Effectiveness and Safety of Atherectomy versus Plain Balloon Angioplasty for Limb Salvage in Tibioperoneal Arterial Disease.

PURPOSE: To evaluate the effectiveness and safety of atherectomy versus plain balloon angioplasty (POBA) for treatment of critical limb ischemia (CLI) due to tibioperoneal arterial disease (TPAD). MATERIALS AND METHODS: Patients enrolled in the Vascular Quality Initiative registry who had CLI (Rutherford Class 4-6) and underwent atherectomy versus POBA alone for isolated TPAD were retrospectively identified. Of eligible patients, a cohort of 2,908 patients was propensity matched 1:1 by clinical and angiographic characteristics. The atherectomy group comprised 1,454 patients with 2,183 arteries treated, and the POBA group comprised 1,454 patients with 2,141 arteries treated. The primary study endpoint was major ipsilateral limb amputation. Secondary endpoints were minor ipsilateral amputations, any ipsilateral amputation, primary patency, target vessel reintervention (TVR), and wound healing at 12 months. RESULTS: The median follow-up period was 507 days, the mean patient age was 69 years ± 11.7, and the mean occluded length was 6.9 cm ± 6.5. There was a trend toward higher technical success rates with atherectomy than with POBA (92.9% vs 91.0%, respectively; P = .06). The rates of major adverse events during the procedure were not significantly different. The 12-month major amputation rate was similar in the atherectomy and POBA groups (4.5% vs 4.6%, respectively; P = .92; odds ratio, 0.97; 95% CI, 0.68-1.37). There was no difference in 12-month TVR (17.9% vs 17.8%; P = .97) or primary patency (56.4% vs 54.5%; P = .64) between the atherectomy and POBA groups. CONCLUSIONS: In a large national registry, treatment of CLI from TPAD using atherectomy versus POBA showed no significant differences in procedural adverse events, major amputations, TVR, or vessel patency at 12 months.

National trends and variability of atherectomy use for peripheral vascular interventions from 2010 to 2019.

OBJECTIVE: Small, older studies have suggested that the use of atherectomy devices has become common in peripheral vascular interventions (PVIs) despite the paucity of strong clinical guidelines. We analyzed the 10-year trends in the use of atherectomy for PVIs across the United States and identified the main predictors of atherectomy use. METHODS: Using the Vascular Quality Initiative registry, we identified all patients who had undergone endovascular PVIs for occlusive lower extremity arterial disease from 2010 to 2019. Procedures in which an atherectomy device had been used as the primary or secondary device were classified as the atherectomy group. We calculated the frequency of atherectomy use over time and across geographic regions. Using regression modeling, we identified the factors that were independently associated with atherectomy use. RESULTS: A total of 205,377 PVIs had been performed for 152,693 unique patients. During the 10-year period, 16.6% of the PVI procedures had used atherectomy, increasing from 8.5% in 2010 to 19.7% in 2019 (Ptrend < .0001). Across 17 geographic regions, we found a significant difference in the prevalence of atherectomy use, ranging from 8.2% to 29%. The strongest predictor of atherectomy use was performance of PVI in an office setting (odds ratio [OR], 10.08; 95% confidence interval [CI], 9.17-11.09) or ambulatory center (OR, 4.0; 95% CI, 3.65-4.39) vs a hospital setting. The presence of severe (OR, 2.6; 95% CI, 2.4-2.85) or moderate (OR, 1.5; 95% CI, 1.4-1.69) lesion calcification was also predictive of atherectomy use. Other predictive factors included elective status, insurance provider, lesion length, prior PVI, claudication symptoms, and diabetes mellitus. CONCLUSIONS: Atherectomy use in PVI significantly increased from 2010 to 2019. We found wide regional variability in the use of atherectomy that seemed to be driven more strongly by nonclinical factors.

Peripheral Artery Disease Intervention: Drug-Coated Balloon vs Drug-Eluting Stent, A Long-Term Comparison.

