[Short-term and long-term mortality comparison between myocardial infarction with and without ST segment elevation undergoing myocardial revascularization by percutaneous coronary angioplasty]. / Comparación de mortalidad a corto y largo plazo entre el infarto del miocardio con y sin supradesnivel del segmento ST sometido a revascularización miocárdica por angioplastia coronaria percutánea.

OBJECTIVES: To compare the early and late mortality of patients that have suffered an ST segment elevation myocardial infarction (STEMI) and a non-ST segment elevated myocardialinfarction (NSTEMI). METHODS: Retrospective study of patients treated at the Regional Clinical Hospital of Concepción from January the 1rst 2013 to December 31 rst 2015, with diagnostic of STEMI and NSTEMI that required coronary angioplasty during their hospitalization. Descriptive and multivariate analysis was performed to compare mortality rates between both populations before 30 days and in follow-up at 4 years. RESULTS: 1838 patients were included with an average follow-up of 82 months. The population with STEMI was 921 and was younger, with a higher prevalence of arterial hypertension and smoking. The population with NSTEMI had a higher prevalence of diabetes mellitus, a lower glomerular filtration rate, and a higher incidence of left main coronary artery disease and chronic occlusions. At the end of follow-up, the overall survival rate was 76%, with no significant difference between the two groups. Patients with STEMI had twice the risk of dying in the first 30 days (Long Rank: 0.012). After 30 days, mortality was higher in the NSTEMI group (80.8% vs 75.6%). CONCLUSIONS: This study did not show significant differences in overall mortality during prolonged follow-up of patients with STEMI and NSTEMI. The STEMI group had a higher risk of early death, while the NSTEMI group had higher long-term mortality.

Impacto da doença renal crônica no perfil lipídico de pacientes tratados por meio de intervenção coronária percutânea / Impact of chronic kidney disease on the lipid profile of patients treated by percutaneous coronary intervention

INTRODUÇÃO: Doenças cardiovasculares (DCV) são a principal causa de óbito de pacientes com doença renal crônica (DRC), tanto naqueles em terapia renal substitutiva quanto naqueles em tratamento conservador. A prevalência da DCV está intimamente ligada à presença e ao controle de fatores de risco tradicionais, como a dislipidemia (DLP), além dos não tradicionais. Atualmente, a intervenção percutânea (ICP) é o principal método de revascularização miocárdica. No entanto, o impacto da DRC no perfil lipídico destes pacientes ainda não está bem esclarecido. OBJETIVO: O objetivo deste estudo foi analisar o perfil lipídico de pacientes submetidos à ICP em duas populações distintas, os com e os sem DRC. METODOLOGIA: Trata-se de um estudo descritivo e transversal com foco na análise de dados laboratoriais dos exames relacionados ao perfil lipídico: Colesterol Total, HDL, LDL e Triglicérides (TGC). Foram incluídos casos atendidos de julho a dezembro de 2023 em um hospital terciário de grande porte. RESULTADOS: A média de idade dos pacientes incluídos na análise foi de 70 anos (± 10 anos), sendo 85,67% portadores de dislipidemia e 37,23% portadores de diabetes mellitus. A média dos valores foi de colesterol total de 146,06 (± 39,83) mg/dl, HDL-colesterol de 40,36 (± 11,28) mg/dl, LDL colesterol de 76,7 mg/dl e triglicerídeos de 145,8 mg/dl. CONCLUSÃO: O grupo com DRC apresentou níveis superiores de triglicerídeos e inferiores de HDL-colesterol em comparação com o grupo sem DRC. Esses resultados corroboram achados anteriores na literatura, como os dados do KNHANES, que sugerem que a relação TG/HDLc é uma proporção lipídica crucial relacionada à DRC, especialmente em populações de alto risco cardiovascular, como a nossa, que já apresenta doença cardiovascular estabelecida.

Revascularização completa versus parcial para idosos com síndrome coronariana aguda: uma metanálise e revisão sistemática de dados randomizados e ajustados multivariáveis / Complete versus partial revascularization for elderly people with acute coronary syndrome: a meta-analysis and systematic review of randomized, multivariable-adjusted data

