High-intensity interval training induces beneficial effects on coronary atheromatous plaques: a randomized trial.

AIMS: Coronary atheroma volume is associated with risk of coronary events in coronary artery disease (CAD). Exercise training is a cornerstone in primary and secondary prevention of CAD, but the effect of exercise on coronary atheromatous plaques is largely unknown. We assessed the effect of 6 months supervised high-intensity interval training (HIIT) on coronary plaque geometry using intravascular ultrasound in patients with stable CAD following percutaneous coronary intervention (PCI). METHODS AND RESULTS: Sixty patients were randomized to two sessions of weekly supervised HIIT at 85-95% of peak heart rate (n = 30) or to follow contemporary preventive guidelines (control group, n = 30). The study endpoints were change in percent atheroma volume (PAV) and total atheroma volume (TAV) normalized for segment length (TAVnorm) at 6-month follow-up. The change in average PAV for matched coronary segments from baseline to follow-up showed a significant between-group difference (-1.4, 95% CI: -2.7 to -0.1, P = 0.036). There was a significant reduction in the HIIT group (-1.2, 95% CI: -2.1 to -0.2, P = 0.017) while not in the control group (0.2, 95% CI: -0.7 to 1.1, P = 0.616). TAVnorm was reduced (-9 mm3, 95% CI: -14.7 to -3.4, P = 0.002) after HIIT, with a significant between-group difference (-12.0 mm3, 95% CI: -19.9 to -4.2, P = 0.003). CONCLUSION: In patients with established CAD, a regression of atheroma volume was observed in those undergoing 6 months of supervised HIIT compared with patients following contemporary preventive guidelines. Our study indicates that HIIT counteracts atherosclerotic coronary disease progression and reduces atheroma volume in residual coronary atheromatous plaques following PCI.

Guideline-Recommended Time Less Than 90 Minutes From ECG to Primary Percutaneous Coronary Intervention for ST-Segment-Elevation Myocardial Infarction Is Associated with Major Survival Benefits, Especially in Octogenarians: A Contemporary Report in 11 226 Patients from NORIC.

Background Using contemporary data from NORIC (Norwegian Registry of Invasive Cardiology) we investigated the predictive value of patient age and time from ECG diagnosis to sheath insertion (ECG-2-sheath) in primary percutaneous coronary intervention for ST-segment-elevation myocardial infarction (STEMI). Methods and Results Data from 11 226 patients collected from all centers offering 24/7/365 primary percutaneous coronary intervention service were explored. For patients aged <80 years the mortality rates were 5.6% and 7.6% at 30 days and 1 year, respectively. For octogenarians the corresponding rates were 15.0% and 24.2%. The Cox hazard ratio was 2.02 (1.93-2.11, P value <0.0001) per 10 years of patient age. Time from ECG-2-sheath was significantly associated with mortality with a 3.6% increase per 30 minutes of time. Using achievement of time goal <90 minutes in patients aged >80 years and mortality at 30 days, mortality was 10.5% and 17.7% for <90 or ≥90 minutes, respectively. The number needed to prevent 1 death was 39 in the whole population and 14 in the elderly. Restricted mean survival gains during median 938 days of follow-up in patients with ECG-2-sheath time <90 minutes were 24 and 76 days for patients aged <80 and ≥80 years, respectively. Conclusions Time from ECG-diagnosis to sheath insertion is strongly correlated with mortality. This applies especially to octogenarians who derive the most in terms of absolute mortality reduction. Registration URL: https://helsedata.no/en/forvaltere/norwegian-institute-of-public-health/norwegian-registry-of-invasive-cardiology/.

CENIT (Impact of Cardiac Exercise Training on Lipid Content in Coronary Atheromatous Plaques Evaluated by Near-Infrared Spectroscopy): A Randomized Trial.

