Spontaneous coronary artery dissection in old patients: clinical features, angiographic findings, management and outcome.

AIMS: Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown. METHODS AND RESULTS: The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups <65 and ≥65 years old and in-hospital outcomes were analysed. Fifty-five patients (17%) were ≥65 years old (95% women). Older patients had more often hypertension (76% vs. 29%, P < 0.01) and dyslipidaemia (56% vs. 30%, P < 0.01), and less previous (4% vs. 18%, P < 0.001) or current smoking habit (4% vs. 33%, P < 0.001). An identifiable trigger was less often present in old patients (27% vs. 43%, P = 0.028). They also had more often severe coronary tortuosity (36% vs. 11%, P = 0.036) and showed more frequently coronary ectasia (24% vs. 9%, P < 0.01). Older patients were more often managed conservatively (89% vs. 75%, P = 0.025), with no significant differences in major adverse cardiac events during index admission (7% vs. 8%, P = 0.858). There were no differences between groups in terms of in-hospital stay, new acute myocardial infarction, unplanned coronary angiography or heart failure. CONCLUSION: Older patients with SCAD show different clinical and angiographic characteristics compared with younger patients. Initial treatment strategy was different between groups, though in-hospital outcomes do not significantly differ (NCT03607981).

Multivessel spontaneous coronary artery dissection involving the left main coronary artery: a case report.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an infrequent and often misdiagnosis of a non-atherosclerotic cause of acute coronary syndrome (ACS). It is an important cause of ACS in young women, responsible for up to 25% of all cases in women <50 years of age without cardiovascular risk factors. Clinical presentation ranges from ST-segment-elevation myocardial infarction (MI) to ventricular fibrillation and sudden death. The treatment of patients with SCAD is a challenge and the ideal management strategy has yet to be determined. CASE SUMMARY: A 42-year-old woman without family history of cardiac disease and neither traditional atherosclerotic risk factors presented to our centre with an anterior acute ST-segment-elevation MI secondary to multiple spontaneous dissections of the left main, anterior descending, and ramus intermedius coronary arteries. Stenting was performed in the left anterior descending coronary artery and left main coronary artery to resolve its occlusion. Fibromuscular dysplasia was confirmed via computed tomography angiography. DISCUSSION: More cases are now being identified of SCAD due to increased clinical index of suspicion, earlier use of invasive angiography, and intracoronary imaging in patients presenting with acute chest pain. Despite this, the absence of previous cardiovascular risk factors and the ignorance of this pathology delay the start of an adequate medical treatment and the performance of a cardiac catheterization. Prognostic data are limited, partly because of its underdiagnosis and lack of prospective studies, so its knowledge is necessary to improve the prognosis of these patients.

MitraClip® Repair in Cardiogenic Shock Due to Acute Mitral Regurgitation: From Near-Death to Walking.

A patient with ischemic myocardiopathy who had undergone resynchronization therapy was admitted to the authors' institution with progressive dyspnea. Echocardiography demonstrated a left ventricular ejection fraction (LVEF) of 25%, with a massive mitral regurgitation (MR) secondary to anterior leaflet prolapse and posterior leaflet restriction. Despite intensive medical treatment, the patient developed cardiogenic shock and required mechanical ventilation, inotropic support and intra-aortic balloon pumping. The patient was rejected for surgery due to the high operative risk, but subsequently underwent a successful percutaneous repair with two MitraClip® devices. Immediately after the intervention there was a progressive improvement that allowed the patient to be discharged, such that the clinical outcome was favorable at the six-month follow up (NYHA class II/IV). This case report describes the benefits of minimally invasive therapy in selected patients who are at very high surgical risk and who, despite being in a critical condition and with low LVEF, experience an outstanding clinical improvement following the resolution of a massive MR.

Out-of-hospital cardiac arrest and stent thrombosis: Ticagrelor versus clopidogrel in patients with primary percutaneous coronary intervention under mild therapeutic hypothermia.

