Sex-based analysis of NSTEMI processes of care and outcomes by hospital: a nationwide cohort study.

BACKGROUND: Contemporary studies demonstrate that non-ST-segment elevation myocardial infarction (NSTEMI) processes of care vary according to sex. Little is known regarding variation in practice between geographical areas and centers. METHODS: We identified 305 014 NSTEMI admissions in the United Kingdom (UK) Myocardial Infarction National Audit Project (MINAP), 2010-2017, including female sex (110 209). Hierarchical, multivariate logistic regression models were fitted assessing for differences in primary outcomes according to sex. Risk standardized mortality rates (RSMR) were calculated for individual hospitals to illustrate correlation with variables of interest. 'Heat-maps' were plotted to show regional and sex-based variation in opportunity-based quality-indicator score (surrogate for optimal processes of care). RESULTS: Women presented older (77y vs. 69y, P < 0.001) and were more often Caucasian (93% vs. 91%, P < 0.001). Women were less frequently managed with an invasive coronary angiogram (ICA) (58% vs. 75%, P < 0.001) or percutaneous coronary intervention (PCI) (35% vs. 49%, P < 0.001)). In our hospital-clustered analysis, we show positive correlation between the RSMR and increasing proportion of women treated for NSTEMI (R2 = 0.17, P < 0.001). There was clear negative correlation between proportion of women who had an optimum OBQI score during their admission and RSMR (R2 = 0.22, P < 0.001), with weaker correlation in men (R2 = 0.08, P < 0.001). Heat-maps according to clinical commissioning group (CCG) demonstrate significant regional variation in OBQI score, with women receiving poorer quality care throughout the UK. CONLUSION: There was a significant in variation of the management of patients with NSTEMI according to sex, with widespread geographical variation. Structural changes are required to enable improved care for women.

Performing elective cardiac invasive procedures during the COVID-19 outbreak: a position statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI).

The rearrangement of healthcare services required to face the coronavirus disease 2019 (COVID-19) pandemic led to a drastic reduction in elective cardiac invasive procedures. We are already facing a "second wave" of infections and we might be dealing during the next months with a "third wave" and subsequently new waves. Therefore, during the different waves of the COVID-19 pandemic we have to face the problems of how to perform elective cardiac invasive procedures in non-COVID patients and which patients/procedures should be prioritised. In this context, the interplay between the pandemic stage, the availability of healthcare resources and the priority of specific cardiac disorders is crucial. Clear pathways for "hot" or presumed "hot" patients and "cold" patients are mandatory in each hospital. Depending on the local testing capacity and intensity of transmission in the area, healthcare facilities may test patients for SARS-CoV-2 infection before the interventional procedure, regardless of risk assessment for COVID-19. Pre-hospital testing should always be conducted in the presence of symptoms suggestive of SARS-CoV-2 infection. In cases of confirmed or suspected COVID-19 positive patients, full personal protective equipment using FFP 2/N95 masks, eye protection, gowning and gloves is indicated during cardiac interventions for healthcare workers. When patients have tested negative for COVID-19, medical masks may be sufficient. Indeed, individual patients should themselves wear medical masks during cardiac interventions and outpatient visits.

EAPCI Core Curriculum for Percutaneous Cardiovascular Interventions (2020): Committee for Education and Training European Association of Percutaneous Cardiovascular Interventions (EAPCI). A branch of the European Society of Cardiology.

The proposed 2020 Core Curriculum for Percutaneous Cardiovascular Interventions aims to provide an updated European consensus that defines the level of experience and knowledge in the field of percutaneous cardiovascular intervention (PCI). It promotes homogenous education and training programmes among countries, and is the cornerstone of the new EAPCI certification, designed to support the recognition of competencies at the European level and the free movement of certified specialists in the European Community. It is based on a thorough review of the ESC guidelines and of the EAPCI textbook on percutaneous interventional cardiovascular medicine. The structure of the current core curriculum evolved from previous EAPCI core curricula and from the "2013 core curriculum of the general cardiologist" to follow the current ESC recommendations for core curricula. In most subject areas, there was a wide - if not unanimous - consensus among the task force members on the training required for the interventional cardiologist of the future. The document recommends that acquisition of competence in interventional cardiology requires at least two years of postgraduate training, in addition to four years devoted to cardiology. The first part of the curriculum covers general aspects of training and is followed by a comprehensive description of the specific components in 54 chapters. Each of the chapters includes statements of the objectives, and is further subdivided into the required knowledge, skills, behaviours, and attitudes.

Differences in 30-day complications and 1-year mortality by sex in patients with a first STEMI managed by the Codi IAM network between 2010 and 2016.