Introdução: Evidências de estudos randomizados apoiam a revascularização completa em vez do culpado apenas para pacientes com síndrome arterial coronariana aguda (SCA) e doenças coronarianas multiarteriais. Se estes resultados se estendem a pacientes idosos, no entanto, não foi completamente explorado. Métodos: Realizamos uma revisão sistemática e meta-análise comparando os resultados clínicos de idosos (definidos como idade >;75 anos) com SCA e DMV submetidos à intervenção coronária percutânea (ICP) completa vs. parcial. Foram pesquisados ​​PubMed, Embase e Cochrane. Calculamos razões de risco agrupadas com intervalos de confiança (IC) de 95% para preservar os dados de tempo até o evento. Resultados: Incluímos 7 estudos, dos quais 2 eram RCT e 5 eram coortes ajustadas multivariáveis, compreendendo um total de 10 147, dos quais 43,8% foram submetidos à revascularização completa. Em comparação com PCI apenas parcial, a revascularização completa foi associada a uma menor mortalidade por todas as causas (razão de risco 0,71; IC 95% 0,60-0,85; P < 0,01), mortalidade cardiovascular (razão de risco 0,64; IC 95% 0,52-0,79; P < 0,01) e infarto do miocárdio recorrente (razão de risco 0,65; IC 95% 0,50-0,85; P < 0,01). Não houve diferença significativa entre os grupos em relação ao risco de revascularizações (razão de risco 0,80; IC 95% 0,53-1,20; P = 0,28). Conclusão: Entre pacientes idosos com SCA e DAC multiarterial, a revascularização completa está associada a um menor risco de mortalidade por todas as causas, mortalidade cardiovascular e infarto do miocárdio recorrente.

Implementing a pharmacogenomic-driven algorithm to guide antiplatelet therapy among Caribbean Hispanics: a non-randomised clinical trial.

OBJECTIVES: To assess whether genotype-guided selection of oral antiplatelet drugs using a clinical decision support (CDS) algorithm reduces the rate of major adverse cardiovascular and cerebrovascular events (MACCEs) among Caribbean Hispanic patients, after 6 months. DESIGN: An open-label, multicentre, non-randomised clinical trial. SETTING: Eight secondary and tertiary care hospitals (public and private) in Puerto Rico. PARTICIPANTS: 300 Caribbean Hispanic patients on clopidogrel, both genders, underwent percutaneous coronary intervention (PCI) for acute coronary syndromes, stable ischaemic heart disease and documented extracardiac vascular diseases. INTERVENTIONS: Patients were separated into standard-of-care (SoC) and genotype-guided (pharmacogenetic (PGx)-CDS) groups (150 each) and stratified by risk scores. Risk scores were calculated based on a previously developed CDS risk prediction algorithm designed to make actionable treatment recommendations for each patient. Individual platelet function, genotypes, clinical and demographic data were included. Ticagrelor was recommended for patients with a high-risk score ≥2 in the PGx-CDS group only, the rest were kept or de-escalated to clopidogrel. The intervention took place within 3-5 days after PCI. Adherence medication score was also measured. PRIMARY AND SECONDARY OUTCOMES: The occurrence rate of MACCEs (primary) and bleeding episodes (secondary). Statistical associations between patient time free of events and predictor variables (ie, treatment groups, risk scores) were tested using Kaplan-Meier survival analyses and Cox proportional-hazards regression models. RESULTS: The genotype-guided group had a clinically lower but not significantly different risk of MACCEs compared with the SoC group (8.7% vs 10.7%, p=0.56; HR=0.56). Among high-risk score patients, genotype-driven guidance of antiplatelet therapy showed superiority over SoC in reducing MACCE incidence 6 months postcoronary stenting (adjusted HR=0.104; p< 0.0001). CONCLUSIONS: The potential benefit of implementing our PGx-CDS algorithm to significantly reduce the incidence rate of MACCEs in post-PCI Caribbean Hispanic patients on clopidogrel was observed exclusively among high-risk patients, with apparently no evident effect in other patient groups. TRIAL REGISTRATION NUMBER: NCT03419325.

Challenges and Advances in Interventional Cardiology for Coronary Artery Disease Management.

The development of percutaneous coronary intervention (PCI) has been one of the greatest advances in cardiology and has changed clinical practice for patients with coronary artery disease (CAD). Despite continuous improvements in operators' experience, techniques, and the development of new-generation devices, significant challenges remain in improving the efficacy of PCI, including calcification, bifurcation, multivascular disease, stent restenosis, and stent thrombosis, among others. The present review aims to provide an overview of the current status of knowledge of endovascular revascularization in CAD, including relevant trials, therapeutic strategies, and new technologies addressing particular scenarios that can impact the prognosis of this vulnerable population.

[Clinical outcomes of percutaneous intervention on the unprotected left main coronary artery]. / Desenlaces clínicos de la intervención percutánea sobre tronco coronario izquierdo no protegido.