BACKGROUND: Out-of-Hospital Cardiac Arrest (OHCA) and mild therapeutic hypothermia (MTH) have been linked to increased risk of Stent Thrombosis (ST) in comatose survivors who undergo percutaneous coronary intervention (PCI). In this sense, there is no formal recommendation about which antiplatelet regimen should be used in patients with acute coronary syndromes (ACS) after OHCA. AIMS: To compare the incidence of probable/definite ST and bleeding events between ticagrelor and clopidogrel, in patients with ACS under MTH after an OHCA. METHODS AND RESULTS: From January 2010 to August 2016, 144 patients underwent MTH after an OHCA. Overall, 114 had an ACS (79%) and 98 (67,3%) were treated with primary PCI and stent implantation. Among them, 61 (62,2%) were treated with clopidogrel, and 32 (32,6%) with ticagrelor. During hospitalization, the incidence of probable or definite ST was significantly higher in patients receiving clopidogrel compared to ticagrelor (11,4% vs. 0%; p: 0.04), and no significant differences in any (28,6% vs. 25%; p: 0.645) or major bleeding (BARC 3 or 5) (11,4% vs. 12,5%; p: 0.685) were found. Hospital mortality did not differ between groups (26,2% vs. 25%; p: 0.862). CONCLUSIONS: In this study, as compared to clopidogrel, ticagrelor was associated with a lower rate of ST, without differences in haemorrhagic events in patients with OHCA for an ACS under MTH. Similarly to other settings, ticagrelor might be a valid alternative to clopidogrel in these patients.

Benefits of chronic total coronary occlusion percutaneous intervention in patients with heart failure and reduced ejection fraction: insights from a cardiovascular magnetic resonance study.

BACKGROUND: Chronic total occlusion percutaneous coronary intervention (CTO-PCI) can improve angina and left ventricular ejection fraction (LVEF). These benefits were not assessed in populations with heart failure with reduced ejection fraction (HFrEF). We studied the effect of CTO-PCI on left ventricular function and clinical parameters in patients with HFrEF. METHODS: Using cardiovascular magnetic resonance (CMR), we studied 29 patients with HFrEF and evidence of viability and/or ischemia in the territory supplied by a CTO who were successfully treated with CTO-PCI. In patients with multi-vessel disease, non-CTO PCI was also performed. Imaging parameters, clinical status, and brain natriuretic peptide (BNP) levels were evaluated before and 6 months after CTO-PCI. RESULTS: A decrease in left ventricular end-systolic volume (160 ± 54 ml vs. 143 ± 58 ml; p = 0.029) and an increase in LVEF (31.3 ± 7.4 % vs. 37.7 ± 8 %; p < 0.001) were observed. There were no differences in LVEF improvement between patients who underwent non-CTO PCI (n = 11) and those without this intervention (n = 18); (p = 0.73). The number of segments showing perfusion defects was significantly reduced (0.5 ± 1 vs. 0.2 ± 0.5; p = 0.043). Angina (p = 0.002) and NYHA functional class (p = 0.004) improved, and BNP levels decreased (p = 0.004) after CTO-PCI. CONCLUSIONS: In this group of patients with HFrEF showing CMR evidence of viability and/or ischemia within the territory supplied by the CTO, an improvement in ejection fraction, left ventricular end-systolic volume and ischemia burden was observed after CTO-PCI. Clinical and laboratory parameters also improved. TRIAL REGISTRATION: ClinicalTrials.gov NCT02570087 . Registered 6 October 2015.

Minimally Invasive Transradial Percutaneous Closure of Aortic Paravalvular Leaks: Following the Steps of Percutaneous Coronary Intervention.

Two patients with severe aortic paravalvular leaks (PVLs) in a mechanical prosthesis were percutaneously treated. Procedures were performed with mild sedation, angiographic guidance, and a 6-French right radial artery approach with good final results. Percutaneous PVL treatment is routinely performed with general anaesthesia, transesophageal echocardiographic guidance, and femoral access. Although another case of radial aortic PVL closure has been previously reported, it was performed with an 8-French radial sheath, transesophageal echocardiographic guidance, and general anaesthesia. According to our initial experience, aortic PVLs could be treated in a minimally invasive way. Larger studies should be conducted to confirm these observations.

