RESUMEN
The use of intravenous antiplatelet therapy during primary percutaneous coronary intervention (PPCI) is not fully standardized. The aim is to evaluate the effectiveness and safety of periprocedural intravenous administration of cangrelor or tirofiban in a contemporary ST-segment elevation myocardial infarction (STEMI) population undergoing PPCI. This was a multicenter prospective cohort study including consecutive STEMI patients who received cangrelor or tirofiban during PPCI at seven Italian centers. The primary effectiveness measure was the angiographic evidence of thrombolysis in myocardial infarction (TIMI) flow < 3 after PPCI. The primary safety outcome was the in-hospital occurrence of BARC (Bleeding Academic Research Consortium) 2-5 bleedings. The study included 627 patients (median age 63 years, 79% males): 312 received cangrelor, 315 tirofiban. The percentage of history of bleeding, pulmonary edema and cardiogenic shock at admission was comparable between groups. Patients receiving cangrelor had lower ischemia time compared to tirofiban. TIMI flow before PPCI and TIMI thrombus grade were comparable between groups. At propensity score-weighted regression analysis, the risk of TIMI flow < 3 was significantly lower in patients treated with cangrelor compared to tirofiban (adjusted OR: 0.40; 95% CI: 0.30-0.53). The risk of BARC 2-5 bleeding was comparable between groups (adjusted OR:1.35; 95% CI: 0.92-1.98). These results were consistent across multiple prespecified subgroups, including subjects stratified for different total ischemia time, with no statistical interaction. In this real-world multicenter STEMI population, the use of cangrelor was associated with improved myocardial perfusion assessed by coronary angiography after PPCI without increasing clinically-relevant bleedings compared to tirofiban.
Asunto(s)
Adenosina Monofosfato , Intervención Coronaria Percutánea , Inhibidores de Agregación Plaquetaria , Infarto del Miocardio con Elevación del ST , Tirofibán , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Adenosina Monofosfato/análogos & derivados , Adenosina Monofosfato/administración & dosificación , Adenosina Monofosfato/uso terapéutico , Adenosina Monofosfato/efectos adversos , Administración Intravenosa , Hemorragia/inducido químicamente , Italia , Inhibidores de Agregación Plaquetaria/administración & dosificación , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/efectos adversos , Estudios Prospectivos , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Tirofibán/administración & dosificación , Tirofibán/uso terapéutico , Resultado del TratamientoRESUMEN
This review article focuses on the role of adenosine in coronary artery disease (CAD) diagnosis and treatment. Adenosine, an endogenous purine nucleoside, plays crucial roles in cardiovascular physiology and pathology. Its release and effects, mediated by specific receptors, influence vasomotor function, blood pressure regulation, heart rate, and platelet activity. Adenosine therapeutic effects include treatment of the no-reflow phenomenon and paroxysmal supraventricular tachycardia. The production of adenosine involves complex cellular pathways, with extracellular and intracellular synthesis mechanisms. Adenosine's rapid metabolism underscores its short half-life and physiological turnover. Furthermore, adenosine's involvement in side effects of antiplatelet therapy, particularly ticagrelor and cangrelor, highlights its clinical significance. Moreover, adenosine serves as a valuable tool in CAD diagnosis, aiding stress testing modalities and guiding intracoronary physiological assessments. Its use in assessing epicardial stenosis and microvascular dysfunction is pivotal for treatment decisions. Overall, understanding adenosine's mechanisms and clinical implications is essential for optimizing CAD management strategies, encompassing both therapeutic interventions and diagnostic approaches.
Asunto(s)
Adenosina , Enfermedad de la Arteria Coronaria , Humanos , Adenosina/metabolismo , Enfermedad de la Arteria Coronaria/metabolismo , Enfermedad de la Arteria Coronaria/tratamiento farmacológico , Animales , Adenosina Monofosfato/análogos & derivados , Adenosina Monofosfato/uso terapéutico , Adenosina Monofosfato/metabolismo , Inhibidores de Agregación Plaquetaria/uso terapéutico , Inhibidores de Agregación Plaquetaria/farmacologíaRESUMEN
Ticagrelor is currently considered a first-line choice in dual antiplatelet therapy (DAPT) following revascularization of acute coronary syndrome (ACS). However, its use is correlated with an increased incidence of two side effects, dyspnea and bradyarrhythmias, whose molecular mechanisms have not yet been defined with certainty and, consequently, neither of the therapeutic decisions they imply. We report the case of a patient with acute myocardial infarction treated with ticagrelor and aspirin as oral antithrombotic therapy after primary percutaneous coronary intervention (PCI), manifesting in a significant bradyarrhythmic episode that required a switch of antiplatelet therapy. Starting from this case report, this article aims to gather the currently available evidence regarding the molecular mechanisms underlying these side effects and propose possible decision-making algorithms regarding their management in clinical practice.
