Quantitative coronary three-dimensional geometry and its association with atherosclerotic disease burden and composition.

BACKGROUND: Isolate features of the coronary anatomy have been associated with the pathophysiology of atherosclerotic disease. Computational methods have been described to allow precise quantification of the complex three-dimensional (3D) coronary geometry. The present study tested whether quantitative parameters that describe the spatial 3D coronary geometry is associated with the extension and composition of the underlying coronary artery disease (CAD). METHODS: Patients with CAD scheduled for percutaneous intervention were investigated with coronary computed tomography angiography (CCTA), and invasive coronary angiography, and virtual histology intravascular ultrasound (IVUS-VH). For all target vessels, 3D centerlines were extracted from CCTA images and processed to quantify 23 geometric indexes, grouped into 3 main categories as follows: (i) length-based; (ii) curvature-based, torsion-based, and curvature/torsion-combined; (iii) vessel path-based. The geometric variables were compared with IVUS-VH parameters assessing the extent and composition of coronary atherosclerosis. RESULTS: A total of 36 coronary patients (99 vessels) comprised the study population. From the 23 geometric indexes, 18 parameters were significantly (p < 0.05) associated with at least 1 IVUS-VH parameter at a univariate analysis. All three main geometric categories provided parameters significantly related with atherosclerosis variables. The 3D geometric indexes were associated with the degree of atherosclerotic extension, as well as with plaque composition. Geometric features remained significantly associated with all IVUS-VH parameters even after multivariate adjustment for clinical characteristics. CONCLUSIONS: Quantitative 3D vessel morphology emerges as a relevant factor associated with atherosclerosis in patients with established CAD.

Metrics of care and cardiovascular outcomes in patients with ST-elevation myocardial infarction treated with pharmacoinvasive strategy: a decade-long network in a populous city in Brazil.

BACKGROUND: Pharmacoinvasive strategy is an effective myocardial reperfusion therapy when primary percutaneous coronary intervention (p-PCI) cannot be performed in a timely manner. METHODS: Authors sought to evaluate metrics of care and cardiovascular outcomes in a decade-long registry of a pharmacoinvasive strategy network for the treatment of ST-elevation myocardial infarction (STEMI). Data from a local network including patients undergoing fibrinolysis in county hospitals and systematically transferred to the tertiary center were accessed from March 2010 to September 2020. Numerical variables were described as median and interquartile range. Area under the curve (AUC-ROC) was used to analyze the predictive value of TIMI and GRACE scores for in-hospital mortality. RESULTS: A total of 2,710 consecutive STEMI patients aged 59 [51-66] years, 815 women (30.1%) and 837 individuals with diabetes (30.9%) were analyzed. The time from symptom onset to first-medical-contact was 120 [60-210] minutes and the door-to-needle time was 70 [43-115] minutes. Rescue-PCI was required in 929 patients (34.3%), in whom the fibrinolytic-catheterization time was 7.2 [4.9-11.8] hours, compared to 15.7 [6.8-22,7] hours in those who had successful lytic reperfusion. All cause in-hospital mortality occurred in 151 (5.6%) patients, reinfarction in 47 (1.7%) and ischemic stroke in 33 (1.2%). Major bleeding occurred in 73 (2.7%) patients, including 19 (0.7%) cases of intracranial bleeding. C-statistic confirmed that both scores had high predictive values for in-hospital mortality, demonstrated by TIMI AUC-ROC of 0.80 [0,77-0.84] and GRACE AUC-ROC of 0.86 [0.83-0.89]. CONCLUSION: In a real world registry of a decade-long network for the treatment of ST-elevation myocardial infarction based on the pharmacoinvasive strategy, low rates of in-hospital mortality and cardiovascular outcomes were observed, despite prolonged time metrics for both fibrinolytic therapy and rescue-PCI. Register Clinicaltrials.gov NCT02090712 date of first registration 18/03/2014.

Zero-contrast imaging for the assessment of transcatheter aortic valve implantation in candidates with renal dysfunction.

