Influence of sex on the timing of coronary angiography and the prescription of antiplatelet therapy in patients with nonST-segment elevation myocardial infarction. / Impacto del sexo en los tiempos de cateterismo y en el uso de pretratamiento antiagregante plaquetario en pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST).

OBJECTIVES: To assess differences in the clinical management of nonST-segment elevation myocardial infarction (NSTEMI), including in-hospital events, according to biological sex. MATERIAL AND METHODS: Prospective observational multicenter study of patients diagnosed with NSTEMI and atherosclerosis who underwent coronary angiography. RESULTS: We enrolled 1020 patients in April and May 2022; 240 (23.5%) were women. Women were older than men on average (72.6 vs 66.5 years, P .001), and more women were frail (17.1% vs 5.6%, P .001). No difference was observed in pretreatment with any P2Y12 inhibitor (prescribed in 68.8% of women vs 70.2% of men, P = .67); however, more women than men were prescribed clopidogrel (56% vs 44%, P = .009). Women prescribed clopidogrel were more often under the age of 75 years and not frail. Coronary angiography was performed within 24 hours less corooften in women (29.8% vs 36.9%, P = .03) even when high risk was recognized. Frailty was independently associated with deferring coronary angiography in the adjusted analysis; biological sex by itself was not related. The frequency and type of revascularization were the same in both sexes, and there were no differences in in-hospital cardiovascular events. CONCLUSION: Women were more often prescribed less potent antithrombotic therapy than men. Frailty, but not sex, correlated independently with deferral of coronary angiography. However, we detected no differences in the frequency of coronary revascularization or in-hospital events according to sex.

OBJETIVO: Evaluar las diferencias en el manejo clínico y eventos intrahospitalarios en una cohorte de pacientes con síndrome coronario agudo sin elevación del segmento ST (SCASEST) en función del sexo. METODO: Estudio observacional, prospectivo y multicéntrico que incluyó pacientes consecutivos con diagnóstico de SCASEST sometidos a coronariografía con enfermedad ateroesclerótica responsable. RESULTADOS: Entre abril y mayo de 2022 se incluyeron 1.020 pacientes; de ellos, 240 eran mujeres (23,5%). En comparación con los hombres, las mujeres fueron mayores (72,6 años vs 66,5 años; p 0,001) y más frágiles (17,1% vs 5,6%; p 0,001). No hubo diferencias en el pretratamiento con un inhibidor del receptor P2Y12 (68,8% vs 70,2%, p = 0,67), aunque las mujeres recibieron más pretratamiento con clopidogrel (56% vs 44%, p = 0,009), principalmente aquellas de edad 75 años y sin fragilidad. En las mujeres se realizaron menos coronariografías precoces (# 24 h) (29,8% vs 36,9%; p = 0,03) a pesar de presentar la misma indicación (criterios de alto riesgo). En el análisis ajustado, la fragilidad, pero no el sexo, se asoció de forma independiente con la realización de una coronariografía diferida. La tasa y el tipo de revascularización fue igual en ambos sexos, y no hubo diferencias en los eventos cardiovasculares intrahospitalarios. CONCLUSIONES: Las mujeres recibieron con mayor frecuencia un tratamiento antitrombótico menos potente. La fragilidad y no el sexo se asoció con la realización de coronariografía diferida. Sin embargo, no hubo diferencias en la tasa de revascularización coronaria ni en los eventos intrahospitalarios en función del sexo.

Timing of coronary angiography and use of antiplatelet pretreatment in patients with NSTEACS in Spain.

INTRODUCTION AND OBJECTIVES: The optimal timing of coronary angiography in patients admitted with non-ST-segment elevation acute coronary syndrome (NSTEACS) as well as the need for pretreatment are controversial. The main objective of the IMPACT-TIMING-GO registry was to assess the proportion of patients undergoing an early invasive strategy (0-24hours) without dual antiplatelet therapy (no pretreatment strategy) in Spain. METHODS: This observational, prospective, and multicenter study included consecutive patients with NSTEACS who underwent coronary angiography that identified a culprit lesion. RESULTS: Between April and May 2022, we included 1021 patients diagnosed with NSTEACS, with a mean age of 67±12 years (23.6% women). A total of 87% of the patients were deemed at high risk (elevated troponin; electrocardiogram changes; GRACE score>140) but only 37.8% underwent an early invasive strategy, and 30.3% did not receive pretreatment. Overall, 13.6% of the patients underwent an early invasive strategy without pretreatment, while the most frequent strategy was a deferred angiography under antiplatelet pretreatment (46%). During admission, 9 patients (0.9%) died, while major bleeding occurred in 34 (3.3%). CONCLUSIONS: In Spain, only 13.6% of patients with NSTEACS undergoing coronary angiography received an early invasive strategy without pretreatment. The incidence of cardiovascular and severe bleeding events during admission was low.

High medium-term incidence of major cardiovascular events in discharged patients with unstable angina.