Asunto(s)
Infarto del Miocardio , Intervención Coronaria Percutánea , Humanos , Ticagrelor/efectos adversos , Inhibidores de Agregación Plaquetaria/efectos adversos , Intervención Coronaria Percutánea/efectos adversos , Aspirina/uso terapéutico , Infarto del Miocardio/terapia , Resultado del TratamientoRESUMEN
Background: This study is aimed at comparing the clinical outcomes of unprotected left main coronary artery disease (ULMCAD) treatment with contemporary percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) in a "real-world" population. Methods and Results: Overall, 558 consecutive patients with ULMCAD (mean age 71 ± 9 years, male gender 81%) undergoing PCI or CABG were compared. The primary endpoint was the composite of death, nonfatal myocardial infarction, or stroke. Diabetes was present in 29% and acute coronary syndrome in 56%; mean EuroSCORE was 11 ± 8. High coronary complexity (SYNTAX score >32) was present in 50% of patients. The primary composite endpoint was similar after PCI and CABG up to 4 years (15.5 ± 3.1% vs. 17.1 ± 2.6%; p=0.585). The primary end point was also comparable in a two propensity score matched cohorts. Ischemia-driven revascularization was more frequently needed in PCI than in CABG (5.5% vs. 1.5%; p=0.010). By multivariate analysis, diabetes mellitus (HR 2.00; p=0.003) and EuroSCORE (HR 3.71; p < 0.001) were the only independent predictors associated with long-term outcome. Conclusions: In a "real-world" population with ULMCAD, a contemporary revascularization strategy by PCI or CABG showed similar long-term clinical outcome regardless of the coronary complexity.
Asunto(s)
Enfermedad de la Arteria Coronaria , Infarto del Miocardio , Intervención Coronaria Percutánea , Anciano , Anciano de 80 o más Años , Puente de Arteria Coronaria/efectos adversos , Puente de Arteria Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Resultado del TratamientoRESUMEN
In the setting of patients with indication to receive dual antiplatelet therapy undergoing surgery or invasive procedures, the risk of perioperative cardiac ischemic events, particularly stent thrombosis, is high, because surgery has a prothrombotic effect and antiplatelet therapy is withdrawn in order to avoid bleeding complications. Cangrelor, an intravenous P2Y12 receptor antagonist, has been tested in a randomized trial as a "bridge" to cardiac surgery from discontinuation of oral P2Y12 receptor antagonists. Thus, a consensus document extended its off-label use in this setting and before non-cardiac surgery. Currently, despite the implementation of a standardized bridging protocol with cangrelor, a residual risk of adverse outcome mainly due to bleeding events, still persist during the perioperative phase.Accordingly, a personalized management driven by platelet reactivity serial measurements and careful assessment of ischemic and bleeding risks has potential to optimize outcomes and costs as compared to a standardized bridging protocol, based on average pharmacodynamic data of oral P2Y12 inhibitors.While specific indications for bridging have been extensively addressed in the aforementioned consensus statement, the aim of the present document is the proposal of a "tailored" clinical decision-making algorithm inspired to the principle of personalized medicine dealing with complex clinical scenarios.