Background: The debate on percutaneous coronary intervention (PCI) of the unprotected left main coronary artery (LMCA) has been constant over time. Objective: To investigate the clinical and procedural characteristics and cardiovascular outcomes of PCI of unprotected LMCA. Material and methods: Observational study which included patients with unprotected LMCA disease undergoing PCI; patients with cardiogenic shock prior to the procedure were excluded. We describe the clinical and angiographic characteristics, as well as the major adverse cardiac and cerebrovascular events (MACCE) according to the year of the procedure. Results: We included 73 patients, with a SYNTAX I score of 31.2 ± 9.1, mostly with ST-elevation acute coronary syndrome (35%). There was a higher frequency of triple vessel coronary disease (63%) and distal LMCA lesions (35%). The provisional stent technique was the most used for distal lesions (58%) and the 2-stent technique for bifurcation lesions (78%), supported by intravascular ultrasound (IVUS) in 38%. During follow-up, 19 presented MACCE (26%), out of which cardiac death occurred in 13%, non-cardiovascular death in 5%, non-fatal acute myocardial infarction in 1%, cerebrovascular event in 2%, and revascularization of the treated vessel in 4%. Conclusions: It was observed a similar frequency to the one appearing in other studies of cardiovascular events, mainly in patients with intermediate risk, which supports the increasing use of percutaneous intervention in this population.

Introducción: el debate sobre la intervención coronaria percutánea (ICP) del tronco coronario izquierdo (TCI) no protegido ha sido constante a lo largo del tiempo. Objetivo: investigar las características clínicas, de procedimiento y los desenlaces cardiovasculares de la ICP del TCI no protegido. Material y métodos: estudio observacional que incluyó pacientes con enfermedad del TCI no protegido sometidos a ICP; se excluyeron pacientes con choque cardiogénico previo al procedimiento. Describimos las características clínicas y angiográficas, así como los eventos adversos cardiovasculares y cerebrales mayores (MACCE) según el año del procedimiento. Resultados: incluimos 73 pacientes, con puntuación de SYNTAX I de 31.2 ± 9.1, mayormente con síndrome coronario agudo con elevación del ST (35%). Hubo mayor frecuencia de enfermedad coronaria trivascular (63%) y lesión distal del TCI (35%). La técnica de stent provisional fue la más usada para lesiones distales (58%) y la técnica de 2 stents para las lesiones en bifurcación (78%), con apoyo del ultrasonido intravascular (IVUS) en el 38%. En el seguimiento se presentaron 19 MACCE (26%), de los cuales la muerte de causa cardiaca se presentó en el 13%, muerte no cardiovascular en 5%, infarto agudo al miocardio no fatal en 1%, evento vascular cerebral en 2% y nueva revascularización del vaso tratado en 4%. Conclusiones: se observó una frecuencia similar a la de otros estudios de eventos cardiovasculares, especialmente en pacientes con riesgo intermedio, lo cual apoya el uso creciente de la intervención percutánea en esta población.

A new parameter in predicting contrast-induced nephropathy: Osaka prognostic score.

OBJECTIVE: Nowadays, the frequency of complications is also increasing following the increasing frequency of coronary angiography and percutaneous coronary intervention. Contrast-induced nephropathy is one of the most common of these complications. This study aimed to investigate the relationship between the Osaka prognostic score, which has previously been shown to have prognostic importance in gastrointestinal malignancies, and the development of contrast-induced nephropathy. METHODS: The study retrospectively examined the data of 1,498 patients who underwent coronary angiography and percutaneous coronary intervention due to acute coronary syndrome between 2018 and 2023. Demographic characteristics and laboratory findings were retrospectively collected from patients' charts and electronic medical records. RESULTS: Osaka prognostic score (0.84±0.25 vs. 2.2±0.32, p<0.001) was higher in patients who developed contrast-induced nephropathy. Also, Osaka prognostic score [OR 2.161 95%CI (1.101-4.241), p<0.001] was found to be an independent risk factor along with age, diabetes mellitus, systolic pulmonary artery pressure, hemoglobin, hemoglobin, C-reactive protein, albumin, N-terminal brain natriuretic peptide, and systemic immune-inflammation index. The receiver operating characteristic curve showed that the optimal cutoff value of Osaka prognostic score to predict the development of contrast-induced nephropathy was 1.5, with a sensitivity of 83.4 and a specificity of 65.9% [area under the curve: 0.874 (95%CI: 0.850-0.897, p≤0.001)]. CONCLUSION: Osaka prognostic score may be an easily calculable, user-friendly, and useful parameter to predict the development of contrast-induced nephropathy in patients undergoing percutaneous coronary intervention after acute coronary syndromes.

Antithrombotic Strategies in Atrial Fibrillation After ACS and/or PCI: A 4-Way Comparison From AUGUSTUS.