Background The effect of physical exercise on lipid content of coronary artery plaques is unknown. With near infrared spectroscopy we measured the effect of high intensity interval training (HIIT) on lipid content in coronary plaques in patients with stable coronary artery disease following percutaneous coronary intervention. Methods and Results In CENIT (Impact of Cardiac Exercise Training on Lipid Content in Coronary Atheromatous Plaques Evaluated by Near-Infrared Spectroscopy) 60 patients were randomized to 6 months supervised HIIT or to a control group. The primary end point was change in lipid content measured as maximum lipid core burden index at 4 mm (maxLCBI4mm). A predefined cutoff of maxLCBI4mm >100 was required for inclusion in the analysis. Forty-nine patients (HIIT=20, usual care=29) had maxLCBI4mm >100 at baseline. Change in maxLCBI4mm did not differ between groups (-1.2, 95% CI, -65.8 to 63.4, P=0.97). The estimated reduction in maxLCBI4mm was -47.7 (95% CI, -100.3 to 5.0, P=0.075) and -46.5 (95% CI, -87.5 to -5.4, P=0.027) after HIIT and in controls, respectively. A negative correlation was observed between change in peak oxygen uptake (VO2peak) and change in lipid content (Spearman's correlation -0.44, P=0.009). With an increase in VO2peak above 1 metabolic equivalent task, maxLCBI4mm was on average reduced by 142 (-8 to -262), whereas the change was -3.2 (154 to -255) with increased VO2peak below 1 metabolic equivalent task. Conclusions Six months of HIIT following percutaneous coronary intervention did not reduce lipid content in coronary plaques compared with usual care. A moderate negative correlation between increase in VO2peak and change in lipid content generates the hypothesis that exercise with a subsequent increase in fitness may reduce lipid content in coronary atheromatous plaques. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02494947.

High-intensity interval training and pulmonary hemodynamics in COPD with hypoxemia.

BACKGROUND: Exercise is recommended for all patients with COPD. Evidence for its benefit is considerably weaker in the more severe stages of the disease. The aim of this study was to investigate whether high-intensity interval training could improve exercise capacity, pulmonary hemodynamics and cardiac function in patients with severe COPD and hypoxemia. METHODS: Stable patients with COPD GOLD stage III or IV and hypoxemia were included. They underwent extensive cardiopulmonary testing including right heart catheterization, lung function tests, echocardiography and 6-minute walk test before and after completion of 10 weeks of high-intensity interval training performed with supplemental oxygen. Primary endpoint was change in pulmonary artery pressure measured by right heart catheterization. RESULTS: Ten patients with very severe airflow obstruction, mean FEV1 28.7% predicted and mean FEV1/VC 0.39 completed the exercise programme. Pulmonary artery pressure remained unchanged following the intervention (26,3 mmHg vs. 25,8 mmHg at baseline, p 0.673). Six-minute walk distance improved by a mean of44.8 m (p 0.010), which is also clinically significant. We found marginally improved left ventricular ejection fraction on echocardiography (54.6% vs 59.5%, p 0.046). CONCLUSION: High-intensity interval training significantly improved exercise capacity while pulmonary hemodynamics remained unchanged. The improvement may therefore be due to mechanisms other than altered pulmonary artery pressure. The increase in ejection fraction is of uncertain clinical significance. The low number of patients precludes firm conclusions.

Stent edge vascular response and in-stent geometry after aerobic exercise.

The purpose of the present study was to investigate the edge vascular response in patients treated with second-generation drug-eluting stents (DES) after 3 months of aerobic exercise intervention. Thirty-two patients with significant coronary artery disease underwent percutaneous coronary intervention with DES implantation prior to randomization to aerobic interval training (AIT, 14 patients) versus moderate continuous training (MCT, 18 patients). Plaque changes were assessed using grayscale and radiofrequency intravascular ultrasound at baseline and follow-up. The main endpoints were changes in plaque burden and necrotic core content in the 5-mm proximal and distal stent edges. Plaque burden in the distal stent edges decreased significantly in both groups (AIT: - 3.3%; MCT: - 0.4%, p = 0.01 for both), and more in the AIT group (p = 0.048). Necrotic core content decreased significantly in the distal stent edges in both groups (- 2.1 mm3 in AIT, - 0.3 mm3 in MCT, p = 0.01 for both), and more in the AIT group (p = 0.03). There were no significant changes in proximal stent edges or in in-stent geometry at follow-up. In this small study of patients treated with DES implantation, 3 months of aerobic exercise training demonstrated decreased plaque burden and necrotic core content in the distal stent edges, with larger reductions in the AIT group.