BACKGROUND: Candidates for transcatheter aortic valve implantation (TAVI) are currently evaluated using computed tomography angiography and invasive cardiac catheterization as an essential part of case selection and pre-procedure interventional planning. However, both imaging methods utilize iodinated agents, which may cause contrast-induced nephropathy, particularly in patients with baseline renal dysfunction. This study aimed to describe a zero-contrast imaging protocol for pre-TAVI evaluation in patients with advanced renal impairment. METHODS: The pre-TAVI zero-contrast scheme consisted of the following multi-modality combinations: (1) gadolinium-free magnetic resonance imaging (three-dimensional navigator-echo with electrocardiogram-gated steady-state free-precession series); (2) iodinated-free multislice computed tomography electrocardiogram-gated; (3) lower limb arterial duplex scan ultrasound; and (4) transesophageal echocardiography. Ultimately, TAVI was performed for those deemed good candidates, and contrast was allowed during the intervention; however, operators were strongly advised to utilize the least volume possible of iodinated agents. This pilot survey included ten patients with symptomatic aortic stenosis and renal dysfunction who underwent zero-contrast multi-modality imaging. RESULTS: All the patients ultimately underwent TAVI. The intervention was successful in all cases, without ≥ moderate residual aortic regurgitation, prosthesis embolization, annulus rupture, major vascular complications, stroke, or death during index hospitalization. The creatinine clearance remained stable throughout the observation period (baseline: 26.85 ± 12.55 mL/min; after multi-modality imaging: 26.76 ± 11.51 mL/min; post-TAVI at discharge: 29.84 ± 13.98 mL/min; p = 0.3 all). CONCLUSION: The proposed contrast-free imaging protocol appears to be a promising clinical tool for pre-TAVI evaluation in patients with severe renal dysfunction.

Prolonged Doppler US-guided pneumatic compression of a radial artery pseudoaneurysm after percutaneous coronary intervention: a simple and effective solution for a rare and challenging problem.

Transradial access is associated with fewer access site-related complications, earlier patient mobilization, and greater postprocedural comfort. Pseudoaneurysms are an extremely rare complication after transradial procedures and the radial artery itself is the most atypical arterial site of occurrence. We report a case in which a non-surgical, non-invasive, simple, and effective solution (prolonged pneumatic compression) was used to manage a radial artery pseudoaneurysm, a very rare and challenging complication of transradial procedures.

O acesso arterial transradial está associado a menos complicações relacionadas ao sítio de punção, com deambulação precoce do paciente e maior conforto pós-procedimento. O pseudoaneurisma é uma complicação extremamente rara após procedimentos transradiais, sendo a artéria radial, por si só, o sítio mais incomum para tal ocorrência. Relata-se um caso de um pseudoaneurisma de artéria radial, uma complicação rara e desafiadora, resolvido com êxito e de maneira simples, não invasiva e não cirúrgica (compressão pneumática prolongada).

Patients with COVID-19 who experience a myocardial infarction have complex coronary morphology and high in-hospital mortality: Primary results of a nationwide angiographic study.

OBJECTIVES: We aimed to explore angiographic patterns and in-hospital outcomes of patients with concomitant coronavirus disease-19 (COVID-19) and myocardial infarction (MI). BACKGROUND: Patients with COVID-19 may experience MI during the course of the viral infection. However, this association is currently poorly understood. METHODS: This is a multicenter prospective study of consecutive patients with concomitant COVID-19 and MI who underwent coronary angiography. Quantitative and qualitative coronary angiography were analyzed by two observers in an independent core lab. RESULTS: A total of 152 patients were included, of whom 142 (93.4%) had COVID-19 diagnosis confirmation. The median time between symptom onset and hospital admission was 5 (1-10) days. A total of 83 (54.6%) patients presented with ST-elevation MI. The median angiographic Syntax score was 16 (9.0-25.3) and 69.0% had multi-vessel disease. At least one complex lesion was found in 73.0% of patients, 51.3% had a thrombus containing lesion, and 57.9% had myocardial blush grades 0/1. The overall in-hospital mortality was 23.7%. ST-segment elevation MI presentation and baseline myocardial blush grades 0 or 1 were independently associated with a higher risk of death (HR 2.75, 95%CI 1.30-5.80 and HR 3.73, 95%CI 1.61-8.61, respectively). CONCLUSIONS: Patients who have a MI in the context of ongoing COVID-19 mostly present complex coronary morphologies, implying a background of prior atherosclerotic disease superimposed on a thrombotic milieu. The in-hospital prognosis is poor with a markedly high mortality, prompting further investigation to better clarify this newly described condition.

