A comparison of simplified or conventional antithrombotic regimens after left atrial appendage closure in patients at high bleeding risk: the PLATEBRISK study.

BACKGROUND: Antithrombotic treatment (ATT) post-left atrial appendage occlusion (LAAO) remains controversial. Furthermore, most of the patients undergoing LAAO are at a very high bleeding risk. AIMS: This study aimed to compare a simplified versus conventional ATT after LAAO in very high bleeding risk patients. METHODS: This is a multicentre, retrospective study including very high bleeding risk patients, according to the Bleeding Academic Research Consortium (BARC) definition, who underwent LAAO. These included patients at >4% risk of BARC 3 to 5 bleeding or >1% risk of intracranial bleeding after the procedure. Two groups were established based on the discharge ATT. The simplified group included single antiplatelet treatment or no treatment, and the conventional group comprised dual antiplatelet treatment or anticoagulation (combined or not with antiplatelet therapy). RESULTS: A total of 1,135 patients were included. The mean CHA2DS2-VASc and HAS-BLED scores were 4.5±1.5 and 3.7±1.0, respectively. There were no differences in the composite endpoint (death, stroke, transient ischaemic attack, device-related thrombus or major bleeding) between the 2 groups (hazard ratio [HR] 0.81, 95% confidence interval [CI]: 0.59-1.11; p=0.188). Although the rate of major bleeding during the first year was numerically lower in the simplified group, it did not reach statistical significance (HR 0.67, 95% CI: 0.41-1.10; p=0.104). Nonetheless, patients with previous major bleeding presented a significantly lower rate of major bleeding when using the simplified treatment (HR 0.61, 95% CI: 0.36-0.99; p=0.049). CONCLUSIONS: In patients with very high bleeding risk, a simplified ATT after LAAO seems to be as effective as conventional protocols. Furthermore, patients with a history of major bleeding experienced a lower risk of major bleeding with the simplified ATT.

Catheter-directed therapy for acute pulmonary embolism: results of a multicenter national registry.

INTRODUCTION AND OBJECTIVES: Catheter-directed therapy (CDT) for acute pulmonary embolism (PE) is an emerging therapy that combines heterogeneous techniques. The aim of the study was to provide a nationwide contemporary snapshot of clinical practice and CDT-related outcomes. METHODS: This Investigator-initiated multicenter registry aimed to include consecutive patients with intermediate-high risk (IHR) or high-risk (HR), acute PE eligible for CDT. The primary outcome of the study was in-hospital all-cause death. RESULTS: A total of 253 patients were included, of whom 93 (36.8%) had HR-PE, and 160 (63.2%) had IHR-PE with a mean age of 62.3±15.1 years. Local thrombolysis was performed in 70.8% and aspiration thrombectomy in 51.8%, with 23.3% of patients receiving both. However, aspiration thrombectomy was favored in the HR-PE cohort (80.6% vs 35%; P<.001). Only 51 patients (20.2%) underwent CDT with specific PE devices. The success rate for CDT was 90.9% (98.1% of IHR-PE patients vs 78.5% of HR-PE patients, P<.001). In-hospital mortality was 15.5%, and was highly concentrated in the HR-PE patients (37.6%) and significantly lower in IHR-PE patients (2.5%), P<.001. Long-term (24-month) mortality was 40.2% in HR-PE patients vs 8.2% in IHR-PE patients (P<.001). CONCLUSIONS: Despite the high success rate for CDT, in-hospital mortality in HR-PE is still high (37.6%) compared with very low IHR-PE mortality (2.5%).

Long-Term Intracoronary Structural and Vasomotor Assessment of the ABSORB Bioresorbable Vascular Scaffold.