Asunto(s)
Inhibidores de Agregación Plaquetaria , Antagonistas del Receptor Purinérgico P2Y , Adenosina Monofosfato/análogos & derivados , Adenosina Monofosfato/farmacología , Adenosina Monofosfato/uso terapéutico , Humanos , Inhibidores de Agregación Plaquetaria/efectos adversos , Medicina de Precisión , Antagonistas del Receptor Purinérgico P2Y/efectos adversosRESUMEN
The appropriate use of dual antiplatelet therapy (DAPT) in elderly patients with acute coronary syndrome (ACS) is largely debated. Due to the "demographic transition" in western countries, the elderly represent a growing percentage of patients admitted to hospitals for ACS, and among this high risk setting population most of early and late adverse outcomes occur. The presence of several concomitant "comorbidities" complicate the management strategy of both medical or invasive treatment and the clinical decision making process is challenging. Moreover, elderly people are constantly underrepresented in clinical trials and studies. As a result, there is no specific evidence about the optimal antithrombotic therapy in elderly and no specific recommendations are mentioned in the current ACS guidelines. Currently, the best practice for old people is still rudimentary and principally extrapolated from general cardiovascular guidelines. The management of elderly patients should be based on the evaluation of ischemic and hemorrhagic risk, life expectancy, comorbidities and parameters that are not included in the scores recommended by the current guidelines such as frailty and disability. In the era of "precision medicine", the evaluation of bleeding and ischaemic risk in elderly patients must be a dynamic process because of the risk changing over time. A"tailored therapy by individualized medicine" is the key of management strategy.
Asunto(s)
Síndrome Coronario Agudo , Síndrome Coronario Agudo/tratamiento farmacológico , Síndrome Coronario Agudo/epidemiología , Anciano , Comorbilidad , Fibrinolíticos/uso terapéutico , Hemorragia/inducido químicamente , Hemorragia/tratamiento farmacológico , Hemorragia/epidemiología , Humanos , Inhibidores de Agregación Plaquetaria/uso terapéuticoRESUMEN
INTRODUCTION: Recurrences within the blanking period (early recurrences) are common after atrial fibrillation (AF) ablation by pulmonary vein isolation (PVI), but their clinical significance is still controversial. We aimed at evaluating the significance of within-blanking recurrences at 12-month follow-up after cryoballoon (CB) PVI, and to assess the real procedural success rate by continuous monitoring of cardiac rhythm. METHODS AND RESULTS: Sixty consecutive AF patients (34 paroxysmal, 56.7%) underwent their first CB-PVI at one Italian center (May 2013 to April 2015), and subsequent implantation of an implantable loop recorder (ILR). Overall, 12-month success rate after the blanking period was 55%. The shortest detected event was 7 minutes long. Late recurrences were more frequent in non-paroxysmal (19/26, 73.1%) than in paroxysmal AF (8/34, 23.5%; P <0.001). Early recurrences occurred in 17 (28.3%) patients, with 14 also having late recurrences (82.3%), while only 13 out of 43 (30.2%) without within-blanking recurrences experienced post-blanking events (P <0.001). Overall, early recurrences showed 51.8% sensitivity (95% CI 31.9-71.3%) and 90.9% specificity (95% CI 75.7-98.1%) for later recurrences, with 82.3% (95% CI 56.6-96.2%) positive and 69.8% (95% CI 53.9-82.8%) negative predictive value. The positive likelihood ratio was 5.7 (95% CI 1.8-17.8). At multivariable analysis, non-paroxysmal AF (HR: 3.113; 95% CI 1.309-7.403; P = 0.010) and within-blanking recurrences (HR: 3.453; 95% CI 1.544-7.722; P = 0.003) were independent predictors of post-blanking AT/AF. CONCLUSION: CB-PVI for paroxysmal AF shows a 12-month success rate of 76.5% after one single procedure, as assessed by continuous cardiac rhythm monitoring. Within-blanking recurrences predict the ablation failure in more than 80% of patients.