Main differences between two highly effective lipid-lowering therapies in subclasses of lipoproteins in patients with acute myocardial infarction.

BACKGROUND: Large observational studies have shown that small, dense LDL subfractions are related to atherosclerotic cardiovascular disease. This study assessed the effects of two highly effective lipid-lowering therapies in the atherogenic subclasses of lipoproteins in subjects with ST-segment elevation myocardial infarction (STEMI). METHODS: Patients of both sexes admitted with their first myocardial infarction and submitted to pharmacoinvasive strategy (N = 101) were included and randomized using a central computerized system to receive a daily dose of simvastatin 40 mg plus ezetimibe 10 mg or rosuvastatin 20 mg for 30 days. Intermediate-density lipoprotein (IDL) and low-density lipoprotein (LDL) subfractions were analysed by polyacrylamide gel electrophoresis (Lipoprint System) on the first (D1) and 30th days (D30) of lipid-lowering therapy. Changes in LDL and IDL subfractions between D1 and D30 were compared between the lipid-lowering therapies (Mann-Whitney U test). RESULTS: The classic lipid profile was similar in both therapy arms at D1 and D30. At D30, the achievement of lipid goals was comparable between lipid-lowering therapies. Cholesterol content in atherogenic subclasses of LDL (p = 0.043) and IDL (p = 0.047) decreased more efficiently with simvastatin plus ezetimibe than with rosuvastatin. CONCLUSIONS: Lipid-lowering therapy with simvastatin plus ezetimibe was associated with a better pattern of lipoprotein subfractions than rosuvastatin monotherapy. This finding was noted despite similar effects in the classic lipid profile and may contribute to residual cardiovascular risk. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02428374, registered on 28/09/2014.

Impact of severe OSA on pharmacoinvasive treatment in ST elevation myocardial infarction patients.

PURPOSE: The negative association between obstructive sleep apnea (OSA) and adverse cardiovascular outcomes in patients undergoing percutaneous coronary intervention (PCI) is well documented. However, little is known about the influence of OSA on fibrinolytic therapy. The aim of this study was to evaluate the impact of severe OSA on pharmacoinvasive treatment in ST elevation myocardial infarction (STEMI) patients. METHODS: We enrolled consecutive STEMI patients without previous vascular disease, heart failure, or OSA diagnosis. All patients underwent either a pharmacoinvasive therapy or primary PCI. Syntax score (SS) was calculated for all patients, and a full bedside polysomnography was performed in the first 72 h of admission. In-hospital events and 30 days readmissions were analyzed. RESULTS: The sample included 116 patients, 87 men. Patients with severe OSA were older (p = 0.01), had higher neck and abdominal circumferences (p < 0.01), and had higher BMI (p < 0.01). They also had lower reperfusion rates post-fibrinolysis (20 vs. 65%; p = 0.001), higher SS (20.2 ± 11.2 vs. 14.6 ± 10.6; p = 0.03), lower left ventricle ejection fraction (45 ± 8 vs. 51 ± 10%; p = 0.02), and a higher incidence of atrial arrhythmias (4 vs. 21%; p = 0.02). STEMI patients with severe OSA presented with threefold increase in the risk for at least one adverse outcome. Regression analysis showed that both severe OSA and hypertension were independent predictors of higher SS. CONCLUSION: Severe OSA was associated with a poor outcome after pharmacoinvasive treatment in STEMI patients.

Benchmarking as a quality of care improvement tool for patients with ST-elevation myocardial infarction: an NCDR ACTION Registry experience in Latin America.