We systematically categorized the longer-term (≥3 years) structural and functional characteristics of the ABSORB bioresorbable vascular scaffold (BVS) using optical coherence tomography imaging and coronary vasomotor reactivity testing and further compared the functional characteristics of BVS stented versus remote coronary segments. A total of 92 patients (mean age 56.4 ± 9.7 years, 22.8% women) who underwent percutaneous coronary intervention (76% with acute coronary syndrome) using the ABSORB BVS (112 lesions) were included. Optical coherence tomography analysis (38,790 visible struts) comprised in-segment quantitative lumen/plaque and semiquantitative plaque composition analysis of the neointimal pattern. Epicardial endothelium-dependent and-independent vasomotion was defined as any vasodilatation at low/intermediate intracoronary dose of acetylcholine (ACh) and nitroglycerine, assessed using quantitative coronary angiography. At a median time of 3.2 years follow-up, 79.8% of BVS segments still demonstrated visible struts with a predominant neointimal fibrotic healing pattern in 84% of BVS segments, with 99.5% of struts demonstrating coverage with apposition. Compared with remote segments, BVS segments demonstrated less endothelium-dependent vasodilatation at low (p = 0.06) and intermediate ACh doses (p = 0.04). Hypertension, longer time interval from index percutaneous coronary intervention, and the degree of in-BVS segment neointimal volume (p <0.03 for all) were each independently associated with abnormal BVS endothelium-dependent vasomotor function. Endothelium-independent function was more likely preserved in non-BVS (remote) segments compared with BVS segments (p = 0.06). In conclusion, at 3+ years post-ABSORB BVS insertion, the rate of complete scaffold resorption was low and residual strut presence was high, with a dominant fibrous healing response contributing toward neointimal hyperplasia and endothelium-dependent and-independent vasomotor dysfunction.

ST-Segment Elevation Myocardial Infarction Following Transcatheter Aortic Valve Replacement.

BACKGROUND: Among patients with acute coronary syndrome following transcatheter aortic valve replacement (TAVR), those presenting with ST-segment elevation myocardial infarction (STEMI) are at highest risk. OBJECTIVES: The goal of this study was to determine the clinical characteristics, management, and outcomes of STEMI after TAVR. METHODS: This was a multicenter study including 118 patients presenting with STEMI at a median of 255 days (interquartile range: 9 to 680 days) after TAVR. Procedural features of STEMI after TAVR managed with primary percutaneous coronary intervention (PCI) were compared with all-comer STEMI: 439 non-TAVR patients who had primary PCI within the 2 weeks before and after each post-TAVR STEMI case in 5 participating centers from different countries. RESULTS: Median door-to-balloon time was higher in TAVR patients (40 min [interquartile range: 25 to 57 min] vs. 30 min [interquartile range: 25 to 35 min]; p = 0.003). Procedural time, fluoroscopy time, dose-area product, and contrast volume were also higher in TAVR patients (p < 0.01 for all). PCI failure occurred more frequently in patients with previous TAVR (16.5% vs. 3.9%; p < 0.001), including 5 patients in whom the culprit lesion was not revascularized owing to coronary ostia cannulation failure. In-hospital and late (median of 7 months [interquartile range: 1 to 21 months]) mortality rates were 25.4% and 42.4%, respectively (20.6% and 38.2% in primary PCI patients), and estimated glomerular filtration rate <60 ml/min (hazard ratio [HR]: 3.02; 95% confidence interval [CI]: 1.42 to 6.43; p = 0.004), Killip class ≥2 (HR: 2.74; 95% CI: 1.37 to 5.49; p = 0.004), and PCI failure (HR: 3.23; 95% CI: 1.42 to 7.31; p = 0.005) determined an increased risk. CONCLUSIONS: STEMI after TAVR was associated with very high in-hospital and mid-term mortality. Longer door-to-balloon times and a higher PCI failure rate were observed in TAVR patients, partially due to coronary access issues specific to the TAVR population, and this was associated with poorer outcomes.

Type III Kounis syndrome after administration of an echocardiography contrast agent.

A dobutamine stress echocardiogram was performed in a 72-year-old woman to assess an intermediate lesion in the left anterior descending artery. After administration of the echocardiography contrast agent, she presented with an anaphylactic reaction and in that context a subacute thrombosis of a drug-eluting stent implanted 15 days before. This is a case of the so-called type III Kounis syndrome.

Meta-Analysis of Acetylsalicylic Acid Desensitization in Patients With Acute Coronary Syndrome.