The introduction of high-sensitivity troponin (hsTn) assays has reduced the diagnosis of unstable angina (UA) in favor of non-ST elevation myocardial infarction (NSTEMI) in the context of non-ST elevation acute coronary syndrome (NSTEACS). It is unclear whether the detection of these hsTn levels affects the prognosis and therefore whether a different therapeutic approach is warranted. This study aims to determine whether using hsTn results in medium-term prognostic differences in patients with UA and NSTEMI. Methods: This multicenter, prospective registry study included consecutive patients who underwent hsTn assays and were discharged with a diagnosis of NSTEACS. Patients were followed for two years. Outcomes were the occurrence of major adverse cardiovascular events (MACE: cardiovascular death, non-fatal myocardial infarction, and non-fatal ischemic stroke), major bleeding, and all-cause mortality. Results: Patients with UA and NSTEMI did not show differences in terms of the invasive interventions received, the coronary artery disease diagnosed, the type of revascularization performed, or the proportion presenting MACE (UA 18.1% vs. NSTEMI 18.9%; p = 0.79). However, patients with NSTEMI had higher cardiovascular mortality at two years (UA 4% vs. NSTEMI 9.2%; p = 0.012), as well as, all-cause mortality (UA vs. 7.9% vs. NSTEMI 16.4%; p = 0.002). Conclusions: Medium-term incidence of MACE was similar in patients with UA and NSTEMI, but cardiovascular and all-cause mortality in NSTEMI patients was over twice that of patients with UA.

Do coronary stents suffer long-term deterioration after repeated intracoronary lithotripsy for rebel underexpansion treatment?

Coronary intravascular lithotripsy (IVL) is the latest developed technique available for stent underexpansion treatment, although it is unclear if this therapy causes stent structure damage. We present the case of a patient with severe, refractory stent underexpansion after primary angioplasty, which was resolved with a double session of IVL. Elective angiographic and optical coherence tomography (OCT) follow-up was performed 1 year after the procedure, which demonstrated the absence of any damage in the stent platform. Paradoxically, the study revealed a critical restenotic lesion in an area distant from the one of interest. Review of the first OCT after the primary procedure revealed 78% underexpansion in that area, which went by unnoticed and could be the cause of restenosis. Repeated IVL therapy may be helpful in cases of rebel stent underexpansion, and it conveys the impression of being safe in the long term in relation to the integrity and effectiveness of the drug-eluting coronary stents.

Intervención coronaria percutánea y anticoagulantes orales / Percutaneous coronary intervention and oral anticoagulation

Los pacientes con anticoagulación oral crónica sometidos a intervención coronaria percutánea constituyen una población con alto riesgo y gran comorbilidad. Se trata de una población en crecimiento y con un pronóstico complejo por los eventos isquémicos y hemorrágicos que pueden padecer en el corto, medio y largo plazo. El tratamiento antitrombótico es sin duda uno de los aspectos fundamentales que considerar en esta población y el que más impacto pronóstico puede generar. El mantenimiento de la anticoagulación oral es el aspecto prioritario en esta población. En los últimos años se han estudiado diferentes regímenes antitrombóticos buscando fundamentalmente una reducción de eventos hemorrágicos, sin penalizar la eficacia. Para ello se ha estudiado sobre todo acortar la duración de la doble antiagregación añadida a la anticoagulación y el uso de antiagregantes plaquetarios en monoterapia, fundamentalmente el clopidogrel, además del anticoagulante oral. Actualmente la llegada de los anticoagulantes orales de acción directa ha generado una gran expectación e ilusión. Estos fármacos, con un mejor perfil de seguridad que los anticoagulantes dicumarínicos, pueden aportar en este contexto importantes mejoras pronósticas. Hay 3 ensayos clínicos con anticoagulantes orales de acción directa en este paciente tan complejo y, junto con otro que se encuentra en fase de seguimiento, es posible que contribuyan a modificar la práctica clínica habitual de forma relevante en los próximos años. Información sobre el suplemento: este artículo forma parte del suplemento titulado «Actualización en el tratamiento de los pacientes con fibrilación auricular sometidos a intervención coronaria», que ha sido patrocinado por Boehringer Ingelheim

Patients on long-term oral anticoagulation therapy who are scheduled to undergo a percutaneous coronary intervention are a high-risk population with a large number of comorbid conditions. This is a growing population that has a complicated prognosis because ischemic and bleeding events can occur over the short, medium and long term. Antithrombotic therapy, without doubt a key consideration in these patients, could have a substantial impact on prognosis. Maintenance therapy with oral anticoagulants is also a priority. Over the last few years, several antithrombotic regimens have been investigated with the principle aim of reducing hemorrhagic events while maintaining efficacy. To this end, studies have focused on: (i) shortening the duration of the dual antiplatelet therapy added to anticoagulation; and (ii) the use of antiplatelet monotherapy, particularly clopidogrel, along with an oral anticoagulant. Recently, the emergence of direct oral anticoagulants has generated great hope and excitement. These new drugs, which have a better safety profile than dicoumarinic anticoagulants, could produce substantial prognostic improvements in this context. The results of three clinical trials of direct oral anticoagulants in these highly complex patients are currently available. Their findings, together with another trial that is now in the follow-up phase, have the potential to substantially modify our usual clinical practice in coming years. Supplement information: this article is part of a supplement entitled "Treatment of patients with atrial fibrillation undergoing percutaneous coronary intervention: an update", which is sponsored by Boehringer Ingelheim