OBJECTIVE: We aim to examine the effect of benchmarking on quality-of-care metrics in patients presenting with ST-elevation myocardial infarction (STEMI) through the implementation of the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) ACTION Registry. DESIGN: From January 2005 to December 2017, 712 patients underwent primary percutaneous coronary intervention PCI-499 before NCDR ACTION Registry implementation (prior to 2013) and 213 after implementation. SETTING: STEMI. PARTICIPANTS: 712 patients. INTERVENTION(S): Primary PCI. MAIN OUTCOME MEASURE(S): We examined hospital performance for the quality indicators in processes and outcomes of the management of patients presenting with STEMI. Outcome measures include door-to-balloon time (DBT), antiplatelet therapy and anti-ischemic drugs prescribed at discharge from pre-NCDR ACTION Registry to post-implementation. RESULTS: There was improvement in DBT, decreasing from 94 min in 2012 (before NCDR adoption) to reach a median of 47 min in 2017 (Ptrend < 0.001). The percentage of cases with the optimal DBT of < 90 min increased from 55.8% before to 90.1% after the implementation of the NCDR ACTION Registry (Ptrend < 0.001). The rate of aspirin (90.3-100%, P < 0.001), P2Y12 inhibitor (70.1-78.4%, P = 0.02), beta-blocker (76.8-100%, P < 0.001) and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers (60.1-99.5%, P < 0.001) prescribed at discharge increased from pre-NCDR ACTION Registry to post-implementation. Adjusted mortality before and after NCDR ACTION Registry implementation showed significant change (from 9.04 to 5.92%; P = 0.027). CONCLUSIONS: The introduction of the ACC NCDR ACTION Registry led to incremental gains in the quality in STEMI management through the benchmarking of process of care and clinical outcomes, achieving reduced DBT, improving guideline-directed medication adherence and increasing patient safety, treatment efficacy and survival.

Initial experience with the use of fractional flow reserve in the hemodynamic evaluation of transplant renal artery stenosis.

OBJECTIVE: To describe and standardize an original protocol for fractional flow reserve (FFR) pre and postangioplasty in an initial series of patients with clinically manifested transplant renal artery stenosis (TRAS). BACKGROUND: There is no data in the literature about the use of FFR in TRAS. METHODS: Patients with TRAS detected in a noninvasive study were referred to diagnostic angiography and stenosis considered visually severe (≥ 60%) were included. After selective cannulation, a PressureWire 0.014" (Certus™-St. Jude Medical) was advanced to the distal portion of the vessel. Resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) and translesional systolic pressure gradient were obtained and FFR and hyperemic translesional systolic and mean pressure gradients (HSG and HMG) were registered after papaverine induced maximum hyperemia-pre and poststent implantation. Creatinine levels and office blood pressure measurements were registered at the baseline, 6 and 12 months after intervention. RESULTS: Ten consecutive patients had successful stent implantation and were included. After treatment, significant increase in FFR (0.76 ± 0.09 vs. 0.96 ± 0.04, P < 0.001) and reduction in systolic hyperemic gradients (-41.40 ± 19.18, P < 0.001) and mean (-24.00 ± 11.65, P < 0.001) were observed. A strong negative correlation was observed between FFR and percent stenosis diameter-%SD (r = -0.89, P < 0.001) and HSG (r = -0.9, P < 0.001) as well as a strong positive correlation between FFR and baseline Pd/Pa ratio (r = 0.9, P < 0.001). CONCLUSION: FFR was a well-tolerated, valid and reproducible tool during percutaneous intervention for TRAS. Good correlation was observed between FFR and others hemodynamic parameters of lesion severity.

Risk and timing of clinical events according to diabetic status of patients treated with everolimus-eluting bioresorbable vascular scaffolds versus everolimus-eluting stent: 2-year results from a propensity score matched comparison of ABSORB EXTEND and SPIRIT trials.

OBJECTIVES: to compare the occurrence of clinical events in diabetics treated with the Absorb bioresorbable vascular scaffold (Absorb BVS; Abbott Vascular, Santa Clara, CA) versus everolimus-eluting metal stents (EES; XIENCE V; Abbott Vascular, Santa Clara, CA) BACKGROUND: There are limited data dedicated to clinical outcomes of diabetic patients treated with bioresorbable scaffolds (BRS) at 2-year horizon. METHODS: The present study included 812 patients in the ABSORB EXTEND study in which a total of 215 diabetic patients were treated with Absorb BVS. In addition, 882 diabetic patients treated with EES in pooled data from the SPIRIT clinical program (SPIRIT II, SPIRIT III and SPIRIT IV trials) were used for comparison by applying propensity score matching using 29 different variables. The primary endpoint was ischemia driven major adverse cardiac events (ID-MACE), including cardiac death, myocardial infarction (MI), and ischemia driven target lesion revascularization (ID-TLR). RESULTS: After 2 years, the ID-MACE rate was 6.5% in the Absorb BVS vs. 8.9% in the Xience group (P = 0.40). There was no difference for MACE components or definite/probable device thrombosis (HR: 1.43 [0.24,8.58]; P = 0.69). The occurrence of MACE was not different for both diabetic status (insulin- and non-insulin-requiring diabetes) in all time points up to the 2-year follow-up for the Absorb and Xience groups. CONCLUSION: In this largest ever patient-level pooled comparison on the treatment of diabetic patients with BRS out to two years, individuals with diabetes treated with the Absorb BVS had a similar rate of MACE as compared with diabetics treated with the Xience EES. © 2017 Wiley Periodicals, Inc.

