The impact of left circumflex coronary artery ostium stenosis on outcomes for patients after percutaneous coronary intervention for unprotected left main disease.

BACKGROUND: The impact of left circumflex coronary artery (LCX) ostium atherosclerosis in left main coronary artery (LM) bifurcation disease is not well-known. AIM: The study aimed to assess whether the involvement of LCX ostium carries prognostic implications in patients undergoing unprotected LM percutaneous coronary intervention (PCI). METHODS: Consecutive 564 patients with unprotected LM (ULMCA) disease who underwent LM PCI between January 2015 and February 2021, with at least 1 year of available follow-up were included in the study. The first group was composed of 145 patients with ULMCA disease with LCX ostium stenosis, and the second group consisted of 419 patients with ULMCA disease without LCX ostium stenosis. RESULTS: Patients in the group with ULMCA disease with LCX ostium stenosis were significantly older and had more comorbidities. The two-stent technique was used more often in the group with LCX ostium stenosis (62.8% vs. 14.6%; P <0.001). During 7-year follow-up, all-cause mortality did not differ significantly between groups with and without LCX ostium stenosis (P = 0.50). The use of one-stent or two-stent technique also did not impact mortality in patients with LCX ostial lesions (P = 0.75). Long-term mortality subanalysis for three groups of patients: (1) patients with LM plus LCX ostium stenosis; (2) LM plus left anterior descending artery (LAD) ostium stenosis; (3) LM plus LCX ostium plus LAD ostium stenosis also did not differ significantly (P = 0.63). CONCLUSIONS: LCX ostium involvement in LM disease PCI is not associated with adverse long-term outcomes, which is highly beneficial for the Heart Team's decision-making process.

Clinical factors affecting survival in patients with D-transposition of the great arteries after atrial switch repair: A meta-analysis.

BACKGROUND: Atrial switch repair (AtrSR) was the initial operation method in patients with D-transposition of the great arteries (D-TGA) constituting the right ventricle as a systemic one. Currently, it has been replaced with arterial switch operation (ASO), but the cohort of adults after AtrSR is still large and requires strict cardiological management of late complications. For this reason, we aimed to evaluate potential long-term mortality risk factors in patients with D-TGA after AtrSR (either Mustard or Senning procedures) Methods: We searched the MEDLINE database for suitable trials. We included 22 retrospective and prospective cohort studies of patients with D-TGA with at least 5 years mean/median follow-up time after Mustard or Senning procedures, with an endpoint of non-sudden cardiac death (n-SCD) and sudden cardiac death (SCD) after at least 30 days following surgery. RESULTS: A total of 2912 patients were enrolled, of whom 351 met the combined endpoint of n-SCD/SCD. The long-term mortality risk factors were New York Heart Association (NYHA) class ≥III/heart failure hospitalization (odds ratio [OR], 7.25; 95% confidence interval [CI], 2.67-19.7), tricuspid valve regurgitation (OR, 4.64; 95% CI, 1.95-11.05), Mustard procedure (OR, 2.15; 95% CI, 1.37-3.35), complex D-TGA (OR, 2.41; 95% CI, 1.31-4.43), and right ventricular dysfunction (OR, 1.94; 95% CI, 0.99-3.79). Supraventricular arrhythmia (SVT; OR, 2.07; 95% CI, 0.88-4.85) and pacemaker implantation (OR, 2.37; 95% CI, 0.48-11.69) did not affect long-term survival in this group of patients. In an additional analysis, SVT showed a statistically significant impact on SCD (OR, 2.74; 95% CI, 1.36-5.53) but not on n-SCD (OR, 1.5; 95% CI, 0.37-6.0). CONCLUSIONS: This meta-analysis demonstrated that at least moderate tricuspid valve regurgitation, NYHA class ≥III/heart failure hospitalization, right ventricular dysfunction, complex D-TGA, and Mustard procedure are risk factors for long-term mortality in patients after AtrSR.

Short- and Long-Term Outcomes of Left Main Coronary Artery Stenting in Patients Disqualified from Coronary Artery Bypass Graft Surgery.

