INOCA: Ischemia in non-obstructive coronary arteries.

This article provides a summary of the clinical spectrum of no obstructive coronary arteries. We describe the pathologies, invasive and noninvasive assessment, and management strategies.

The invasive investigation of INOCA in the coronary catheterization lab.

Over half of all patients with angina have no angiographically demonstratable obstructive coronary disease, with a significant proportion of these patients having undiagnosed microvascular dysfunction and/or vasospastic angina. In chronic coronary syndrome, ischemia with non-obstructive coronary artery disease (INOCA) often remains undiagnosed, or uninvestigated. INOCAmay occur due to vasospastic angina and microvascular dysfunction and require invasive assessment in the coronary catheterization lab. To evaluate INOCA coronary flow reserve (CFR) and the index of microcirculatory resistance (IMR) are used to assess microvascular dysfunction before acetylcholine provocation testing for coronary spasm. This review provides an overview of the invasive investigation of INOCA in the coronary catheterization lab for patients with angina to be optimally managed.

Sex-Specific Differences in Potent P2Y12 Inhibitor Use in British Cardiovascular Intervention Society Registry STEMI Patients.

BACKGROUND: Sex-based outcome differences for women with ST-segment-elevation myocardial infarction (STEMI) have not been adequately addressed, and the role played by differences in prescription of potent P2Y12 inhibitors (P-P2Y12) is not well defined. This study explores the hypothesis that disparities in P-P2Y12 (prasugrel or ticagrelor) use may play a role in outcome disparities for women with STEMI. METHODS: Data from British Cardiovascular Intervention Society national percutaneous coronary intervention database were analyzed, and 168 818 STEMI patients treated with primary percutaneous coronary intervention from 2010 to 2020 were included. RESULTS: Among the included women (43 131; 25.54%) and men (125 687; 74.45%), P-P2Y12 inhibitors were prescribed less often to women (51.71%) than men (55.18%; P<0.001). Women were more likely to die in hospital than men (adjusted odds ratio, 1.213 [95% CI, 1.141-1.290]). Unadjusted mortality was higher among women treated with clopidogrel (7.57%), than P-P2Y12-treated women (5.39%), men treated with clopidogrel (4.60%), and P-P2Y12-treated men (3.61%; P<0.001). The strongest independent predictor of P-P2Y12 prescription was radial access (adjusted odds ratio, 2.368 [95% CI, 2.312-2.425]), used in 67.93% of women and 74.38% of men (P<0.001). Two risk adjustment models were used. Women were less likely to receive a P-P2Y12 (adjusted odds ratio, 0.957 [95% CI, 0.935-0.979]) with risk adjustment for baseline characteristics alone, when procedural factors including radial access were included in the model differences were not significant (adjusted odds ratio, 1.015 [95% CI, 0.991-1.039]). CONCLUSIONS: Women were less likely to be prescribed prasugrel or ticagrelor, were less likely to have radial access, and had a higher mortality when being treated for STEMI. Improving rates of P-P2Y12 use and radial access may decrease outcome disparities for women with STEMI.

Narrowing disparities in PCI outcomes in women; From risk assessment, to referral pathways and outcomes.

This review evaluates published data regarding outcomes for women with ACS undergoing PCI. Data is discussed from a patient centred perspective and timeline, beginning with sex-based differences in perception of risk, time to presentation, time to treatment, access to angiography, access to angioplasty, the impact of incomplete revascularization, prescribing practices, under-representation of women in randomized controlled trials and in cardiology physician workforces. The objective of the review is to identify factors contributing to outcome disparities for women with ACS, and to discuss potential solutions to close this outcome gap.

Management of Multivessel Disease and Physiology Testing in ST Elevation Myocardial Infarction.