Tissue characterization and phenotype classification in patients presenting with acute myocardial infarction: Insights from the iWonder study.

OBJECTIVES: We sought to assess a new modality of radiofrequency intravascular ultrasound (IVUS) called iMAP-IVUS (Boston Scientific, Santa Clara, California) during the evaluation of patients presenting with high-risk acute coronary syndromes. BACKGROUND: There are limited data on plaque tissue characterization and phenotype classification using iMAP-IVUS. METHODS: In the iWonder study patients presenting with ST-elevation myocardial infarction (STEMI) or non-STEMI underwent three-vessel grayscale IVUS and iMAP-IVUS tissue characterization prior to percutaneous intervention. In total 385 lesions from 100 patients were divided into culprit (n = 100) and nonculprit (n = 285) lesions. Lesion phenotype was classified as (i) thin-cap fibroatheroma (iMAP-derived TCFA); (ii) thick-cap fibroatheroma; (iii) pathological intimal thickening; (iv) fibrotic plaque; and (v) fibrocalcific plaque. RESULTS: Culprit lesions had smaller minimum lumen cross-sectional area (MLA) with greater plaque burden compared to non-culprit lesions. Volumetric analysis showed that culprit lesions had longer length and larger vessel and plaque volumes compared to non-culprit lesions. iMAP-IVUS revealed that culprit lesions presented more NC and fibrofatty volume, both at lesion level and at the MLA site (all P < 0.001). Any fibroatheroma was more frequently identified in culprit lesions compared with non-culprit lesions (93% vs. 78.9%, P = 0.001), anywhere within the lesion 19.0%, P < 0.001) as well as at the MLA site (18.0% vs. 9.5%, P = 0.07). CONCLUSIONS: Three-vessel radiofrequency iMAP-IVUS demonstrated a greater plaque burden and higher prevalence of any fibroatheroma as well as iMAP-derived TCFAs in culprit versus non-culprit lesions in patients presenting with STEMI or non-STEMI undergoing percutaneous coronary intervention. © 2017 Wiley Periodicals, Inc.

Gender-related differences on short- and long-term outcomes of patients undergoing transcatheter aortic valve implantation.

OBJECTIVES: This study aimed to compare gender-related differences in outcomes of patients undergoing TAVI over a long-term follow-up period. BACKGROUND: Transcatheter aortic valve implantation (TAVI) has been considered the standard therapy for patients with inoperable or high-risk symptomatic aortic stenosis. The influence of gender-related differences in outcomes of patients undergoing TAVI is currently on debate. METHODS: From January 2008 to January 2015, 819 patients (49% men) underwent TAVI and were included in a multicenter Brazilian registry. Patients were followed-up and clinical outcomes were evaluated according to the updated Valve Academic Research Consortium-2 criteria. RESULTS: Mean follow-up was 497 ± 478 days. Compared with women, men had a lower rate of major or life-threatening bleeding (12.0% vs. 20.6%; HR = 0.57 [95CI% 0.40-0.81]; P = 0.001), and major vascular complications (6% vs. 11.7%; HR = 0.50 [95CI% 0.31-0.82]; P = 0.004). At 30 days, all-cause mortality was lower in men than in women (6.5% vs. 11.5%; P = 0.013), however, cumulative all-cause mortality was similar between groups (25.9% vs. 29.7%, men and women, respectively, HR = 0.92 [95CI% 0.71-1.19]; P = 0.52) over the entire follow-up period. By adjusted Cox regression model, renal function, diabetes, peripheral artery disease, and chronic obstructive pulmonary disease (COPD) remained independently predictors of all-cause mortality. CONCLUSIONS: In this large-scale study evaluating patients undergoing TAVI, 30-day mortality was higher among women than men driven by significant higher rates of major or life-threatening bleeding and major vascular complications. However, all-cause mortality on long-term follow-up was similar between groups. © 2016 Wiley Periodicals, Inc.