The study aims to evaluate the short- and long-term outcomes of left main percutaneous coronary interventions (LM PCI) in patients disqualified from coronary artery bypass graft surgery (CABG). We included 459 patients (mean age: 68.4 ± 9.4 years, 24.4% females), with at least 1-year follow-up; 396 patients in whom PCI was offered as an alternative to CABG (Group 1); and 63 patients who were disqualified from CABG by the Heart Team (Group 2). The SYNTAX score (29.1 ± 9.5 vs. 23.2 ± 9.7; p < 0.001) and Euroscore II value (2.72 ± 2.01 vs. 2.15 ± 2.16; p = 0.007) were significantly higher and ejection fraction was significantly lower (46% vs. 51.4%; p < 0.001) in Group 2. Patients in Group 2 more often required complex stenting techniques (33.3% vs. 16.2%; p = 0.001). The procedure success rates were very high and did not differ between groups (100% vs. 99.2%; p = 0.882). We observed no difference in periprocedural complication rates (12.7% vs. 7.8%; p = 0.198), but the long-term all-cause mortality rate was higher in Group 2 (26% vs. 21%; p = 0.031). LM PCI in patients disqualified from CABG is an effective and safe procedure with a low in-hospital complication rate. Long-term results are satisfactory.

Do non-vitamin K antagonist oral anticoagulants increase the risk of myocardial infarction?

Non-vitamin K antagonist oral anticoagulants (NOACs), compared with warfarin, have a favorable risk-benefit profile. However, in the RE-LY study in patients with atrial fibrillation (AF), the number of patients with MI was higher in the dabigatran group as compared to the warfarin group. Many meta-analyses showed that dabigatran treatment led to an increased risk of myocardial infarction (MI). Large real-world data (RWD) did not confirm an increase in the risk of MI during dabigatran treatment. In our meta-analysis we excluded RWD, and each of the four drugs was evaluated in two key-phase III randomized controlled trials: in patients with AF and patients with AF and chronic coronary syndrome or acute coronary syndrome treated with percutaneous coronary interventions. In each study, warfarin was the comparator for NOACs. In this homogeneous group of patients, dabigatran, in direct comparison with warfarin, significantly increased the risk of MI by about 30%. Moreover, the risk of MI was also significantly higher than the opposite effect of activated factor (F) X inhibitors (FXa inhibitors) vs. warfarin. In our network meta-analysis, considering individual NOACs in recommended doses, we found an increased risk of MI compared to warfarin only in patients treated with dabigatran 150 mg twice a day and, in particular, 110 mg twice a day. In this review we present evidence supporting our opinion that in patients with AF and coronary stenting, the choice of NOACs (direct FXa vs. thrombin inhibitors) is equally as important as choosing the optimal antiplatelet therapy (single or dual antiplatelet therapy).

Very long-term follow-up of patients with coronary bifurcation lesions treated with bioresorbable scaffolds.

BACKGROUNDS: The data concerning the use of bioresorbable vascular scaffolds (BVS) in coronary bifurcation lesions are limited. AIMS: The objective of the study was to evaluate the early and very long-term clinical outcomes of bifurcation stenting with ABSORB BVS. METHODS: One hundred consecutive patients with coronary bifurcation lesions treated with BVS were included. A total of 124 BVS were implanted. Provisional side branch stenting was performed in 66 patients, distal main stenting in 14 patients, systematic T stenting in 2, and T with minimal protrusion (TAP) in 5 patients. Side branch ostial stenting was performed in additional 12 patients. RESULTS: The procedural success was achieved in 98% of patients. In long-term follow-up, the rate of cardiac death was 4.0%, target vessel myocardial infarction was 5.0%, and target vessel revascularization (TVR) was 11%. The cumulative incidence of definite/probable scaffold thrombosis (ST) was 2% at long-term follow-up. Comparison with the historical drug-eluting stents (DES) group revealed higher mortality and major adverse cardiac events rate in the ABSORB group. CONCLUSIONS: Stenting of coronary bifurcation lesions of low-to-moderate complexity with BVS was feasible with good acute performance and acceptable results. However, the risk of death and major adverse cardiovascular events was higher as compared with DES.

