A comparison between radial artery compression devices for patent hemostasis after transradial percutaneous interventions.

OBJECTIVES: Patent hemostasis (PH) is essential for preventing radial artery occlusion (RAO) after trans-radial procedures; however, it remains unclear how it should be obtained. The aim of this multicenter randomized study was to evaluate whether the use of an adjustable device (AD), inflated with a pre-determined amount of air (AoA), was more effective than a non-adjustable device (non-AD) for achieving PH, thereby reducing the incidence of RAO. METHODS: We enrolled a total of 480 patients undergoing transradial procedure at 3 Italian institutions. Before the procedure, a modified Reverse Barbeau Test (mRBT) was performed in all patients to evaluate the AoA to be eventually inflated in the AD. After the procedure, patients were randomized into 2 groups: (1) AD Group, using TR-Band (Terumo) inflated with the pre-determined AoA; and 2) non-AD Group, using RadiStop (Abbott). An RBT was performed during compression to demonstrate the achievement of PH, as well as 24 hours later to evaluate the occurrence of RAO. RESULTS: PH was more often obtained in the AD Group compared with the non-AD Group (90% vs 64%, respectively, P less than .001), with no difference in terms of bleedings. RAO occurred more often in the non-AD Group compared with the AD Group (10% vs 3%, respectively, P less than .001). Of note, mRBT was effective at guiding AD inflation and identifying high-risk patients in whom PH was more difficult to obtain. CONCLUSIONS: The use of AD, filled with a predetermined AoA, allowed PH significantly more often compared with non-AD, providing a significantly reduced incidence of RAO.

[Follow-up of patients after an acute coronary event: the Apulia PONTE-SCA program]. / Follow-up del paziente dopo sindrome coronarica acuta: il progetto PONTE-SCA Puglia.

BACKGROUND: Patients who suffered from acute coronary syndrome (ACS) need a tight follow-up in order to optimize therapy and prevent adverse events. The aim of the PONTE-SCA Puglia program was to evaluate the impact of an integrated management of patients between hospital and local territorial outpatient facilities on adherence and outcome of patients discharged after ACS event. METHODS: This was a prospective, longitudinal, cohort study which enrolled patients who suffered ACS and/or coronary revascularization in a Hub hospital of ASL Bari. Patients underwent clinical and laboratory evaluation at 30 days, 3 months, 6 months, and 1 year after the index event. The following endpoints were considered: all-cause mortality, ACS recurrence/cardiac ischemia/angina, restenosis/intrastent thrombosis, stroke/transient ischemic attack, heart failure, all-cause bleeding. We evaluated persistence on therapies and the percentage of patients who attained therapeutic goals. RESULTS: A total of 2476 patients (mean age 67.2 ± 12.0 years, 77.4% male) were enrolled. At 1-year follow-up, 99.5% of patients (p<0.05) were on statin therapy, 16.1% (p<0.01) on ezetimibe, and 9.9% (p<0.01) on proprotein convertase subtilisin/kexin type 9 inhibitors. All-cause mortality was 3.1% at 1-year follow-up, whereas recurrence of ACS/cardiac ischemia/angina and restenosis/stent thrombosis were 3% and 1.3%, respectively. The prevalence of all bleeding complications was 2.2%. CONCLUSIONS: The PONTE-SCA Puglia program allowed to implement a dedicated taking in charge of patients after an ACS/coronary revascularization event, to manage a dedicated follow-up route for them, to ameliorate persistence on recommended therapies, and to keep lower the incidence of major adverse cardiovascular events and bleedings.

Comparison of the Effect of Dual-Axis Rotational Coronary Angiography Versus Conventional Coronary Angiography on Frequency of Acute Kidney Injury, X-Ray Exposure Time, and Quantity of Contrast Medium Injected.

Dual-axis rotational coronary angiography (DARCA) has already been shown to reduce both the amount of contrast medium and radiation exposure compared with conventional coronary angiography (CCA). However, a clinical benefit of such imaging modality has never been demonstrated. The aim of this study was to evaluate the efficacy of DARCA to prevent acute kidney injury (AKI) compared with CCA. Consecutive patients who underwent coronary angiography were enrolled to DARCA (n = 80) or CCA (n = 80). Patients presenting with ST-segment elevation myocardial infarction or previously underwent coronary artery bypass graft were excluded. The 2 groups were homogeneous in terms of both clinical and procedural characteristics. Total x-ray time and total amount of contrast medium were significantly lower in the DARCA group compared with the CCA group (x-ray time 3.2 minutes [1.8 to 7.0] vs 5.1 minutes [2.6 to 9.9], p = 0.002; contrast medium amount 40 ml [31 to 116] vs 80 ml [50 to 150], p <0.001). AKI more often occurred in the CCA group compared with the DARCA group (16 [20%] vs 4 [5%], p = 0.007). Moreover, in patients presenting with acute coronary syndrome (ACS) or who underwent percutaneous coronary intervention (PCI), AKI more often occurred in the CCA group compared with the DARCA group (ACS patients, 6 [29%] vs 2 [6%], p = 0.04, and PCI patients, 11 [33%] vs 0 [0%], p <0.001). In addition, in patients with high pretest probability of coronary artery disease, AKI more often occurred in the CCA group compared with the DARCA group (11 [55%] vs 2 [6%], p <0.001). In conclusion, DARCA significantly reduces both x-ray exposure and amount of contrast medium usage, thereby reducing the occurrence of AKI compared with CCA.

