Clinical features and long-term outcomes in patients under 35 years with coronary artery disease: Nested case-control study.

INTRODUCTION AND OBJECTIVES: Coronary artery disease (CAD) is a globally significant cardiovascular condition, ranking among the leading causes of morbidity and mortality. CAD has been predominantly associated with advanced age and classic cardiovascular risk factors. However, over the past decades, there has been a concerning rise in its occurrence among young adults, including patients under 35 years old. The present study analyzes the clinical features and outcomes of patients aged ≤35 years with CAD, compared to two age-matched control groups. METHOD: A nested case-control study of ≤35-year-old patients referred for coronary angiography due to clinical suspicion of CAD. Patients were divided into three groups: patients ≤35 years with CAD, subjects ≤35 years without CAD, and young patients ≥36-40 years with CAD. RESULTS: Of the 19321 coronary angiographies performed at our center over 10 years, 408 (2.1%) patients were ≤40 years old, 109 patients aged ≤35 years. Risk factors that showed a relationship with the presence of CAD were smoking (OR 2.49; 95% CI 1.03-6.03; p=0.042) and family history of coronary disease (OR 6.70; 95% CI 1.46-30.65; p=0.014). The group aged ≤35 years with CAD exhibited a risk of major cardiovascular adverse events (MACE) (HR 13.3; 95% CI 1.75-100; p<0.001) than subjects ≤35 years without CAD. The probability of major adverse cardiovascular events was associated with being ≤35 years old, diabetes, dyslipidemia, and depression. CONCLUSION: Patients aged ≤35 exhibited a poor long-term prognosis, with a high risk of new revascularization and acute myocardial infarction during the follow-up period. Focusing on preventive measures can have a significant impact on overall prognosis.

Initial experience with orbital atherectomy in a non-surgical center in Portugal.

INTRODUCTION AND OBJECTIVES: Percutaneous coronary intervention (PCI) of severely calcified lesions is associated with a higher risk of procedural complications, suboptimal stent expansion, and in-stent restenosis. Lesion preparation with orbital atherectomy (OA) in severely calcified lesions has been shown to increase procedural success and decrease reintervention rates. In this study, we sought to report the procedural safety and efficacy of our initial experience with OA in a non-surgical center in Portugal. METHODS: Patients with severely calcified coronary lesions who were treated with intended intravascular ultrasound (IVUS) guided OA were included in a prospective single-center registry. We evaluated several endpoints, including: debulking success, defined <50% residual stenosis severity after OA; procedural success, defined as stent implantation according to Optimal-IVUS PCI criteria; use of additional calcium debulking strategies; and procedural complications, including coronary no-reflow, dissection, perforation or side branch occlusion. Patients were followed up for 30 days to assess early cardiovascular or procedure-related death, myocardial infarction, myocardial injury and reintervention. RESULTS: Between January 2023 and September 2023, 37 patients and 53 coronary arteries underwent OA. IVUS imaging was used in all cases. Debulking and procedural success were achieved in 90.5% and 97.3% of cases, respectively. In 26 (49.1%) lesions, additional calcium debulking techniques were needed. Procedural complications occurred in three cases and one patient died during hospitalization. CONCLUSION: Our initial experience with OA for heavily calcified coronary lesions demonstrated high procedural success and overall favorable clinical outcomes.

Tratamento hemodinâmico em pacientes com infarto agudo do miocárdio: fatores / Preditores da elevação do custo hemodynamic treatment in patients with acute myocardial infarction: predictors of cost increase / Tratamiento hemodinámico em pacientes com infarto agudo de miocardio: predictores de aumento do costos

Objetivo: Analisar os fatores preditores para a elevação do custo direto do tratamento hemodinâmico em pacientes com infarto agudo do miocárdio. Métodos: Estudo transversal, com análise documental de 124 prontuários de pacientes com infarto agudo do miocárdio submetidos a procedimentos hemodinâmicos subsidiados pelo SUS, no período de 2016 a 2017. Foram consideradas como variáveis as características sociais e clínicas, a completitude do prontuário e o custo do tratamento. Resultados: O custo médio do tratamento hemodinâmico é de R$ 6.141,94 reais; sendo que a maioria dos pacientes teve custo de tratamento entre R$ 3 a 5 mil reais. Evidenciou-se que os fatores preditores para o custo são: nível de escolaridade; tempo de internação; e completitude do prontuário. O tipo de procedimento e o diagnóstico do paciente são condições clínicas que não interferem no custo do tratamento. Conclusão: O financiamento do sistema público de saúde é deficitário, pois corresponde a metade do menor nível de custo de tratamento hemodinâmico evidenciado. (AU)