Asunto(s)
Fibrilación Atrial/cirugía , Criocirugía , Electrocardiografía Ambulatoria/métodos , Frecuencia Cardíaca , Venas Pulmonares/cirugía , Telemetría , Potenciales de Acción , Adulto , Anciano , Fibrilación Atrial/diagnóstico , Fibrilación Atrial/fisiopatología , Distribución de Chi-Cuadrado , Criocirugía/efectos adversos , Supervivencia sin Enfermedad , Femenino , Humanos , Italia , Estimación de Kaplan-Meier , Masculino , Persona de Mediana Edad , Análisis Multivariante , Valor Predictivo de las Pruebas , Modelos de Riesgos Proporcionales , Venas Pulmonares/fisiopatología , Recurrencia , Reproducibilidad de los Resultados , Estudios Retrospectivos , Factores de Riesgo , Procesamiento de Señales Asistido por Computador , Factores de Tiempo , Resultado del TratamientoRESUMEN
Background: ST elevation myocardial infarctions are usually a consequence of the occlusion of a single coronary artery, but in 2.5% of the cases, two or more culprit lesions are found. Simultaneous coronary artery occlusion is a potentially life-threatening condition that leads to cardiogenic shock or ventricular arrhythmias. Case summary: We presented the case of a 74-year-old man presenting with chest pain and ST segment elevation (STE) in inferior leads and evidence of alternating STE in anterior leads in a pattern like Wellens syndrome type A in subsequent electrocardiogram (ECGs). Emergency coronary angiography (CA) revealed thrombotic occlusion of the proximal right coronary artery (RCA) and sub-occlusion of mid left anterior descending artery (LAD). During the CA, he became haemodynamically unstable requiring intravenous inotropes and vasopressors, and he underwent primary percutaneous coronary intervention of both RCA and LAD culprit lesions. His subsequent hospital stay was uneventful, and he was discharged 5 days later. Discussion: ST elevation myocardial infarction with more than one culprit coronary artery is a rare but at high risk of haemodynamic decompensation. The causes of occlusion of multiple coronary arteries may be several: coronary embolism, coronary ectasia, simultaneous plaque disruption, coronary vasospasm, hypercoagulability states, smoking, and illicit drug abuse. The presumed mechanism behind the presented case may be a combination of release of pro-thrombotic cytokines due to the thrombotic occlusion of the first coronary and low output state secondary to myocardial dysfunction leading to impaired flow in a severe stenotic coronary artery with subsequent thrombosis.
RESUMEN
(1) Background: This single-center retrospective study aimed to evaluate whether sodium-glucose cotransporter-2 inhibitors (SGLT2-i) therapy may have a nephroprotective effect to prevent contrast-induced acute kidney injury (CI-AKI) in patients with heart failure (HF) undergoing iodinated contrast medium (ICM) invasive procedures. (2) Methods: The population was stratified into SGLT2-i users and SGLT2-i non-users according to the chronic treatment with gliflozins. The primary endpoint was CI-AKI incidence during hospitalization. Secondary endpoints were all-cause mortality and the need for continuous renal replacement therapy (CRRT). (3) Results: In total, 86 patients on SGLT2-i and 179 patients not on SGLT2-i were enrolled. The incidence of CI-AKI in the gliflozin group was lower than in the non-user group (9.3 vs. 27.3%, p < 0.001), and these results were confirmed after propensity matching analysis. Multivariable logistic regression showed that only SGLT2-i treatment was an independent preventive factor for CI-AKI (OR: 0.41, 95% CI: 0.16-0.90, p = 0.045). The need for CRRT was reported only in five patients in the non-SGLT2-i-user group compared to zero patients in the gliflozin group (p = 0.05). (4) Conclusions: SGLT2-i therapy was associated with a lower risk of CI-AKI in patients with HF undergoing ICM invasive procedures.
RESUMEN
BACKGROUND: Myocardial reperfusion is the main target of treatment in patients with ST-segment elevation myocardial infarction (STEMI). The intracoronary administration of cangrelor bolus could favor a higher local drug concentration, favoring an earlier thrombotic resolution and a reduced distal micro-embolization. METHODS: Seventy-one patients undergoing primary percutaneous coronary intervention (PCI) for STEMI: 37 treated with intracoronary and 34 with intravenous bolus administration of cangrelor. The primary endpoint was ST-segment elevation resolution (STR) ≥ 50% after 30 min from the end of the PCI. Other explorative reperfusion indices investigated were: STR ≥ 50% at 24 hours, STR ≥ 70% at 30 min, Thrombolysis In Myocardial Infarction frame count and the QT dispersion. Moreover, acute and subacute stent thrombosis, bleeding events and 30-day mortality have been evaluated. RESULTS: More frequent STR ≥ 50% was observed in the intravenous cangrelor bolus group as compared to the intracoronary administration at 30 min (71.9% vs. 45.5%; p = 0.033), the difference was maintained 24 hours after PCI (87.1% vs. 63.6%; p = 0.030). STR ≥ 70% at 30 min was statistically more frequent in the intravenous bolus administration cohort (66.7% vs. 28.6% p = 0.02). At multivariable analysis, intravenous cangrelor administration was significantly related to STR ≥ 50% (odds ratio: 3.586; 95% confidence interval: 1.134-11.335; p = 0.030). The incidence of Bleeding Academic Research Consortium 3-5 bleedings was 15.5% and mortality was 4.2% without any significant difference between the two groups. CONCLUSIONS: In conclusion the results of the study do not show any advantages in the administration of intracoronary bolus of cangrelor in patients affected by STEMI and treated with primary PCI.