Peri-Procedural Troponin Elevation after Percutaneous Coronary Intervention for Left Main Coronary Artery Disease.

Left main (LM) percutaneous coronary interventions (PCI) are challenging and highly invasive procedures. Periprocedural myocardial injury (Troponin (Tn) elevation > 99th percentile) is frequently detected after LM PCI, being identified even in up to 67% of patients. However, the prognostic implications of periprocedural Tn elevation after LM PCI remain controversial. We aim to assess the impact and prognostic significance of the periprocedural troponin elevation on long-term outcomes in patients undergoing LM PCI in a real-world setting. Consecutive 673 patients who underwent LM PCI in our department between January 2015 to February 2021 were included in a prospective registry. The first group consisted of 323 patients with major cardiac Troponin I elevation defined as an elevation of Tn values > 5× the 99th percentile in patients with normal baseline values or post-procedure Tn rise by >20% in patients with elevated pre-procedure Tn in whom the Tn level was stable or falling (based on the fourth universal definition of myocardial infarction). The second group consisted of patients without major cardiac Troponin I elevation. Seven-year long-term all-cause mortality was not higher in the group with major Tn elevation (36.9% vs. 40.6%; p = 0.818). Naturally, periprocedural myocardial infarction was diagnosed only in patients from groups with major Tn elevation (4.9% of all patients). In-hospital death and other periprocedural complications did not differ significantly between the two study groups. The adjusted HRs for mortality post-PCI in patients with a periprocedural myocardial infarction were not significant. Long-term mortality subanalysis for the group with criteria for cardiac procedural myocardial injury showed no significant differences (39.5% vs. 38.8%; p = 0.997). The occurrence of Tn elevation (>1×; >5×; >35× and >70× URL) after LM PCI was not associated with adverse long-term outcomes. The results of the study suggest that the isolated periprocedural troponin elevation is not clinically significant.

A Meta-Analysis Evaluating the Colchicine Therapy in Patients With Coronary Artery Disease.

Background: Evidence from recent studies has shown the benefits of colchicine for patients with coronary artery disease. The aim was to assess the effect of colchicine treatment on cardiovascular events, with an estimation of the risk of discontinuation and net clinical benefit. Methods and Results: Fourteen trials with a total of 13,186 patients were selected through a systematic search. Colchicine therapy significantly reduced the relative risk of primary endpoint by about 30% [RR 0.70 (95%CI:0.56-0.88)]. Compared with placebo, colchicine significantly reduced the risk of ischemia-driven revascularization [RR 0.57 (95%CI 0.41-0.80)], ischemia-driven revascularization and resuscitation [RR 0.50 (95%CI 0.34-0.73)], myocardial infarction [RR 0.73 (95%CI 0.57-0.95)], and stroke [RR 0.49 (95%CI 0.30-0.7)]. Patients treated with colchicine in comparison with placebo have a significant increase in the risk of treatment cessation (RR 1.60 95%CI 1.06-2.42). However, in the analysis which excluded studies without placebo, the relative risk of discontinuation was smaller (RR 1.34 95%CI 0.97-1.84) and in the three largest studies, the risk of discontinuation was lower and insignificant [RR 1.26 (95%CI 0.87-1.83)]. The net clinical benefit was 17.8/1,000 patients (p < 0.001). Conclusion: In coronary artery disease, low-dose colchicine significantly reduces the risk of the primary composite endpoint by about 30%. The drug should be considered as part of the preventive treatment in patients with good tolerance.

Non-Vitamin K Antagonist Oral Anticoagulants and Risk of Myocardial Infarction in Patients with Atrial Fibrillation with or without Percutaneous Coronary Interventions: A Meta-Analysis.