FFR prediction model based on conventional quantitative coronary angiography and the amount of myocardium subtended by an intermediate coronary artery stenosis.

BACKGROUND: Coronary angiography has poor predictive value for functionally significant coronary artery stenosis. The Fractional Flow Reserve (FFR) currently represents the gold standard to define the ischemic potential of epicardial stenosis and, recently, the instantaneous wave-free ratio (iFR), has also been introduced as alternative to the FFR, but it still remains an invasive procedure. We aimed this study in order to evaluate the accuracy of the "Angiography-DeriveD hEmoDynamic index" (ADDED index) to predict the FFR as compared with the iFR. METHODS AND RESULTS: Consecutive patients with at least one equivocal stenosis in one major coronary artery were enrolled. Both the FFR and iFR were measured. The amount of jeopardized myocardium was evaluated using the Duke Jeopardy Score (DJS). Two-dimensional quantitative coronary angiography (QCA) was used to assess the angiographic features of the coronary stenosis and both the reference vessel diameter (RVD) and minimal lumen diameter (MLD) were calculated. The ADDED index was defined as the ratio between DJS and MLD. We evaluated 100 intermediate coronary artery stenoses in 83 patients. Both FFR and iFR inversely correlated with the ADDED index (respectively, r2=0.59, p<0.001 and r2=0.61, p<0.001). This latter also showed high accuracy in predicting the FFR value (ROC analysis: 0.94[0.90-0.99], p<0.001) as well as the iFR (0.91[0.86-0.97], p<0.001, difference: 0.03 SD 0.04, p=0.52). CONCLUSIONS: The ADDED index, taking into account both the MLD and DJS, showed high accuracy to predict FFR and it might be used to detect functionally significant coronary artery stenosis.

The CAPITAL study (CArdiovascular Prevention wIth Telecardiology in ApuLia): preliminary results.

BACKGROUND: The CArdiovascular Prevention wIth Telecardiology in ApuLia (CAPITAL) study aimed to investigate the prevalence of cardiovascular risk factors, the status of cardiovascular prevention, and the compliance to international scientific societies' guidelines on cardiovascular prevention in a Mediterranean region. METHODS: The CAPITAL study was based on the assessment of cardiovascular risk and compliance to guidelines on cardiovascular prevention, and on an electrocardiogram screening with remote telemedicine support performed in pharmacies of Apulia (Italy); the study was expected to enroll 10 000 consecutive patients accessing their usual pharmacy. RESULTS: In the first 1000 patients enrolled, 16% were smokers, 9% diabetic, 26% hypertensive, 43% overweight, and 23% obese; 37% of the patients treated with antihypertensive drugs did not achieve the target levels, regardless of the number of antihypertensive drugs given, and 60% of subjects treated with lipid-lowering drugs did not achieve the target levels.Twenty-two per cent of the patients subjected to the lipid-lowering drugs did not check their cholesterol levels in the past 12 months, and 21% of those taking antihypertensive drugs did not check their blood pressure levels.Left ventricular hypertrophy was detected at electrocardiogram examination in 3.4% of the cases, and in 2.6% of the patients with unknown hypertension: 52% of the hypertensive patients were not checked with an electrocardiogram in the past 12 months, 44% of the diabetic patients, and 44% of subjects treated with lipid-lowering drugs. CONCLUSIONS: The awareness, therapy, and control of cardiovascular risk factors in a Mediterranean real-world population are unsatisfactory. There is a large scope of an improvement in the control of cardiovascular risk factors. Telemedicine support and pharmacy-based assessment may be helpful in implementing strategies aimed at the improvement of cardiovascular prevention.

Pre-hospital electrocardiogram triage with tele-cardiology support is associated with shorter time-to-balloon and higher rates of timely reperfusion even in rural areas: data from the Bari- Barletta/Andria/Trani public emergency medical service 118 registry on primary angioplasty in ST-elevation myocardial infarction.