Interhospital Variability in Drug Prescription After Acute Coronary Syndrome: Insights From the ACDC Study.

INTRODUCTION AND OBJECTIVES: To analyze the rate of patients admitted for acute coronary syndrome who concomitantly received acetylsalicylic acid, statins, and angiotensin-converting enzyme inhibitors at discharge, and to analyze interhospital variability in the prescription of these drugs and its potential prognostic impact. METHODS: Interhospital variability in drug prescription was estimated using the intraclass correlation coefficient and median odds ratio (hierarchical analysis). Cox regression analysis was used to estimate the risk of death or myocardial infarction associated with prescription of all 3 agents at 2-years of follow-up. RESULTS: In total, 489 (53.3%) of 917 patients were prescribed all 3 agents. The rate was similar in patients with hypertension and diabetes (56.8%). There was significant variability among centers in the prescription of the 3 drugs at discharge (from 23% to 77% of patients). Hypertension (odds ratio=1.93; 95% confidence interval, 1.42-2.61), ejection fraction < 45% (odds ratio=2.2; 95% confidence interval, 1.44-3.37), being in a clinical trial (odds ratio=1.89; 95% confidence interval, 1.24-2.88), and renal failure (odds ratio=0.53; 95% confidence interval, 0.29-0.94) were associated with prescription of the 3 drugs. After adjustment for these factors, residual variability persisted (intraclass correlation coefficient 0.046 [95% credibility interval, 0.007 to 0.192]; median odds ratio=1.46 [95% credibility interval, 1.16-2.32]). There was no clear association between the prescription of all 3 drugs and the risk of events during follow-up (hazard ratio=0.81, 95% confidence interval, 0.55-1.18; P=.27). CONCLUSIONS: The prescription rate for acetylsalicylic acid, angiotensin-converting enzyme inhibitors, and statins after acute coronary syndrome is suboptimal, varies among centers, and is possibly related to different health care approaches.

Beneficio de la implementación de un sistema de atención en red sobre las mujeres con infarto agudo de miocardio con elevación del segmento ST / Benefit of the implementation of a ST-segment elevation myocardial infarction network on women

Objetivo: El sistema de atención en red por infarto con elevación del segmento ST «Codi Infart¼ se implementó en Cataluña (España) en junio de 2009. El objetivo del estudio fue evaluar el beneficio de la instauración del Codi Infart para las mujeres atendidas en nuestra institución. Método: Las mujeres referidas para angioplastia primaria se dividieron en 2 grupos de acuerdo con el Codi Infart: grupo no-Codi Infart (enero de 2003 a mayo de 2009) y grupo Codi Infart (junio de 2009 a diciembre de 2012); y se compararon lugar de procedencia, periodos, tratamientos recibidos y tasa de eventos cardiovasculares mayores definida como muerte por todas las causas, reinfarto o accidente cerebrovascular durante el ingreso, a 30 y 180 días. Resultados: De una población total de 2,426 pacientes, 501 (20.7%) eran mujeres. De ellas, 186 mujeres (2,09 casos/mes) pertenecían al grupo no-Codi Infart y 315 mujeres (10,16 casos/mes) al grupo Codi Infart. El porcentaje de mujeres atendidas aumentó desde la introducción del Codi Infart(22.2% vs. 18.5%, p = 0.028). Además, inicialmente el grupo Codi Infart presentó mayor porcentaje de mujeres atendidas fuera de nuestra institución (84.1% vs. 16.7%, p < 0.001), y menores tiempos totales de isquemia (220 [155-380] vs. 272 [196-456], p = 0.003), pero no se detectaron diferencias en eventos cardiovasculares mayores a 180 días (14.2% vs. 15.6%, p = 0.692). Conclusiones: La instauración del Codi Infart permitió aumentar de manera notable la tasa y el porcentaje de mujeres con infarto de miocardio con elevación del segmento ST tratadas mediante angioplastia primaria y reducir los tiempos totales de isquemia.