Reproducibility of optical coherence tomography in vein grafts used for coronary revascularization.

BACKGROUND: Optical coherence tomography (OCT) is a high-resolution imaging modality able to provide near-histological images of vessel walls making it possible to distinguish intima and media layers of the vessel wall separately. The use of this imaging technique is increasing while data on the variability and reliability is lacking. The aim of this study was to investigate the reproducibility of frequency-domain OCT in vein grafts used for coronary revascularization. METHODS: Five pullbacks were analyzed by the same analyst with a 1-month delay (intraobserver) and by two different analysts (interobserver). Five pairs of pullbacks from the same catheters and vein graft were also analyzed (inter pullback). RESULTS: Optical coherence tomography showed low variability in intra- and interobserver analysis with relative differences of mean media and intima thicknesses and areas of less than 5% for most parameters. Relative differences of the same parameters in the inter pullback analysis were in the 5-15% range. Intra- and interobserver reliability was excellent (intraclass correlation coefficient [ICC] > 0.90) for intima thickness and intima, media and intima-media area measurements. Inter pullback reliability was good (ICC: 0.75-0.90) for intima and intima-media area measurements, and moderate to good for mean intima thickness measurements (ICC: 0.79; 0.7338-0.8284). CONCLUSIONS: Optical coherence tomography provides good reproducibility for the measurements of parameters relevant for the development of atherosclerosis in vein grafts. CLINICAL TRIAL REGISTRATION: ID NCT01834846.

Pedicled Vein Grafts in Coronary Surgery: Perioperative Data From a Randomized Trial.

BACKGROUND: Less-than-optimal long-term patency of the saphenous vein is one of the main obstacles for the success of coronary artery bypass grafting (CABG). Results from the IMPROVE-CABG trial has shown that harvesting the saphenous vein with a pedicle of perivascular tissue less than 5 mm while using manual distention provides comparable occlusion rates but significantly less intimal hyperplasia at early follow-up. The impact of pedicled veins on duration of operations, leg wound infections, and postoperative bleeding is unknown. METHODS: One hundred patients undergoing first-time elective CABG were randomly assigned to conventional or pedicled vein harvesting. Perioperative and postoperative data were collected prospectively during the hospital stay and at follow-up. RESULTS: Duration of extracorporeal circulation was significantly longer in the pedicled vein group (mean: 76 min versus 65 min, p = 0.006); however, no significant difference was found in the cross-clamp time. No significant difference was found in intraoperative vein graft flow, postoperative bleeding, or leg wound infections (4% in each group). No reoperations were due to vein graft bleeding. CONCLUSIONS: Harvesting a pedicled vein provides comparable postoperative bleeding and leg wound infection rates in selected patients. The technique is associated with a slightly longer duration of extracorporeal circulation than harvesting conventional veins. Promising early results using the pedicled vein technique may contribute to a change in standard vein harvesting technique for CABG in selected patients.

Transthoracic Doppler for detection of stenoses in the three main coronary arteries by use of stenotic to prestenotic velocity ratio and aliased coronary flow.

AIMS: Our aim was to determine the feasibility and accuracy of diagnosing significant coronary artery stenoses using peak stenotic to prestenotic velocity ratio (pSPVR) measurements when compared with results from quantitative coronary angiography and coronary flow velocity reserve (CFVR) assessed by transthoracic echocardiography (TTE). METHODS AND RESULTS: One hundred and eight patients scheduled for coronary angiography were studied using transthoracic Doppler echocardiography. Stenoses were identified by local colour aliasing by colour flow Doppler, and further evaluated by pSPVR, using a pSPVR of ≥2.0 as a cut-off for significant stenosis. When pSPVR could not be measured, local mosaic coronary flow pattern at Nyquist limit ≥0.48 m/s was used. Sixty-five lesions suggestive of stenosis were found by TTE. Combining findings of pSPVR ≥2.0 and local mosaic flow at Nyquist limit ≥0.48 m/s, the sensitivity and specificity of demonstrating significant stenoses (diameter stenosis, 50-99%) in the left main coronary artery (LM), left anterior descending coronary (LAD), left circumflex coronary (Cx), and right coronary artery (RCA) were 75 and 98%, 74 and 95%, 40 and 87%, and 34 and 98%, respectively. The pSPVR did not differ significantly between arteries with reduced and normal CFVR, with a cut-off of CFVR <2.0. CONCLUSIONS: Findings of pSPVR ≥2.0 or localized colour flow aliasing are useful in the non-invasive diagnosis of significant coronary disease in the three main coronary arteries, with high specificity for detecting significant stenoses. These findings showed high sensitivity for identifying significant stenoses in the LM and LAD, but showed lower ability to detect those lesions in the Cx and RCA.

