Effects of ticagrelor and prasugrel on coronary microcirculation in elective percutaneous coronary intervention.

OBJECTIVE: To compare the effects of ticagrelor and prasugrel on absolute coronary blood flow (Q) and microvascular resistance (R) in patients with stable coronary artery disease (CAD) treated with elective percutaneous coronary intervention (PCI) (NCT05643586). Besides being at least as effective as prasugrel in inhibiting platelet aggregation, ticagrelor has been shown to have additional properties potentially affecting coronary microcirculation. METHODS: We randomly assigned 50 patients to ticagrelor (180 mg) or prasugrel (60 mg) at least 12 hours before intervention. Continuous thermodilution was used to measure Q and R before and after PCI. Platelet reactivity was measured before PCI. Troponin I was measured before, 8 and 24 hours after PCI. RESULTS: At baseline, fractional flow reserve, Q and R were similar in two study groups. Patients in the ticagrelor group showed higher post-PCI Q (242±49 vs 205±53 mL/min, p=0.015) and lower R values (311 (263, 366) vs 362 (319, 382) mm Hg/L/min, p=0.032). Platelet reactivity showed a negative correlation with periprocedural variation of Q values (r=-0.582, p<0.001) and a positive correlation with periprocedural variation of R values (r=0.645, p<0.001). The periprocedural increase in high-sensitivity troponin I was significantly lower in the ticagrelor compared with the prasugrel group (5 (4, 9) ng/mL vs 14 (10, 24) ng/mL, p<0.001). CONCLUSIONS: In patients with stable CAD undergoing PCI, pretreatment with a loading dose of ticagrelor compared with prasugrel improves post-procedural coronary flow and microvascular function and seems to reduce the related myocardial injury.

Platelet reactivity and clinical outcomes following percutaneous coronary intervention in complex higher-risk patients.

AIMS: To investigate the levels of platelet reactivity and the impact of high platelet reactivity (HPR) on long-term clinical outcomes of complex higher-risk and indicated patients (CHIP) with stable coronary artery disease (CAD) treated with elective percutaneous coronary intervention (PCI). METHODS: We enrolled 500 patients undergoing elective PCI for stable CAD and treated with aspirin and clopidogrel. Patients were divided into four groups based on the presence of CHIP features and HPR. Primary endpoint was the occurrence of major adverse clinical events (MACE) at 5 years. RESULTS: The prevalence of HPR was significantly greater in the CHIP population rather than non-CHIP patients (39.9% vs 29.8%, P = 0.021). Patients with both CHIP features and HPR showed the highest estimates of MACE (22.1%, log-rank P = 0.047). At Cox proportional hazard analysis, the combination of CHIP features and HPR was an independent predictor of MACE (hazard ratio 2.57, 95% confidence interval 1.30-5.05, P = 0.006). CONCLUSION: Among patients with stable CAD undergoing elective PCI and treated with aspirin and clopidogrel, the combination of CHIP features and HPR identifies a cohort of patients with the highest risk of MACE at 5 years, who might benefit from more potent antiplatelet strategies.

Coronary Artery Bypass Grafting or Fractional Flow Reserve-Guided Percutaneous Coronary Intervention in Diabetic Patients With Multivessel Disease.

BACKGROUND: In diabetic patients with multivessel coronary artery disease, coronary artery bypass grafting (CABG) has shown long-term benefits over percutaneous coronary intervention (PCI). Physiology-guided PCI has shown to improve clinical outcomes in multivessel coronary artery disease, though its impact in diabetic patients has never been investigated. We evaluated long-term clinical outcomes of diabetic patients with multivessel coronary artery disease treated with fractional flow reserve (FFR)-guided PCI compared with CABG. METHODS: From 2010 to 2018, 4622 diabetic patients undergoing coronary angiography were screened for inclusion. The inclusion criterion was the presence of at least 2-vessel disease defined as with diameter stenosis ≥50%, in which at least 1 intermediate stenosis (diameter stenosis, 30%-70%) was treated or deferred according to FFR. Inverse probability of treatment weighting analysis was used to account for baseline differences with a contemporary cohort of patients treated with CABG. The primary end point was major adverse cardiovascular and cerebrovascular events, defined as all-cause death, myocardial infarction, revascularization, or stroke. RESULTS: A total of 418 patients were included in the analysis. Among them, 209 patients underwent CABG and 209 FFR-guided PCI. At 5 years, the incidence of major adverse cardiovascular and cerebrovascular events was higher in the FFR-guided PCI versus the CABG group (44.5% versus 31.9%; hazard ratio, 1.60 [95% CI, 1.15-2.22]; P=0.005). No difference was found in the composite of all-cause death, myocardial infarction, or stroke (28.8% versus 27.5%; hazard ratio, 1.05 [95% CI, 0.72-1.53]; P=0.81). Repeat revascularization was more frequent with FFR-guided PCI (24.9% versus 8.2%; hazard ratio, 3.51 [95% CI, 1.93-6.40]; P<0.001). CONCLUSIONS: In diabetic patients with multivessel coronary artery disease, CABG was associated with a lower rate of major adverse cardiovascular and cerebrovascular events compared with FFR-guided PCI, driven by a higher rate of repeat revascularization. At 5-year follow-up, no difference was observed in the composite of all-cause death, myocardial infarction, or stroke between CABG and FFR-guided PCI. Graphic Abstract: A graphic abstract is available for this article.