Risk stratification of patients undergoing medical therapy after coronary angiography.

AIM: We sought to investigate the prognostic impact of the SYNTAX (Synergy between PCI with TAXUS and Cardiac Surgery) score (SS) on 1-year clinical outcomes in patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) undergoing medical therapy only. METHODS AND RESULTS: Among the 13 819 patients enrolled in the ACUITY trial and undergoing coronary angiogram, 4491 patients were treated with medical therapy as the initial strategy. Of those, baseline SS and complete angiographic analysis were available in 1275 patients. Patients were divided in four groups based on the presence or absence of coronary artery disease (CAD) and subsequently, among patients with CAD, by SS. Major adverse cardiac events (MACE) and its individual components (death, myocardial infarction, and unplanned revascularization) were compared between groups. Among the 1275 patients, the mean SS was 3.5 ± 7.0 (range 0-45). SYNTAX score was 0 in 842 patients, >0 and ≤5 in 170, >5 and ≤11 in 119, and >11 in 144 patients. The 1-year rates of MACE were higher in patients with CAD and higher SS. By multivariable analysis, the SS was a strong predictor of all adverse ischaemic events, including mortality. By receiver operator characteristic analysis, an SS cut-off of 8 showed the best prognostic accuracy for death and MACE. CONCLUSION: In patients with NSTE ACS undergoing medical therapy, the SS, especially when >8, was shown to be a strong predictor of 1-year MACE, including mortality. This finding has important clinical implications for risk stratification of patients with NSTE ACS undergoing medical therapy after an initial angiogram.

Characterization and clinical significance of right ventricular mechanics in pulmonary hypertension evaluated with cardiovascular magnetic resonance feature tracking.

BACKGROUND: Prognosis in pulmonary hypertension (PH) is related to right ventricular (RV) function. Quantification of RV mechanics may offer additive value. The objective of our study is to determine the feasibility and clinical and prognostic value of RV strain analysis by cardiovascular magnetic resonance (CMR) based feature tracking (FT) in PH. METHODS: We retrospectively enrolled 116 patients (age 52.2 ± 12 years, 73.6 % women) referred to CMR for PH evaluation who underwent right heart catheterization within 1 month. Using dedicated FT software, peak global longitudinal and circumferential RV strain and strain rates (GLS, GCS, GLSR, and GCSR, respectively) were quantified from standard cine images. Using multivariate regression analysis, we evaluated the associations of strain with a composite endpoint of death, lung transplantation, or functional class deterioration. RESULTS: RV strain analysis was feasible in 110 (95 %) patients. Patients were classified into: Group A (no PH, normal right ventricular ejection fraction [RVEF]; n = 17), Group B (PH, normal RVEF; n = 26), or Group C (PH, abnormal RVEF; n = 67). All strain and strain rate values were reduced in Group C. Furthermore, GCSR was significantly reduced in Group B (-0.92 [-1.0/-0.7]; p < 0.001) compared to Group A (-1.12 [-1.3/-0.9]; p < 0.001). After adjustment for six clinically meaningful covariates, GLS (hazard ratio 1.06; p = 0.026), GLSR (hazard ratio 2.52; p = 0.04), and GCSR (hazard ratio 4.5; p = 0.01) were independently associated with the composite endpoint. GCSR successfully discriminated patients with and without events (p = 0.01). CONCLUSIONS: Quantification of RV strain with CMR-FT is feasible in the majority of patients, correlates with disease severity, and is independently associated with poor outcomes in PH.

SYNTAX score and the risk of stent thrombosis after percutaneous coronary intervention in patients with non-ST-segment elevation acute coronary syndromes: an ACUITY trial substudy.