Acetylsalicylic acid (ASA) hypersensitivity represents a clinical challenge in acute coronary syndrome (ACS) patients urgently requiring ASA for antiplatelet therapy. ASA desensitization has been reported with successful outcomes in cardiac patients. The aim of this review is to determine the safety and efficacy of ASA desensitization therapy in ACS patients. A PubMed database search was conducted for articles containing combinations of keywords, "aspirin desensitization" or "aspirin hypersensitivity" and "acute coronary syndrome" between January 1, 1990 and August 1, 2018. The primary end point was desensitization protocol success. Secondary end points included hypersensitivity adverse events and ASA discontinuation due to hypersensitivity adverse events at follow-up. Fifteen reports consisting of 480 ACS patients with previous hypersensitivity to ASA were included. The pooled desensitization success rate was 98.3% (95% confidence interval: 97.2% to 99.5%). There was no statistical difference in outcomes between protocols ≤ 2 hours and > 2 hours in duration (96.3[92.3 to 100.3]% vs 97.2[94.6 to 99.8]%; p = 0.71). Protocols with > 6 dose escalations were associated with higher success rates compared to those with ≤ 6 doses (99.2[97.9 to 100.4]% vs 95.4[93 to 97.8]%; p = 0.007). At follow-up between 1 and 46 months (mode 12 months), zero hypersensitivity adverse events were reported. Consequently, no ASA discontinuations were related to hypersensitivity adverse events. In conclusion, ASA desensitization therapy is safe and effective in patients with ACS. Protocols with > 6 dose escalations may be optimal for ASA desensitization in ACS patients.

Myocardial infarction associated with infective endocarditis: a case series.

INTRODUCTION: Embolic myocardial infarction is an uncommon but increasingly recognized complication of infective endocarditis (IE). Its incidence ranges between 1% and 10%, but it has a high mortality rate. A high index of suspicion is required to diagnose it. Only case reports and small studies on this condition have been published; thus, it is unknown what the ideal treatment is. We review the challenges to diagnosing this disease and the most effective treatments for it. CASE PRESENTATION: We report a case series of three patients with acute coronary syndrome (ACS) in IE. The first patient presented with non-ST-elevation ACS. He underwent a stent placement for late-diagnosed embolic myocardial infarction, after which he was treated conservatively without valve replacement, with good results. The second patient with ST-elevation presented with ACS, for which conventional balloon angioplasty and successful double valve replacement were performed. ST-elevation ACS was also observed in the last patient, who experienced periannular complications, which necessitated surgery. DISCUSSION: Acute coronary syndrome is a rare complication of IE but is associated with an increased risk of heart failure and high mortality rate. Its management is complicated and cannot be standardized. Because each situation is unique, a multidisciplinary discussion is required to choose the best treatment.

Safety of transradial diagnostic cardiac catheterization in patients under oral anticoagulant therapy.

BACKGROUND: Cardiac catheterization in anticoagulated patients is usually performed after the anticoagulation has been withdrawn, at least in the previous 48h, and sometimes bridging therapy with heparin is used. METHODS: A prospective observational study including 489 patients undergoing transradial catheterization was conducted. A total of 140 patients were under acenocoumarol (group A) and they were compared with the remainder (group B) for complications after the procedure (bleeding and vascular access complications). RESULTS: Patients in group A were older (74±12 years vs. 68±17 years, p<0.01) and the main indication for anticoagulation was atrial fibrillation (58.6%). No complications occurred during the procedures. There were no acute bleedings just after the bandage removal. During the first 24h, only 3 (2.1%) radial occlusions in group A and 2 (0.6%) in group B (p=0.14) were recorded. Hematomas between 5 and 10cm appeared in 5% of the group A vs. 4.6% in group B. During the 1-month follow-up period, one more radial occlusion in each group was recorded and there were 4 (1.1%) additional mild hematomas in group B and none in group A (p=0.48). CONCLUSIONS: Performing a transradial diagnostic cardiac catheterization without removal of the oral chronic anticoagulation appears safe in patients under acenocumarol therapy.

Incidencia y pronóstico de las complicaciones mecánicas del IAMCEST sometido a angioplastia primaria: datos de un registro unicéntrico de Código Infarto / Incidence and prognosis of mechanical complications of stemi after primary angioplasty: Data from a single-center registry of an infarction code program

No disponible

Early aspirin desensitization in unstable patients with acute coronary syndrome: Short and long-term efficacy and safety.