INTRODUCTION AND OBJECTIVES: ST-segment elevation myocardial infarction (STEMI) emergency care networks aim to increase reperfusion rates and reduce ischemic times. The influence of sex on prognosis is still being debated. Our objective was to analyze prognosis according to sex after a first STEMI. METHODS: This multicenter cohort study enrolled first STEMI patients from 2010 to 2016 to determine the influence of sex after adjustment for revascularization delays, age, and comorbidities. End points were 30-day mortality, the 30-day composite of mortality, ventricular fibrillation, pulmonary edema, or cardiogenic shock, and 1-year all-cause mortality. RESULTS: From 2010 to 2016, 14 690 patients were included; 24% were women. The median [interquartile range] time from electrocardiogram to artery opening decreased throughout the study period in both sexes (119 minutes [85-160] vs 109 minutes [80-153] in 2010, 102 minutes [81-133] vs 96 minutes [74-124] in 2016, both P=.001). The rates of primary PCI within 120 minutes increased in the same period (50.4% vs 57.9% and 67.1% vs 72.1%, respectively; both P=.001). After adjustment for confounders, female sex was not associated with 30-day complications (OR, 1.06; 95%CI, 0.91-1.22). However, female 30-day survivors had a lower adjusted 1-year mortality than their male counterparts (HR,0.76; 95%CI, 0.61-0.95). CONCLUSIONS: Compared with men, women with a first STEMI had similar 30-day mortality and complication rates but significantly lower 1-year mortality after adjustment for age and severity.

El riesgo competitivo puede explicar en gran medida la disminución de los ingresos por enfermedad cardiovascular aguda durante la pandemia de COVID-19. Respuesta / Competing risk largely explains the drop in admissions for acute cardiovascular disease during the COVID-19 pandemic. Response

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EAPCI Position Statement on Invasive Management of Acute Coronary Syndromes during the COVID-19 pandemic.

The coronavirus disease 2019 (COVID-19) pandemic poses an unprecedented challenge to healthcare worldwide. The infection can be life threatening and require intensive care treatment. The transmission of the disease poses a risk to both patients and healthcare workers. The number of patients requiring hospital admission and intensive care may overwhelm health systems and negatively affect standard care for patients presenting with conditions needing emergency interventions. This position statements aims to assist cardiologists in the invasive management of acute coronary syndrome (ACS) patients in the context of the COVID-19 pandemic. To that end, we assembled a panel of interventional cardiologists and acute cardiac care specialists appointed by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) and from the Acute Cardiovascular Care Association (ACVC) and included the experience from the first and worst affected areas in Europe. Modified diagnostic and treatment algorithms are proposed to adapt evidence-based protocols for this unprecedented challenge. Various clinical scenarios, as well as management algorithms for patients with a diagnosed or suspected COVID-19 infection, presenting with ST- and non-ST-segment elevation ACS are described. In addition, we address the need for re-organization of ACS networks, with redistribution of hub and spoke hospitals, as well as for in-hospital reorganization of emergency rooms and cardiac units, with examples coming from multiple European countries. Furthermore, we provide a guidance to reorganization of catheterization laboratories and, importantly, measures for protection of healthcare providers involved with invasive procedures.

Drug-eluting stents in elderly patients with coronary artery disease (SENIOR): a randomised single-blind trial.

BACKGROUND: Elderly patients regularly receive bare-metal stents (BMS) instead of drug-eluting stents (DES) to shorten the duration of double antiplatelet therapy (DAPT). The aim of this study was to compare outcomes between these two types of stents with a short duration of DAPT in such patients. METHODS: In this randomised single-blind trial, we recruited patients from 44 centres in nine countries. Patients were eligible if they were aged 75 years or older; had stable angina, silent ischaemia, or an acute coronary syndrome; and had at least one coronary artery with a stenosis of at least 70% (≥50% for the left main stem) deemed eligible for percutaneous coronary intervention (PCI). Exclusion criteria were indication for myocardial revascularisation by coronary artery bypass grafting; inability to tolerate, obtain, or comply with DAPT; requirement for additional surgery; non-cardiac comorbidities with a life expectancy of less than 1 year; previous haemorrhagic stroke; allergy to aspirin or P2Y12 inhibitors; contraindication to P2Y12 inhibitors; and silent ischaemia of less than 10% of the left myocardium with a fractional flow reserve of 0·80 or higher. After the intended duration of DAPT was recorded (1 month for patients with stable presentation and 6 months for those with unstable presentation), patients were randomly allocated (1:1) by a central computer system (blocking used with randomly selected block sizes [two, four, eight, or 16]; stratified by site and antiplatelet agent) to either a DES or similar BMS in a single-blind fashion (ie, patients were masked), but those assessing outcomes were masked. The primary outcome was to compare major adverse cardiac and cerebrovascular events (ie, a composite of all-cause mortality, myocardial infarction, stroke, or ischaemia-driven target lesion revascularisation) between groups at 1 year in the intention-to-treat population, assessed at 30 days, 180 days, and 1 year. This trial is registered with ClinicalTrials.gov, number NCT02099617. FINDINGS: Between May 21, 2014, and April 16, 2016, we randomly assigned 1200 patients (596 [50%] to the DES group and 604 [50%] to the BMS group). The primary endpoint occurred in 68 (12%) patients in the DES group and 98 (16%) in the BMS group (relative risk [RR] 0·71 [95% CI 0·52-0·94]; p=0·02). Bleeding complications (26 [5%] in the DES group vs 29 [5%] in the BMS group; RR 0·90 [0·51-1·54]; p=0·68) and stent thrombosis (three [1%] vs eight [1%]; RR 0·38 [0·00-1·48]; p=0·13) at 1 year were infrequent in both groups. INTERPRETATION: Among elderly patients who have PCI, a DES and a short duration of DAPT are better than BMS and a similar duration of DAPT with respect to the occurrence of all-cause mortality, myocardial infarction, stroke, and ischaemia-driven target lesion revascularisation. A strategy of combination of a DES to reduce the risk of subsequent repeat revascularisations with a short BMS-like DAPT regimen to reduce the risk of bleeding event is an attractive option for elderly patients who have PCI. FUNDING: Boston Scientific.