Predictors of Beneficial Coronary Plaque Changes after Aerobic Exercise.

PURPOSE: It has been demonstrated that aerobic exercise induces beneficial changes in coronary atherosclerosis via reduced necrotic core and plaque burden. Clinical factors that may be associated with favorable exercise-induced intracoronary effects are unknown. METHODS: This study used post hoc analysis of associations between baseline clinical variables and reductions in coronary necrotic core and plaque burden after aerobic exercise intervention. Coronary plaque characteristics were measured with grayscale and radiofrequency intravascular ultrasound in 36 patients (median age, 58.5 yr; seven women) with stable CAD (SCAD) or non-ST elevation acute coronary syndrome (NSTE-ACS). Screening of clinical variables was performed with random forest analysis followed by multivariate linear regression. RESULTS: The only significant clinical variable for necrotic core reduction was clinical presentation of disease (SCAD vs NSTE-ACS, P = 0.011). The changes in necrotic core after exercise were -4.94 mm3 (-10.33; -1.33) in patients with SCAD and 1.03 mm3 (-4.29; 3.71) in patients with NSTE-ACS (P = 0.01). Necrotic core was reduced in 17 patients (94%) with SCAD and eight patients (44%) with NSTE-ACS (P = 0.01). R2 for the model including baseline clinical presentation and baseline necrotic core volume was 0.90. There were no significant explanatory variables for plaque burden reduction. CONCLUSIONS: Exercise-induced plaque stabilization via reduced coronary necrotic core may be strongly dependent on clinical presentation of CAD. We hypothesized that an increased proinflammatory load renders patients with NSTE-ACS more resistant to exercise-induced plaque stabilization than patients with SCAD. Furthermore, aerobic exercise may have a particular potential for inducing beneficial effects on coronary atherosclerosis in patients with SCAD compared with patients in the early phase after an acute coronary syndrome.

Coronary atheroma regression and plaque characteristics assessed by grayscale and radiofrequency intravascular ultrasound after aerobic exercise.

The aim of the present study was to investigate effects of aerobic interval training (AIT) versus moderate continuous training (MCT) on coronary atherosclerosis in patients with significant coronary artery disease on optimal medical treatment. Thirty-six patients were randomized to AIT (intervals at ≈ 90% of peak heart rate) or MCT (continuous exercise at ≈ 70% of peak heart rate) 3 times a week for 12 weeks after intracoronary stent implantation. Grayscale and radiofrequency intravascular ultrasounds (IVUS) were performed at baseline and follow-up. The primary end point was the change in plaque burden, and the secondary end points were change in necrotic core and plaque vulnerability. Separate lesions were classified using radiofrequency IVUS criteria. We demonstrated that necrotic core was reduced in both groups in defined coronary segments (AIT -3.2%, MCT -2.7%, p <0.05) and in separate lesions (median change -2.3% and -0.15 mm(3), p <0.05). Plaque burden was reduced by 10.7% in separate lesions independent of intervention group (p = 0.06). No significant differences in IVUS parameters were found between exercise groups. A minority of separate lesions were transformed in terms of plaque vulnerability during follow-up with large individual differences between and within patients. In conclusion, changes in coronary artery plaque structure or morphology did not differ between patients who underwent AIT or MCT. The combination of regular aerobic exercise and optimal medical treatment for 12 weeks induced a moderate regression of necrotic core and plaque burden in IVUS-defined coronary lesions.