BACKGROUND: The optimal antithrombotic regimen for patients with atrial fibrillation (AF) who had an acute coronary syndrome (ACS) or have undergone percutaneous coronary intervention (PCI) is not known. OBJECTIVES: The authors sought to determine which antithrombotic regimen best balances safety and efficacy. METHODS: AUGUSTUS, a multicenter 2 × 2 factorial design randomized trial compared apixaban with vitamin K antagonist (VKA) and aspirin with placebo in patients with AF with recent ACS and/or PCI treated with a P2Y12 inhibitor. We conducted a 4-way analysis comparing safety and efficacy outcomes in the 4 randomized groups. The primary outcome was a composite of all-cause death, major or clinically relevant nonmajor bleeding, or hospitalization for cardiovascular causes over 6-month follow-up. Secondary outcomes included individual components of the primary endpoint. RESULTS: A total of 4,614 patients were enrolled. All patients were treated with a P2Y12 inhibitor. The primary endpoint occurred in 21.9% of patients randomized to apixaban plus placebo, 27.3% randomized to apixaban plus aspirin, 28.0% randomized to VKA plus placebo, and 33.3% randomized to VKA plus aspirin. Rates of major or clinically relevant nonmajor bleeding and hospitalization for cardiovascular causes were lower with apixaban and placebo compared with the other 3 antithrombotic strategies. There was no difference between the 4 randomized groups with respect to all-cause death. CONCLUSIONS: In patients with AF and a recent ACS and/or PCI, an antithrombotic regimen that included a P2Y12 inhibitor and apixaban without aspirin resulted in a lower incidence of the composite of death, bleeding, or cardiovascular hospitalization than regimens including VKA, aspirin, or both. (An Open-label, 2 x 2 Factorial, Randomized Controlled, Clinical Trial to Evaluate the Safety of Apixaban vs. Vitamin K Antagonist and Aspirin vs. Aspirin Placebo in Patients with Atrial Fibrillation and Acute Coronary Syndrome or Percutaneous Coronary Intervention; NCT02415400).

Prevalence and prognostic implications of the no-reflux phenomenon in patients undergoing primary percutaneous coronary intervention at a university center in a middle-income country.

OBJECTIVE: To analyze the prevalence of no-reflow and the 30-day mortality in a university center in a middle-income country. METHOD: We analyzed 2463 patients who underwent primary PCI from January 2006 to December 2021. The outcome measure was 30-day mortality. RESULTS: Of a total of 2463 patients, no-reflow phenomenon was found in 413 (16.8%) patients, 30-day mortality was 16.7 vs. 4.29% (p < 0.001). Patients with no-reflow were older 60 (53-69.5) vs. 59 (51-66) (p = 0.001), with a higher delay in onset of symptom to emergency department arrival 270 vs. 247 min (p = 0.001). No-reflow patients also had had fewer previous myocardial infarction, 11.6 vs. 18.4 (p = 0.001) and a Killip class > 1, 37 vs. 26% (p < 0.001). No-reflow patients were more likely to have an anterior myocardial infarction (55.4 vs. 47.8%; p = 0.005) and initial TIMI flow 0 (76 vs. 68%; p < 0.001). CONCLUSION: No-reflow occurred in 16.8% of STEMI patients undergoing primary PCI and was more likely with older age, delayed presentation, anterior myocardial infarction and Killip class > 1. No-reflow was associated with a higher mortality at 30-day follow-up.

OBJETIVOS: Analizar la prevalencia de no reflujo y la mortalidad a 30 días en un centro universitario de un país de ingresos medios. MÉTODO: Analizamos 2,463 pacientes que se sometieron a ICP primaria desde enero de 2006 hasta diciembre de 2021. La medida de resultado fue la mortalidad a los 30 días. RESULTADOS: Del total de 2,463 pacientes, se encontró fenómeno de no reflujo en 413 (16.8%), la mortalidad a los 30 días fue del 16.7 vs. 4.29% (p < 0.001). Los pacientes sin reflujo tenían mayor edad 60 (53-69.5) vs. 59 (51-66) (p = 0.001), con mayor retraso del inicio de los síntomas a la llegada a urgencias, 270 vs. 247 min (p = 0.001). Los pacientes sin reflujo también tenían menos infarto de miocardio previo, 11.6 vs. 18.4 (p = 0.001), y una clase Killip > 1, 37 vs. 26% (p < 0.001). Los pacientes sin reflujo tenían más probabilidades de tener un infarto de miocardio anterior (55.4 vs. 47.8%; p = 0.005) y flujo TIMI inicial 0 (76 vs. 68%; p < 0.001). CONCLUSIÓN: Ocurrió ausencia de reflujo en el 16.8% de los pacientes con IAMCEST sometidos a ICP primaria y fue más probable con la edad avanzada, presentación tardía, infarto de miocardio anterior y clase Killip > 1. El no reflujo se asoció con una mayor mortalidad a los 30 días de seguimiento.

Prognostic value of angiographic microvascular resistance in patients with ST-segment elevation myocardial infarction.