The study aimed to assess the risk of myocardial infarction (MI) and major adverse cardiac events during non-vitamin K antagonist oral anticoagulants (NOAC) compared to warfarin therapy in patients with atrial fibrillation (AF), both treated and not treated with percutaneous coronary interventions (PCI). In a systematic search, we selected eight randomized clinical trials with a total of 81,943 patients. Dabigatran, compared to warfarin, significantly increased the risk of MI (relative risk [RR] 1.38, 95% CI 1.14-1.67), while the FXa inhibitors' effect did not differ significantly from warfarin (RR 0.96, 95% CI 0.86-1.09). The RR comparison between analyzed subgroups (dabigatran vs. FXa inhibitors) showed a significant difference (Chi2 = 9.51, df = 1, p = 0.002). In a network meta-analysis, dabigatran 110 mg b.i.d. increased the risk of MI compared to warfarin, apixaban, edoxaban, and rivaroxaban. Also, dabigatran 150 mg b.i.d. increased the risk of MI compared to warfarin, apixaban, and rivaroxaban. Moreover, we tried to estimate the treatment ranking of the best therapy for MI prevention in patients with AF treated with PCI. Rivaroxaban had a 90% probability of being ranked the best therapy for MI prevention, whereas dabigatran 110 mg had an 8.2% probability. Dabigatran 150 mg was the most effective in stroke prevention (94% probability). Each NOAC is associated with a different risk of MI. Furthermore, we should consider FXa inhibitors as the first line NOACs in AF and coronary artery disease patients. PROSPERO ID CRD42020179808.

A Personalized Approach to Percutaneous Coronary Interventions in the Left Main Coronary Artery-Is the Female Gender Associated with Worse Outcomes?

There is still controversy whether the female gender is associated with worse outcomes after the percutaneous coronary intervention within the left main (LM PCI). This study aimed to examine gender-based differences in real-life LM PCI patients and present a gender-personalized LM PCI approach. Consecutively, 613 patients underwent LM PCI in our department from January 2015 to June 2019. Five hundred and thirty-three patients, with at least a one-year follow-up, were included in the study. There were 130 (24.4%) women and 403 (75.6%) men. Compared with men, women were older (70.0 ± 9.4 vs. 67.7 ± 9.2; p = 0.006) and had higher diabetes, hypertension, and chronic kidney disease rates. Left ventricle ejection fraction was higher in women (53.5 ± 9.4 vs. 49.5 ± 11.2; p = 0.001). Euroscore II and SYNTAX scores did not differ between the genders. However, we observed a trend towards more frequent use of complex PCI techniques in women (26.2% vs. 19.4%; p = 0.098). The overall periprocedural complication rates (10.0% vs. 7.7%; p = 0.406) and the periprocedural myocardial infarction rates did not differ. Contrast-induced nephropathy was more frequent in women (6.9% vs. 3.0%; p = 0.044). Long-term all-cause mortality did not differ (20% vs. 22.5%; p = 0.069). Both genders presented similar rates of periprocedural complications, and no significant differences in long-term all-cause mortality were revealed. Our results suggest that the female gender in LM PCI is not a predictor of adverse outcomes. Further studies are required to determine the optimal revascularization strategy in women.

The impact of right coronary artery support on outcomes of patients with unprotected left main disease undergoing percutaneous coronary intervention.

BACKGROUND: Many operators are discouraged from performing left main (LM) percutaneous coronary interventions (PCI) in the absence of right coronary artery (RCA) support due to the increased procedure risk. AIMS: We aimed at assessing the impact of absent functional RCA on prognostic implications in patients undergoing unprotected LM PCI. METHODS: 613 patients underwent LM PCI in our department between 2015 and 2019. Consecutive 385 patients with unprotected LM and at least 1-year follow-up were included in the study. The study population comprosed 272 patients with unprotected left main coronary artery disease (ULMCAD) with dominant RCA, without any significant lesions (Group 1), and 113 ULMCAD patients and without RCA support (Group 2). RESULTS: In Group 2, 32.7% patients had a significant RCA stenosis, 48.7% had chronic total occlusion (CTO) of RCA, and 18.6% had recessive RCA. Patients in Group 2 were older and had higher prevalence of chronic obstructive pulmonary disease (COPD). SYNTAX Score (median [IQR] 26.0 [20.0-33.0] vs 19.0 [13.0-25.5]; P <0.001) was higher and left ventricular ejection fraction was lower (median [IQR] 50.0 [40.0-60.0]% vs 55.0 [45.0-60.0]%; P = 0.01) in this group. All periprocedural complications did not differ among the groups. Long-term all-cause mortality at a median follow-up of 1149 days did not differ significantly (23% vs 20%; P = 0.37). The long-term mortality in CTO-RCA group was also not significantly different. CONCLUSIONS: Patients with ULMCAD who have undergone LM PCI in the absence of RCA support, compared with those with ULMCAD and RCA support, differed neither in the prevalence of periprocedural complications nor in long-term all-cause mortality.

