High on-aspirin treatment platelet reactivity and restenosis after percutaneous coronary intervention: results of the Intracoronary Stenting and Antithrombotic Regimen-ASpirin and Platelet Inhibition (ISAR-ASPI) Registry.

OBJECTIVE: The aim of this study was to assess the association between high on-aspirin treatment platelet reactivity (HAPR) and the subsequent risk of restenosis after percutaneous coronary intervention (PCI) with predominantly drug-eluting stents. BACKGROUND: The association between HAPR and subsequent risk of restenosis after PCI is unclear. METHODS: This study included 4839 patients undergoing PCI (02/2007-12/2011) in the setting of the Intracoronary Stenting and Antithrombotic Regimen-ASpirin and Platelet Inhibition (ISAR-ASPI) registry. Platelet function was assessed with impedance aggregometry using the multi-plate analyzer immediately before PCI and after intravenous administration of aspirin (500 mg). The primary outcome was clinical restenosis, defined as target lesion revascularization at 1 year. Secondary outcomes included binary angiographic restenosis and late lumen loss at 6- to 8-month angiography. RESULTS: The upper quintile cut-off of platelet reactivity measurements (191 AU × min) was used to categorize patients into a group with HAPR (platelet reactivity > 191 AU × min; n = 952) and a group without HAPR (platelet reactivity ≤ 191 AU × min; n = 3887). The primary outcome occurred in 94 patients in the HAPR group and 405 patients without HAPR (cumulative incidence, 9.9% and 10.4%; HR = 0.96, 95% CI 0.77-1.19; P = 0.70). Follow-up angiography was performed in 73.2% of patients. There was no difference in binary restenosis (15.2% vs. 14.9%; P = 0.79) or late lumen loss (0.32 ± 0.57 vs. 0.32 ± 0.59 mm; P = 0.93) between patients with HAPR versus those without HAPR. CONCLUSIONS: This study did not find an association between HAPR, measured at the time of PCI, and clinical restenosis at 1 year after PCI.

One-Year Ischemic and Bleeding Events According to Renal Function in Patients With Non-ST-Segment Elevation Acute Coronary Syndromes Treated With Percutaneous Coronary Intervention and Third-Generation Antiplatelet Drugs.

The optimal antiplatelet therapy of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) and chronic kidney disease (CKD) remains unknown. This study included 2,364 patients with NSTE-ACS undergoing predominantly percutaneous coronary intervention (PCI), who were randomized to ticagrelor or prasugrel in the ISAR-REACT 5 trial. Estimated glomerular filtration rate (eGFR) was calculated using the Chronic Kidney Disease Epidemiology Collaboration equation. The primary end point was 1-year mortality. Overall, there were 85 deaths (3.6%): 6 deaths (17.1%) in patients with eGFR <30, 31 deaths (6.9%) in patients with eGFR 30 to <60, 34 deaths (3.0%) in patients with eGFR 60 to <90, and 14 deaths (2.0%) in patients with eGFR ≥90 ml/min/1.73 m2; adjusted hazard ratio (HR)=1.15, 95% confidence interval (CI) 1.01 to 1.31; p = 0.033 for 10 ml/min/1.73 m2 decrement in the eGFR. Bleeding occurred in 129 patients (5.5%): 7 bleeds (20.2%) in patients with eGFR <30, 36 bleeds (8.0%) in patients with eGFR 30 to <60, 64 bleeds (5.6%) in patients with eGFR 60 to <90, and 22 bleeds (3.1%) in patients with eGFR ≥90 ml/min/1.73 m2; adjusted HR=1.11 (1.01 to 1.23); p = 0.045 for 10 ml/min/1.73 m2 decrement in the eGFR. One-year mortality and bleeding did not differ significantly between ticagrelor and prasugrel in all categories of impaired renal function. In conclusion, in patients with NSTE-ACS undergoing PCI with drug-eluting stents and third-generation antiplatelet drugs, impaired renal function was independently associated with higher risk of 1-year mortality and bleeding. The ischemic and bleeding risks appear to differ little between ticagrelor and prasugrel in all categories of impaired renal function.