BACKGROUND: The Angiographic Microvascular Resistance (AMR), derived from a solitary angiographic view, has emerged as a viable substitute for the Index of Microcirculatory Resistance (IMR). However, the prognostic significance in ST-Segment Elevation Myocardial Infarction (STEMI) patients is yet to be established. This research endeavors to explore the prognostic capabilities of AMR in patients diagnosed with STEMI. METHODS: In this single-center, retrospective study, 232 patients diagnosed with STEMI who received primary Percutaneous Coronary Intervention (PCI) were recruited from January 1, 2018, to June 30, 2022. Utilizing the maximally selected log-rank statistics analysis, participants were divided into two cohorts according to an AMR threshold of 2.55 mmHg*s/cm. The endpoint evaluated was a composite of all-cause mortality or hospital readmission due to heart failure. RESULTS: At a median follow-up of 1.74 (1.07, 3.65) years, the composite endpoint event was observed in 28 patients within the higher AMR group and 8 patients within the lower AMR group. The higher AMR group showed a significantly higher risk for composite outcome compared to those within the low-AMR group (HRadj: 3.33; 95% CI 1.30‒8.52; p = 0.03). AMR ≥ 2.55 mmHg*s/cm was an independent predictor of the composite endpoint (HR = 2.33; 95% CI 1.04‒5.21; p = 0.04). Furthermore, a nomogram containing age, sex, left ventricle ejection fraction, post-PCI Quantitative Flow Ratio (QFR), and AMR was developed and indicated a poorer prognosis in the high-risk group for STEMI patients at 3 years. (HR=4.60; 95% CI 1.91‒11.07; p < 0.01). CONCLUSIONS: AMR measured after PCI can predict the risk of all-cause death or readmission for heart failure in patients with STEMI. AMR-involved nomograms improved predictive performance over variables alone.

Preoperative coronary interventions for preventing acute myocardial infarction in the perioperative period of major open vascular or endovascular surgery.

BACKGROUND: Postoperative myocardial infarction (POMI) is associated with major surgeries and remains the leading cause of mortality and morbidity in people undergoing vascular surgery, with an incidence rate ranging from 5% to 20%. Preoperative coronary interventions, such as coronary artery bypass grafting (CABG) or percutaneous coronary interventions (PCI), may help prevent acute myocardial infarction in the perioperative period of major vascular surgery when used in addition to routine perioperative drugs (e.g. statins, angiotensin-converting enzyme inhibitors, and antiplatelet agents), CABG by creating new blood circulation routes that bypass the blockages in the coronary vessels, and PCI by opening up blocked blood vessels. There is currently uncertainty around the benefits and harms of preoperative coronary interventions. OBJECTIVES: To assess the effects of preoperative coronary interventions for preventing acute myocardial infarction in the perioperative period of major open vascular or endovascular surgery. SEARCH METHODS: We searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, and CINAHL EBSCO on 13 March 2023. We also searched the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov. SELECTION CRITERIA: We included all randomised controlled trials (RCTs) or quasi-RCTs that compared the use of preoperative coronary interventions plus usual care versus usual care for preventing acute myocardial infarction during major open vascular or endovascular surgery. We included participants of any sex or any age undergoing major open vascular surgery, major endovascular surgery, or hybrid vascular surgery. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes of interest were acute myocardial infarction, all-cause mortality, and adverse events resulting from preoperative coronary interventions. Our secondary outcomes were cardiovascular mortality, quality of life, vessel or graft secondary patency, and length of hospital stay. We reported perioperative and long-term outcomes (more than 30 days after intervention). We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: We included three RCTs (1144 participants). Participants were randomised to receive either preoperative coronary revascularisation with PCI or CABG plus usual care or only usual care before major vascular surgery. One trial enrolled participants if they had no apparent evidence of coronary artery disease. Another trial selected participants classified as high risk for coronary disease through preoperative clinical and laboratorial testing. We excluded one trial from the meta-analysis because participants from both the control and the intervention groups were eligible to undergo preoperative coronary revascularisation. We identified a high risk of performance bias in all included trials, with one trial displaying a high risk of other bias. However, the risk of bias was either low or unclear in other domains. We observed no difference between groups for perioperative acute myocardial infarction, but the evidence is very uncertain (risk ratio (RR) 0.28, 95% confidence interval (CI) 0.02 to 4.57; 2 trials, 888 participants; very low-certainty evidence). One trial showed a reduction in incidence of long-term (> 30 days) acute myocardial infarction in participants allocated to the preoperative coronary interventions plus usual care group, but the evidence was very uncertain (RR 0.09, 95% CI 0.03 to 0.28; 1 trial, 426 participants; very low-certainty evidence). There was little to no effect on all-cause mortality in the perioperative period when comparing the preoperative coronary intervention plus usual care group to usual care alone, but the evidence is very uncertain (RR 0.79, 95% CI 0.31 to 2.04; 2 trials, 888 participants; very low-certainty evidence). The evidence is very uncertain about the effect of preoperative coronary interventions on long-term (follow up: 2.7 to 6.2 years) all-cause mortality (RR 0.74, 95% CI 0.30 to 1.80; 2 trials, 888 participants; very low-certainty evidence). One study reported no adverse effects related to coronary angiography, whereas the other two studies reported five deaths due to revascularisations. There may be no effect on cardiovascular mortality when comparing preoperative coronary revascularisation plus usual care to usual care in the short term (RR 0.07, 95% CI 0.00 to 1.32; 1 trial, 426 participants; low-certainty evidence). Preoperative coronary interventions plus usual care in the short term may reduce length of hospital stay slightly when compared to usual care alone (mean difference -1.17 days, 95% CI -2.05 to -0.28; 1 trial, 462 participants; low-certainty evidence). We downgraded the certainty of the evidence due to concerns about risk of bias, imprecision, and inconsistency. None of the included trials reported on quality of life or vessel graft patency at either time point, and no study reported on adverse effects, cardiovascular mortality, or length of hospital stay at long-term follow-up. AUTHORS' CONCLUSIONS: Preoperative coronary interventions plus usual care may have little or no effect on preventing perioperative acute myocardial infarction and reducing perioperative all-cause mortality compared to usual care, but the evidence is very uncertain. Similarly, limited, very low-certainty evidence shows that preoperative coronary interventions may have little or no effect on reducing long-term all-cause mortality. There is very low-certainty evidence that preoperative coronary interventions plus usual care may prevent long-term myocardial infarction, and low-certainty evidence that they may reduce length of hospital stay slightly, but not cardiovascular mortality in the short term, when compared to usual care alone. Adverse effects of preoperative coronary interventions were poorly reported in trials. Quality of life and vessel or graft patency were not reported. We downgraded the certainty of the evidence most frequently for high risk of bias, inconsistency, or imprecision. None of the analysed trials provided significant data on subgroups of patients who could potentially experience more substantial benefits from preoperative coronary intervention (e.g. altered ventricular ejection fraction). There is a need for evidence from larger and homogeneous RCTs to provide adequate statistical power to assess the role of preoperative coronary interventions for preventing acute myocardial infarction in the perioperative period of major open vascular or endovascular surgery.