Objective: The ST-segment elevation myocardial infarction network "Codi Infart" was implemented in Catalonia (Spain) in June 2009. The objective of this study was to evaluate the impact of the implementation of the Codi Infart on women. Method: Women referred for primary percutaneous coronary intervention, were divided into two groups according to Codi Infart: Non-Codi Infart group (January 2003 to May 2009) and Codi Infart group (June 2009 to December 2012). Place of first medical contact, time intervals in diagnosis and treatment, treatments received and rate of major cardiovascular adverse events defined as all-cause death, reinfarction or stroke in-hospital, at 30 and 180 days were compared. Results: From a total population of 2,426 patients, 501 (20.7%) were women. One-hundred eighty-six women (2.09 cases/month) belonged to Non-Codi Infart group and 315 women (10.16 cases/month) to Codi Infart group. The percentage of women attended increased since the introduction of CI (22.2% vs. 18.5%, P = .028). In addition, the Codi Infart group had a higher percentage of women initially attended outside our institution (84.1% vs. 16.7%, P < .001), and lower total ischemia time (220 [155-380] vs. 272 [196-456], P = .003). However, no differences in 180-day major cardiovascular adverse events were detected (14.2% vs. 15.6%, P = .692). Conclusions: The implementation of the major cardiovascular adverse events allowed to increase the rate and the percentage of women with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention and reducing total ischemic time.

Sex-related Impact on Clinical Outcome of Everolimus-eluting Versus Bare-metal Stents in ST-segment Myocardial Infarction. Insights From the EXAMINATION Trial.

INTRODUCTION AND OBJECTIVES: The use of second-generation drug-eluting stents compared with bare-metal stents in patients with ST-segment elevation myocardial infarction reduces the rate of major adverse cardiac events. We aimed to evaluate the impact of sex on the performance of everolimus-eluting stents vs bare-metal stents in ST-segment elevation myocardial infarction at 2-year follow-up. METHODS: This is a sub-study of the EXAMINATION trial that randomized 1498 patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention to everolimus-eluting or bare-metal stents. Primary end point was combined all-cause death, any recurrent myocardial infarction, and any revascularization. All end points were analyzed according to sex at 2-year follow-up. RESULTS: Of 1498 patients included in the trial, 254 (17.0%) were women. Women were older and had higher prevalence of hypertension and lower prevalence of smoking compared with men. In contrast with men, stent diameter was smaller in women. After multivariate analysis, the primary end point was similar between women and men (hazard ratio=0.95; 95% confidence interval, 0.66-1.37), and among women, between those treated with bare-metal vs everolimus-eluting stents (hazard ratio=2.48; 95% confidence interval, 0.95-6.46). Women showed a lower rate of repeat revascularization than men (hazard ratio=0.55; 95% confidence interval, 0.32-0.95) despite worse baseline characteristics. This difference was driven by better performance of the everolimus-eluting stent in women. CONCLUSIONS: Despite poorer baseline clinical characteristics, women with ST-segment elevation myocardial infarction treated with percutaneous coronary intervention showed outcomes similar to men. The use of everolimus-eluting stents may represent an added value in women as it showed a reduced rate of repeated revascularization compared to men.

Comparison of paclitaxel-eluting stents (Taxus) and everolimus-eluting stents (Xience) in left main coronary artery disease with 3 years follow-up (from the ESTROFA-LM registry).

Evidence regarding therapy with drug-eluting stents in the left main coronary artery (LM) is based mostly on trials performed with first-generation drug-eluting stents. The aim of this study was to evaluate long-term clinical outcomes after treatment for unprotected LM disease with paclitaxel-eluting stents (PES) and everolimus-eluting stents (EES). The ESTROFA-LM is a multicenter retrospective registry including consecutive patients with unprotected LM disease treated with PES or EES. A total of 770 patients have been included at 21 centers, 415 with treated PES and 355 with EES. Treatment with 2 stents was more frequent with PES (17% vs 10.4%, p = 0.007), whereas intravascular ultrasound was more frequently used with EES (35.2% vs 26%, p = 0.006). The 3-year death and infarction survival rates were 86.1% for PES and 87.3% for EES (p = 0.50) and for death, infarction, and target lesion revascularization were 83.6% versus 82% (p = 0.60), respectively. Definite or probable thrombosis was 1.6% for PES and 1.4% for EES (p = 0.80). The use of 2 stents, age, diabetes, and acute coronary syndromes were independent predictors of mortality. In the subgroup of distal lesions, the use of intravascular ultrasound was an independent predictor of better outcome. Comparison of propensity score-matched groups did not yield differences between the 2 stents. In conclusion, the results of this multicenter registry show comparable safety and efficacy at 3 years for PES and EES in the treatment of LM disease. The use of bifurcation stenting techniques in distal lesions was a relevant independent predictor for events. The use of intravascular ultrasound appears to have a positive impact on patients treated for LM distal disease.