Ten-year patterns of stent thrombosis after percutaneous coronary intervention with new- versus early-generation drug-eluting stents: insights from the DECADE cooperation.

INTRODUCTION AND OBJECTIVES: The DECADE cooperation is a pooled analysis of individual patient data from drug-eluting stent (DES) trials with a 10-year follow-up. This analysis reports the risk of definite stent thrombosis (ST) through to 10 years after percutaneous coronary intervention (PCI) in patients treated with early- and new-generation DES. METHODS: Individual patient data from 5 DES trials with a 10-year follow-up were pooled. The primary endpoint was definite ST up to 10 years after PCI. Patients were divided into 2 groups as per the generation of DES implanted (early and new DES). Individual participant data were analyzed using a 1-stage approach. RESULTS: We included 9700 patients, 6866 in the new DES group and 2834 in the early DES group. Through to 10 years, definite ST occurred in 69 of 6866 patients treated with new DES and in 91 of 2834 patients treated with early DES (1.0% vs 3.5%, adjusted hazard ratio, 0.32; 95%CI, 0.23-0.45). The rate of definite ST was lower in the new DES group than in the early DES group from 1 to 5 years (rate ratio, 0.14; 95%CI, 0.08-0.26) and from 5 to 10 years (rate ratio, 0.23; 95%CI, 0.08-0.61) after PCI. CONCLUSIONS: The incidence of definite ST through to 10 years after PCI with new-generation DES was 1%. New-generation DES are associated with a lower 10-year incidence of definite ST than early-generation DES, particularly beyond 1 year after PCI.

Body mass index and efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndromes.

INTRODUCTION AND OBJECTIVES: The efficacy and safety of ticagrelor vs prasugrel in patients with acute coronary syndromes (ACS) according to body mass index (BMI) remain unstudied. We assessed the efficacy and safety of ticagrelor vs prasugrel in patients with ACS according to BMI. METHODS: Patients (n=3987) were grouped into 3 categories: normal weight (BMI <25kg/m2; n=1084), overweight (BMI ≥ 25 to <30kg/m2; n=1890), and obesity (BMI ≥ 30kg/m2; n=1013). The primary efficacy endpoint was the 1 year incidence of all-cause death, myocardial infarction, or stroke. The secondary safety endpoint was the 1 year incidence of Bleeding Academic Research Consortium type 3 to 5 bleeding. RESULTS: The primary endpoint occurred in 63 patients assigned to ticagrelor and 39 patients assigned to prasugrel in the normal weight group (11.7% vs 7.5%; HR, 1.62; 95%CI, 1.09-2.42; P=.018), 78 patients assigned to ticagrelor and 58 patients assigned to prasugrel in the overweight group (8.3% vs 6.2%; HR, 1.36; 95%CI, 0.97-1.91; P=.076), and 43 patients assigned to ticagrelor and 37 patients assigned to prasugrel in the obesity group (8.6% vs 7.3%; HR, 1.18; 95%CI, 0.76-1.84; P=.451). The 1-year incidence of bleeding events did not differ between ticagrelor and prasugrel in patients with normal weight (6.5% vs 6.6%; P=.990), overweight (5.6% vs 5.0%; P=.566) or obesity (4.4% vs 2.8%; P=.219). There was no significant treatment arm-by-BMI interaction regarding the primary endpoint (Pint=.578) or secondary endpoint (Pint=.596). CONCLUSIONS: In patients with ACS, BMI did not significantly impact the treatment effect of ticagrelor vs prasugrel in terms of efficacy or safety. CLINICAL TRIAL REGISTRATION: NCT01944800.

COVID-19-associated myocarditis presenting as new-onset heart failure and atrial fibrillation.

