restenosis rate per bifurcation was 20.9% and 25.9%, respectively (P = .41). There was no difference overall in the occurrence of target lesion revascularization (TLR) per bifurcation, 22 with SES (12.9%) and 18 with PES (15.1%), P = .61. The TLR rate was similar for SES and PES in bifurcations treated with 1 stent (6.7% vs 11.4%, P = .40) and in bifurcations treated with both branch stenting (20.0% vs 20.4%, P =1.0). CONCLUSIONS: In this cohort, the long-term clinical outcomes appear similar overall between SES and PES in the treatment of coronary bifurcations irrespective of whether a 1-stent or 2-stent strategy was used.

Screening for Atrial Fibrillation Using Economical and Accurate Technology (From the SAFETY Study).

The prevalence of atrial fibrillation (AF) is estimated at more than 3% in the adult population and there has been increased interest in screening for AF. In the SAFETY trial we chose to evaluate if inexpensive, wearable, consumer electrocardiography (ECG) sensing devices (Polar-H7 [PH7] and Firstbeat Bodyguard 2 [BG2]), could be used to detect AF accurately. We undertook a case-control study of 418 participants aged >65 (82 with AF and/or flutter at the study visit and 336 without) attending 3 general practice surgeries in Hampshire, UK for a single screening visit. The PH7 and BG2 devices were tested alongside 2 established AF detection devices (AliveCor and WatchBP) in random order and the diagnosis of AF was confirmed by 12-Lead ECG interpreted by a panel of cardiologists. The sensitivity (95% confidence interval [CI] range), specificity (95% CI range), and overall accuracy (95% CI range) of the 4 devices were: AliveCor: 87.8% (78.7% to 94.0%), 98.8% (97.0% to 99.7%), 96.7% (94.4% to 98.2%); WatchBP: 96.3% (89.7% to 99.2%), 93.5% (90.3% to 95.9%), 94.0% (91.3% to 96.1%): PH7: 96.3% (89.7% to 99.2%), 98.2% (96.2% to 99.3%), 97.9% (96.0% to 99.0%). BG2: 96.3% (89.7% to 99.2%), 98.5% (96.6% to 99.5%), 98.1% (96.3% to 99.2%). The PH7 and BG2 devices were highly reliable (the devices acquired sufficient data and obtained a diagnostic result in all but 1 participant on the first attempt). In conclusion, inexpensive, consumer heart rate monitoring devices (PH7 and BG2) can be used to detect AF accurately with sensitivity and specificity >95%. The consumer devices performed as well or better than WatchBP and AliveCor and have the capability to store or transmit ECG data which could be used to confirm AF.

Late restenosis following sirolimus-eluting stent implantation.

Despite encouraging results from randomized trials, concerns exist about long-term results of sirolimus-eluting stent implantation. We sought to determine whether in-stent restenosis occurring >1 year ("late") after sirolimus-eluting stent implantation is a real clinical entity. We analyzed data on all sirolimus-eluting stents implanted in our institution before March 2003. During the study period 928 lesions in 433 patients were treated. Angiographic follow-up was performed in 306 patients (70.6%) with 679 lesions (73.2%). Angiography after 1 year was performed only in symptomatic patients. We considered restenosis "early" if it occurred during the first year and late if after 1 year. Late restenosis required demonstration of a widely patent stent at 6 to 9 months, with repeat angiography after 1 year demonstrating restenosis. Restenosis occurred in 160 lesions overall (23.5%). Of the 31 (4.6%) that were documented after 1 year, 13 were excluded from analysis due to absence of 6- to 9-month angiography; the remaining 18 (2.6%, 1.7 to 4.2) fulfilled our criteria for late restenosis (median time of documentation 607 days, interquartile range 511 to 923). In conclusion, late restenosis is an infrequent but real entity; its existence implies we should not discount the possibility of restenosis as the cause of symptoms that develop >1 year after sirolimus-eluting stent implantation.

Is sirolimus better than paclitaxel? A review of the comparative data on drug-eluting stents.

Drug-eluting stents have been unequivocally demonstrated to reduce in-stent restenosis when compared to bare metal stents, with resultant lower rates of repeat revascularization. Comparative data are now emerging which compare the performance of sirolimus- and paclitaxel-eluting stents to each other rather than to bare metal stents. In this article, we review these data with the aim of placing the studies in context thereby providing an overall view of this rapidly developing field as it stands at present.

Concurrent implantation of sirolimus- and paclitaxel-eluting stents in the same vessel.

OBJECTIVE: To assess the safety and efficacy of concurrent implantation of sirolimus-eluting (SES) and paclitaxel-eluting (PES) stents in the same coronary artery. BACKGROUND: When it is impossible to deliver multiple drug eluting stents (DES) of the same type, the operator must opt to implant a different DES or a bare metal stent. There are currently no published data evaluating this approach. METHODS: We identified all cases in which one or more SES and PES were implanted in either the same lesion or adjacent segments of the same vessel during a single procedure between March 2003 and March 2005. Endpoints analyzed were; in-hospital major adverse cardiac events (MACE), and follow-up MACE (including stent thrombosis). RESULTS: We identified 44 patients with 89 lesions. This was a complex cohort of patients with a median of 3.5 stents implanted, 3 lesions and 2 vessels treated and a median stent length implanted of 80.5 mm, while 83% of the lesions were type B2/C. Eight patients had peri-procedural myocardial infarction. During follow-up; 1 cardiac death occurred, no patients had a myocardial infarct or stent thrombosis, 11 underwent target lesion and vessel revascularization (25%) and 13 had a major adverse cardiac event (29.5%). CONCLUSIONS: In this cohort of patients, the concurrent use of SES and PES in the same vessel was associated with outcomes in keeping with the complexity of disease treated. Our data show that it is not unreasonable to implant different DES in the same vessel, although we would not advocate this as routine practice.

Patterns of restenosis after drug-eluting stent implantation: Insights from a contemporary and comparative analysis of sirolimus- and paclitaxel-eluting stents.

AIM: To evaluate patterns of restenosis following implantation of sirolimus-eluting stent (SES) and paclitaxel-eluting stent (PES) in comparable unselected lesions. METHODS AND RESULTS: We have identified all episodes of restenosis after SES or PES implantation in our institutions between March 2003 and March 2005. Restenosis pattern was classified as focal, diffuse, proliferative, or occlusive. The position of focal restenosis was also categorized as proximal, in-stent, distal, or multi-focal. We have characterized 150 and 149 restenotic lesions in SES and PES groups, respectively. The incidence of diffuse and occlusive restenosis was significantly higher in PES than in SES (47.6 vs. 27.0%, P < 0.001). Multivariable (OR 2.693, 95% CI 1.425-5.089, P = 0.002) and propensity (OR 3.00, 95% CI 1.584-5.672, P < 0.001) analyses confirmed the positive association of PES with non-focal restenosis. For both stents, focal-edge restenosis was significantly more likely to occur proximally than distally (61.0 vs. 16.9%, P < 0.001 for PES and 45.8 vs. 16.8%, P < 0.001 for SES). CONCLUSION: Focal restenosis remains the most common pattern with SES. In contrast, just under half of restenosis in PES is the more severe non-focal pattern. Paradoxically, the majority of focal restenosis occurs at the proximal stent margin for both platforms.