For decades, advances in ST elevation myocardial infarction (STEMI) care have been driven by timely reperfusion of the occluded culprit vessel. More recently, however, the focus has shifted to revascularization of nonculprit vessels in STEMI patients. Five landmark randomized trials, all published in the past 7 years, have highlighted the importance of complete revascularization in STEMI treatment. This review focuses on evidence-based management of STEMI in the setting of multivessel disease, highlighting contemporary data that investigate the impact of complete revascularization.

Diabetes and Incomplete Revascularisation in ST Elevation Myocardial Infarction.

BACKGROUND: Incomplete revascularisation is common and prognostically important. The degree to which incomplete revascularisation (IR) is associated with adverse cardiac outcomes in patients with diabetes and ST-elevation myocardial infarction (STEMI) is unknown. METHODS: Late outcomes (3.6 years) were evaluated in 589 consecutive STEMI patients treated with percutaneous coronary intervention in this observational study. Associations between incomplete revascularisation, and diabetes were assessed. A residual SYNergy Between Percutaneous Coronary Intervention With TAXus and Cardiac Surgery (SYNTAX) Score (rSS) >8 defined IR. The primary endpoint studied was cardiac death, myocardial infarction or cerebrovascular accident. RESULTS: Incomplete revascularisation occurred in 36% of patients with diabetes (46/127) and 32% of patients without diabetes (147/462); p=0.329. The primary endpoint occurred in 27% of patients with diabetes compared to 18% of patients without diabetes (p=0.042); and in 28% with a rSS>8 compared to 16% of patients with a rSS≤8 (p<0.001). The primary endpoint occurred in 35% of patients with both diabetes and a rSS>8, 27% without diabetes with a rSS>8, 22% with diabetes and a rSS≤8, and 14% of with patients neither factor (p<0.001), with cardiac death rates respectively of 22%, 9%, 6%, 2% (p<0.001). Patients with both IR and diabetes accounted for only 8% of STEMI patients but 30% of all cardiac deaths. On multivariable analyses diabetes and IR were independently associated with cardiac death, myocardial infarction and cerebrovascular accident; both p<0.05. CONCLUSIONS: Diabetes and IR contribute independently to late outcomes in STEMI patients. The prognostic impact of diabetes was not due to IR alone. Diabetes acts synergistically with incomplete revascularisation to worsen prognosis.

Comparison of Late Cardiac Death and Myocardial Infarction Rates in Women Vs Men With ST-Elevation Myocardial Infarction.

Women and patients with incomplete revascularization (IR) have a worse prognosis after ST elevation myocardial infarction (STEMI). However, the extent to which IR affects outcomes for women with STEMI compared with men is not well characterized. Thus, we examined late outcomes of 589 consecutive STEMI patients who received percutaneous coronary intervention and assessed SYNTAX scores (SS), both at baseline and after all procedures (residual SS). A residual SS >8 defined IR. The primary end point was cardiac death or myocardial infarction (MI), with median follow-up of 3.6 years [interquartile range [IQR] 2.6 to 4.7]. Women (n = 123) had lower baseline SSs 15.0 [IQR 9 to 20], than men (n = 466), 16.0 [IQR 9 to 20; p = 0.02. After all planned procedures, the residual SS was 5.0 [IQR 0 to 9] in women and 5.0 (IQR 1 to 11] in men, p = 0.37. Cardiac death or MI occurred in (97/589) patients (16%), 24% (30/123) in women and 14% (67/466) in men (hazard ratio [HR] 1.75; 95% confidence intervals [CI] 1.14 to 2.69; p = 0.01). In patients with residual SYNTAX score (rSS) >8 cardiac death or MI occurred in 43% (15/35) of women and 23% 36/158 men (HR 2.14; 95% CI 1.17 to 3.91; p = 0.01). In patients with rSS = 0 to 8 cardiac death or MI occurred in 17% (15/88) of women and 10% of men (31/308) (HR 1.68; 95% CI 0.91 to 3.12; p = 0.10; interaction p value 0.58). Multivariate analysis found women were 1.77 times more likely than men to experience cardiac death or MI (95% CI 1.13 to 2.77; p = 0.01). In conclusion, we found despite a lower burden of disease at presentation and no difference in rates of IR between men and women, outcome differences were substantial. Women with rSS >8 were twice as likely as men with the same rSS to experience cardiac death or MI post-STEMI. Differences remained significant postrisk adjustment.