OBJECTIVE: We sought to investigate the relationship between the SYNTAX score (SS) and stent thrombosis (ST) in patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) undergoing percutaneous coronary intervention (PCI). BACKGROUND: The relationship between the SS and ST is undetermined. METHODS: We stratified 2,627 patients undergoing PCI in the ACUITY trial by SS tertile according to the current population (true tertiles, SS <7, SS = 7-12, and SS >12) and by the SYNTAX trial (original SYNTAX tertiles, SS <23, SS = 23-32, and SS >32). Thirty-day and 1-year rates of definite/probable ST were determined for each tertile. RESULTS: A total 30 (1.1%) and 41 (1.6%) definite/probable ST events occurred by 30 days and 1 year, respectively. When stratified by true tertiles, 30-day and 1-year rates of definite/probable ST were significantly greater in the highest tertile (SS >12; 2.0% and 2.8%) compared with the intermediate (SS = 7-12; 0.7% and 1.1%) and lowest tertiles (SS <7; 0.6% and 0.7%), P = 0.007 and P = 0.0009, respectively. When stratified by original SYNTAX tertiles, 30-day and 1-year rates of definite/probable ST were significantly greater in the highest (SS >32; 6.3% and 8.8%) and intermediate tertiles (SS = 23-32; 2.8% and 3.7%) compared with the lowest tertile (SS < 22; 0.8% and 1.2%), P <0.0001 for both. By multivariable analysis, the SS was an independent predictor for both 30-day and 1-year definite/probable ST. CONCLUSIONS: In patients with NSTE-ACS undergoing PCI, the extent and severity of CAD, as assessed by the SS before revascularization, was strongly associated with the occurrence of ST both at 30 days and 1 year. © 2014 Wiley Periodicals, Inc.

Prognostic value of serial brain natriuretic Peptide measurements in patients with acute myocardial infarction.

OBJECTIVES: Elevated B-type natriuretic peptide (BNP) levels following acute myocardial infarction (AMI) are associated with adverse outcomes. The role of serial BNP monitoring after AMI has been poorly investigated. We aimed to evaluate the prognostic value of in-hospital serial BNP measurements in AMI patients. METHODS: Patients with AMI (n=1,924) were retrospectively evaluated. We selected patients with at least 2 in-hospital BNP measurements. The association between in-hospital mortality and BNP measurements (earliest, highest follow-up and the variation between measurements) were tested in multivariate models. RESULTS: Serial BNP levels were determined in 176 patients. Compared to the rest of the population, these patients were older and had higher mortality rates. In the adjusted models, only the highest follow-up BNP remained associated with in-hospital death (odds ratio 1.06; 95% confidence interval, CI, 1.01-1.15; p=0.014). Receiver-operating characteristic curve analysis demonstrated that the highest follow-up BNP was the best predictor of in-hospital death (area under the curve=0.75; 95% CI 0.64-0.86). CONCLUSIONS: Serial BNP monitoring was performed in a high-risk subgroup of AMI patients. The highest follow-up BNP was a better predictor of short-term death than the baseline and in-hospital variation values. In AMI patients, a later in-hospital BNP assessment may be more useful than an early measurement.

A randomized trial comparing dual axis rotational versus conventional coronary angiography in a population with a high prevalence of coronary artery disease.

OBJECTIVES: To compare the safety, radiation dose, and contrast volume between dual axis rotational coronary angiography (DARCA) and conventional coronary angiography (CCA). BACKGROUND: CCA is performed in multiple, predefined stationary views, at different angulations around the patient, for both the left and right coronary arteries. DARCA (AlluraXperSwing™, Philips, the Netherlands) involves a pre-set rotation of the C-arm around the patient and allows for the visualization of each coronary artery in different views, using a single automatic pump contrast injection. METHODS: From November 2012 to February 2013, 201 patients were randomly assigned to either CCA (n = 100) or DARCA (n = 101). Exclusion criteria included acute coronary syndrome (ACS), prior PCI or CABG. CCAs were performed in 4 acquisition runs for the left coronary artery and 2 to 3 acquisition runs for the right coronary artery, whereas DARCAs were performed in a single run for each coronary artery. RESULTS: Baseline demographics and clinical characteristics were similar for both groups. The overall prevalence of CAD was 77.6%. The DARCA group had a significant reduction in the amount of contrast, 60 ml (IQR: 52.5-71.5 ml) versus 76 ml (IQR: 68-87 ml), P < 0.0001; and radiation dose by Air Kerma, 269.5 mGy (IQR: 176-450.5) versus 542.1 mGy (IQR: 370.7-720.8), P < 0.0001. There were fewer patients requiring additional projections in the DARCA group: 54.0% versus 75.0%; P = 0.002. CONCLUSIONS: In a population with a high prevalence of CAD, DARCA was safe and resulted in a significant decrease in contrast volume and radiation dose.

Influence of gender on the risk of death and adverse events in patients with acute myocardial infarction undergoing pharmacoinvasive strategy.