Objectives: The aim of the study is to evaluate current trends and long-term durability of both drug-eluting stents (DES) and drug-coated balloons (DCB) in the treatment of peripheral artery disease (PAD). Background: PAD affects more than 200 million people worldwide. Endovascular treatment of critical PAD has advanced in recent years. DES and DCB have demonstrated superiority compared to balloon angioplasty or bare metal stenting. The current literature lacks any long-term, direct comparison. Methods: A retrospective analysis was completed on patients who had femoral-popliteal interventions from June 2014 to June 2018 with either DCB or DES. Patient medical data and lesion characteristics were retrieved using the Vascular Quality Initiative database. Outcomes were analyzed through December 2019. Primary endpoint of time to clinical event-driven target lesion reintervention (TLR) and secondary endpoint of all-cause mortality were examined. Results: Four hundred eighty-three patients with a total of 563 interventions met the inclusion criteria. Three hundred fifty-nine DCB and 204 DES were performed. Of the DCBs, 132 required bailout stenting at the time of procedure. The mean time for TLR in the DES group was 1,277 days (SD 546), compared to 904 days (SD 330.1) for DCB. For patients requiring TLR, DES remained patent significantly longer (373 days longer on average) (p < 0.001). For all-cause mortality there was no significant difference at 50 months between DCB and DES (p = 0.06). Conclusions: In patients who required TLR, DES had a significantly longer length of time to reintervention vs DCB (average 373 days), although no difference in mortality was observed.

Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year Single-Center Observational Study.

OBJECTIVE: To describe our institution's experience with the AngioVac system. BACKGROUND: Intracardiac and intravascular masses previously required surgical excision, but now, there are a number of minimally invasive options. With the advent of vacuum aspiration, more specifically the AngioVac System (AngioDynamics, NY, USA), there exists a system with both low mortality and minor complications. However, the number of retrospective studies remains limited. Outcome data for high-risk patients are also limited. METHODS: Data were collected and analyzed in patients who underwent AngioVac therapy at our tertiary care center from January 2014 to December 2020. RESULTS: Our results demonstrated a 93.3% intraoperative success rate and a 100% intraoperative survival rate. However, a number of complications, including but not limited to hematomas, anemia, and hypotension, occurred, as described below. CONCLUSIONS: Our experiences demonstrated good outcomes and continue to support the usefulness of the AngioVac System. The data also support the use of AngioVac as a treatment option for the debulking or removal of right heart masses in critically ill patients.

Contemporary practice pattern of revascularization in a large tertiary care referral center in non-ST elevation myocardial infarction: A propensity-matched 10-year experience.

OBJECTIVES: We sought to compare the effects of early versus delayed percutaneous coronary intervention (PCI) on the outcomes at 1 year in patients presenting with non-ST-segment elevation myocardial infarction (NSTEMI). BACKGROUND: Prompt reperfusion in NSTEMI remains controversial. Randomized studies have shown conflicting results regarding the benefits of early intervention versus delayed intervention (defined as intervention performed within 24 hr vs. 24-72 hr of presentation, respectively). This study was conducted to determine the clinical outcomes post PCI in a large tertiary care center. METHODS: A propensity-matched group of 1,640 NSTEMI patients [62.4% males (n = 1,023), median age 65 years] was studied for a composite of death, myocardial infarction (MI), stroke, and heart failure in 1 year as a primary endpoint after PCI. Patients were divided into an early intervention group (EIG) and delayed intervention group (DIG). Timing of PCI was determined by the treating interventional cardiologist. RESULTS: The primary outcome was significantly lower in the EIG than DIG (20.4% vs. 24.9%, P = 0.029), which was mainly derived from mortality benefit in the EIG. There was no difference in occurrence of death, MI, stroke, or heart failure between the groups at 30 days. CONCLUSIONS: An earlier PCI in patients with NSTEMI is associated with a significant reduction in the composite outcome of death, MI, heart failure, or stroke at 1 year compared with delayed PCI. Based on this large cohort of patients from a real-world referral center, contemporary reperfusion practices in NSTEMI may need to be re-examined with a bias toward early intervention.

