Low-Dose Ticagrelor in Patients With High Ischemic Risk and Previous Myocardial Infarction: A Multicenter Prospective Real-World Observational Study.

Prolonged dual antiplatelet therapy after 12 months in patients with previous myocardial infarction (MI) is attractive to reduce long-term ischemic complications. In the PEGASUS-TIMI 54, the use of low-dose ticagrelor (60 mg b.i.d.) plus aspirin after 12 months from MI reduced the risk of ischemic events, at the price of limited increase on bleeding complications. However, data on the use of low-dose ticagrelor in real-world practice lack. We aim at providing data on prescription/eligibility criteria and outcomes in patients receiving low-dose ticagrelor in the real-world setting. We enrolled consecutive patients eligible for ticagrelor 60 mg according to Italian national regulation in 3 high-volume centers and collected 1-year outcomes. The primary objective of the study is to generate real-world data about clinical characteristics, eligibility criteria, major adverse cardiovascular events, bleeding, and adverse event in patients receiving low-dose ticagrelor from our cohort. One hundred eighty-one patients were consecutively enrolled with a median follow-up of 18 months. The most used and the least used prescription criteria were multivessel coronary disease (72.4%) and chronic kidney disease (15.5%), respectively. At 1-year follow-up, the rate of major adverse cardiovascular events was 4.97%; of these, 3.86% of patients had a MI, and 1.1% had a stroke/transient ischemic attack, whereas no major bleeding occurred. In conclusion, in a real-world study, including patients with previous MI, low-dose ticagrelor for prolonged dual antiplatelet therapy showed to be effective and safe, with no major bleeding occurring at follow-up.

Urgent Myocardial Revascularization in Non ST-Segment Elevation Acute Myocardial Infarction Guided by Speckle Tracking Echocardiography: A Challenging Interventional Decision-Making.

A 68-year-old man with a non-ST elevation myocardial infarction (NSTEMI) presented with a low risk profile indicating invasive revascularization within 72 h. However, left ventricular (LV) global longitudinal strain (GLS) calculated by two-dimensional speckle tracking echocardiography (2D-STE) in the Emergency Room showed substantial myocardial infarction. Therefore, urgent reperfusion therapy was decided and delivered within 30 min from hospital admission. LV GLS fully recovered after the invasive procedure and the final infarct size was 7%. This case shows that very early revascularization in NSTEMI patients can be guided by 2D-STE and might be considered for those patients with substantial LV myocardial infarction.

Noninvasive Evaluation of Intraventricular Flow Dynamics by the HyperDoppler Technique: First Application to Normal Subjects, Athletes, and Patients with Heart Failure.

Background: HyperDoppler is a new echocardiographic color Doppler-based technique that can assess intracardiac flow dynamics. The aim of this study was to verify the feasibility and reproducibility of this technique in unselected patients and its capability to differentiate measures of vortex flow within the left ventricle (LV) in normal sedentary subjects, athletes, and patients with heart failure. Methods: Two hundred unselected, consecutive patients presenting at the echocardiographic laboratory, 50 normal subjects, 30 athletes, and 50 patients with chronic heart failure and LV ejection fraction <50% were enrolled. Images were acquired using a MyLab X8 echo-scanner. Area, intensity, depth, length, and kinetic energy dissipation (KED) of vortex flow were measured. Results: The HyperDoppler technique feasibility was 94.5%. According to the intraclass correlation coefficient evaluations, repeatability and reproducibility of vortex flow measures were good for vortex area (0.82, 0.85), length (0.83, 0.82), and depth (0.87, 0.84) and excellent for intensity (0.92, 0.90) and KED (0.98, 0.98). Combining different vortex flow measures, the LV flow profile of healthy sedentary individuals, athletes, and heart failure patients could be differentiated. Conclusions: HyperDoppler is a feasible, reliable, and practical technique for the assessment of LV flow dynamics and may distinguish normal subjects and patients with heart failure.

Imbalance Between Interleukin-1ß and Interleukin-1 Receptor Antagonist in Epicardial Adipose Tissue Is Associated With Non ST-Segment Elevation Acute Coronary Syndrome.

INTRODUCTION: Interleukin-1beta (IL-1ß) is crucially involved in the pathogenesis of coronary atherosclerotic diseases (CAD) and its inhibition has proven cardiovascular benefits. Epicardial adipose tissue (EAT) is a local source of inflammatory mediators which may negatively affect the surrounding coronary arteries. In the present study, we explored the relationship between serum and EAT levels of IL-1ß and IL-1 receptor antagonist (IL-1ra) in patients with chronic coronary syndrome (CCS) and recent acute coronary syndrome (ACS). METHODS: We obtained EAT biopsies in 54 CCS (Group 1) and 33 ACS (Group 2) patients undergoing coronary artery bypass grafting. Serum and EAT levels of IL-1ß and IL-1ra were measured in all patients. An immunophenotypic study was carried out on EAT biopsies and the CD86 events were studied as markers of M1 macrophages. RESULTS: Circulating levels of IL-1ß were significantly higher in the overall CAD population compared to a control group [7.64 pg/ml (6.86; 8.57) vs. 1.89 pg/ml (1.81; 2.29); p < 0.001]. In contrast, no differences were observed for serum IL-1ra levels between CAD and controls. Comparable levels of serum IL-1ß were found between Groups 1 and 2 [7.6 pg/ml (6.9; 8.7) vs. 7.9 pg/ml (7.2; 8.6); p = 0.618]. In contrast, significantly lower levels of serum IL-1ra were found in Group 2 compared to Group 1 [274 pg/ml (220; 577) vs. 603 pg/ml (334; 1022); p = 0.035]. No differences of EAT levels of IL-1ß were found between Group 2 and Group 1 [3.4 pg/ml (2.3; 8.4) vs. 2.4 pg/ml (1.9; 8.0); p = 0.176]. In contrast, significantly lower EAT levels of IL-1ra were found in Group 2 compared to Group 1 [101 pg/ml (40; 577) vs. 1344 pg/ml (155; 5327); p = 0.002]. No correlation was found between EAT levels of IL-1ß and CD86 and CD64 events. CONCLUSION: The present study explores the levels of IL-1ß and IL-1ra in the serum and in EAT of CCS and ACS patients. ACS seems to be associated to a loss of the counter-regulatory activity of IL-1ra against the pro-inflammatory effects related to IL-1ß activation.

Intracardiac Flow Analysis: Techniques and Potential Clinical Applications.

Analysis of intracardiac flows has gained increasing interest in the last years. This analysis has become possible due to the development of technologies for noninvasive cardiovascular imaging, which allow visualization and quantitation of intracardiac flow dynamics. Several studies have shown that abnormalities in cardiac function are related to changes in intracardiac vortical flows. Thus, analysis of cardiac vortex has been used for better understanding of the pathophysiology in many heart diseases and to test initial clinical hypotheses. The aims of this review are to introduce the reader to the topic of intracardiac flow dynamics, to briefly describe current cardiac imaging techniques for analysis of the intracardiac vortex, and to indicate potential clinical applications of a vortex-based approach to the study of cardiac function.