Reproducibility of grayscale and radiofrequency IVUS data acquisition in stented coronary arteries.

OBJECTIVES: Variability in data acquisition from intervened coronary arteries could represent a source of error that has implications for the design of serial stent studies. We assessed inter-pullback reproducibility of volumetric grayscale and radiofrequency intravascular ultrasound (IVUS) data in stented coronary arteries. DESIGN: Fifteen patients with coronary artery lesions treated with stent implantation were included and examined with two separate pullbacks using the Eagle Eye Gold-phased array 20 MHz IVUS catheter (Volcano). The arteries were divided into five segments, giving a total of 150 sub-segments for analyses. Matching of frames was performed using landmarks that were clearly visible in coronary angiography and intravascular pullbacks. Data were analyzed off-line at an independent Corelab. RESULTS: The inter-pullback reproducibility of geometrical data was very good for non-stented segments with relative differences less than 5% between pullbacks for lumen-, vessel-, and plaque volumes. For stented segments reproducibility was poorer with relative differences between pullbacks in the range of 5-10%. The inter-pullback reproducibility of compositional data demonstrated large standard deviations of relative differences, indicating a weaker agreement. CONCLUSIONS: Agreements between pullbacks were weaker in stented than those in non-stented segments. Based on our data, future longitudinal IVUS studies in intervened vessels should account for a variability of 5-10% attributed to the acquisition of images.

Coronary artery occlusions diagnosed by transthoracic Doppler.

BACKGROUND: Our aim was to assess whether anterograde flow velocities in septal perforating branches could identify an occluded contralateral coronary artery, and to assess the feasibility and accuracy of diagnosing occlusions in the three main coronary arteries by the combined use of several noninvasive parameters indicating collateral flow. METHODS: A total of 108 patients scheduled for coronary angiography because of chest pain or acute coronary syndromes were studied using transthoracic Doppler echocardiography. RESULTS: Anterograde peak diastolic flow velocities (pDV) in septal perforating branches were higher in patients with angiographic occluded contralateral artery compared with corresponding velocities in patients without significant disease in the contralateral artery (0.80 ± 0.31 m/sec versus 0.37 ± 0.13 m/sec, p < 0.001). Receiver operating characteristic curve showed pDV ≥ 0.57 m/sec to be the optimal cutoff value to identify occluded contralateral artery, with a sensitivity of 79% and a specificity of 69%. Demonstration of at least one positive parameter (retrograde flow in main coronary arteries, reversed flow in septal perforating and left circumflex marginal branches, pDV ≥ 0.57 m/sec, or demonstration of other epicardial or intramyocardial collaterals) indicating collateral flow to an occluded main coronary artery had sensitivity, specificity, positive and negative predictive value of 89%, 94%, 63%, and 99%, respectively, for detection of a coronary occlusion. With this combined use of several parameters, 25 of 28 coronary occlusions were identified. CONCLUSIONS: By investigating several parameters indicating collateral flow, we were able to identify most of the main coronary occlusions in the patient cohort. Furthermore, our study demonstrated that coronary artery occlusions may result in complex and diverging coronary pathophysiology depending on which coronary artery segment is occluded and the extent of accompanying coronary artery disease. TRIAL REGISTRATION: ClinicalTrials.gov number NTC00281346.

Transthoracic Doppler echocardiography for detection of stenoses in the left coronary artery by use of poststenotic coronary flow profiles: a comparison with quantitative coronary angiography and coronary flow reserve.