Pharmacoinvasive treatment is an acceptable alternative for patients with ST-segment elevation myocardial infarction (STEMI) in developing countries. The present study evaluated the influence of gender on the risks of death and major adverse cardiovascular events (MACE) in this population. Seven municipal emergency rooms and the Emergency Mobile Healthcare Service in São Paulo treated STEMI patients with tenecteplase. The patients were subsequently transferred to a tertiary teaching hospital for early (<24 h) coronary angiography. A total of 469 patients were evaluated [329 men (70.1%)]. Compared to men, women had more advanced age (60.2 ± 12.3 vs. 56.5 ± 11 years; p = 0.002); lower body mass index (BMI; 25.85 ± 5.07 vs. 27.04 ± 4.26 kg/m2; p = 0.009); higher rates of hypertension (70.7 vs. 59.3%, p = 0.02); higher incidence of hypothyroidism (20.0 vs. 5.5%; p < 0.001), chronic renal failure (10.0 vs. 8.8%; p = 0.68), peripheral vascular disease (PVD; 19.3 vs. 4.3%; p = 0.03), and previous history of stroke (6.4 vs. 1.3%; p = 0.13); and higher thrombolysis in myocardial infarction risk scores (40.0 vs. 23.7%; p < 0.001). The overall in-hospital mortality and MACE rates for women versus men were 9.3 versus 4.9% (p = 0.07) and 12.9 versus 7.9% (p = 0.09), respectively. By multivariate analysis, diabetes (OR 4.15; 95% CI 1.86-9.25; p = 0.001), previous stroke (OR 4.81; 95% CI 1.49-15.52; p = 0.009), and hypothyroidism (OR 3.75; 95% CI 1.44-9.81; p = 0.007), were independent predictors of mortality, whereas diabetes (OR 2.05; 95% CI 1.03-4.06; p = 0.04), PVD (OR 2.38; 95% CI 0.88-6.43; p = 0.08), were predictors of MACE. In STEMI patients undergoing pharmacoinvasive strategy, mortality and MACE rates were twice as high in women; however, this was due to a higher prevalence of risk factors and not gender itself.

Ascending aortic rupture incidentally revealed at the cath lab: surprising, rare, and life-threatening.

An 80-year-old woman who was an active smoker with neglected long-term hypertension, but no known previous aortic or connective tissue disorders, presented to the emergency department complaining of sudden chest pain associated with cardiogenic shock.

Cardiotoxic Effects Produced by Omeprazole and Methylene Blue in an Animal Model of Cardiac Ischemia and Reperfusion and Potential Implications for the Pharmacological Strategy for Vasoplegic Syndrome.

Defined as systemic hypotension caused by intense vasodilation due to the loss of systemic vascular resistance, vasoplegic syndrome (VS) is associated with elevated morbidity and mortality in humans. Although vasopressors such as norepinephrine and vasopressin are the first-choice drugs for VS treatment, several other drugs such as methylene blue (MB) can be used as adjuvant therapy including rescue therapy. To develop new pharmacological strategies to reduce the risk of VS, we investigated the effects of treatments with MB (2 mg/kg/IV), omeprazole (OME, 10 mg/kg/IV), and their combination in an animal model of cardiac ischemia-reperfusion (CIR). The ventricular arrhythmia (VA), atrioventricular block (AVB), and lethality (LET) incidence rates caused by CIR (evaluated via ECG) and serum levels of the cardiac lesion biomarkers creatine kinase-MB (CK-MB) and troponin I (TnI) in adult rats pretreated with saline solution 0.9% and submitted to CIR (SS + CIR group) were compared to those pretreated with MB (MB + CIR group), OME (OME + CIR group), or the MB + OME combination (MB + OME + CIR group). The AVB and LET incidence rates in the MB + CIR (100%), OME + CIR (100%), and MB + OME + CIR (100%) groups were significantly higher compared to the SS + CIR group (60%). The serum level of CK-MB in these groups were also significantly higher compared to the SS + CIR group, demonstrating that the treatments before CIR with MB, OME, and MB + OME produced similar effects in relation to cardiac function and the occurrence of lesions. These results demonstrate that the treatment of animals subjected to the CIR protocol with OME produced the same effects promoted by the treatment with MB, which may suggest the possibility of using OME alone or in combination with MB in medical clinics in treatment of VS.