Objective: To analyze the predictive factors for the increase in the direct cost of hemodynamic treatment in patients with acute myocardial infarction. Methods: Cross-sectional study, with documental analysis of 124 medical records of patients with acute myocardial infarction undergoing hemodynamic procedures subsidized by the SUS, in the period from 2016 to 2017. Social and clinical characteristics, completeness of the medical record and cost were considered as variables of the treatment. Results: The average cost of hemodynamic treatment is R$ 6,141.94 reais; and most patients had a treatment cost between R$ 3 to 5 thousand reais. It was evident that the predictive factors for the cost are: level of education; length of stay; and completeness of the medical record. The type of procedure and the patient's diagnosis are clinical conditions that do not affect the cost of treatment. Conclusion: The financing of the public health system is deficient, as it corresponds to half of the lowest level of hemodynamic treatment cost evidenced. (AU)

Objetivo: Analizar los factores predictivos del incremento del coste directo del tratamiento hemodinámico en pacientes con infarto agudo de miocardio. Métodos: Estudio transversal, con análisis documental de 124 historias clínicas de pacientes con infarto agudo de miocardio sometidos a procedimientos hemodinámicos subvencionados por el SUS, en el período de 2016 a 2017. Se consideraron características sociales y clínicas, integridad de la historia clínica y costo. como variables del tratamiento. Resultados: El costo promedio del tratamiento hemodinámico es de R$ 6.141,94 reales; y la mayoría de los pacientes tuvo un costo de tratamiento entre R$ 3 a 5 mil reales. Se evidenció que los factores predictivos del costo son: nivel de educación; duración de la estancia; e integridad del expediente médico. El tipo de procedimiento y el diagnóstico del paciente son condiciones clínicas que no afectan el costo del tratamiento. Conclusión: El financiamiento del sistema público de salud es deficiente, ya que corresponde a la mitad del nivel más bajo de costo de tratamiento hemodinámico evidenciado. (AU)

O Valor Preditivo do Índice Prognóstico Inflamatório para Detecção de No-Reflow em Pacientes com Infarto do Miocárdio com Supradesnivelamento do Segmento ST / The Predictive Value of the Inflammatory Prognostic Index for Detecting No-Reflow in ST-Elevation Myocardial Infarction Patients

Resumo Fundamento: O no-reflow (NR) é caracterizado por uma redução aguda no fluxo coronário que não é acompanhada por espasmo coronário, trombose ou dissecção. O índice prognóstico inflamatório (IPI) é um novo marcador que foi relatado como tendo um papel prognóstico em pacientes com câncer e é calculado pela razão neutrófilos/linfócitos (NLR) multiplicada pela razão proteína C reativa/albumina. Objetivo: Nosso objetivo foi investigar a relação entre IPI e NR em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST) submetidos a intervenção coronária percutânea primária (ICPp). Métodos: Um total de 1.541 pacientes foram incluídos neste estudo (178 com NR e 1.363 com refluxo). A regressão penalizada LASSO (Least Absolute Shrinkage and Select Operator) foi usada para seleção de variáveis. Foi criado um nomograma baseado no IPI para detecção do risco de desenvolvimento de NR. A validação interna com reamostragem Bootstrap foi utilizada para reprodutibilidade do modelo. Um valor de p bilateral <0,05 foi aceito como nível de significância para análises estatísticas. Resultados: O IPI foi maior em pacientes com NR do que em pacientes com refluxo. O IPI esteve associado de forma não linear com a NR. O IPI apresentou maior capacidade discriminativa do que o índice de imunoinflamação sistêmica, NLR e relação PCR/albumina. A adição do IPI ao modelo de regressão logística multivariável de base melhorou a discriminação e o efeito do benefício clínico líquido do modelo para detecção de pacientes com NR, e o IPI foi a variável mais proeminente no modelo completo. Foi criado um nomograma baseado no IPI para prever o risco de NR. A validação interna do nomograma Bootstrap mostrou uma boa capacidade de calibração e discriminação. Conclusão: Este é o primeiro estudo que mostra a associação de IPI com NR em pacientes com IAMCSST submetidos a ICPp.