The impact of incomplete revascularization on early and late outcomes in ST-elevation myocardial infarction.

BACKGROUND: In ST-elevation myocardial infarction (STEMI) in patients with multivessel disease, there is a lack of consensus regarding the importance of complete revascularization and the timing of treatment of nonculprit stenoses. Our objective was to investigate the impact of incomplete revascularization in STEMI patients using the residual Synergy Between PCI with TAXUS and Cardiac Surgery score (rSS) to define completeness of revascularization. METHODS: This study examined associations between incomplete revascularization, determined by the rSS, and the combined outcome of cardiac death and myocardial infarction (MI). Patients were divided into groups: rSS = 0 (complete revascularization), rSS = 1-8 (incomplete revascularization with a low burden of residual disease), or rSS >8 (incomplete revascularization with a high burden of residual disease). RESULTS: The rSS score was calculated in 589 consecutive patients; 25% had an rSS of 0, 42% rSS 1-8, and 33% rSS >8. At median follow-up of 3.5 years, cardiac death and MI occurred in 5% of rSS = 0 patients, 15% rSS = 1-8, and 26% with rSS >8 (P < .001). The rSS was powerful independent predictor of cardiac death and MI (hazard ratio 5.05, CI 2.89-12.00, rSS >8 vs rSS 0, P < .001 and hazard ratio 2.96, CI 1.31-6.69, rSS = 1-8 vs rSS = 0, P = .009), respectively, and an independent predictor of mortality, MI, unplanned revascularization, and major adverse cardiovascular events. CONCLUSIONS: In patients with STEMI, the rSS independently predicts cardiac death and MI. Patients with an rSS >8 had substantially higher rates of cardiac death or MI. The rSS can be used to define incomplete revascularization in STEMI and predict adverse outcomes.

Validation of the RETRIEVE (REverse TRIage EVEnts) Criteria for Same Day Return of Non-ST Elevation Acute Coronary Syndrome Patients to Referring Non-PCI Centres.

BACKGROUND: There are continuing bed constraints in percutaneous coronary intervention centres (PCI) so efficient patient triage from referral hospitals is pivotal. To evaluate a strategy of PCI centre (PCIC) bed-sparing we examined return of patients to referral hospitals screened by the RETRIEVE (REverse TRIage EVEnts) criteria and validated its use as a tool for screening suitability for same day transfer of non-ST-elevation acute coronary syndrome (NSTEACS) patients post PCI to their referring non-PCI centre (NPCIC). METHODS: From May 2008 to May 2011, 433 NSTEACS patients were prospectively screened for suitability for same day transfer back to the referring hospital at the completion of PCI. Of these patients, 212 were excluded from same day transfer using the RETRIEVE criteria and 221 patients met the RETRIEVE criteria and were transferred back to their NPCIC. RESULTS: Over the study period, 218 patients (98.6%) had no major adverse events. The primary endpoint (death, arrhythmia, myocardial infarction, major bleeding event, cerebrovascular accident, major vascular site complication, or requirement for return to the PCIC) was seen in only three transferred patients (1.4%). CONCLUSIONS: The RETRIEVE criteria can be used successfully to identify NSTEACS patients suitable for transfer back to NPCIC following PCI. Same day transfer to a NPCIC using the RETRIEVE criteria was associated with very low rates of major complications or repeat transfer and appears to be as safe as routine overnight observation in a PCIC.

Management of acute coronary syndromes in patients with diabetes: implications of the FREEDOM trial.