Severity of Coronary Atherosclerosis and Risk of Diabetes Mellitus.

BACKGROUND: Cardio-vascular target organ damage predicts the onset of type 2 diabetes mellitus (DM) in hypertensive patients. Whether an increased incidence of DM is also in relation to the severity of coronary atherosclerosis is unknown. OBJECTIVE: We evaluated the onset of DM in relation to the extent and severity of coronary atherosclerosis, using the SYNTAX (Synergy between Percutaneous Coronary Intervention with Taxus and Cardiac Surgery) score (SS), in patients with stable angina or acute coronary syndromes, referred for coronary angiography (CA). METHODS: Non-diabetic patients that underwent CA for the first time were included, and the SS was computed. Predictors of DM onset in low, medium, and high SSs were investigated. RESULTS: Five hundred and seventy patients were included, and the mean SS was 6.3 ± 7.6. During a median follow-up of 79 months (interquartile range (IQR): 67-94), 74 patients (13%) developed DM. The risk of DM onset was significantly higher in the patients with a medium or high SS (hazard ratio (HR)-95% confidence interval (CI): 16 (4-61), p < 0.0001; and 30 (9-105), p < 0.0001, vs low SS, respectively), even after adjustment for obesity, history of hypertension, impaired fasting glucose, and cardiovascular therapy. CONCLUSIONS: The severity and extent of the coronary atherosclerosis, evaluated by the SS, is a strong and independent predictor of the development of DM in patients, referred to CA.

Antiplatelet therapy in valvular and structural heart disease interventions.

Transcatheter interventions for valvular and structural heart diseases are rapidly expanding due to greater operators' experience and development of new generation devices associated with increased procedural safety. They represent the standard strategy for patients with prohibitive risk for open surgery. These procedures are associated with a significant occurrence of both thrombotic and bleeding complications, thus in this setting, even more than in other percutaneous procedures, the balance between thrombotic and bleeding risk is critical. This review describes the current data available on the antithrombotic management of patients undergoing transcatheter aortic valve implantation (TAVI), percutaneous mitral valve repair with the MitraClip system, percutaneous left atrial appendage occlusion and percutaneous patent foramen ovale (PFO)/atrial septal defects (ASD) closure.

Interrupted versus uninterrupted novel oral anticoagulant peri-implantation of cardiac device: A single-center randomized prospective pilot trial.

BACKGROUND: Many patients requiring cardiac implantable electronic device (CIED) implantation are on long-term oral anticoagulant therapy. While continuation of warfarin has been shown to be safe and reduce bleeding complications compared to interruption of warfarin therapy and heparin bridging, it is not known which novel oral anticoagulants (NOAC) regimen (interrupted vs uninterrupted) is better in this setting. METHODS: One-hundred and one patients were randomized to receive CIED implantation with either interrupted or uninterrupted/continuous NOAC therapy before surgery. No heparin was used in either treatment arm. The primary end-point was the presence of a clinically significant pocket hematoma after CIED implantation. The secondary end-point was a composite of other major bleeding events, device-related infection, thrombotic events, and device-related admission length postdevice implantation. RESULTS: Both treatment groups were equally balanced for baseline variables and concomitant medications. One clinically significant pocket hematoma occurred in the uninterrupted NOAC group and none in the interrupted group (P  =  0.320). There was no difference in other bleeding complications. No thrombotic events were observed in either of the two groups. CONCLUSIONS: Despite the paucity of bleeding events, data from this pilot study suggest that uninterrupted NOAC therapy for CIED implantation appears to be as safe as NOAC interruption and does not increase bleeding complications.

Should pre-operative left atrial volume receive more consideration in patients with degenerative mitral valve disease undergoing mitral valve surgery?

BACKGROUND: Severe primary mitral regurgitation (MR) carries a significant incidence of mortality and morbidity. Though a number of prognostic factors have been identified, the best timing for mitral valve repair is still debated. We assessed the role of Left Atrial Volume Indexed (LAVI) as predictor of adverse events after mitral valve surgery. METHODS: 134 patients with severe MR were studied with a follow-up of 42±16months. Endpoints were Post-Operative Atrial Fibrillation (POAF), atrial and ventricular remodeling (LARR/LVRR) and correlation with outcome. POAF was defined as AF occurring within 2weeks and late AF (LAF) more than 2weeks after surgery. LARR was defined as LAVI reduction ≥15% and LVRR as any reduction of ventricular mass after surgery. RESULTS: Forty-one patients experienced POAF, 26 had LAF. Pre-operative LAVI was an independent risk factor for POAF (OR 1.03, CI [1.00-1.06], p=0.01), LAF (OR 1.03, CI [1.00-1.06], p=0.02), LARR and LVRR (OR 1.04, CI [1.01-1.07], p=0.002, respectively). LARR was found in 75 patients, while LVRR in 111. Patients with heart remodeling had less incidence of LAF and cardiac adverse events, better diastolic function and improved their NYHA class after surgery. CONCLUSIONS: LAVI should be given more weight into decision making for patients with MR as it predicts POAF and LAF and reverse atrial and ventricular remodeling, both associated to long-term outcome.