Abstract Background: No-reflow (NR) is characterized by an acute reduction in coronary flow that is not accompanied by coronary spasm, thrombosis, or dissection. Inflammatory prognostic index (IPI) is a novel marker that was reported to have a prognostic role in cancer patients and is calculated by neutrophil/lymphocyte ratio (NLR) multiplied by C-reactive protein/albumin ratio. Objective: We aimed to investigate the relationship between IPI and NR in ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). Methods: A total of 1541 patients were enrolled in this study (178 with NR and 1363 with reflow). Lasso panelized shrinkage was used for variable selection. A nomogram was created based on IPI for detecting the risk of NR development. Internal validation with Bootstrap resampling was used for model reproducibility. A two-sided p-value <0.05 was accepted as a significance level for statistical analyses. Results: IPI was higher in patients with NR than in patients with reflow. IPI was non-linearly associated with NR. IPI had a higher discriminative ability than the systemic immune-inflammation index, NLR, and CRP/albumin ratio. Adding IPI to the baseline multivariable logistic regression model improved the discrimination and net-clinical benefit effect of the model for detecting NR patients, and IPI was the most prominent variable in the full model. A nomogram was created based on IPI to predict the risk of NR. Bootstrap internal validation of nomogram showed a good calibration and discrimination ability. Conclusion: This is the first study that shows the association of IPI with NR in STEMI patients who undergo pPCI.

Além do Escore GRACE SCA: É Necessário um Modelo Diferente para Homens e Mulheres após IAMCSST? / Beyond the GRACE ACS Score: Do We Need a Different Model for Men and Women after STEMI?

Resumo Fundamento As mulheres, em comparação aos homens, apresentam piores resultados após a síndrome coronariana aguda (SCA). No entanto, ainda não está claro se o sexo feminino em si é um preditor independente de tais eventos adversos. Objetivo Este estudo tem como objetivo avaliar a associação entre o sexo feminino e a mortalidade hospitalar após infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Métodos Conduzimos um estudo de coorte retrospectivo, recrutando pacientes consecutivos com IAMCSST, internados em um hospital terciário de janeiro de 2018 a fevereiro de 2019. Todos os pacientes foram tratados de acordo com as recomendações das diretrizes atuais. Modelos de regressão logística multivariada foram aplicados para avaliar a mortalidade hospitalar utilizando variáveis de GRACE. A precisão do modelo foi avaliada usando o índice c. Um valor de p < 0,05 foi estatisticamente significativo. Resultados Dos 1.678 pacientes com SCA, 709 apresentaram IAMCSST. A população era composta por 36% de mulheres e a idade média era de 61 anos. As mulheres tinham maior idade (63,13 anos vs. 60,53 anos, p = 0,011); apresentavam hipertensão (75,1% vs. 62,4%, p = 0,001), diabetes (42,2% vs. 27,8%, p < 0,001) e hiperlipidemia (34,1% vs. 23,9%, p = 0,004) mais frequentemente; e apresentaram menor probabilidade de serem submetidas a intervenção coronária percutânea (ICP) por acesso radial (23,7% vs. 46,1%, p < 0,001). A taxa de mortalidade hospitalar foi significativamente maior em mulheres (13,2% vs. 5,6%, p = 0,001), e o sexo feminino permaneceu em maior risco de mortalidade hospitalar (OR 2,79, IC de 95% 1,15-6,76, p = 0,023). Um modelo multivariado incluindo idade, sexo, pressão arterial sistólica, parada cardíaca e classe de Killip atingiu 94,1% de precisão na previsão de mortalidade hospitalar, e o índice c foi de 0,85 (IC de 95% 0,77-0,93). Conclusão Após ajuste para os fatores de risco no modelo de previsão do GRACE, as mulheres continuam em maior risco de mortalidade hospitalar.