Modern Imaging Techniques in Cardiomyopathies.

Modern advanced imaging techniques have allowed increasingly more rigorous assessment of the cardiac structure and function of several types of cardiomyopathies. In contemporary cardiology practice, echocardiography and cardiac magnetic resonance imaging are widely used to provide a basic framework in the evaluation and management of cardiomyopathies. Echocardiography is the quintessential imaging technique owing to its unique ability to provide real-time images of the beating heart with good temporal resolution, combined with its noninvasive nature, cost-effectiveness, availability, and portability. Cardiac magnetic resonance imaging provides data that are both complementary and uniquely distinct, thus allowing for insights into the disease process that until recently were not possible. The new catchphrase in the evaluation of cardiomyopathies is multimodality imaging, which is purported to be the efficient integration of various methods of cardiovascular imaging to improve the ability to diagnose, guide therapy, or predict outcomes. It usually involves an integrated approach to the use of echocardiography and cardiac magnetic resonance imaging for the assessment of cardiomyopathies, and, on occasion, single-photon emission computed tomography and such specialized techniques as pyrophosphate scanning.

Laser-Assisted Transgraft Embolization: A Technique for the Treatment of Type II Endoleaks.

A transgraft embolization (TGE) technique was performed in a patient to treat a type II endoleak. Using a transfemoral arterial approach, the endograft was punctured using a coronary laser catheter aimed toward the type II endoleak nidus, which was treated with Onyx (Medtronic, Minneapolis, Minnesota). TGE resulted in successful embolization, as demonstrated on 1-year follow-up CT angiography, which showed complete elimination of the type II endoleak and shrinkage of the aneurysmal sac. TGE is an alternative to transarterial embolization, translumbar embolization, and transcaval embolization.

Relationship of cardiac troponin to systolic global longitudinal strain in hypertrophic cardiomyopathy.

BACKGROUND: A high proportion of stable hypertrophic cardiomyopathy (HCM) patients have elevated serum cardiac troponin I (cTnI), but its clinical and echocardiographic determinants are unknown. Our objective was to determine the prevalence and clinical predictors of positive troponin (cTnI+) in a well-defined population of HCM patients using a highly sensitive assay. METHODS: We retrospectively interrogated medical records of 167 stable HCM patients from 1/2011 to 3/2014. cTnI >0.04 ng/mL was considered positive. RESULTS: Thirty-four percent were troponin-positive (median cTnI was 0.1 [0.07, 0.2] ng/dL). cTnI as a continuous variable correlated positively with maximal left ventricular wall thickness (LVT), maximal interventricular septal thickness, and global longitudinal strain (GLS) (P<.001). Unadjusted OR (95% CI) for positive troponin was 0.5 (0.3-0.9, P=.05) for obstructive HCM, 3.2 (1.7-5.9, P<.0001) for increased LVT, 0.3 (0.2-0.6, P<.0001) for -5% increase in GLS, 0.2 (0.04-0.9, P=.04) for moderate-to-severe mitral regurgitation, and 1.9 (0.9-3.9, P=.06) for implantable cardioverter defibrillator history. After adjusting for these variables, only maximum LVT (OR 2.5 [95% CI: 1.1-5.7, P=.02]) and GLS (OR 0.3 [95% CI: 0.2-0.6, P=.001]) were independent predictors. The percentage of patients with a positive cTnI increased from 19% to 24% and 57% across tertiles of LVT (P=.003) and decreased from 54% to 33% and 14% across tertiles of GLS (P<.0001). CONCLUSION: In this cohort of HCM patients, the association of reduced GLS and positive troponin was independent of LVT. Further studies are warranted to evaluate whether their combination adds prognostic value in identifying high-risk patients to define effective and early intervention strategies.

Role of endovascular stenting in radiation-induced stenosis of lower extremity veins.

Radiation-induced venous stenosis is rare with a few isolated cases reported in the medical literature involving the lower limb. Management options in such cases are thus not streamlined. We describe an unusual case of iliac vein stenosis in a patient with rectal carcinoma after combined chemoradiation therapy, managed with endovascular stenting. The possible mechanisms underlying the pathogenesis of venous stricture and their treatment options have been reviewed.