Prolonged antithrombotic therapy in patients after acute coronary syndrome: A critical appraisal of current European Society of Cardiology guidelines.

The increased risk of non-cardiovascular death in patients receiving clopidogrel or prasugrel in comparison with the placebo group in the Dual Antiplatelet Therapy (DAPT) trial in contrast to the decreased risk of cardiovascular death and all-cause death seen in patients treated with low-dose ticagrelor in the EU label population of the PEGASUS-TIMI 54 trial, resulted in inclusion in the 2020 ESC NSTE-ACS guidelines the recommendation for use of clopidogrel or prasugrel only if the patient is not eligible for treatment with ticagrelor. The prevalence of the primary outcome composed of cardiovascular death, stroke, or myocardial infarction was lower in the low-dose rivaroxaban and acetylsalicylic acid (ASA) group than in the ASA-alone group in the COMPASS trial. Moreover, all-cause mortality and cardiovascular mortality rates were lower in the rivaroxaban-plus-ASA group. Comparison of the PEGASUS-TIMI 54 and COMPASS trial patient characteristics clearly shows that each of these treatment strategies should be addressed at different groups of patients. A greater benefit in post-acute coronary syndrome (ACS) patients with a high risk of ischemic events and without high bleeding risk may be expected with ASA and ticagrelor 60 mg b.i.d. when the therapy is continued without interruption or with short interruption only after ACS. On the other hand, ASA and rivaroxaban 2.5 mg b.i.d. seems to be a better option when indications for dual antithrombotic therapy (DATT) appear after a longer time from ACS (more than 2 years) and/or from cessation of DAPT (more than 1 year) and in patients with multiple vascular bed atherosclerosis. Thus, both options of DATTs complement each other rather than compete, as can be presumed from the recommendations. However, a direct comparison between these strategies should be tested in future clinical trials.

Islets of heterogeneous myocardium within the scar in cardiac magnetic resonance predict ventricular tachycardia after myocardial infarction.

INTRODUCTION: We assessed findings in cardiac magnetic resonance (CMR) as predictors of ventricular tachycardia (VT) after myocardial infarction (MI), which could allow for more precise identification of patients at risk of sudden cardiac death. METHODS: Forty-eight patients after prior MI were enrolled and divided into two groups: with (n = 24) and without (n = 24) VT. VT was confirmed by electrophysiological study and exit site was estimated based on 12-lead electrocardiogram. All patients underwent CMR with late gadolinium enhancement. RESULTS: The examined groups did not differ significantly in clinical and demographical parameters (including LV ejection fraction). There was a significant difference in the infarct age between the VT and non-VT group (15.8 ± 8.4 vs 7.1 ± 6.7 years, respectively; P = .002), with the cut-off point at the level of 12 years. In the scar core, islets of heterogeneous myocardium were revealed. They were defined as areas of potentially viable myocardium within or adjacent to the core scar. The number of islets was the strongest independent predictor of VT (odds ratio [OR], 1.42; confidence interval [CI], 1.17-1.73), but total islet size and the largest islet area were also significantly higher in the VT group (OR, 1.04; CI, 1.02-1.07 and OR, 1.16; CI, 1.01-1.27, respectively). Myocardial segments with fibrosis forming 25%-75% of the ventricular wall were associated with a higher incidence of VT (7.5 ± 2.1 vs 5.7 ± 2.6; P = .014). Three-dimension CMR reconstruction confirmed good correlation of the location of the islets/channels with VT exit site during electroanatomical mapping in five cases. CONCLUSIONS: The identification and quantification of islets of heterogeneous myocardium within the scar might be useful for predicting VT in patients after MI.