A 58-year-old man presented to the emergency department with recent-onset palpitations and progressive exertional dyspnoea. ECG demonstrated new-onset atrial fibrillation. Transthoracic echocardiogram showed global impairment in left ventricular systolic function with left ventricular ejection fraction of 20%. Cardiac MRI (CMRI) demonstrated generalised severe myocarditis. A SARS-CoV-2 PCR was positive for SARS-CoV-2 RNA. As such, we diagnosed our patient with COVID-19-associated myocarditis based on CMRI appearances and positive SARS-CoV-2 swab. This case highlights that COVID-19-associated myocarditis can present as new atrial fibrillation and heart failure without the classic COVID-19-associated symptoms.

Real World Prescribing Strategies for Patients With an Indication for Oral Anticoagulation Undergoing Percutaneous Coronary Intervention.

BACKGROUND: Limited data are available regarding real-world prescribing in patients with an indication for oral anticoagulation (OAT) who undergo percutaneous coronary intervention (PCI). Most current guidelines recommend a period of triple therapy with OAT and dual antiplatelet (DAPT) agents over dual therapy with an OAT and DAPT but the clinical benefit is still unclear giving rise to limited evidence-based recommendations. AIM: To analyze the appropriateness of OAT and anti-platelet strategies post PCI in a real-world cohort of patients in 2 academic teaching hospitals. METHODS AND RESULTS: In total, 103 patients were retrospectively analyzed. As the initial 3 month stragey, 97 patients (94.2%) received triple therapy, 4 received Dual Therapy (3.9%) and 2 received DAPT (1.9%). Patients with predominant bleeding risk were significantly less likely to receive triple therapy (75% vs. 95.7% vs. 95.8%, P < 0.05). Apixaban was the most common OAT (65.7%) which in most cases was prescribed at an inappropriately reduced dose of 2.5 mg BD (80.4%). The MACE, bleeding and all-cause mortality rates did not differ significantly between groups. DISCUSSION: Our study demonstrates the widespread use of triple therapy for the first 3 months of treatment in 2 Irish academic hospitals. DOACs were prescribed in most cases at reduced doses not currently known to prevent stroke. This study highlights the need for more explicit management algorithms to improve evidence-based management in this area.

Cardiac amyloidosis presenting with recurrent ischaemic strokes.

A 72-year-old man presented to our service with sudden onset right-sided weakness, aphasia and gaze palsy with diplopia. CT angiogram demonstrated an acute thrombotic occlusion of the distal basilar artery, a basilar infarct and the patient underwent successful thrombectomy. ECG and telemetry demonstrated slow atrial fibrillation (AF). His transthoracic echocardiogram (TTE) showed a reduced ejection fraction of 25% with global hypo-kinesis, a dilated left ventricle (LV) and LV hypertrophy (LVH). Repeat TTE appeared suspicious for an infiltrative cardiomyopathy with LVH and a speckled appearance to the myocardium. Approximately 10 months later, he suffered another ischaemic stroke post-elective cardioversion for AF while on anticoagulation. Cardiac MRI demonstrated areas of delayed gadolinium enhancement consistent with amyloidosis. Fat pad biopsy was positive for amyloidosis. Our patient has made an excellent recovery from the ischaemic strokes and is being managed in our heart failure clinic.

Performing diagnostic radial access coronary angiography on uninterrupted direct oral anticoagulant therapy: a prospective analysis.