BACKGROUND: We report the preliminary data from a regional registry on ST-elevation myocardial infarction (STEMI) patients treated with primary angioplasty in Apulia, Italy; the region is covered by a single public health-care service, a single public emergency medical service (EMS), and a single tele-medicine service provider. METHODS: Two hundred and ninety-seven consecutive patients with STEMI transferred by regional free public EMS 1-1-8 for primary-PCI were enrolled in the study; 123 underwent pre-hospital electrocardiograms (ECGs) triage by tele-cardiology support and directly referred for primary-PCI, those remaining were just transferred by 1-1-8 ambulances for primary percutaneous coronary intervention (PCI) (diagnosis not based on tele-medicine ECG; already hospitalised patients, emergency-room without tele-medicine support). Time from first ECG diagnostic for STEMI to balloon was recorded; a time-to-balloon <1 h was considered as optimal and patients as timely treated. RESULTS: Mean time-to-balloon with pre-hospital triage and tele-cardiology ECG was significantly shorter (0:41 ± 0:17 vs 1:34 ± 1:11 h, p<0.001, -0:53 h, -56%) and rates of patients timely treated higher (85% vs 35%, p<0.001, +141%), both in patients from the 'inner' zone closer to PCI catheterisation laboratories (0:34 ± 0:13 vs 0:54 ± 0:30 h, p<0.001; 96% vs 77%, p<0.01, +30%) and in the 'outer' zone (0:52 ± 0:17 vs 1:41 ± 1:14 h, p<0.001; 69% vs 29%, p<0.001, +138%). Results remained significant even after multivariable analysis (odds ratio for time-to-balloon 0.71, 95% confidence interval (CI) 0.63-0.80, p<0.001; 1.39, 95% CI 1.25-1.55, p<0.001, for timely primary-PCI). CONCLUSIONS: Pre-hospital triage with tele-cardiology ECG in an EMS registry from an area with more than one and a half million inhabitants was associated with shorter time-to-balloon and higher rates of timely treated patients, even in 'rural' areas.

Prehospital telemedicine electrocardiogram triage for a regional public emergency medical service: is it worth it? A preliminary cost analysis.

BACKGROUND: Telemedicine has been shown to improve quality of health-care delivery in several fields of medicine; its cost-effectiveness, however, is still a matter of debate. HYPOTHESIS: Pre-hospital telemedicine electrocardiogram triage for regional public emergency medical service may reduce costs. METHODS: An economic evaluation (cost analysis) was performed from the perspective of regional health-care system. Patients enrolled in the study and considered for cost analysis were those who called the local emergency medical service (EMS; dialing 1-1-8) during 2012 and underwent prehospital field triage with a telemedicine electrocardiogram (ECG) in the case of suspected acute cardiac disease (acute coronary syndrome, arrhythmia). The prehospital ECGs were read by a remote cardiologist, available 24/7. Cost savings associated with this method were calculated by subtracting the cost of prehospital triage with telemedicine support from the cost of conventional emergency department triage (ECG and consultation by a cardiologist). RESULTS: During 2012, the regional EMS performed 109 750 ECGs by telemedicine support. The associated total cost for the regional health-care system was €1 833 333, with a €16.70 cost per single ECG/consultation. Given the cost of similar conventional emergency department treatment from a regional rate list of €24.80 to €55.20, the savings was €8.10 to €38.40 per ECG/consultation (total savings, €891 759.50 to €4 219 379.50). The cost for ruling out an acute cardiac disease was €25.30; for a prehospital diagnosis of cardiovascular disease, €49.20. With 629 prehospital diagnoses of ST-elevation myocardial infarction and reported reductions in mortality thanks to prehospital diagnosis deduced from prior studies, 69 lives per year presumably could be saved, with a cost per quality-adjusted life year gained of €1927, €990/€ - 2508 after correction for potential savings. CONCLUSIONS: Prehospital EMS triage with telemedicine ECG in patients with suspected acute cardiac disease may reduce health-care costs.

[Anomalous origin of the coronary arteries: five case reports and review of the literature]. / Origine anomala delle coronarie: cinque casi clinici e revisione della letteratura.

BACKGROUND: Although individual patient outcomes are highly variable, coronary artery anomalies may be associated with sudden cardiac death or acute coronary syndrome. METHODS: We report 5 cases of anomalous origin of coronary arteries: a single coronary artery originating from the right sinus of Valsalva, a case of isolated anomalous right coronary artery originating separately from the left sinus of Valsalva, a case of right coronary artery originating between the right and left sinus of Valsalva, a case of anomalous left circumflex artery originating from the right sinus of Valsalva, and a case of anomalous left anterior descending coronary artery originating from the right sinus of Valsalva. RESULTS: Although in one case the right coronary artery runned between the aorta and the right pulmonary artery, no significant alterations due to coronary artery compression or atheromatous lesions at the anomalous coronary ostia were observed. In all reported cases, symptoms were different as a result of cardiovascular comorbidities. All coronary anomalies were identified at coronary angiography, which was performed for other indications. CONCLUSIONS: The identification of a clear correlation between symptoms and coronary artery anomalies seems challenging in clinical practice. However, it is crucial to confirm or rule out the presence of coronary compression caused by the anomalous origin of coronary arteries.