BACKGROUND: Aspirin hypersensitivity is not a rare condition among patients with acute coronary syndrome. However, despite the publication of several successful desensitization protocols, the procedure is not as widespread as expected. We present a cohort of patients with acute coronary syndrome undergoing aspirin desensitization to evaluate its short- and long-term efficacy and safety and to reinforce data from previous studies. METHODS: Of 1306 patients admitted to our Coronary Care Unit between February 2011 and February 2013, 24 (1.8%) had a history of aspirin hypersensitivity. All 24 patients underwent an eight-dose aspirin desensitization protocol (0.1, 0.3, 1, 3, 10, 25, 50 and 100 mg of aspirin given by mouth every 15 minutes) after premedication with antihistamines and corticosteroids or antileucotrienes. Previously prescribed ß blockers and angiotensin-converting enzyme inhibitors were not discontinued. All patients were desensitized within 72 hours of admission. Those requiring urgent catheterization (five patients with ST segment elevation myocardial infarction) were desensitized within 12 hours of catheterization and the remainder before catheterization. RESULTS: All patients were successfully desensitized and only one presented with an urticarial reaction. The five patients with ST segment elevation myocardial infarction were treated with abciximab until desensitization was complete. All but one patient underwent catheterization and 20 underwent percutaneous coronary intervention, most (66%) with the implantation of a bare metal stent. At follow-up (a minimum of 6-24 months), only two patients had discontinued aspirin, both due to gastrointestinal bleeding, and no hypersensitivy reaction had occurred. CONCLUSIONS: Aspirin desensitization is effective and safe in unstable patients with acute coronary syndrome in both the short and long term.

Caracterización del síndrome de tako-tsubo en España: resultados del registro nacional RETAKO / Characterization of tako-tsubo cardiomyopathy in Spain: results from the RETAKO national registry

Introducción y objetivos: El síndrome de tako-tsubo es una entidad de etiología y epidemiología inciertas, capaz de semejarse a un infarto y que, aunque suele tener buen pronóstico, no está exenta de complicaciones. El objetivo del presente trabajo es caracterizar esta enfermedad en nuestro medio a través de un registro (REgistro nacional multicéntrico sobre síndome de TAKOtsubo). Métodos: El registro prospectivo incluyó a 202 pacientes incidentes en 23 hospitales entre 2012-2013. Se recogieron las características clínicas, analíticas, electrocardiográficas y de imagen, así como los eventos durante el seguimiento. Se incluyó a los pacientes cuando sus médicos consideraron probado el caso, y la incidencia de la enfermedad se calculó en función de los cateterismos solicitados con el diagnóstico presunto de síndrome coronario agudo. Resultados: Los casos fueron predominantemente mujeres (90%), con una media de edad de 70 años y frecuentes factores de riesgo cardiovascular, hipertensión arterial (67%), dislipemia (41%), diabetes mellitus (15%) y tabaquismo (15%). Sin clara distribución semanal o estacional, se calculó una incidencia del 1,2%. El dolor torácico fue el síntoma predominante, con algún desencadenante (psíquico, físico o ambos) en el 72%, y la mayoría consultó en las primeras 6 h. La estancia mediana fue de 7 días; apareció algún síntoma de insuficiencia cardiaca en el 34,0% y arritmias en el 26,7% y murió el 2,4%.ConclusionesEl síndrome de tako-tsubo es una enfermedad poco incidente, que afecta predominantemente a mujeres posmenopáusicas, en más de la mitad de los casos tras una situación psicológicamente estresante. Se caracteriza por dolor anginoso, sin distribución estacional; aunque no está exenta de morbimortalidad, conlleva buen pronóstico (AU)