Asunto(s)
Infarto del Miocardio , Intervención Coronaria Percutánea , Infarto del Miocardio con Elevación del ST , Humanos , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/métodos , Infarto del Miocardio con Elevación del ST/terapia , Infarto del Miocardio con Elevación del ST/tratamiento farmacológico , Reperfusión Miocárdica , Resultado del Tratamiento , Infarto del Miocardio/terapia , Hemorragia/inducido químicamente , Inhibidores de Agregación Plaquetaria/uso terapéuticoRESUMEN
Treatment of coronary chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) has rapidly increased during the past decades. Different strategies and approach were developed in the recent past years leading to an increase in CTO-PCI procedural success. The goal to achieve an extended revascularization with a high rate of completeness is now supported by strong scientific evidences and consequently, has led to an exponential increase in the number of CTO-PCI procedures, even if are still underutilized. It has been widely demonstrated that complete coronary revascularization, achieved by either coronary artery bypass graft or PCI, is associated with prognostic improvement, in terms of increased survival and reduction of major adverse cardiovascular events. The application of "contemporary" strategies aimed to obtain a state-of-the-art revascularization by PCI allows to achieve long-term clinical benefit, even in high-risk patients or complex coronary anatomy with CTO. The increasing success of CTO-PCI, allowing a complete or reasonable incomplete coronary revascularization, is enabling to overcome the last great challenge of interventional cardiology, adding a "complex" piece to "complete" the puzzle.
RESUMEN
The characteristics and clinical course of hospitalized patients with coronavirus disease 2019 (COVID-19) have been widely described, while long-term data are still poor. The aim of this study was to evaluate the long-term clinical outcome and its association with right ventricular (RV) dysfunction in hospitalized patients with COVID-19. This was a prospective multicenter study of consecutive COVID-19 patients hospitalized at seven Italian Hospitals from 28 February to 20 April 2020. The study population was divided into two groups according to echocardiographic evidence of RV dysfunction. The primary study outcome was 1-year mortality. The propensity score matching was performed to balance for potential baseline confounders. The study population consisted of 224 patients (mean age 69 ± 14, male sex 62%); RV dysfunction was diagnosed in 63 cases (28%). Patients with RV dysfunction were older (75 vs. 67 years, p < 0.001), had higher prevenance of coronary artery disease (27% vs. 11%, p = 0.003), and lower left ventricular ejection fraction (50% vs. 55%, p < 0.001). The rate of 1-year mortality (67% vs. 28%; p ≤ 0.001) was significantly higher in patients with RV dysfunction compared with patients without. After propensity score matching, patients with RV dysfunction showed a worse long-term survival (62% vs. 29%, p < 0.001). The multivariable Cox regression model showed an independent association of RV dysfunction with 1-year mortality. RV dysfunction is a relatively common finding in hospitalized COVID-19 patients, and it is independently associated with an increased risk of 1-year mortality.
RESUMEN
BACKGROUND: Currently, the use of advanced ventricular support systems during percutaneous mitral valve repair (PMVR) procedures is confined to very few selected cases in emergency or bailout situations. No cases are reported of planned use of ventricular support devices in the subgroup of high-risk patients undergoing PMVR. CASE SUMMARY: We report two cases of planned and 'protected' procedures of PMVR with Impella CP mechanical circulatory support. No procedure-related complications occurred. At 6-month clinical follow-up evaluation, an improvement of symptoms and functional class (New York Heart Association) was reported. DISCUSSION: In the two cases reported, PMVR with Impella CP assistance was feasible, safe and effective in the setting of severe mitral regurgitation associated with dilated and severe left ventricular dysfunction. Extending the concept of 'complex high-risk and indicated patients/procedures' (CHIP) from the environment of coronary intervention, a 'protected' approach could lead to improve technical feasibility and clinical outcome in structural interventions, as advocated for 'protected-percutaneous coronary intervention'.