Culprit Lesion Coronary Intervention Before Complete Angiography in ST-Elevation Myocardial Infarction: A Randomized Clinical Trial.

Importance: Rapid reperfusion during primary percutaneous coronary intervention (PCI) is associated with improved outcomes among patients with ST-elevation myocardial infarction (STEMI). Although attempts at reducing the time from STEMI diagnosis to arrival at the catheterization laboratory have been widely investigated, intraprocedural strategies aimed at reducing the time to reperfusion are lacking. Objective: To evaluate the effect of culprit lesion PCI before complete diagnostic coronary angiography (CAG) vs complete CAG followed by culprit lesion PCI on reperfusion times among patients with STEMI. Design, Setting, and Participants: This open-label, prospective, randomized clinical trial was conducted between April 1, 2021, and August 31, 2022, among patients admitted to a tertiary center in Jerusalem, Israel, with a diagnosis of STEMI undergoing primary PCI. All patients were followed up for 1 year. Analysis was on an intention-to-treat basis. Intervention: Patients were randomized in a 1:1 ratio to undergo either culprit lesion PCI before complete CAG or complete CAG followed by culprit lesion PCI. Main Outcomes and Measures: A needle-to-balloon time of 10 minutes or less. Results: A total of 216 patients were randomized, with 184 patients (mean [SD] age, 62.9 [12.2] years; 155 men [84.2%]) included in the final intention-to-treat analysis; 90 patients (48.9%) were randomized to undergo culprit lesion PCI before CAG, and 94 (51.1%) were randomized to undergo to CAG followed by PCI. Patients who underwent culprit lesion PCI before complete CAG had a shorter mean (SD) needle-to-balloon time (11.4 [5.9] vs 17.3 [13.3] minutes; P < .001). The primary outcome of a needle-to-balloon time of 10 minutes or less was achieved for 51.1% of patients (46 of 90) who underwent culprit lesion PCI before CAG and for 19.1% of patients (18 of 94) who underwent complete CAG followed by culprit lesion PCI (odds ratio, 4.4 [95% CI, 2.2-9.1]; P < .001). Rates of adverse events were similar between groups. In a subgroup analysis, the effect of culprit lesion PCI before complete CAG on the primary outcome was consistent. There were no differences in rates of in-hospital, 30-day, and 1-year all-cause mortality. Conclusions and Relevance: In this randomized clinical trial of patients with STEMI, culprit lesion PCI before complete CAG resulted in shorter reperfusion times. Larger trials are needed to validate these results and to evaluate the effect on clinical outcomes. Trial Registration: ClinicalTrials.gov Identifier: NCT05415085.

Late in-hospital pressure gradient measurements improve prediction of long-term outcome of alcohol septal ablation in hypertrophic cardiomyopathy.

BACKGROUND: Left ventricular outflow gradient is associated with increased morbidity and mortality in hypertrophic cardiomyopathy. Alcohol septal ablation is the alternative to surgery in cases refractory to drug therapy. The implication of LVOG measured 1 week post-ASA for prediction of outcome is unknown. OBJECTIVE: To observe the pattern of LVOG course and prediction of long-term clinical and hemodynamic outcome of ASA. METHODS: Baseline clinical and echocardiographic parameters were prospectively recorded in 14 consecutive patients with a first ASA, at the time of ASA, 3 and 7 days after ASA (in-hospital), and 3 and > or = 12 months after ASA (last follow-up). RESULTS: There was improvement in NYHA class, exercise parameters and LVOG in 11 of 14 patients (P < 0.005 in all). Maximal creatine kinase level was lower than 500 U/L in those without such improvement and 850 U/L or higher in successful cases. LVOG dropped from 79 +/- 30 to 19 +/- 6 mmHg after the ASA. LVOG was 50 +/- 21 mmHg on day 3, 39 +/- 26 on day 7, 32 +/- 26 at 3 months and 24 +/- 20 mmHg at last follow-up. LVOG identified 27% sustained procedural successes on day 3 and 73% on day 7. The overall predictive accuracy of the test for sustained success and failure was 36% on day 3 and 71% on day 7. Combination of maximal CK and LVOG on day 7 showed four distinct outcome patterns: "early success" with low LVOG and high CK (73% of successful cases), "late success" with high LVOG and high CK, and "early failure" and "late failure" with both low CK and high or low LVOG, respectively. CONCLUSION: LVOG measurement 7 days post-ASA combined with maximal CK levels predicts late procedural outcome in the majority of patients.

Impact of Age on the Safety and the Hemodynamic Response Pattern During High Dose Dobutamine Echocardiography.

BACKGROUND: The purpose of the present study was to assess the safety and hemodynamic response of high dose dobutamine echocardiography (DE) in different age groups. DE is frequently used in the diagnosis of coronary artery disease; its safety in very elderly patients is not established, and there are no standards for blood pressure and heart rate response. METHODS AND RESULTS: The test was performed using up to 50 µg/kg/min in 400 patients: 164 middle-aged (age < 65 years), 187 elderly (age, 65-79 years), and 49 very elderly (age >/= 80 years). It was stopped because of side effects in 91 (23%) patients. Serious side effects occurred in 1.5% of the patients. There was a significant (60% +/- 35%) increase in heart rate, and a modest (10% +/- 19%) increase in the blood pressure (P <.001). The change in heart rate was similar in the three age groups, but there was a blunting of the blood pressure response with age. Hypotension was related to ischemia only in the very old. CONCLUSIONS: High-dose dobutamine is safe in all age groups. Dobutamine induces mainly a chronotropic and less a hypertensive response. The chronotropic response of the very old is similar with that of younger patients, but the hypertensive response is blunted in this group.

Quantification of Atherosclerotic Burden in the Descending Aorta by Transesophageal Echocardiography: Inter- and Intraobserver Variability.

Atherosclerotic plaques had been imaged but not quantitated in the thoracic aorta using transesophageal echocardiography. The aim of this study was to describe a method for measuring the atherosclerotic plaque area in the descending aorta by transesophageal echocardiography (TEE) and to evaluate its reproducibility. TEE examinations were performed by two independent sonographers, in 21 patients with angiographically proven coronary artery disease. Two hundred fifty-six transverse segments (mean 12 +/- 3 patient) of the descending aorta were adequately recorded. In each segment the plaque and the lumen areas in the half of the aortic segment distant from the transesophageal probe were measured by one reader in the two studies (intersonographer reproducibility). Interreader reproducibility was also evaluated. The correlation coefficient between the first and second study (intersonographer reproducibility) was 0.81. The standard deviation of the difference between examinations equaled 0.137 cm(2) and the mean absolute difference between examinations was 0.003 cm(2) (95% CI: -0.015; 0.021; P = 0.75). The correlation coefficient between the two readers was 0.86, the standard deviation of the difference between readers was 0.175 cm(2) and the mean absolute difference was 0.006 cm(2) (95% CI: -0.029; 0.018; P = 0.63). A method for quantitative measurement of aortic atherosclerotic plaque area was evaluated and found to have high intersonographer and intereader reproducibilities. This method might be used in the future for noninvasive evaluation of regression or progression of aortic atherosclerosis.