Introduction and aims: The etiology and epidemiology of tako-tsubo cardiomyopathy remain uncertain. The symptoms of this condition are often similar to those of myocardial infarction and, although it usually has a good prognosis, it is not without complications. Our aim was to characterize this disease in our setting using a dedicated registry (Spanish REgistry for TAKOtsubo cardiomyopathy). Results: The patients were predominantly women (90%), with a mean age of 70 years, and many had cardiovascular risk factors, such as hypertension (67%), dyslipidemia (41%), diabetes mellitus (15%), and smoking (15%). The incidence of tako-tsubo cardiomyopathy was 1.2%, and there was no clear weekly or seasonal distribution pattern. Chest pain was the predominant symptom, a triggering factor (emotional, physical, or both) was present in 72%, and most patients consulted within the first 6 h after symptom onset. The median duration of hospitalization was 7 days. There were heart failure symptoms in 34.0%, arrhythmia in 26.7%, and 2.4% of patients died. Conclusions: The incidence of tako-tsubo cardiomyopathy is low. This disease primarily affects postmenopausal women, and occurs after a situation of emotional stress in more than half of affected individuals. It is characterized by anginal pain, shows no seasonal distribution, and has a good prognosis, although it is not without morbidity and mortality (AU)

Characterization of Tako-tsubo Cardiomyopathy in Spain: Results from the RETAKO National Registry.

INTRODUCTION AND AIMS: The etiology and epidemiology of tako-tsubo cardiomyopathy remain uncertain. The symptoms of this condition are often similar to those of myocardial infarction and, although it usually has a good prognosis, it is not without complications. Our aim was to characterize this disease in our setting using a dedicated registry (Spanish REgistry for TAKOtsubo cardiomyopathy). METHODS: The prospective registry included 202 incident patients in 23 hospitals from 2012 to 2013. The patients' clinical characteristics and analytical, echocardiographic, and imaging results were recorded, as were the events during follow-up. Patients were included when the attending physician considered the case proven, and incidence was calculated relative to the catheterizations requested for a presumptive diagnosis of acute coronary syndrome. RESULTS: The patients were predominantly women (90%), with a mean age of 70 years, and many had cardiovascular risk factors, such as hypertension (67%), dyslipidemia (41%), diabetes mellitus (15%), and smoking (15%). The incidence of tako-tsubo cardiomyopathy was 1.2%, and there was no clear weekly or seasonal distribution pattern. Chest pain was the predominant symptom, a triggering factor (emotional, physical, or both) was present in 72%, and most patients consulted within the first 6h after symptom onset. The median duration of hospitalization was 7 days. There were heart failure symptoms in 34.0%, arrhythmia in 26.7%, and 2.4% of patients died. CONCLUSIONS: The incidence of tako-tsubo cardiomyopathy is low. This disease primarily affects postmenopausal women, and occurs after a situation of emotional stress in more than half of affected individuals. It is characterized by anginal pain, shows no seasonal distribution, and has a good prognosis, although it is not without morbidity and mortality.

[Influence of age in short and long term prognostic of ischemic cardiogenic shock]. / Influencia de la edad en el pronóstico a corto y largo plazo del choque cardiogénico de origen isquémico.

OBJECTIVE: To compare the prognosis during hospitalization and maximum follow-up of 4 years in patients with myocardial infarction complicated with cardiogenic shock. METHOD: Prospective observational study practiced in a coronary Care Unit managed by cardiologists. We included patients with myocardial infarction complicated with cardiogenic shock who received early coronary revascularization. Patients were divided into two groups: older than 75 years (group A) and lower (group B), and we compared the evolution during hospitalization and maximum follow-up of 4 years. Primary end point was mortality rate in the maximum follow-up of 4years. Secondary end point was mortality rate during hospitalization. RESULTS: Ninety-seven patients were included, 45% Group A. Patients of Group B were mostly men (81% vs. 57%; P=.014), diabetics (48% vs. 21%; P=0.006), and smokers (39.6% vs. 5%). Mortality rate during hospitalization was higher in Group A (54.5%) vs. 30.2% in Group B (P=.022). Mortality rate during follow-up (primary variable) was 73% in Group A vs. 38% in Group B (P=.007). CONCLUSIONS: Myocardial infarction complicated with cardiogenic shock in elderly patients is an entity with high mortality during hospitalization and continues to worsen during long term follow-up.