Long-term clinical results of biodegradable vascular scaffold ABSORB BVS™ using the PSP-technique in patients with acute coronary syndrome.

BACKGROUND: The PSP (predilatation, sizing, post-dilatation)-technique was developed to improve the prognosis of patients after bioresorbable vascular scaffold (BVS) implantation. In acute coronary syndrome (ACS) the use of BVS is particularly demanding and carries some potential risk regarding aggressive lesion preparation, proper vessel sizing due to spasm and thrombus inside the artery. The aim herein, was to determine the long-term results of BVS stenting in ACS patients depending on the scaffold implantation technique. METHODS: The present study is a prospective, two-center study, which consisted of 182 patients who underwent percutaneous coronary intervention (PCI) with BVS (Absorb, Abbott Vascular, Santa Clara, California, USA) implantation for the ACS. All patients were divided into two groups. The first consisted of 52 patients treated with the PSP-technique (PSP group). The second group enrolled 130 patients treated with a non-PSP procedure (non-PSP group). RESULTS: The procedure was successful in all patients. The mean observation time was 28.8 ± 16.5 months (median 28.3 months, interquartile range 24.0 [17.0-41.0] months). It was found that target vessel failure (TVF) was consistently reduced in patients using the PSP-technique as compared with the non-PSP group (5.8% vs. 17.7%, p = 0.03). Moreover, PSP-technique was superior to non-PSP-technique concerning major adverse cardiac events (MACE) (3.7% vs. 22.3%, p = 0.02). Logistic regression analysis revealed that the use of PSP technique significantly decreased the risk of target vessel revascularization (odds ratio [OR] 0.11, p = 0.01), TVF (OR 0.28, p = 0.03) and MACE (OR 0.29, p = 0.02). CONCLUSIONS: The PSP-technique for BVS implantation improves long-term results and should also be recommended for newer generations of the bioresorbable scaffold.

Triple versus double antithrombotic therapy in patients with atrial fibrillation and stent implantation: a meta­analysis of randomized trials.

BACKGROUND: Appropriate double (DT) and triple (TT) antithrombotic therapy in patients with atrial fibrillation and stent implantation is unclear. AIM: The aim of the study was to perform a meta­analysis of studies comparing DT and TT in patients with atrial fibrillation and stent implantation. METHODS: Of the 450 reports, 5 randomized trials were included in the meta­analysis: WOEST, ISAR­REACT, PIONEER AF­PCI, RE­DUAL PCI, and AUGUSTUS, with a total of 9931 patients. RESULTS: Treatment efficacy, as assessed by the incidence of major adverse cardiac events, did not differ significantly between both therapeutic strategies: 8.98% for DT vs 8.71% for TT (odds ratio [OR], 1.02; 95% CI, 0.86-1.21). The incidence of hemorrhagic complications was significantly lower in patients treated with DT than TT (13.1% and 21.0%, respectively; OR, 0.57; 95% CI, 0.47-0.70). In over 90% of patients, DT included clopidogrel along with an oral anticoagulant (non-vitamin K antagonist oral anticoagulant or vitamin K antagonist). CONCLUSIONS: The results of our meta­analysis are clearly in line with the current trend of the fastest possible reduction in the use of TT in favor of DT. Almost half lower risk of hemorrhagic complications during DT compared with TT, with similar efficacy of the 2 strategies, provides an argument for the wider use of DT in patients with AF and stent implantation.

Optimal Timing of P2Y12 Inhibitor Loading in Patients Undergoing PCI: A Meta-Analysis.