Hypertrophic Cardiomyopathy-Septal Perforator Arteries Doppler Flow Dynamics.

BACKGROUND: Patients with hypertrophic cardiomyopathy (HCM) have been shown to exhibit abnormal diastolic vessel flow; however, flow pattern profiles and their possible association with different grades of diastolic dysfunction have not been studied. Color Doppler two-dimensional echocardiography permits visualization of the septal perforator arteries, and pulsed-wave Doppler allows recording of diastolic septal artery flow (SAF). Through routine visualization of the septal perforator arteries and acquisition of SAF, we noticed 3 patterns of SAF in patients with HCM. In this study, we aimed to assess the feasibility of the acquisition of SAF and to describe types of SAF in an HCM cohort and their associations with diastolic function. METHODS: We reviewed two-dimensional echocardiograms and the electronic records of 108 patients with HCM in whom septal artery color and spectral Doppler had been performed. The peak diastolic and end-diastolic velocities, diastolic slope, diastolic flow time-velocity integral, and systolic flow reversal of the septal perforator arteries were recorded with pulsed-wave Doppler. Echocardiographic and clinical characteristics were analyzed. RESULTS: A reproducible pulsed-wave Doppler tracing was recorded in 54% of patients with HCM. Three distinct patterns of SAF were identified: type 1-smooth, linear holodiastolic velocity decrease; type 2-with presence of an atrial dip; and type 3-biphasic velocity decrease with an early, rapid diastolic slope and a mid-to-late gentle slope. These 3 SAFs correlated with different grades of diastolic dysfunction. CONCLUSION: Septal artery flow could be detected in more than 50% of patients with HCM. Three distinct types of SAF were identified, correlating with different grades of diastolic dysfunction. These 3 types of SAF can provide additional information about left ventricular end-diastolic pressure and diastolic function in patients with HCM in whom diastolic function may be difficult to determine.

Age-Based Outcomes in Patients Who Underwent Septal Reduction Therapy.

There are no national data on age-based outcomes of septal reduction therapy. Using the National Inpatient Sample, we included all adult patients who underwent septal myectomy (SM) or alcohol septal ablation (ASA) from 2005 to 2019. The primary objective was to evaluate the in-hospital mortality and new permanent pacemaker (PPM) placement after SM and ASA in 3 age groups. In total, 9,564 patients underwent SM and 5,084 underwent ASA. Compared with the age group 18 to 39 years, the odds of in-hospital mortality after SM were similar in age group 40 to 64 years and 4.46 times higher than in age group ≥65 years; the higher mortality in the older group was explained by higher co-morbidity burden on the risk-adjusted analysis. Furthermore, compared with age group 18 to 39 years, the odds of new PPM placement after SM were higher in the age groups 40 to 64 years and ≥65 years, despite the risk adjustment (adjusted odds ratio [AOR] 3.17, 95% confidence interval [CI] 1.33 to 7.58 and AOR 4.39, 95% CI 1.78 to 10.8, respectively). The odds of in-hospital mortality after ASA were similar in age groups 65 to 79 years and 18 to 64 years. However, the odds of in-hospital mortality were higher in the age group ≥80 years than in the age group 18 to 64 years, although this difference were not present after risk adjustment. The odds of new PPM after ASA were higher for the age groups 65 to 79 years and ≥80 years than age group 18 to 64 years, despite the risk adjustment (AOR 1.78, 95% CI 1.22 to 2.60 and AOR 3.10, 95% CI 2.09 to 6.57, respectively). Finally, we also estimated these absolute risks in different age groups. In conclusion, this national data will inform health care providers to better understand the aged-based risks of outcomes after septal reduction therapy.

Regional Disparities in the Use of Septal Reduction Therapy and Associated Outcomes in the United States (from a Real-World Database).