Clinical impact of intravascular ultrasound guidance in drug-eluting stent implantation for unprotected left main coronary disease: pooled analysis at the patient-level of 4 registries.

OBJECTIVES: This study sought to investigate the clinical impact of the use of intravascular ultrasound (IVUS) during revascularization of patients with left main coronary artery (LM) disease with drug-eluting stents (DES). BACKGROUND: Whether the use of IVUS during the procedure adds a clinical benefit remains unclear. There is only 1 previous observational study, with relevant limitations, supporting the value of this strategy. METHODS: We performed a patient-level pooled analysis of 4 registries of patients with LM disease treated with DES in Spain. A propensity score-matching method was used to obtain matched pairs of patients with and without IVUS guidance. RESULTS: A total of 1,670 patients were included, and 505 patients (30.2%) underwent DES implantation under IVUS guidance (IVUS group). By means of the matching method, 505 patients without the use of IVUS during revascularization were selected (no-IVUS group). Survival free of cardiac death, myocardial infarction, and target lesion revascularization at 3 years was 88.7% in the IVUS group and 83.6% in the no-IVUS group (p = 0.04) for the overall population, and 90% and 80.7%, respectively (p = 0.03), for the subgroups with distal LM lesions. The incidence of definite and probable thrombosis was significantly lower in the IVUS group (0.6% vs. 2.2%; p = 0.04). Finally, IVUS-guided revascularization was identified as an independent predictor for major adverse events in the overall population (hazard ratio: 0.70, 95% confidence interval: 0.52 to 0.99; p = 0.04) and in the subgroup with distal lesions (hazard ratio: 0.54, 95% confidence interval: 0.34 to 0.90; p = 0.02). CONCLUSIONS: The results of this pooled analysis show an association of IVUS guidance during percutaneous coronary intervention with better outcomes in patients with LM disease undergoing revascularization with DES.

Consensus document on the radial approach in percutaneous cardiovascular interventions: position paper by the European Association of Percutaneous Cardiovascular Interventions and Working Groups on Acute Cardiac Care** and Thrombosis of the European Society of Cardiology.

Radial access use has been growing steadily but, despite encouraging results, still varies greatly among operators, hospitals, countries and continents. Twenty years from its introduction, it was felt that the time had come to develop a common evidence-based view on the technical, clinical and organisational implications of using the radial approach for coronary angiography and interventions. The European Association of Percutaneous Cardiovascular Interventions (EAPCI) has, therefore, appointed a core group of European and non-European experts, including pioneers of radial angioplasty and operators with different practices in vascular access supported by experts nominated by the Working Groups on Acute Cardiac Care and Thrombosis of the European Society of Cardiology (ESC). Their goal was to define the role of the radial approach in modern interventional practice and give advice on technique, training needs, and optimal clinical indications.

HoliMAb: a holistic approach for Media-Adventitia border detection in intravascular ultrasound.

We present a fully automatic methodology for the detection of the Media-Adventitia border (MAb) in human coronary artery in Intravascular Ultrasound (IVUS) images. A robust border detection is achieved by means of a holistic interpretation of the detection problem where the target object, i.e. the media layer, is considered as part of the whole vessel in the image and all the relationships between tissues are learnt. A fairly general framework exploiting multi-class tissue characterization as well as contextual information on the morphology and the appearance of the tissues is presented. The methodology is (i) validated through an exhaustive comparison with both Inter-observer variability on two challenging databases and (ii) compared with state-of-the-art methods for the detection of the MAb in IVUS. The obtained averaged values for the mean radial distance and the percentage of area difference are 0.211 mm and 10.1%, respectively. The applicability of the proposed methodology to clinical practice is also discussed.