Endothelial and smooth muscle cells dysfunction distal to recanalized chronic total coronary occlusions and the relationship with the collateral connection grade.

OBJECTIVES: This study sought to assess the vascular function in patients with chronic total coronary occlusions (CTO) immediately after successful percutaneous recanalization and its relation with the pre-existing collateral circulation. BACKGROUND: CTOs represent a long-acting occlusion of a coronary vessel, in which the progressively developed collateral circulation may limit ischemia and symptoms. However, it is unknown if the coronary segment distal to the occlusion has a preserved vascular function. METHODS: We prospectively enrolled 19 consecutive patients, after percutaneous coronary intervention of a CTO. Luminal diameter, measured by quantitative coronary angiography, and coronary blood flow at level of epicardial coronary artery distal to the treated CTO was assessed before and after administration of acetylcholine (Ach), adenosine, and nitroglycerin (NTG). Collaterals were assessed angiographically by grading of Rentrop and of collateral connections (CC1: threadlike continuous connection; CC2: side branch-like connection). RESULTS: Overall, Ach and adenosine caused coronary artery vasoconstriction (p=0.001 and p=0.004, respectively), whereas NTG failed to induce vasodilation (p=0.084). Coronary blood flow significantly decreased with Ach (p=0.005), significantly increased with NTG (p=0.035), and did not change with adenosine (p=0.470). Patients with CC2 collaterals (n=8) had less vasoconstriction response and reduction in coronary blood flow after Ach (p=0.005 and p=0.008, respectively), and better vasomotor response to NTG (p=0.029) than patients with CC1 collaterals (n=11). CONCLUSIONS: Significant endothelial and smooth muscle dysfunction is present in the distal segments of successfully recanalized CTOs, and that seems to be more pronounced in the presence of a low grading of collateral circulation.

Assessment of peripheral endothelial-dependent vasodilatation within the first year after heart transplantation.

BACKGROUND: Peripheral endothelial dysfunction (ED) has been found in patients with severe heart failure. Whether ED improves after heart transplantation (HTx) is still a matter of controversy. METHODS: Forearm endothelium-dependent vasoreactivity was assessed in 40 patients after HTx. Flow-mediated vasodilatation (FMD) was measured by high-resolution brachial artery ultrasound to assess endothelial function at 1, 6, and 12 months after HTx. Cardiac allograft vasculopathy (CAV) was assessed by coronary angiography at 1 and 12 months and by intravascular ultrasound (IVUS) at 1 year. RESULTS: Mean FMD at 1 month was 1.9% +/- 2.6%, improving to 3.3% +/- 3.2% at 6 months (p < 0.005) and to 5.1% +/- 3.4% at 1 year (p < 0.0001). FMD was significantly impaired in 33 patients (82%) at 1 month, in 27 (67%) at 6 months, and in 19 (47%) at 1 year after HTx. CAV was diagnosed by IVUS in 19 patients (63%) at 1 year. Patients without peripheral ED at 1 month had lower incidence of increased intimal thickness of 0.5 mm or more at 1 year after HTx (20% vs 75%, p < 0.01). CONCLUSIONS: Impairment of peripheral FMD was highly prevalent soon after HTx and was present in nearly 50% of patients at 1 year. Patients without peripheral ED at 1 month were associated with lower probability of CAV. Although more studies are needed, the evaluation of peripheral endothelial function at 1 month after HTx could be potentially useful to identify patients at lower risk of CAV.