Evaluation of Success and Complications Scores for Chronic Total Occlusion Percutaneous Coronary Interventions: Insights from the Latin American Registry.

Chronic total occlusion (CTO) percutaneous coronary intervention is a complex procedure and is associated with considerable risk of complications. Several success and complication scores have been developed; however, data regarding their external validation in other populations such as Latin America are scarce. This study aimed to evaluate the accuracy of the main predictors of success and complications in a broad cohort of procedures in the Latin American (LATAM) CTO registry. From April 2008 to December 2023, 3,706 consecutive procedures listed in the LATAM CTO registry were screened. Of these, 2,835 procedures had sufficient information to analyze the Multicenter CTO Registry in Japan (J-CTO); Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS); Ostial location, Rentrop grade, and Age (ORA); Clinical and Lesion-related Score (CL-score); and EuroCTO Score (CASTLE) success scores. The complication scores were PROGRESS (MACE, mortality, and pericardiocentesis) and Outcomes, Patient health status, and Efficiency iN Chronic Total Occlusion hybrid procedures (OPEN-CTO),OPEN-CLEAN. The J-CTO and CASTLE scores demonstrated the highest areas under the curve (AUC) of 0.718 and 0.703, respectively. The AUC value for the CL-score was 0.685, whereas the PROGRESS score had an AUC of 0.598 and the ORA AUC was 0.545. The level of agreement between scores was low; only 4% of the procedures were classified as difficult or very difficult by all scores and <1% were classified as easy by all 5 scores. Of the complication scores, PROGRESS mortality (AUC 0.651) and PROGRESS MACE (AUC 0.588) showed the best performance, identifying groups with >10% event rate. These results may improve the selection of revascularization techniques, especially for patient demographics that are historically underrepresented in CTO research.

Effects of different early cardiac rehabilitation exercise treatments on the prognosis of acute myocardial infarction patients receiving percutaneous coronary intervention.