BACKGROUND: The aim of this study was to determine whether poststenotic diastolic-to-systolic velocity ratio (DSVR) assessed by transthoracic Doppler echocardiography could accurately identify significant stenoses in the left coronary artery. METHODS: A total of 108 patients scheduled for coronary angiography because of chest pain or acute coronary syndromes were studied. RESULTS: The success rates of peak DSVR (pDSVR) measurements in the distal to mid left anterior descending coronary artery and marginal branches of the left circumflex coronary artery were 85% and 32%, respectively. With peak coronary flow velocity reserve as a reference, pDSVR was significantly higher in arteries with normal coronary flow reserve (peak coronary flow velocity reserve ≥ 2.0) compared with arteries with reduced coronary flow reserve (peak coronary flow velocity reserve < 2.0) (1.86 ± 0.32 vs 1.53 ± 0.31, P < .0001). In comparison with quantitative coronary angiography, pDSVR was significantly higher in lesions with diameter stenosis < 50% compared with those with diameter stenosis of 50% to 75% (1.92 ± 0.32 vs 1.53 ± 0.18, P < .0001) or diameter stenosis of 76% to 100% (1.43 ± 0.13, P < .0001). Receiver operating characteristic curves showed pDSVR < 1.68 to be the optimal cutoff value for identifying both functionally significant stenoses and diameter stenoses ≥ 50%, with sensitivity of 86% and 90%, specificity of 74% and 84%, positive predictive value of 51% and 71%, and negative predictive value of 94% and 95%, respectively. CONCLUSIONS: Transthoracic pDSVR measurements in the distal to mid left anterior descending coronary artery and marginal branches of the left circumflex coronary artery had high accuracy for excluding functionally significant stenoses in the left coronary artery, as well as for identifying angiographic significant stenoses.

Coronary flow velocity reserve in the three main coronary arteries assessed with transthoracic Doppler: a comparative study with quantitative coronary angiography.

BACKGROUND: The purpose of this study was to evaluate the potential of combined use of transthoracic Doppler echocardiographic coronary flow velocity reserve (CFVR) measurements and findings of retrograde coronary flow in the three main coronary arteries for the assessment of borderline (angiographic diameter stenosis, 50%-75%) and high-grade (angiographic diameter stenosis, 76%-100%) coronary artery stenoses. METHODS: A total of 108 patients scheduled for coronary angiography because of chest pain or acute coronary syndromes were studied. CFVR was measured during adenosine-induced hyperemia in the mid to distal segments of the left anterior descending coronary artery, the marginal branches of the left circumflex coronary artery, and the posterior descending coronary artery, with peak CFVR (pCFVR) <2.0 implying hemodynamic significant stenosis. CFVR results were compared with results from quantitative coronary angiography, with stenosis severity in the left main and three major coronary arteries divided into three groups: (1) diameter stenosis 0% to 49%, (2) diameter stenosis 50% to 75%, and (3) diameter stenosis 76% to 100%. RESULTS: In patients with antegrade flow in the relevant coronary artery segment, CFVR was successfully measured in the mid to distal left anterior descending artery, the marginal branches of the left circumflex artery, and the posterior descending artery in 97%, 63%, and 75% of patients, respectively. CFVR was significantly different among the stenosis groups, with pCFVR of 2.79 ± 0.77 in group 1, 2.01 ± 0.72 in group 2, and 1.50 ± 0.69 in group 3 (P < .001 among groups). Angiography confirmed retrograde flow in seven of the nine arteries found by transthoracic echocardiography. Findings of pCFVR <2.0 or retrograde coronary artery flow correctly identified 42 of 49 patients with stenoses in group 3, with sensitivity, specificity, and positive and negative predictive values of 86%, 70%, 70%, and 85%, respectively. In group 2, pCFVR values were widely distributed above or below the defined pCFVR cutoff value. CONCLUSIONS: CFVR measurement in the mid to distal left anterior descending artery was feasible in almost all patients, and in the marginal branches of the left circumflex artery and the posterior descending artery in two thirds and three quarters of patients, respectively. Use of the combined echocardiographic criteria had high precision for diagnosing severe coronary stenoses (diameter stenosis, 76%-100%). The functional significance of angiographically borderline stenoses (diameter stenosis, 50%-75%) may be further differentiated by the use of CFVR measurements.

Recovery of function after acute myocardial infarction evaluated by tissue Doppler strain and strain rate.