Abstract Background Women, in comparison to men, experience worse outcomes after acute coronary syndrome (ACS). However, whether the female sex per se is an independent predictor of such adverse events remains unclear. Objective This study aims to assess the association between the female sex and in-hospital mortality after ST-elevation myocardial infarction (STEMI). Methods We conducted a retrospective cohort study by enrolling consecutive STEMI patients admitted to a tertiary hospital from January 2018 to February 2019. All patients were treated per current guideline recommendations. Multivariable logistic regression models were applied to evaluate in-hospital mortality using GRACE variables. Model accuracy was evaluated using c-index. A p-value < 0.05 was statistically significant. Results Out of the 1678 ACS patients, 709 presented with STEMI. The population consisted of 36% women, and the median age was 61 years. Women were older (63.13 years vs. 60.53 years, p = 0.011); more often presented with hypertension (75.1% vs. 62.4%, p = 0.001), diabetes (42.2% vs. 27.8%, p < 0.001), and hyperlipidemia (34.1% vs. 23.9%, p = 0.004); and were less likely to undergo percutaneous coronary intervention (PCI) via radial access (23.7% vs. 46.1%, p < 0.001). In-hospital mortality rate was significantly higher in women (13.2% vs. 5.6%, p = 0.001), and the female sex remained at higher risk for in-hospital mortality (OR 2.79, 95% CI 1.15-6.76, p = 0.023). A multivariate model including age, sex, systolic blood pressure, cardiac arrest, and Killip class was 94.1% accurate in predicting in-hospital mortality, and the c-index was 0.85 (95% CI 0.77-0.93). Conclusion After adjusting for the risk factors in the GRACE prediction model, women remain at higher risk for in-hospital mortality.

Ionizing radiation exposure in complex percutaneous coronary intervention: Defining local diagnostic reference levels in the catheterization laboratory.

INTRODUCTION AND OBJECTIVES: Concerns regarding the consequences of ionizing radiation (IR) have been increasing in the field of interventional cardiology (IC). There is little information on reported national and local radiation diagnostic reference levels (DRLs) in catheterization laboratories in Portugal. This study was designed to assess the IR dose exposure during complex percutaneous coronary intervention (PCI), and to set the respective DRLs and future achievable doses (ADs). METHODS: This was a retrospective cohort study which took place between 2019 and 2020, including patients who underwent complex PCI. Complex PCI was defined as all procedures that encompass treatment of chronic total occlusions (CTO) or left main coronary artery. DRLs were defined as the 75th percentile of the distribution of the median values of air kerma area product (PKA) and cumulative air kerma (Ka,r). ADs were set at the 50th percentile of the study dose distribution. Multivariate analysis was performed using linear regression to identify predictors significantly associated with radiation dose (Ka,r). RESULTS: A total of 242 patients were included in the analysis. Most patients underwent a CTO procedure (146, 60.3%). Patients were aged 67.9±11.2 years and mostly male (81.4%). DRLs were set in Ka,r (3012 mGy) and PKA (162 Gy cm2) for complex PCI. ADs were also set in Ka,r (1917 mGy) and PKA (101 Gy cm2). Independent predictors of Ka,r with a positive correlation were PKA (0.893, p<0.001), fluoroscopy time (0.520, p<0.001) and PCI time (0.521, p<0.001). CONCLUSIONS: This study reports the results of IR in complex PCI. DRLs were set for IR dose exposure measured in Ka,r (3012 mGy) and PKA (162 Gy cm2). ADs, values to be achieved in future assessment, were set to Ka,r (1917 mGy) and PKA (101 Gy cm2).

Three-dimensional simulation for interventional cardiology procedures: Face and content validity.

INTRODUCTION AND OBJECTIVES: Three-dimensional (3D) model simulation provides the opportunity to manipulate real devices and learn intervention skills in a realistic, controlled, and safe environment. To ensure that simulators provide a realistic surrogate to real procedures they must undergo scientific validation. We aimed to evaluate the 3D-printed simulator SimulHeart® for face and content validity to demonstrate its value as a training tool in interventional cardiology (IC). METHODS: Health professionals were recruited from sixteen Portuguese IC units. All participants received a 30-minute theoretical introduction, 10-minute demonstration of each task and then performed the intervention on a 3D-printed simulator (SimulHeart®). Finally, a post-training questionnaire focusing on the appearance of the simulation, simulation content, and satisfaction/self-efficacy was administered. RESULTS: We included 56 participants: 16 "experts" (general and interventional cardiologists), 26 "novices" (cardiology residents), and 14 nurses and allied professionals. On a five-point Likert scale, the overall mean score of face validity was 4.38±0.35 and the overall mean score of content validity was 4.69±0.32. There was no statistically significant difference in the scores provided by "experts" and "novices". Participants reported a high level of satisfaction/self-efficacy with 60.7% considering it strongly improved their skills. The majority (82.1%) "agreed" or "strongly agreed" that after the simulation they felt confident to perform the procedure on a patient. CONCLUSION: The 3D-printed simulator (SimulHeart®) showed excellent face and content validity. 3D simulation may play an important role in future IC training programs. Further research is required to correlate simulator performance with clinical performance in real patients.