OBJECTIVES: Exercise rehabilitation is the core of Cardiac Rehabilitation (CR) and will improve the prognosis of patients receiving Percutaneous Coronary Intervention (PCI surgery). The current study retrospectively analyzed the effects of different exercise-based CR strategies on the prognosis of AMI patients receiving PCI treatment. METHODS: Clinicopathological information from 127 patients was collected and divided into different groups based on the exercise-based CR received, including Continuous Resistance Exercise (COR), Continuous Aerobic Exercise (COA), Interval Resistance Exercise (IVR), Interval Aerobic Exercise (IVA), Inspiratory Muscle Exercises (ITM), and Control. The differences regarding cardio-pulmonary function, hemodynamics, and life quality were analyzed against different CR strategies. RESULTS: All the exercise-based CR strategies showed improving effects compared with patients in the Control group regarding cardio-pulmonary parameters, with IVR showing the strongest improving effects (IVR > ITM > COR > IVA > COA) (p < 0.05) at the first recoding point. However, the improving effects of exercise-based CR declined with time. Regarding the effects on hemodynamics parameters, the improving effects of exercise-based CR were only observed regarding LVEF, and the effects of IVR were also the strongest (IVR > COR > ITM > COA > IVA) (p < 0.05). Similar improving effects were also observed for 6MWT and life quality (IVR showing the strongest improving effects) (p < 0.05), which all declined three months after the surgery. CONCLUSIONS: The current study showed that exercise-based CRs had better improving effects than the normal nursing strategy on the prognosis of AMI patients receiving PCI surgery.

Antithrombotic Strategies According to Age: Insights from the AUGUSTUS Trial.

OBJECTIVE: We aimed to evaluate the safety and efficacy of antithrombotic strategies by age in patients with atrial fibrillation and acute coronary syndrome and/or percutaneous coronary intervention in AUGUSTUS. METHODS: Patients were stratified into 3 age groups: <65, 65-74, and ≥75 years. Outcomes of interest were major or clinically relevant non-major bleeding, major bleeding, death or rehospitalization, and ischemic events. Treatment effects of apixaban vs. vitamin K antagonist (VKA) and aspirin vs. placebo were assessed across age groups using Cox models. RESULTS: Of 4614 patients, 1267 (27.5%) were <65, 1802 (39.0%) were 65-74, and 1545 (33.5%) were ≥75 years. Apixaban was associated with lower rates of major or clinically relevant non-major bleeding than VKA (<65: HR 0.69 [0.47-1.00]; 65-74: HR 0.57 [0.43-0.75]; ≥75: HR 0.81 [0.63-1.04]). Death or hospitalization occurred less often with apixaban, regardless of age. No differences were observed in rates of ischemic events between apixaban and VKA according to age. Aspirin was associated with higher rates of bleeding than placebo (<65: HR 1.67 [1.15-2.43]; 65-74: HR 2.32 [1.73-3.10]; ≥75: HR 1.69 [1.31-2.19]). Rates of death or rehospitalization and ischemic events were similar among patients receiving aspirin or placebo across age groups. CONCLUSIONS: Apixaban was associated with greater absolute reduction in bleeding than VKA in older age groups, reflecting their higher hemorrhagic risk. Aspirin increased bleeding in all age groups vs. placebo. Our findings support the use of apixaban plus a purinergic receptor P2Y12(P2Y12) inhibitor without aspirin in patients with atrial fibrillation and recent acute coronary syndrome/percutaneous coronary intervention, regardless of age.

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

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.

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% 1,15­6,76, 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% 0,77­0,93). CONCLUSÃO: Após ajuste para os fatores de risco no modelo de previsão do GRACE, as mulheres continuam em maior risco de mortalidade hospitalar.

Evaluation of the Patients with Recurrent Angina After Coronary Artery Bypass Grafting.

INTRODUCTION: In this study, we aimed to evaluate the most common causes of recurrent angina after coronary artery bypass grafting (CABG) and our treatment approaches applied in these patients. METHODS: We included all patients who underwent CABG, with or without percutaneous coronary intervention after CABG, at our hospital from September 2013 to December 2019. Patients were divided into two groups according to the time of onset of anginal pain after CABG. Forty-five patients (58.16 ± 8.78 years) had recurrent angina in the first postoperative year after CABG and were specified as group I (early recurrence). Group II (late recurrence) comprised 82 patients (58.05 ± 8.95 years) with angina after the first year of CABG. RESULTS: The mean preoperative left ventricular ejection fraction was 53.22 ± 8.87% in group I, and 54.7 ± 8.58% in group II (P=0.38). No significant difference was registered between groups I and II regarding preoperative angiographic findings (P>0.05). Failed grafts were found in 27.7% (n=28/101) of the grafts in group I as compared to 26.8% (n=51/190) in group II (P>0.05). Twenty-four (53.3%) patients were treated medically in group I, compared with 54 (65.8%) patients in group II (P=0.098). There was a need for intervention in 46.6% (n=21) of group I patients, and in 34.1% (n=28) of group II patients. CONCLUSION: Recurrent angina is a complaint that should not be neglected because most of the patients with recurrent angina are diagnosed with either native coronary or graft pathology in coronary angiography performed.

Partial-Cost Analysis and Economic Impact of Ambulatory Coronary Angioplasty in a Private Hospital in the Caribbean: Análisis Parcial de Costos e Impacto Económico de la Angioplastia Coronaria Ambulatoria en un Hospital Privado del Caribe.

