Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy.

Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.

Incidence and Predictors of Adverse Events Among Initially Stable ST-Elevation Myocardial Infarction Patients Following Primary Percutaneous Coronary Intervention.

Background Cardiac intensive care units were originally created in the prerevascularization era for the early recognition of ventricular arrhythmias following a myocardial infarction. Many patients with stable ST-segment-elevation myocardial infarction (STEMI) are still routinely triaged to cardiac intensive care units after a primary percutaneous coronary intervention (pPCI), independent of clinical risk or the provision of critical care therapies. The aim of this study was to determine factors associated with in-hospital adverse events in a hemodynamically stable, postreperfusion population of patients with STEMI. Methods and Results Between April 2012 and November 2019, 2101 consecutive patients with STEMI who received pPCI in the Vancouver Coastal Health Authority were evaluated. Patients were stratified into those with and without subsequent adverse events, which were defined as cardiogenic shock, in-hospital cardiac arrest, stroke, re-infarction, and death. Multivariable logistic regression models were used to determine predictors of adverse events. After excluding patients presenting with cardiac arrest, cardiogenic shock, or heart failure, the final analysis cohort comprised 1770 stable patients with STEMI who had received pPCI. A total of 94 (5.3%) patients developed at least one adverse event: cardiogenic shock 55 (3.1%), in-hospital cardiac arrest 42 (2.4%), death 28 (1.6%), stroke 21 (1.2%), and re-infarction 5 (0.3%). Univariable predictors of adverse events were older age, female sex, prior stroke, chronic kidney disease, and atrial fibrillation. There was no significant difference in reperfusion times between those with and without adverse events. Following multivariable adjustment, moderate to severe chronic kidney disease (creatinine clearance <44 mL/min; 13% of cohort) was associated with adverse events (odds ratio 2.24 [95% CI, 1.12-4.48]) independent of reperfusion time, age, sex, smoking status, hypertension, diabetes, and prior myocardial infarction/PCI/coronary artery bypass grafting. Conclusions Only 1 in 20 initially stable patients with STEMI receiving pPCI developed an in-hospital adverse event. Moderate to severe chronic kidney disease independently predicted the risk of future adverse events. These results indicate that the majority of patients with STEMI who receive pPCI may not require routine admission to a cardiac intensive care unit following reperfusion.

Novel multi-marker proteomics in phenotypically matched patients with ST-segment myocardial infarction: association with clinical outcomes.

Early prediction of significant morbidity or mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) represents an unmet clinical need. In phenotypically matched population of 139 STEMI patients (72 cases, 67 controls) treated with primary percutaneous coronary intervention, we explored associations between a 24-h relative change from baseline in the concentration of 91 novel biomarkers and the composite outcome of death, heart failure, or shock within 90 days. Additionally, we used random forest models to predict the 90-day outcomes. After adjustment for false discovery rate, the 90-day composite was significantly associated with concentration changes in 14 biomarkers involved in various pathophysiologic processes including: myocardial fibrosis/remodeling (collagen alpha-1, cathepsin Z, metalloproteinase inhibitor 4, protein tyrosine phosphatase subunits), inflammation, angiogenesis and signaling (interleukin 1 and 2 subunits, growth differentiation factor 15, galectin 4, trefoil factor 3), bone/mineral metabolism (osteoprotegerin, matrix extracellular phosphoglycoprotein and tartrate-resistant acid phosphatase), thrombosis (tissue factor pathway inhibitor) and cholesterol metabolism (LDL-receptor). Random forest models suggested an independent association when inflammatory markers are included in models predicting the outcomes within 90 days. Substantial heterogeneity is apparent in the early proteomic responses among patients with acutely reperfused STEMI patients who develop death, heart failure or shock within 90 days. These findings suggest the need to consider synergistic multi-biomarker strategies for risk stratification and to inform future development of novel post-myocardial infarction therapies.

Initial Findings From the North American COVID-19 Myocardial Infarction Registry.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has impacted many aspects of ST-segment elevation myocardial infarction (STEMI) care, including timely access to primary percutaneous coronary intervention (PPCI). OBJECTIVES: The goal of the NACMI (North American COVID-19 and STEMI) registry is to describe demographic characteristics, management strategies, and outcomes of COVID-19 patients with STEMI. METHODS: A prospective, ongoing observational registry was created under the guidance of 3 cardiology societies. STEMI patients with confirmed COVID+ (group 1) or suspected (person under investigation [PUI]) (group 2) COVID-19 infection were included. A group of age- and sex-matched STEMI patients (matched to COVID+ patients in a 2:1 ratio) treated in the pre-COVID era (2015 to 2019) serves as the control group for comparison of treatment strategies and outcomes (group 3). The primary outcome was a composite of in-hospital death, stroke, recurrent myocardial infarction, or repeat unplanned revascularization. RESULTS: As of December 6, 2020, 1,185 patients were included in the NACMI registry (230 COVID+ patients, 495 PUIs, and 460 control patients). COVID+ patients were more likely to have minority ethnicity (Hispanic 23%, Black 24%) and had a higher prevalence of diabetes mellitus (46%) (all p < 0.001 relative to PUIs). COVID+ patients were more likely to present with cardiogenic shock (18%) but were less likely to receive invasive angiography (78%) (all p < 0.001 relative to control patients). Among COVID+ patients who received angiography, 71% received PPCI and 20% received medical therapy (both p < 0.001 relative to control patients). The primary outcome occurred in 36% of COVID+ patients, 13% of PUIs, and 5% of control patients (p < 0.001 relative to control patients). CONCLUSIONS: COVID+ patients with STEMI represent a high-risk group of patients with unique demographic and clinical characteristics. PPCI is feasible and remains the predominant reperfusion strategy, supporting current recommendations.