Interventional cardiology in cancer patients: A position paper from the Portuguese Cardiovascular Intervention Association and the Portuguese Cardio-Oncology Study Group of the Portuguese Society of Cardiology.

The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.

O Impacto Clínico e Econômico do Atraso na Terapia de Reperfusão: Evidências do Mundo Real / The Clinical and Economic Impact of Delayed Reperfusion Therapy: Real-World Evidence

Resumo Fundamento: A terapia de reperfusão precoce é reconhecida como a abordagem mais eficaz para reduzir as taxas de letalidade de casos em pacientes com infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Objetivo: Estimar as consequências clínicas e econômicas do atraso da reperfusão em pacientes com IAMCSST. Métodos: O presente estudo de coorte retrospectivo avaliou as taxas de mortalidade e as despesas totais decorrentes do atraso na terapia de reperfusão em 2.622 indivíduos com IAMCSST. Os custos de cuidados hospitalares e perda de produtividade por morte ou incapacidade foram estimados sob a perspectiva do Sistema Único de Saúde indexado em dólares internacionais (Int$) ajustados pela paridade do poder de compra. Foi considerado estatisticamente significativo p < 0,05. Resultados: Cada hora adicional de atraso na terapia de reperfusão foi associada a um aumento de 6,2% (intervalo de confiança de 95%: 0,3% a 11,8%, p = 0,032) no risco de mortalidade hospitalar. As despesas gerais foram 45% maiores entre os indivíduos que receberam tratamento após 9 horas em comparação com aqueles que foram tratados nas primeiras 3 horas, impulsionados principalmente pelos custos hospitalares (p = 0,005). Um modelo de regressão linear multivariada indicou que para cada 3 horas de atraso na trombólise, houve um aumento nos custos hospitalares de Int$ 497 ± 286 (p = 0,003). Conclusões: Os achados do nosso estudo oferecem mais evidências que enfatizam o papel crucial da terapia de reperfusão imediata no salvamento de vidas e na preservação dos recursos de saúde pública. Estes resultados enfatizam a necessidade urgente de implementação de uma rede para gerir casos de IAMCSST.

Abstract Background: Early reperfusion therapy is acknowledged as the most effective approach for reducing case fatality rates in patients with ST-segment elevation myocardial infarction (STEMI). Objective: Estimate the clinical and economic consequences of delaying reperfusion in patients with STEMI. Methods: This retrospective cohort study evaluated mortality rates and the total expenses incurred by delaying reperfusion therapy among 2622 individuals with STEMI. Costs of in-hospital care and lost productivity due to death or disability were estimated from the perspective of the Brazilian Unified Health System indexed in international dollars (Int$) adjusted by purchase power parity. A p < 0.05 was considered statistically significant. Results: Each additional hour of delay in reperfusion therapy was associated with a 6.2% increase (95% CI: 0.3% to 11.8%, p = 0.032) in the risk of in-hospital mortality. The overall expenses were 45% higher among individuals who received treatment after 9 hours compared to those who were treated within the first 3 hours, primarily driven by in-hospital costs (p = 0.005). A multivariate linear regression model indicated that for every 3-hour delay in thrombolysis, there was an increase in in-hospital costs of Int$497 ± 286 (p = 0.003). Conclusions: The findings of our study offer further evidence that emphasizes the crucial role of prompt reperfusion therapy in saving lives and preserving public health resources. These results underscore the urgent need for implementing a network to manage STEMI cases.

Intravascular imaging modalities in coronary intervention: Insights from 3D-printed phantom coronary models.