BACKGROUND: Diabetes mellitus (DM) is a powerful independent risk factor for multivessel, diffuse coronary artery disease (CAD). The optimal coronary revascularization strategy in DM is not clearly defined, but past trials have suggested an advantage for coronary artery bypass grafting (CABG). Recently, the Future Revascularization Evaluation in Patients with Diabetes Mellitus: Optimal Management of Multivessel Disease (FREEDOM) trial found patients randomized to CABG had lower rates of death and myocardial infarction (MI) compared with those randomized to percutaneous coronary intervention (PCI). OBJECTIVE: This article reviews the contemporary management of patients with DM presenting with acute coronary syndromes, particularly ST-elevation MI, in the post-FREEDOM era. METHODS: We undertook a comprehensive review of published literature addressing trials in this field performed to address current knowledge both in the pre- and post-FREEDOM era. RESULTS: The implications of FREEDOM for patients with acute coronary syndrome are that CABG provides a significant benefit, compared with PCI with drug-eluting stents, to patients with DM and multivessel coronary artery disease; and that patients similar to those enrolled in FREEDOM should receive CABG in preference to PCI. The relevance of FREEDOM's findings to the large proportion of patients who would not meet inclusion criteria-including patients with an acute coronary syndrome undergoing an early or emergent invasive strategy, remains uncertain. DISCUSSION: FREEDOM's outcomes have generated uncertainty regarding best practice once thrombolysis in myocardial infarction grade 3 flow is re-established in patients with DM and multivessel disease. Current interventional guidelines recommend optimally treating the culprit artery; however, decisions made at the time of revascularization influence future revascularization strategies, particularly stent choice and resultant P2Y12 receptor antagonist therapy. The preferred method for future revascularization may be questioned if the patient's residual coronary stenoses do not, post-PCI, meet the FREEDOM inclusion criteria, or where the left anterior descending artery is the infarct-related artery, and after left anterior descending artery PCI the patient would not receive an internal mammary graft. The management of residual disease and the preferred (further) revascularization strategy needs to be tested in an appropriately powered randomized trial. CONCLUSIONS: The optimal revascularization strategy in patients with acute coronary syndrome, diabetes, and multivessel disease, in particular those with ST elevation, is unclear, and not guided by level A (or B) evidence. Currently CABG is favored over PCI, and an individually tailored, collaborative approach, guided by a multidisciplinary heart team, should be employed.

An unmet need for implantable cardioverter-defibrillators in New Zealand.

AIMS: This study examined the prior history of all patients presenting to the regional ambulance service with community cardiac arrest to determine what proportion of these patients had prior indications for implanted cardioverter-defibrillator (ICD) therapy. METHODS AND RESULTS: We reviewed the medical history of all adult patients presenting to our regional ambulance service with cardiac arrest between 1 June 2007 and 31 May 2008 (n= 144). Patients were classified as either not having an ICD indication, having a possible ICD indication, or having an ICD indication by two electrophysiologists. Eighty-seven patients (60%) had no pre-existing indication for an ICD. Twenty-two patients (15%) had a possible indication for an ICD but required further investigation to confirm this. This group consisted of 6 patients (4%) with previously documented left ventricular ejection fraction <35%, but without a measurement in the last 12 months, 14 patients (10%) with heart failure (n= 10) or syncope (n= 4) without appropriate investigations, and 2 patients with an ICD indication but with co-morbidities that required further investigation. Thirty-five patients (24%) had a documented indication for an ICD. In 11 (8%) there was no evidence of a contraindication, in 3 (2%) alternative therapy was judged more appropriate, and in 21 (15%) contraindications to ICD implantation were also present. Addition of the 11 patients with an ICD indication and the 6 patients with a documented indication requiring updated measurement, 17 patients (12%) had a prior documented ICD indication but had not been referred for this therapy. CONCLUSIONS: Our observation that 12% of sudden cardiac arrest patients had prior indications for an ICD demonstrates that there is an unmet need for ICDs in New Zealand.