Purpose: We sought to assess the safety of performing diagnostic radial access coronary angiography with uninterrupted anticoagulation on patients receiving direct oral anticoagulant therapy. Background: Direct oral anticoagulants have become a popular choice for the prevention of thromboembolism. Risk factors for thromboembolism are common among cardiovascular conditions and indications for direct oral anticoagulant therapy as well as coronary angiography often overlap in patients. It has been hypothesised that uninterrupted direct oral anticoagulant therapy would increase haemorrhagic and access site complications, however data in this area is limited. Methods: This was a prospective observational analysis of 49 patients undergoing elective diagnostic coronary angiography while receiving uninterrupted anticoagulation with direct oral anticoagulants. This population was compared with a control group of 49 unselected patients presenting to the cardiology service for elective diagnostic coronary angiography. Continuous variables were analysed using the independent samples t-test and categorical variables using Pearson's χ2 test. Results: The mean duration of radial compression for the control group was 235.8±62.8 min and for the uninterrupted direct oral anticoagulant group was 258.4±56.5 min. There was no significant difference in mean duration of radial compression (p=0.07; 95% CI=-1.4 to 46.5). There was also no difference in the complication rate between the two groups (p=1). Conclusions: We observed similar complication rates and radial artery compression time postangiography in both groups. This small prospective observational study suggests that uninterrupted continuation of direct oral anticoagulants during coronary angiography is safe. Larger randomised control studies in this area would be beneficial.

Assessing suitability for sacubitril-valsartan therapy in an Irish cohort: challenges and opportunities.

INTRODUCTION: Sacubitril-valsartan has been shown by the PARADIGM-HF trial to decrease hospital admissions and improve mortality in patients with heart failure with reduced ejection fraction. The PARADIGM trial had stringent exclusion criteria. It is not known how applicable these trial criteria are to real-life practice. In this study, we sought to determine the percentage of patients eligible for sacubitril-valsartan therapy in a level 3 hospital without a dedicated heart failure service. METHODS: All patients discharged from our service with a diagnosis of congestive cardiac using our hospital in-patient enquiry (HIPE) system underwent hierarchal analysis. In order to be deemed eligible for sacubitril-valsartan therapy, patients had to meet PARADIGM-HF inclusion criteria. RESULTS: Our 143 patients represented a more clinically unwell, elderly cohort than the PARADIGM trial study population. Only 24 patients (16.66%) had an ejection fraction of 40% or less. Our results indicate that only 4/143 patients in a real-world setting (2.79%) were eligible for sacubitril-valsartan therapy at the point of discharge as per the PARADIGM-HF study criteria. This is primarily due to the higher than expected percentage of patients in our cohort with an ejection fraction of over 40% (n = 120) and the low percentage of patients on therapeutic doses of ACEI/ARB (n = 15). CONCLUSIONS: Our study showed that a smaller than expected proportion of our patients in real-world practice are suitable for sacubitril-valsartan therapy at discharge. Most patients were in the HFPEF cohort which does not currently have evidence for treatment with sacubitril-valsartan. Low rates of prescribing of basic heart failure medicatons and the absence of dedicated heart failure services in a non-tertiary centre may explain the poor compliance observed. Improving guideline adherence and increasing awareness of evidence-based medication use at primary and secondary care levels would be of benefit to Irish heart failure patients.

Left distal trans-radial access facilitates earlier discharge post-coronary angiography.

AIMS: In 2017, Kiemeneij published a paper on distal trans-radial artery access for coronary angiography in 62 patients. This paper proposed several advantages to this method. Since this paper was published, several other papers have been published describing this technique, with less than 200 cases in total described. We performed a non randomized control study of left distal trans-radial access in patients undergoing coronary angiography in our center. METHODS: We prospectively identified patients presenting for coronary angiography to our center for enrolment in this study. We recruited 94 patients (47 ldTRA, 47 age and sex matched controls). Pre-defined endpoints for the study were as follows: time until radial compression device (RCD) removal, procedural time, radiation dose, fluoroscopy time, and contrast dose. RESULTS: Patient and procedural characteristics did not differ significantly between the two groups. With regard to our primary endpoint, patients undergoing ldTRA required, on average, 69 min less time until removal of the RCD (167.8 ± 30 vs 236.6 ± 63.9 min, P < 0.0001). Procedural length did not vary between groups (28.95 ± 5.89 vs 29.76 ± 8.16 min, P = 0.5824). Similarly, there was no statistically significant difference in radiation dose area product (5032.66 ± 2740 vs 4826 ± 2796 Gy/cm2 , P = 0.7191), contrast dose (82.93 ± 23 vs 92.1 ± 33 mL, P = 0.1215), and fluoroscopy time between the two groups (5.41 ± 3.42 vs 4.82 ± 2.97 min, P = 0.3742). CONCLUSIONS: Our study confirms that ldTRA is a feasible technique for diagnostic coronary angiography in a modern cardiac catheterization laboratory. It results in decreased post-procedure radial artery compression time without increasing procedural time or radiation dose.