Fusing in-vitro and in-vivo intravascular ultrasound data for plaque characterization.

Accurate detection of in-vivo vulnerable plaque in coronary arteries is still an open problem. Recent studies show that it is highly related to tissue structure and composition. Intravascular Ultrasound (IVUS) is a powerful imaging technique that gives a detailed cross-sectional image of the vessel, allowing to explore arteries morphology. IVUS data validation is usually performed by comparing post-mortem (in-vitro) IVUS data and corresponding histological analysis of the tissue. The main drawback of this method is the few number of available case studies and validated data due to the complex procedure of histological analysis of the tissue. On the other hand, IVUS data from in-vivo cases is easy to obtain but it can not be histologically validated. In this work, we propose to enhance the in-vitro training data set by selectively including examples from in-vivo plaques. For this purpose, a Sequential Floating Forward Selection method is reformulated in the context of plaque characterization. The enhanced classifier performance is validated on in-vitro data set, yielding an overall accuracy of 91.59% in discriminating among fibrotic, lipidic and calcified plaques, while reducing the gap between in-vivo and in-vitro data analysis. Experimental results suggest that the obtained classifier could be properly applied on in-vivo plaque characterization and also demonstrate that the common hypothesis of assuming the difference between in-vivo and in-vitro as negligible is incorrect.

Fast rigid registration of vascular structures in IVUS sequences.

Intravascular ultrasound (IVUS) technology permits visualization of high-resolution images of internal vascular structures. IVUS is a unique image-guiding tool to display longitudinal view of the vessels, and estimate the length and size of vascular structures with the goal of accurate diagnosis. Unfortunately, due to pulsatile contraction and expansion of the heart, the captured images are affected by different motion artifacts that make visual inspection difficult. In this paper, we propose an efficient algorithm that aligns vascular structures and strongly reduces the saw-shaped oscillation, simplifying the inspection of longitudinal cuts; it reduces the motion artifacts caused by the displacement of the catheter in the short-axis plane and the catheter rotation due to vessel tortuosity. The algorithm prototype aligns 3.16 frames/s and clearly outperforms state-of-the-art methods with similar computational cost. The speed of the algorithm is crucial since it allows to inspect the corrected sequence during patient intervention. Moreover, we improved an indirect methodology for IVUS rigid registration algorithm evaluation.

Pseudo-reestenosis en el stent. Diagnóstico mediante ecografía intracoronaria / Stent pseudorestenosis. Diagnosis using intravascular ultrasound

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Función endotelial en segmentos arteriales previamente sometidos a angioplastia coronaria / Endothelial function in coronary segments previously treated with balloon angioplasty

Introducción y objetivo. La angioplastia coronaria comporta una denudación endotelial y una posterior reendotelización. El objetivo de nuestro estudio ha sido determinar el estado de la función endotelial en segmentos coronarios sometidos a angioplastia y sin reestenosis. Métodos. Se analizó la respuesta vasodilatadora dependiente del endotelio en 12 pacientes con enfermedad de un vaso a los 6 meses de practicada la angioplastia mediante la infusión intracoronaria selectiva a dosis crecientes de acetilcolina (10-6, 10-5, 10-4 M) en la arteria previamente tratada. Siete pacientes con arterias coronarias normales o con mínimas irregularidades y sin factores de riesgo constituyeron el grupo control. La respuesta vasomotora a las diferentes dosis de acetilcolina se analizó mediante angiografía coronaria cuantitativa. Resultados. El estudio de la función endotelial demostró una respuesta global vasodilatadora en el segmento dilatado a la máxima dosis de acetilcolina (incremento del diámetro del 3,6 ñ 3,5 por ciento), similar a la respuesta observada en el grupo control (incremento del diámetro del 3 ñ 6 por ciento; p = NS).En particular, se observó una función endotelial normal en 8 pacientes (67 por ciento) y una respuesta vasoconstrictora en 4 enfermos (33 por ciento). Se ha detectado una correlación positiva entre la respuesta a la máxima dosis de acetilcolina y la lesión residual a los 6 meses de evolución (r = 0,67; p = 0,02). Conclusiones. En pacientes que han sido tratados mediante angioplastia y que no presentan reestenosis, los segmentos dilatados muestran frecuentemente una función endotelial normal. Un mayor grado de estenosis residual en las zonas dilatadas se asocia a una menor alteración de la función endotelial (AU)