Influencia de la edad en el pronóstico a corto y largo plazo del choque cardiogénico de origen isquémico / Influence of age in short and long term prognostic of ischemic cardiogenic shock

Objetivo: Comparar la evolución durante el ingreso y a largo plazo de pacientes con choque cardiogénico de origen isquémico. Método: Estudio observacional prospectivo unicéntrico llevado a cabo en la unidad coronaria de un hospital terciario manejada por cardiólogos. Se incluyen pacientes con choque cardiogénico de origen isquémico que recibieron revascularización coronaria precoz. Dividimos a los pacientes en 2 grupos: mayores de 75 anos (grupo A) y menores (grupo B), y comparamos la evolución durante el ingreso y en un seguimiento máximo de 4 años. El objetivo principal fue estimar la mortalidad a los 4 años. El objetivo secundario se definió como la mortalidad intrahospitalaria. Resultados: Incluimos a 97 pacientes, 44 del grupo A (45%). Los pacientes del grupo B eran con más frecuencia varones (81 vs. 57%, p = 0.014), diabéticos (49 vs. 21%, p: 0.006) y fumadores (39.6 vs. 4.5%, p < 0.05). La mortalidad hospitalaria fue superior en el grupo A (54.5 vs. 30.2%, p = 0.022). El objetivo principal ocurrió en 32 pacientes del grupo A frente a 20 del grupo B (73 vs. 38%, p = 0.007). Conclusión: El choque cardiogénico de origen isquémico en paciente mayores de 75 anos presenta una alta mortalidad durante la estancia hospitalaria y en el seguimiento a largo plazo.

Objective: To compare the prognosis during hospitalization and maximum follow-up of 4 years in patients with myocardial infarction complicated with cardiogenic shock. Method: Prospective observational study practiced in a coronary Care Unit managed by cardiologists. We included patients with myocardial infarction complicated with cardiogenic shock who received early coronary revascularization. Patients were divided into two groups: older than 75 years (group A) and lower (group B), and we compared the evolution during hospitalization and maximum follow-up of 4 years. Primary end point was mortality rate in the maximum follow-up of 4years. Secondary end point was mortality rate during hospitalization. Results: Ninety-seven patients were included, 45% Group A. Patients of Group B were mostly men (81% vs. 57%; P =.014), diabetics (48% vs. 21%; P = 0.006), and smokers (39.6% vs. 5%). Mortality rate during hospitalization was higher in Group A (54.5%) vs. 30.2% in Group B(P = .022). Mortality rate during follow-up (primary variable) was 73% in Group A vs. 38% in Group B (P =.007). Conclusions: Myocardial infarction complicated with cardiogenic shock in elderly patients is an entity with high mortality during hospitalization and continues to worsen during long term follow-up.

Dolor torácico y ascenso del ST en cara anterior / Chest pain and ST elevation in anterior leads

Presentamos el caso de una mujer de 79 años que ingresa en el servicio de Cardiología tras acudir a Urgencias con síntomas sugerentes de un síndrome coronario agudo, llegando a un diagnóstico cada vez más frecuente y quizá infradiagnosticado años atrás. El Síndrome de Takotsubo es una entidad clínica predominante en mujeres postmenopáusicas y se presenta típicamente tras un estrés físico o psíquico intenso. El cuadro clínico remeda el de un síndrome coronario agudo, sin embargo es característica la ausencia de lesiones angiográficas coronarias y un patrón ecocardiográfico de "balonización" del ventrículo izquierdo por hipercontractilidad de los segmentos basales y discinesia apical. Estas alteraciones suelen recuperarse completamente en el transcurso de unas semanas. Exponemos además una pequeña revisión sobre el estado actual del diagnóstico y tratamiento (AU)

We report a case of a 79 year old woman admitted to our Cardiology department for symptoms suggestive of acute coronary syndrome, eventually reaching an increasingly common diagnosis of a syndrome that was perhaps under-diagnosed in previous years. Takotsubo syndrome is a clinical entity predominantly occurring in postmenopausal women typically after severe physical or psychological stress. The symptoms mimic an acute coronary syndrome, however the absence of coronary angiographic lesions and an echocardiographic pattern of "apical ballooning" in the left ventricle because of hyperkinesis of the basal segments and apical dyskinesia are characteristic of this syndrome. These symptoms are usually fully resolved within a few weeks. We also present a brief review of the current state of its diagnosis and treatment (AU)