Circadian and seasonal variations in patients with acute STEMI: A retrospective, single PPCI center study.

This was a retrospective observational analysis of all (n = 876) ST-segment elevation myocardial infarction (STEMI) patients treated with primary percutaneous coronary intervention (PPCI) at University Hospital Limerick (UHL) from 2012 to 2016 to determine whether chronological patterns existed in incidence and mortality at our center. Data were obtained from the electronic Cardiology STEMI database in UHL. Statistical analysis was performed using the Independent Samples t Test, ANOVA and Pearson's Chi-Squared test. The rate of STEMI from 0800 and 2259 hours (46.9/hr) was greater than 2300 to 0759 hours (19.1/hr) (p < 0.001). No association was found between 30-day mortality and weekend/weekdays presentation (p = 0.81) or off/in hour presentation (p = 0.86). No seasonal variation was found in STEMI incidence at our center using international (p = 0.29) or Celtic (p = 0.82) seasonal calendars. 30-Day mortality is equivalent whether STEMI patients treated with PPCI present during "normal working hours" or during the "out of hours"/weekend period at our center. The majority of STEMIs occur during the hours 0800 to 2259, but no further chronological relationship was observed in incidence.

Atrial myxoma presenting as infective endocarditis.

A 23-year-old Asian student presented to our service with a 1-month history of fever, weight loss of 10 kg, night sweats, fatigue and general malaise. He was previously well with no significant medical or family history. He had a low-grade pyrexia and cardiac auscultation revealed a diastolic murmur consistent with 'tumour plop'. He had no sequelae of endocarditis. He had low-grade pyrexia of 37.7°C, and ECG showed sinus tachycardia at 130 bpm. He had raised inflammatory markers and was started on broad spectrum antibiotics. Blood cultures grew Streptococcus viridans twice. Transthoracic and transo-oesophageal echocardiography revealed a large mobile mass attached to the interatrial septum, suspicious for atrial myxoma, flopping into the left ventricle but not causing left ventricular outflow tract obstruction. All valves looked normal in appearance. He was treated with antibiotics for 2 weeks until inflammatory markers normalised. The patient was referred for cardiothoracic surgery where a large atrial myxoma (5 cm×3 cm) was excised just superior to the mitral valve. It had areas of necrosis and was colonised with S. viridans He had an unremarkable postoperative course and made a complete recovery.

Eosinophilic myocarditis: an often subtle and potentially under-recognised phenomenon.

A 34-year-old woman presented to our service with chest pain, a troponin rise and dynamic ECG changes. Of note, she had complained of fatigue, feeling constitutionally unwell and a generalised rash in the days prior to her presentation. Her echocardiogram showed normal wall motion and preserved ejection fraction. Her eosinophil count, normal at presentation, rose to a peak of 12.21×105/L. She was haemodynamically stable throughout with no evidence clinically of congestive cardiac failure. CT coronary angiogram showed no obstructive coronary artery disease. Cardiac MRI demonstrated areas of late gadolinium enhancement consistent with myocarditis. A diagnosis of eosinophilic myocarditis was made. No tissue biopsy was performed due to the patchy myocardial involvement and high potential for low-yield biopsy. Our patient was treated conservatively and has made an excellent recovery.