Antemortem diagnosis of nonbacterial thrombotic endocarditis in a patient with previously resected pancreatic adenocarcinoma: a case report.

BACKGROUND: Nonbacterial thrombotic endocarditis (NBTE) is a rare manifestation of a number of systemic diseases, which include advanced malignancy and hypercoagulable states. CASE SUMMARY: We present a 67-year-old woman who had presented with chest pain and heart failure. Eight years ago, she had a successful Whipple resection for pancreatic adenocarcinoma. Echocardiography revealed mitral valve vegetations with negative blood cultures. She had multiple infarcts in the kidney, spleen, and brain. She was found to have a mass in the left 8th rib, consistent with metastatic pancreatic adenocarcinoma on biopsy. Ultimately, a diagnosis of NBTE was made after excluding other causes for her presentation. Because of her general poor condition, she expressed the wish for palliative care and later died 28 days after presentation. DISCUSSION: This case illustrates the possibility of NBTE in patients successfully treated for pancreatic adenocarcinoma and highlights the consideration of this relatively rare differential in patients with a previously treated malignancy presenting with heart failure.

Secondary mitral regurgitation: percutaneous edge-to-edge repair on the cutting edge?

PURPOSE OF REVIEW: Secondary mitral regurgitation commonly complicates heart failure. Although the evidence for its management is most robust for treating the underlying cardiomyopathy, treatment aimed at additionally reducing the severity of mitral regurgitation with a percutaneous edge-to-edge device, MitraClip, has recently emerged. RECENT FINDINGS: Despite the use of contemporary evidence-based heart failure therapies, patients with secondary mitral regurgitation and heart failure continue to remain at high risk for adverse clinical events; in both the MITRA-FR and COAPT trials, an extremely high event rate was evident in the medically managed arms over the respective 12-24-month follow-up. Data supporting the use of MitraClip to mitigate adverse outcomes in secondary mitral regurgitation is, however, conflicting. In MITRA-FR no difference was noted between MitraClip compared with the medically managed arm for the composite of all-cause death or heart failure hospitalization at 12 months. However, in COAPT, a significant reduction in the rate of heart failure re-hospitalization over 2 years was evident with MitraClip compared with medical therapy alone. SUMMARY: Recommendations exist for the use of MitraClip in patients with primary mitral regurgitation and prohibitive surgical risk. However, with the divergent results of two recent high-quality randomized trials, its role in patients with secondary mitral regurgitation remains controversial.

Kidney function modifies the selection of treatment strategies and long-term survival in stable ischaemic heart disease: insights from the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) registry.

Aims: Patients with chronic kidney disease (CKD) have been under-represented in stable ischaemic heart disease (SIHD) trials despite their heightened risk of cardiovascular mortality. We examine associations between kidney disease, treatment selection, and long-term survival in patients with SIHD. Methods and results: SIHD patients with angiographically significant stenosis (≥70%) were categorized by renal function [dialysis-dependent, severe CKD [estimated glomerular filtration rate (eGFR) < 30], mild-moderate CKD (eGFR 30-59), and no CKD (eGFR ≥ 60)] and by treatment groups [revascularization ≤3 months of angiogram (percutaneous coronary intervention or coronary artery bypass surgery) vs. medical therapy]. The association between renal function category and treatment on long-term survival was examined and adjusted for differences in age, sex, co-morbidities, and coronary anatomy. Of the 17 910 SIHD patients, 0.7% (n = 118) were dialysis-dependent, 1.2% (n = 215) severe CKD, 12.0% (n = 2157) mild-moderate CKD, and 86.1% (n = 15420) no CKD. The presence of CKD was associated with significantly lower adjusted odds of receiving revascularization [reference no CKD: dialysis-dependent: odds ratio (OR) 0.52 (0.35, 0.79), severe (non-dialysis) CKD: OR 0.54 (0.40, 0.73), and mild-moderate CKD: OR 0.80 (0.71, 0.89)]. Over a median follow-up of 8.0 (interquartile range 3.2) years, patients with progressive CKD had higher long-term mortality (dialysis-dependent, 53.4%; severe CKD, 30.2%; mild-moderate CKD, 22.2%; no CKD, 11.9%, Ptrend < 0.0001). Revascularization was associated with improved long-term survival [adjusted hazard ratio (HR): dialysis-dependent: HR 0.29 (0.15, 0.55), severe CKD: HR 0.63 (0.36, 1.08), mild-moderate CKD: HR 0.49 (0.40, 0.60), and no CKD: HR 0.47 (0.42, 0.52)] (Pinteraction < 0.001). Conclusion: In SIHD, the presence of CKD was accompanied by lower revascularization rates and a higher risk of mortality. However, revascularization in CKD was associated with improved long-term survival.