INTRODUCTION AND OBJECTIVES: Several studies comparing optical coherence tomography (OCT) and intravascular ultrasound (IVUS) have revealed that OCT consistently provides smaller area and diameter measurements. However, comparative assessment in clinical practice is difficult. Three-dimensional (3D) printing offers a unique opportunity to assess intravascular imaging modalities. We aim to compare intravascular imaging modalities using a 3D-printed coronary artery in a realistic simulator and to assess whether OCT underestimates intravascular dimensions, exploring potential corrections. METHODS: A standard realistic left main anatomy with an ostial left anterior descending artery lesion was replicated using 3D printing. After provisional stenting and optimization, IVI was obtained. Modalities included 20 MHz digital IVUS, 60 MHz rotational IVUS (HD-IVUS) and OCT. We assessed luminal area and diameters at standard locations. RESULTS: Considering all coregistered measurements, OCT significantly underestimated area, minimal diameter and maximal diameter measurements in comparison to IVUS and HD-IVUS (p<0.001). No significant differences were found between IVUS and HD-IVUS. A significant systematic dimensional error was found in OCT auto-calibration by comparing known reference diameter of guiding catheter (1.8 mm) to measured mean diameter (1.68 mm±0.04 mm). By applying a correction factor based on the reference guiding catheter area to OCT, the luminal areas and diameters were not significantly different compared to IVUS and HD-IVUS. CONCLUSION: Our findings suggest that automatic spectral calibration method for OCT is inaccurate, with a systematic underestimation of luminal dimensions. When guiding catheter correction is applied the performance of OCT is significantly improved. These results may be clinically relevant and need to be validated.

Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement: Feasibility in clinical practice.

INTRODUCTION AND OBJECTIVE: Coronary artery disease is highly prevalent among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR). As indications for TAVR are now expanding to younger and lower-risk patients, the need for coronary angiography (CA) and percutaneous coronary intervention (PCI) during their lifetime is expected to increase. The objective of our study was to assess the need for CA and the feasibility of re-engaging the coronary ostia after TAVR. METHODS: We performed a retrospective analysis of 853 consecutive patients undergoing TAVR between August 2007 and December 2020. Patients who needed CA after TAVR were selected. The primary endpoint was the rate of successful coronary ostia cannulation after TAVR. RESULTS: Of a total of 31 CAs in 28 patients (3.5% of 810 patients analyzed: 57% male, age 77.8±7.0 years) performed after TAVR, 28 (90%) met the primary endpoint and in three cannulation was semi-selective. All failed selective coronary ostia cannulations occurred in patients with a self-expanding valve. Sixteen (52%) also had indication for PCI, which was successfully performed in all. The main indication for CA was non-ST-elevation acute coronary syndrome (35%, n=11). Two cases of primary PCI occurred without delay. There were no complications reported during or after the procedure. CONCLUSION: Although CA was rarely needed in patients after TAVR, selective diagnostic CA was possible in the overwhelming majority of patients. PCI was performed successfully in all cases, without complications.

Percutaneous versus surgical revascularization of unprotected left main coronary artery: Data from the Portuguese Registry of Acute Coronary Syndromes (ProACS).

BACKGROUND: In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary artery (ULMCA) culprit lesion has been under-investigated. Therefore, we compared clinical characteristics and short- and medium-term outcomes of percutaneous and surgical revascularization in ACS. METHODS AND RESULTS: Of 31886 patients enrolled in a multicenter, national, prospective registry study between October 2010 and December 2020, 246 (0.8%) had ULMCA as a culprit lesion and underwent percutaneous coronary intervention (PCI) alone (n=133, 54%) or coronary artery bypass grafting (CABG) alone (n=113, 46%). Patients undergoing PCI presented more frequently ongoing chest pain (68% versus 41%, p<0.001) and cardiogenic shock (25% versus 1%, p<0.001). Time from admission to revascularization was higher in surgical group with a median time to CABG of 4.5 days compared to 0 days to PCI (p<0.001). Angiographic success rate was 93.2% in patients who underwent PCI. Primary endpoint (all-cause death, non-fatal reinfarction and/or non-fatal stroke during hospitalization) occurred in 15.9% of patients and was more frequent in the PCI group (p<0.001). After adjustment, surgical revascularization was associated with better in-hospital prognosis (odds ratio (OR) 0.164; 95% confidence interval (CI), 0.04-0.64; p=0.009). Similar results were achieved after propensity score matching. No difference was found at one-year all-cause death. CONCLUSION: Percutaneous coronary intervention was the most common revascularization strategy in the ACS with ULMCA culprit lesion. PCI was preferred in unstable patients and presented a high angiographic success. CABG was often delayed and preferred in low-risk patients. At one-year follow-up, PCI and CABG conferred a similar prognosis. The two approaches appear complementary in this high risk cohort.