BACKGROUND AND AIM: The timing of P2Y12 inhibitor loading in patients undergoing percutaneous coronary intervention (PCI) is a matter of debate. The aim of our study was to compare the efficacy and safety of oral P2Y12 inhibitors: clopidogrel, ticagrelor and prasugrel administered at two different time points in relation to PCI: early (> 2 hours pre-PCI) versus late (< 2 hours pre-PCI or post-PCI). METHODS: This is a systematic review and meta-analysis. Randomized controlled trials and non-randomized studies were included. Outcomes evaluated were combined major adverse cardiovascular events (MACEs), myocardial infarction (MI), target vessel revascularization, death and bleeding complications. Summary estimates of the relative risks with therapy were calculated. RESULTS: Twenty-three studies met the selection criteria and included 60,907 patients. Early P2Y12 inhibitor loading was associated with a 22% relative risk reduction (RRR) of MACE (95% confidence interval [CI] = 0.68-0.89; p < 0.001). Early clopidogrel loading was associated with a 25% RRR of MACE (95% CI = 0.65-0.85; p < 0.001), a 30% RRR of MI (95% CI = 0.6-0.82; p < 0.0001) and 25% RRR of death (95% CI = 0.64-0.87; p = 0.0002), without an impact on major bleedings. In ST-elevation myocardial infarction as well as non-ST elevation acute coronary syndrome (NSTE-ACS), early clopidogrel loading resulted in 35 and 22% RRR in 30 days MACE (p < 0.001), respectively, with no impact in elective PCI. Whereas early loading with prasugrel and ticagrelor did not improve ischaemic outcomes, prasugrel administered early increased bleeding risks in NSTE-ACS. CONCLUSION: Early clopidogrel loading is associated with a better efficacy and similar safety, whereas timing of ticagrelor or prasugrel loading had no effects on ischaemic events.

Treatment of patients with acute coronary syndrome: Recommendations for medical emergency teams: Focus on antiplatelet therapies. Updated experts' standpoint.

A group of Polish experts in cardiology and emergency medicine, encouraged by the European Society of Cardiology (ESC) guidelines, have recently published common recommendations for medical emergency teams regarding the pre-hospital management of patients with acute coronary syndrome. Due to the recent publication of the 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation and 2017 focused update on dual antiplatelet therapy in coronary artery disease the current panel of experts decided to update the previous standpoint. Moreover, new data coming from studies presented after the previous document was issued were also taken into consideration.

Impact of digoxin on risk of death in heart failure patients treated with b-blockers. Results from Polish part of ESC Heart Failure Long-Term Registry.

BACKGROUND: Digoxin is used in the treatment of atrial fibrillation (AF) and heart failure (HF). It was reported to increase the risk of death in HF. Studies on digoxin are based mainly on patients treated some years ago, before the era of common b-blocker use. AIM: This study aims to show the influence of digoxin in a modern cohort of HF patients on top of the contemporary guideline-directed treatment. METHODS: This study retrospectively analyses the Polish part of the European Society of Cardiology Heart Failure Long-Term Registry. It includes 912 patients treated for HF between February 2012 and January 2013, and followed until May 2014. At baseline, 19.1% took digoxin, 89.6% angiotensin convertase enzyme inhibitors or angiotensin receptor blockers, 91.9% b-blockers, and 69.4% mineralocorticoid receptor antagonists. RESULTS: Digoxin is associated with increased risk of death after adjustment for significant covariates in patients who have HF with reduced ejection fraction (HFrEF) but no AF history (hazard ratio [HR] 2.52, 95% confidence interval [CI] 1.23-5.19; p = 0.011), and it does not influence significantly the risk of hospitalisation (adjusted HR 1.46, 95% CI 1.05-1.72; p = 0.11). Digoxin use shows no significant association with the risk of death or hospitalisation in patients with AF and HFrEF or HF with preserved ejection fraction (HFpEF). Patients on digoxin present a significantly worse clinical status with lower left ventricular ejection fraction and higher New York Heart Association class, and fewer of them received the guideline-directed treatment. CONCLUSIONS: Digoxin is associated with increased risk of death in HFrEF patients without AF history receiving the guideline- -directed treatment. Digoxin seems to be employed in patients with worse clinical status, which may at least partially explain its association with increased risk of death.