OBJECTIVES: This study aimed to assess direct costs of percutaneous coronary intervention (PCI) without hospital admission versus PCI with hospital admission longer than 24 hours in a private hospital-institutional perspective in the Dominican Republic in 2022. METHODS: This study has a comparative approach based on a prospective cross-sectional partial-cost analysis. We evaluated the direct costs of 10 patients from PCI without hospital admission approach and 10 patients from a hospital admission longer than 24 hours as a control group. We used a "first-come-first-served" approach from December 2021 to March 2022. The analysis used the electronic invoice generated for each patient. RESULTS: PCI without hospital admission approach represents $472.56 in patient savings, equivalent to a cost reduction of 12.5%. The subcosts analysis showed the pharmacy section as the main driver of the overall cost difference. CONCLUSIONS: PCI without hospital admission was economically cost-saving compared with the control approach in direct costs in the Dominican perspective. The economic benefit is substantial and compliments the ease of use. This analysis may lead to improvements in institutional management of resources and can potentially be adapted to other health systems in the region.

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

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.

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.

Impact of previous percutaneous coronary intervention on angiographic and clinical outcomes in patients with ST-segment elevation myocardial infarction.

BACKGROUND: The prognosis of patients with ST-segment elevation myocardial infarction (STEMI) and previous percutaneous coronary intervention (PCI) is uncertain. OBJECTIVE: To evaluate if previous PCI in patients with STEMI increases the risk of major cardiovascular events, and if final epicardial blood flow differs according to the reperfusion strategy. MATERIAL AND METHODS: Observational, longitudinal, comparative sub-study of the PHASE-MX trial that included patients with STEMI and reperfusion within 12 hours of symptom onset, who were classified according to their history of PCI. The occurrence of the composite primary endpoint (cardiovascular death, re-infarction, congestive heart failure and cardiogenic shock) within 30 days was evaluated using Kaplan-Meier estimates, log-rank test and Cox proportional hazards model. Epicardial blood flow was assessed using the TIMI grading system after reperfusion. RESULTS: A total of 935 patients were included; 85.6% were males and 6.9% had a history of PCI; 53% underwent pharmacoinvasive therapy, and 47%, primary PCI. The incidence of the composite primary endpoint at 30 days in patients with a history of PCI was 9.8% vs 13.3% in those with no previous PCI (p = 0.06). Among the patients with previous PCI, 87.1% reached a final TIMI grade 3 flow after primary PCI vs. 75% in the group with pharmacoinvasive strategy (p = 0.235). CONCLUSIONS: A history of PCI does not increase the risk of major cardiovascular events at 30 days; however, it impacted negatively on the final angiographic blood flow of patients that received pharmacoinvasive therapy (compared to primary PCI).

ANTECEDENTES: El pronóstico de los pacientes con infarto agudo de miocardio con elevación del segmento ST (IAMCEST) y antecedente de intervención coronaria percutánea (ICP) es incierto. Objetivos: Evaluar si la ICP previa en pacientes con IAMCEST incrementa el riesgo de eventos cardiovasculares mayores y si el flujo final epicárdico varía según la estrategia de reperfusión. MATERIAL Y MÉTODOS: Subestudio de PHASE-MX, observacional, longitudinal y comparativo, de pacientes con IAMCEST reperfundidos en menos de 12 horas de iniciados los síntomas, divididos conforme el antecedente de ICP. El acaecimiento del criterio de valoración principal (muerte cardiovascular, reinfarto, insuficiencia cardíaca y choque cardiogénico) dentro de los 30 días se comparó con estimaciones de Kaplan-Meier, prueba de rangos logarítmicos y modelo de riesgos proporcionales de Cox. El flujo epicárdico final se evaluó con el sistema de clasificación del flujo TIMI después de la reperfusión. RESULTADOS: Se incluyeron 935 pacientes, 85.6 % del sexo masculino, 6.9 % de los cuales tenía antecedente de ICP; 53 % recibió terapia farmacoinvasiva y 47 %, ICP primaria. La incidencia del criterio de valoración principal en pacientes con ICP previa fue de 9.8 % versus 13.3 % en aquellos sin ese antecedente (p = 0.06); 87.1 % de los pacientes con ICP previa obtuvo flujo final de grado TIMI 3 versus 75 % del grupo con estrategia farmacoinvasiva (p = 0.235). CONCLUSIONES: El antecedente de ICP no incrementa el riesgo de eventos cardiovasculares mayores a los 30 días en pacientes con IAMCEST; sin embargo, impacta negativamente en el flujo sanguíneo angiográfico final de los pacientes que recibieron terapia farmacoinvasiva (en comparación con ICP primaria).