Spontaneous coronary artery dissection: A review for clinical and interventional cardiologists.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome, especially among young to middle-aged women with few traditional cardiovascular risk factors and low pretest probability for atherosclerotic coronary artery disease. Diagnosis by invasive coronary angiography is the gold standard and conservative therapy is generally recommended, with percutaneous or surgical revascularization being reserved for cases of clinical instability, high-risk anatomy or as bailout. Unlike atherothrombotic coronary artery disease, strong evidence on optimal medical therapy is scarce, posing unique challenges in cases of pregnancy-associated SCAD. The follow-up strategy is also of major importance, as recurrent SCAD is not infrequent, lifestyle changes and pharmacological therapy should be planned for the long term, and SCAD-associated conditions need to be addressed. This review aims to provide a practical management approach to SCAD patients for both clinical and interventional cardiologists.

Impact of door in-door out time on total ischemia time and clinical outcomes in patients with ST-elevation myocardial infarction.

INTRODUCTION: Patients with ST-elevation myocardial infarction (STEMI) requiring inter-hospital transfer for primary percutaneous coronary intervention (PCI) often have delays in reperfusion. The door in-door out (DIDO) time is recommended to be less than 30 min. OBJECTIVES: To assess the DIDO time of hospitals that transfer patients with STEMI to a PCI center and to assess its impact on total ischemia time and clinical outcomes in patients with STEMI. METHODS: We performed a retrospective study of 523 patients with STEMI transferred to a PCI center for primary PCI between January 1, 2013 and June 30, 2017. RESULTS: Median DIDO time was 82 min (interquartile range, 61-132 min). Only seven patients (1.3%) were transferred in ≤30 min. Patients with DIDO times over 60 min had significantly longer system delays (207.3 min vs. 112.7 min; p<0.001) and total ischemia time (344.2 min vs. 222 min; p<0.001) than patients transferred in ≤60 min. Observed in-hospital mortality was significantly higher among patients with DIDO times >60 min vs. ≤60 min (5.1% vs. 0%; p=0.006; adjusted odds ratio for in-hospital mortality, 1.27 [95% CI 1.062-1.432]). By the end of follow-up, patients belonging to the >60 min group had a higher mortality (p=0.016), and survival time was significantly shorter (p=0.011). CONCLUSION: A DIDO time ≤30 min was observed in only a small proportion of patients transferred for primary PCI. DIDO times of ≤60 min were associated with shorter delays in reperfusion, lower in-hospital mortality and longer survival times.

Impact of the COVID-19 pandemic on percutaneous coronary interventions in Portugal.

INTRODUCTION: The COVID-19 pandemic has imposed an unprecedented burden on healthcare systems worldwide, changing the profile of interventional cardiology activity. OBJECTIVES: To quantify and compare the number of percutaneous coronary interventions (PCIs) performed for acute and chronic coronary syndromes during the first COVID-19 outbreak with the corresponding period in previous years. METHODS: Data on PCI from the prospective multicenter Portuguese Registry on Interventional Cardiology (RNCI) were used to analyze changes in PCI for ST-elevation myocardial infarction (STEMI), non-ST-elevation acute coronary syndromes (NSTE-ACS) and chronic coronary syndromes (CCS). The number of PCIs performed during the initial period of the COVID-19 outbreak in Portugal, from March 1 to May 2, 2020, was compared with the mean frequency of PCIs performed during the corresponding period in the previous three years (2017-2019). RESULTS: The total number of PCIs procedures was significantly decreased during the initial COVID-19 outbreak in Portugal (-36%, p<0.001). The reduction in PCI procedures for STEMI, NSTE-ACS and CCS was, respectively, -25% (p<0.019), -20% (p<0.068) and -59% (p<0.001). CONCLUSIONS: Compared with the corresponding period in the previous three years, the number of PCI procedures performed for STEMI and CCS decreased markedly during the first wave of the COVID-19 pandemic in Portugal.