Clinical and Angiographic Outcomes in Coronary Artery Bypass Surgery with Multiple versus Single Distal Target Grafts.

BACKGROUND: Coronary artery bypass grafting (CABG) with multiple distal target (MDT) grafts requires less graft material and reduces cardiopulmonary bypass time; however, there may be a higher incidence of graft failure. A real-world analysis reporting long-term outcomes associated with MDT grafts is lacking. MATERIAL AND METHODS: In 6262 consecutive patients who underwent an isolated first CABG from 2004-2012, patients with MDTs were propensity matched to those with single distal target (SDT) grafts. Logistic regression adjusted for traditional, anatomical, and functional definitions of complete revascularization (CR). Outcomes included 30-day, 1-year, and long-term mortality (median 6.29 years). Results: A total of 549 (8.8%) CABG patients had a MDT graft. CR defined using traditional (96.1% versus 92.0%, P = .005), anatomical (89.0% versus 80.20%, P < .001), and functional (90.7% versus 82.6, P < .001) definitions was more frequent in MDT patients. No significant differences in mortality were observed at 30 days (2% versus 3.3%, P = .18), 1-year (3.8% versus 4.9%, P = .37), or through end of follow-up (18.0% versus 16.6% P = .52) between the MDT and SDT groups, respectively. Similarly, no differences were observed after adjustment for all definitions of CR. Graft failure in MDT and SDT patients was 37.8% and 27.6%, respectively (P = .18). CONCLUSION: In a contemporary population-based cohort, no differences in mortality were observed between CABG patients with MDT and SDT grafts. Our findings support the safety of MDT grafts to facilitate CR in patients and when graft material is limited.

Symptomatic graft failure and impact on clinical outcome after coronary artery bypass grafting surgery: Results from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry.

BACKGROUND: In contemporary coronary artery bypass graft (CABG) surgery, the association between symptomatic graft failure (GF) and long-term clinical outcome remains unclear. We sought to identify the clinical characteristics and outcomes of GF in symptomatic patients requiring cardiac catheterization within 1 year of CABG surgery. METHODS: Using the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease registry, 5,276 patients undergoing CABG surgery from September 2002 to August 2011 were identified. Clinical outcomes in patients with symptomatic GF were observed. Predictors of GF were analyzed at a graft level, whereas long-term survival was assessed at a patient level. A propensity score matching technique was used to adjust for baseline characteristics. RESULTS: Of our CABG cohort, 5.3% (281 patients [285 arterial and 653 vein grafts]) required symptom based coronary angiography within 1 year of CABG surgery. Acute coronary syndrome was the most common presentation (64.4%). At angiography, 27.0% (77/285) of arterial and 34.5% (225/653) of vein grafts were occluded. Respectively, arterial and vein GFs were treated as follows: percutaneous coronary intervention 61.0% versus 41.8%, re-do CABG 9.1% versus 0%, and medically without intervention 29.9% versus 58.2%. A strong trend toward reduced patient survival was noted with "arterial graft failure" (arterial ± vein GF) compared to "vein graft failure only" (no arterial GF) (adjusted hazard ratio 2.2, 95% CI 0.98-5.0, P = .056). CONCLUSION: Although the rate of cardiac catheterization within 1 year of CABG is infrequent, these patients exhibit high GF rates and commonly present with an acute coronary syndrome. In addition, "arterial graft failure" compared to "vein graft failure only" confers a higher risk of adverse long-term survival.

A prospective review of acute coronary syndromes in an urban hospital in sub-Saharan Africa.

OBJECTIVES: To determine the epidemiology of acute coronary syndromes (ACS) in sub-Saharan Africa. METHODS: A prospective survey was carried out of all patients with a diagnosis of ACS who were admitted to the critical care unit of a tertiary teaching hospital over a 25-month period. Demographics, presentation, management and outcomes were subsequently recorded. RESULTS: A total of 111 (5.1% of all hospitalisations) patients were recruited, with 56% presenting with ST-elevation myocardial infarction (STEMI) and the rest non-ST-elevation myocardial infarction (NSTEMI) or unstable angina (UA). Chest pain was the most common presenting symptom, and up to one-third of all STEMI patients did not receive any form of reperfusion therapy, primarily due to late presentation. As in the developed world, diabetes, hypertension and cigarette smoking still account for the most common predisposing risk-factor profile, and the mortality associated with ACS is about six to 10% in our unit. CONCLUSIONS: ACS, contrary to common belief, is increasingly more prevalent in sub-Saharan Africa, with similar risk profiles to that in the developed world. Late presentation to hospital is common and accounts for the increased mortality associated with this condition.