The regional differences in the use of septal reduction therapies and the associated outcomes in patients with Hypertrophic obstructive cardiomyopathy (HOCM) are unknown. The primary objective of our study was to evaluate the regional disparities in the use of septal reduction therapies, including septal myectomy and alcohol septal ablation, in patients with HOCM. The secondary objective was to analyze the regional differences in the outcomes in these patients. Patients with HOCM had 87% higher risk-adjusted odds of getting septal myectomy (adjusted odds ratio 1.87, p = 0.03) and 37% lower risk-adjusted odds of getting alcohol septal ablation (adjusted odds ratio 0.63, p = 0.03) in the Midwest than in the Northeast. The in-hospital mortality rate was higher for patients who underwent septal myectomy in the South versus the Northeast on the unadjusted analysis. These differences persisted despite the adjustment for demographic and clinical characteristics. Additional adjustment for hospital volume partially explained these disparities, but the adjustment for both hospital volume and hospital teaching status completely explained these disparities. The risk-adjusted in-hospital mortality in patients who underwent alcohol septal ablation was similar in the South versus other regions. In conclusion, regional disparities may exist in the use of septal myectomy and alcohol septal ablation, and patients with HOCM should be referred to high-volume teaching hospitals for septal myectomy for better outcomes, which may also eliminate the extra burden of hospital mortality in the South.

Left subclavian artery pseudoaneurysm after blunt chest trauma with left upper extremity ischemia.

We describe a 74-year-old male with delayed onset of acute left upper extremity ischemia after blunt chest trauma with left clavicular fracture, resulting in left subclavian artery injury, including pseudoaneurysm formation, intramural hematoma, thrombosis, and distal embolization to the brachial artery. The patient presented with left upper extremity pain, forearm and hand numbness, and digital cyanosis. The patient was treated with a hybrid approach, consisting of transfemoral percutaneous deployment of a covered stent in the left subclavian artery and concomitant surgical thrombectomy of the left brachial artery, resulting in excellent recovery and resolution of symptoms.

Sex Disparities in Diagnostic Evaluation and Revascularization in Patients With Acute Myocardial Infarction-A 15-Year Nationwide Study.

Background Although sex disparities in the diagnostic evaluation and revascularization of patients with acute myocardial infarction are well documented, no study has evaluated longitudinal trends in these disparities. Methods and Results Using the National Inpatient Sample from 2005 to 2019, 9 259 932 patients with acute myocardial infarction were identified. We divided 15 years into five 3-year periods. The primary objective was to evaluate sex-based trends in the use of diagnostic angiography, percutaneous coronary intervention, and coronary artery bypass graft (CABG) among patients with non-ST-segment-elevation myocardial infarction and ST-segment-elevation myocardial infarction (STEMI) over 15 years. The secondary objective was to evaluate sex disparities in mortality, length of stay, and cost. For non-ST-segment-elevation myocardial infarction, we saw a small reduction in sex disparity in the use of all diagnostic angiography in period 5 versus period 1 (4% versus 5.3%; P<0.01), no change in sex disparity in percutaneous coronary intervention use in period 5 versus period 1 (5.6% versus 5%; P=0.16), and a widening sex disparity in CABG in period 5 versus period 1 (5.4% versus 4.4%; P<0.01). However, we noted decreasing sex disparities in the use of diagnostic angiography, percutaneous coronary intervention, and CABG for ST-segment-elevation myocardial infarction in mostly all periods compared with period 1 (P<0.05, all comparisons), but differences still existed in period 5. Risk-adjusted in-hospital mortality was higher after CABG for non-ST-segment-elevation myocardial infarction and after percutaneous coronary intervention and CABG for ST-segment-elevation myocardial infarction in women than men. Conclusions Despite variable trends in sex disparities in diagnostic and revascularization procedures for acute myocardial infarction, disparities still exist.

Age-Based Trends in the Outcomes of Percutaneous Left Atrial Appendage Occlusion: Insights from a Real-World Database.