Avaliação do Nível de Fluxo Coronário com MOTS-C em Pacientes com IAMCSST Submetidos à ICP Primária / Evaluation of Coronary Flow Level with Mots-C in Patients with STEMI Undergoing Primary PCI

Resumo Fundamentos Os efeitos protetores da fase de leitura aberta mitocondrial do 12S rRNA-c (MOTS-C) em doenças cardiovasculares foram demonstrados em vários estudos. Entretanto, há pouca documentação da relação entre MOTS-C e fluxo sanguíneo coronariano no infarto do miocárdio com supradesnivelamento do segmento ST (IAMCSST). Objetivo Nosso objetivo foi investigar o papel do MOTS-C, que é conhecido por ter propriedades citoprotetoras na patogênese do fenômeno de no-reflow, comparando a taxa de fluxo coronariano e os níveis de MOTS-C em pacientes com IAMCSST submetidos à ICP primária. Métodos 52 pacientes com IAMCSST e 42 pacientes sem estenose >50% nas artérias coronárias foram incluídos no estudo. O grupo IAMCSST foi dividido em dois grupos de acordo com o grau de fluxo TIMI (do inglês Thrombolysis In Myocardial Infarction) pós-ICP: (i) No-reflow: graus 0, 1 e 2 e (ii) grau 3 (sucesso angiográfico). Um valor de p <0,05 foi considerado significante. Resultados Os níveis de MOTS-C foram significativamente menores no grupo IAMCSST em comparação ao grupo controle (91,9 ± 8,9 pg/mL vs. 171,8±12,5 pg/mL, p<0,001). Além disso, a análise da curva Receiver Operating Characteristics (ROC) indicou que os níveis séricos de MOTS-C tinham um valor diagnóstico na previsão de no-reflow (Área sob a curva ROC [AUC]: 0,95, IC95%: 0,856-0,993, p < 0,001). Um valor de MOTS-C ≥84,15 pg/mL medido na hospitalização mostrou ter sensibilidade de 95,3% e especificidade de 88,9% na previsão de no-reflow. Conclusão MOTS-C é um preditor forte e independente de no-reflow e eventos cardiovasculares adversos maiores (ECAM) intra-hospitalar em pacientes com IAMCSST. Também foi observado que baixos níveis de MOTS-C podem ser um importante marcador prognóstico e podem ter um papel na patogênese do IAMCSST.

Abstract Background The protective effects of mitochondrial open reading frame of the 12S rRNA-c (MOTS-C) on cardiovascular diseases have been shown in numerous studies. However, there is little documentation of the relationship between MOTS-C and coronary blood flow in ST-segment elevation myocardial infarction (STEMI). Objective We aimed to investigate the role of MOTS-C, which is known to have cytoprotective properties in the pathogenesis of the no-reflow phenomenon, by comparing the coronary flow rate and MOTS-C levels in patients with STEMI submitted to primary PCI. Methods 52 patients with STEMI and 42 patients without stenosis >50% in the coronary arteries were included in the study. The STEMI group was divided into two groups according to post-PCI TIMI (Thrombolysis In Myocardial Infarction) flow grade:(i) No-reflow: grade 0, 1, and 2 and (ii) grade 3(angiographic success). A p value of <0.05 was considered significant. Results MOTS-C levels were significantly lower in the STEMI group compared to the control group (91.9 ± 8.9 pg/mL vs. 171.8±12.5 pg/mL, p<0.001). In addition, the Receiver Operating Characteristics (ROC) curve analysis indicated that serum MOTS-C levels had a diagnostic value in predicting no-reflow (Area Under the ROC curve [AUC]:0.95, 95% CI:0.856-0.993, p<0.001). A MOTS-C ≥84.15 pg/mL measured at admission was shown to have 95.3% sensitivity and 88.9% specificity in predicting no-reflow. Conclusion MOTS-C is a strong and independent predictor of no-reflow and in-hospital MACE in patients with STEMI. It was also noted that low MOTS-C levels may be an important prognostic marker of and may have a role in the pathogenesis of STEMI.