BACKGROUND: The aim of this study was to investigate the changes and time course of recovery of regional myocardial function within the first week following successful primary coronary intervention in patients with first-time ST-segment elevation myocardial infarctions using myocardial deformation analysis, which is more quantitative and thus more objective than the wall motion score. METHODS: Thirty-one consecutive patients admitted with ST-segment elevation myocardial infarctions were studied on days 1, 2, 3, and 7 using strain and strain rate tissue Doppler echocardiography. RESULTS: The mean peak troponin T level was 7.0 microg/L, and 15 patients had anterior and 16 had inferior infarct localization. Peak systolic strain rate and end-systolic strain increased significantly on day 2, both in segments with moderately reduced function (-0.6 to -1.0 s(-1) vs -8% to -15%, P < .001) and in severely reduced function (-0.2 to -1.0 s(-1) vs 1% to -12%, P < .001), but there were no further changes. Mean wall motion score in infarct related segments decreased significantly from day 1 to day 2 (2.7 to 2.4, P = .001) and from day 3 to day 7 (2.3 to 2.2, P = .001). CONCLUSIONS: Recovery of regional function after ST-segment elevation myocardial infarction occurred within 2 days and could be detected by wall motion score, strain rate, and strain. However, strain and strain rate were better discriminative parameters for the changes in function as well as being better to assess near normalization on day 2. This could have a clinical impact on early management in patients who undergo percutaneous coronary intervention.

Transthoracic echocardiography for imaging of the different coronary artery segments: a feasibility study.

BACKGROUND: Transthoracic echocardiography (TTE) may be used for direct inspection of various parts of the main coronary arteries for detection of coronary stenoses and occlusions. We aimed to assess the feasibility of TTE to visualise the complete segments of the left main (LM), left descending (LAD), circumflex (Cx) and right (RCA) coronary arteries. METHODS: One hundred and eleven patients scheduled for diagnostic coronary angiography because of chest pain or acute coronary syndrome had a TTE study to map the passage of the main coronary arteries. LAD, Cx and RCA were each divided into proximal, middle and distal segments. If any part of the individual segment of a coronary artery with antegrade blood flow was not visualised, the segment was labeled as not satisfactorily seen. RESULTS: Complete imaging of the LM was achieved in 98% of the patients. With antegrade directed coronary artery flow, the proximal, middle and distal segments of LAD were completely seen in 96%, 95% and 91% of patients, respectively. Adding the completely seen segments with antegrade coronary flow and segments with retrograde coronary flow, the proximal, middle and distal segments of LAD were adequately visualised in 96%, 96% and 93% of patients, respectively. With antegrade directed coronary artery flow, the proximal, middle and distal segments of Cx were completely seen in 88%, 61% and 3% and in RCA in 40%, 28% and 54% of patients. Retrograde coronary artery flow was correctly identified as verified by coronary angiography in seven coronary segments, mainly in the posterior descending artery (labeled as the distal segment of RCA) and distal LAD. CONCLUSIONS: TTE is a feasible method for complete demonstration of coronary flow in the LM, the proximal Cx and the different segments of LAD, but less suitable for the RCA and mid and distal segments of the Cx. (ClinicalTrials.gov number NTC00281346.).

[Antithrombotic therapy after percutanous coronary intervention with stenting]. / Antitrombotisk behandling etter perkutan koronar intervensjon med stent.

BACKGROUND: Patients with stent thrombosis have a serious prognosis and a high mortality. Insufficient blood platelet inhibition may be the cause of the condition. This article reviews patients--with stents in their coronary arteries--that have had documented effects of long-term blood platelet treatment. MATERIAL AND METHODS: The article is based on literature identified through a Pubmed search and own experience. RESULTS: Premature discontinuation of acetylsalicylic acid and/or clopidogrel, and non-cardiac surgery shortly after stenting are commonly associated with stent thrombosis. Elective non-cardiac surgery should be done without discontinuation of blood platelet inhibitors when possible. It should be delayed for a minimum of 6 weeks after implantation of bare metal stents and for a minimum of 6 months after drug-eluting stents. For patients who need anticoagulation bare metal stents are preferred, and a combination of warfarin, acetylsalicylic acid and clopidogrel should be used as antithrombotic medication. CONCLUSION: It is important to provide adequate information about correct antithrombotic drug use to patients, physicians and pharmacies in order to avoid stent thrombosis and acute myocardial infarction.