The age-based trends in-hospital outcomes in patients with percutaneous left atrial appendage occlusion (LAAO) are unknown. Using the National Readmission Database from 2016 to 2019, patients who underwent LAAO were divided into 2 age groups: 60 to 79 and ≥80 years. The primary objective was to evaluate the age-based trends in the outcomes related to LAAO. The secondary objectives were to evaluate the mean cost and total cumulative cost of readmissions in both age groups in 2019. We identified 58,818 patients who underwent LAAO, of whom 36,964 (63%) were aged 60 to 79 years, and 21,854 (37%) were ≥80 years. The hospital mortality, pericardial complications, acute kidney injury, and in-hospital cardiac arrest did not change over time. The risk-adjusted postoperative stroke and bleeding requiring blood transfusion decreased in patients aged ≥80 years (p trend 0.03 for both outcomes). The length of stay decreased, and early discharge rates increased over time in both the unadjusted and risk-adjusted models in both age groups. The risk-adjusted 90-day readmission rates also decreased in patients aged ≥80 years. The inflation-adjusted cost did not change over time on the unadjusted and adjusted analyses. The total cumulative all-cause 90-readmission cost for both groups in 2019 was $31.7 million. Most outcomes after LAAO either improved or did not change from 2016 to 2019. Hospital mortality has remained <0.5% consistently since 2016. The risk-adjusted postoperative stroke, bleeding, and 90-day readmission rates improved in elderly vulnerable patients aged ≥80 years. The inflation-adjusted cost did not improve despite the decreasing length of stay and improving early discharge rates.

Early Thoracic Endovascular Aortic Repair of Uncomplicated Type B Thoracic Aortic Dissection: An Aorta Team Approach.

BACKGROUND: Although uncomplicated Type B aortic dissection (uTBAD) is traditionally treated with optimal medical therapy (OMT) as per guidelines, recent studies, performed primarily in interventional radiology or surgical operating rooms, suggest superiority of thoracic endovascular aortic repair (TEVAR) over OMT due to recent advancements in endovascular technologies. We report a large, single-center, case control study of TEVAR versus OMT in this population, undertaken solely in a cardiac catheterization laboratory (CCL) with a cardiologist and surgeon. We aimed to determine if TEVAR for uTBAD results in better outcomes compared with OMT. METHODS: This was a retrospective chart review of all patients with uTBAD during the last 13 years, with 46 cases (TEVAR group) and 56 controls (OMT group). RESULTS: In the TEVAR group, the procedure duration of 2.5 hours resulted in 100% procedural success for stent placement, with 63% undergoing protective left subclavian artery bypass, 0% mortality or stroke, and a lower readmission rate (1 vs. 2%; p = 0.04 in early TEVAR cases), but a longer length of stay (12.9 vs. 8.5 days: p = 0.006). The risk of all-cause long-term mortality was markedly reduced in the TEVAR group (RR = 0.38; p = 0.01), irrespective of early (<14 days) versus late intervention. On follow-up computed tomography imaging, the false lumen stabilized or decreased in 85% of cases, irrespective of intervention timing. CONCLUSION: TEVAR performed solely in the CCL is safe and effective, with lower all-cause mortality than OMT. These data, in collaboration with previous data on TEVAR in different settings, call for consideration of an update of practice guidelines.

Racial Disparities in Diagnostic Evaluation and Revascularization in Patients With Acute Myocardial Infarction-A 15-Year Longitudinal Study.

We aimed to evaluate longitudinal trends of racial and ethnic disparities in the utilization of diagnostic angiograms, percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG) for non-ST elevation myocardial infarction (NSTEMI) and ST elevation myocardial infarction (STEMI). We retrospectively analyzed the National Inpatient Sample (2005-2019). The 15-year period was divided into 5, 3-year periods. Our study included 9 million adult patients (NSTEMI, 72%; STEMI, 28%). No improvement in utilization of these procedures was seen in period 5 (2017-2019) vs period 1 (2005-2007) for both NSTEMI and STEMI in non-White patients vs White patients (P > 0.05 for all comparisons), excepting in CABG for STEMI in Black patients vs White patients (difference in CABG rate: period 1, 2.6%; period 5, 1.4%; P = 0.03). Reducing disparities in PCI for NSTEMI and both PCI and CABG for STEMI in Black patients vs White patients was associated with improved outcomes.

Chewed Versus Swallowed Ticagrelor in P2Y12 Inhibitor-Naïve Patients Undergoing Percutaneous Coronary Intervention.

Purpose: Dual antiplatelet therapy is standard for patients undergoing percutaneous coronary intervention (PCI) with stents. Traditionally, patients swallow the loading dose of a P2Y12 inhibitor before or during PCI. Time to achieve adequate platelet inhibition after swallowing the loading dose varies significantly. Chewed tablets may allow more rapid inhibition of platelet aggregation. However, data for this strategy in patients with stable ischemic heart disease or non-ST-elevation acute coronary syndrome (NSTE-ACS) are less robust. Methods: In this single-center prospective trial, 112 P2Y12-naïve patients with stable ischemic heart disease or NSTE-ACS on aspirin therapy and who received ticagrelor after coronary angiography but before PCI were randomized to chewing (n=55) or swallowing (n=57) the ticagrelor loading dose (180 mg). Baseline variables were compared using 2-sample t-test and chi-squared/Fisher's exact tests as appropriate, with alpha set at 0.05. P2Y12 reaction units (PRU) were compared at baseline, 1 hour, and 4 hours using Wilcoxon rank-sum test. Patients then received standard ticagrelor dosing. Results: After exclusions, P2Y12 PRU in the chewed and swallowed groups at baseline, 1 hour, and 4 hours after ticagrelor loading dose were 243 vs 256 (P=0.75), 143 vs 210 (P=0.09), and 28 vs 25 (P=0.89), respectively. No differences were found in major adverse cardiac events (MACE) or major bleeding at 30 days and 1 year. Conclusions: In patients with stable ischemic heart disease or NSTE-ACS, chewing rather than swallowing ticagrelor may lead to slightly faster inhibition of platelet aggregation at 1 hour with no increase in MACE or major bleeding.

Myocardial Work in Apical Hypertrophic Cardiomyopathy.

BACKGROUND: Pressure-strain loop analysis is a novel echocardiographic technique to calculate myocardial work indices that has not been applied to patients with apical hypertrophic cardiomyopathy (ApHCM). We hypothesized that myocardial work indices differ between patients with ApHCM and those with non-ApHCM. This study aimed to (1) evaluate myocardial work indices in patients with ApHCM compared with those with non-ApHCM, (2) describe associations with relevant clinical variables, and (3) examine associations with significant late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging. METHODS: We retrospectively identified 48 patients with ApHCM and 69 with non-ApHCM who had measurements of global longitudinal strain (GLS), global work index (GWI), global constructive work (GCW), global wasted work, and global work efficiency. We evaluated available cardiac magnetic resonance imaging data on 34 patients with ApHCM and 51 with non-ApHCM. Multivariable regression models correcting for traditional cardiac risk factors were used to evaluate the associations of myocardial work indices with relevant clinical variables. RESULTS: Median GLS (-11% vs -18%, P < .001), GWI (966 mm Hg% vs 1803 mm Hg%, P < .001), and GCW (1,050 mm Hg% vs 1,988 mm Hg%, P < .001) were significantly impaired in patients with ApHCM compared with those with non-ApHCM. Increasing N-terminal pro b-type natriuretic peptide, abnormal ultrasensitive troponin, and increasing maximal left ventricular wall thickness were significantly associated with reduced GWI and GCW in patients with ApHCM (P < .05). Global constructive work had only modest accuracy (area under the curve [AUC] = 0.70) to predict LGE in patients with ApHCM. However, in patients with non-ApHCM, GLS was the strongest predictor of LGE (AUC = 0.91), with a -17% cutoff yielding 81% sensitivity and 80% specificity. CONCLUSION: Myocardial work indices are significantly impaired in patients with ApHCM compared to those with non-ApHCM and correlate with important clinical variables. Global longitudinal strain, GWI, and GCW are more strongly predictive of fibrosis in patients with non-ApHCM than ApHCM.