Achievement of long-term lipid targets in a cohort of patients with acute coronary syndrome in real-world clinical practice.

INTRODUCTION AND OBJECTIVES: According to the recent European epidemiological studies, the degree of lipid control in patients with very high vascular risk is suboptimal. This study analyzes the epidemiological characteristics, cardiovascular risk factors, lipid profile, recurrence, and degree of achievement of long-term lipid targets, according to the ESC/EAS Guidelines, in a cohort of patients with acute coronary syndrome (ACS) in a real-world clinical practice setting. METHODS: This work is a retrospective cohort study of patients diagnosed with ACS admitted to the Coronary Unit of a tertiary hospital from January 1, 2012 to December 31, 2015 and followed-up on until March 2022. RESULTS: A total of 826 patients were studied. During the follow-up period, greater prescribing of combined lipid-lowering therapy was observed, mainly high- and moderate-intensity statins and ezetimibe. At 24 months after the ACS, 33.6% of living patients had LDL levels <70 mg/dl and 9.3% had LDL levels <55 mg/dl. At the end of the follow-up (101 [88-111] months), the corresponding figures were 54.5% and 21.1%. Some 22.1% of patients had a recurrent coronary event and only 24.6% achieved an LDL level <55 mg/dl. CONCLUSIONS: Achievement of the LDL targets recommended by the ESC/EAS guidelines is suboptimal in patients with ACS, both at two years and in the long-term (7-10 years), especially in patients with recurrent ACS.

Nonvalvular atrial fibrillation and retinal vein occlusion: The Valdecilla Cohort.

INTRODUCTION AND OBJECTIVES: Retinal vein occlusion (RVO) and nonvalvular atrial fibrillation (NVAF) are associated with vascular risk factors (VRF) and aging. The aim of this study is to analyze differences in the prevalence of VRF, vascular events, glaucoma, and anticoagulant treatment in patients with NVAF and RVO compared to a control group of the general population from the same geographic area. METHODS: This is a prospective, single-center, case-control study. All patients diagnosed with RVO from December 2008 to March 2020 as well as a control group were included. Clinical, laboratory, electrocardiographic, and carotid ultrasound variables were analyzed. RESULTS: A total of 386 patients with RVO and 343 controls were studied. Patients with RVO and NVAF were older and more of them had hypertension, a history of vascular events, and carotid atheromatosis than subjects with RVO without NVAF. In patients with NVAF who were on anticoagulants, those who had RVO differed from the controls with NVAF in that they had a higher prevalence of glaucoma (32 vs. 5.3%; p<0.034), with no significant differences regarding age, VRF, vascular events, or type of anticoagulant therapy (acenocumarol or direct-acting oral anticoagulants). CONCLUSIONS: Patients with RVO and NVAF were older and had a higher prevalence of hypertension and carotid atheromatosis than subjects with RVO without NVAF. Patients with NVAF and RVO had higher prevalence of glaucoma than subjects with NVAF without RVO. In patients with NVAF, it is recommended to optimized VRF treatment and glaucoma control to prevent the development of RVO.

Resultados clínicos tempranos tras el implante percutáneo de válvula aórtica por acceso transaxilar comparado con el acceso transfemoral. Datos del registro español de TAVI / Early clinical outcomes after transaxillary versus transfemoral TAVI. Data from the Spanish TAVI registry

Introducción y objetivos: El acceso transaxilar (ATx) se ha convertido en el acceso alternativo al transfemoral (ATF), más utilizado en pacientes sometidos a implante percutáneo de válvula aórtica (TAVI). El objetivo principal de este estudio es comparar la mortalidad total hospitalaria y a los 30 días de los pacientes incluidos en el registro español de TAVI a los que se trató por acceso ATx frente a ATF. Métodos: Se analizó a todos los pacientes incluidos en el registro español de TAVI tratados por ATx o ATF. Los eventos hospitalarios y a los 30 días de seguimiento se definieron según las recomendaciones de la Valve Academic Research Consortium. Se evaluó el impacto de la vía de acceso mediante emparejamiento por puntuación de propensión según las características clínicas y ecográficas. Resultados: Se incluyó a 6.603 pacientes, 191 (2,9%) tratados por ATx y 6.412 con ATF. Después del ajuste (grupo de ATx, n=113; grupo de ATF, n=3.035), el éxito del dispositivo fue similar entre ambos grupos (el 94% en el grupo de ATx frente al 95% en el de ATF; p=0,95); sin embargo, se observó un incremento en la tasa de infarto agudo de miocardio (OR=5,3; IC95%, 2,0-13,8; p=0,001), complicaciones renales (OR=2,3; IC95%, 1,3-4,1; p=0,003) e implante de marcapasos (OR=1,6; IC95%, 1,01-2,6; p=0,03) en el grupo de ATx comparado con el de ATF. De mismo modo, la mortalidad hospitalaria y a los 30 días fueron superiores en el grupo de ATx (respectivamente, OR=2,2; IC95%, 1,04-4,6; p=0,039; y OR=2,3; IC95%, 1,2-4,5; p=0,01). Conclusiones: El ATx se asocia con un aumento en la mortalidad total tanto hospitalaria como a los 30 días frente al ATF. Ante estos resultados, el ATx debe considerarse solo en caso de que el ATF no sea posible (AU)

Introduction and objectives: Transaxillary access (TXA) has become the most widely used alternative to transfemoral access (TFA) in patients undergoing transcatheter aortic valve implantation (TAVI). The aim of this study was to compare total in-hospital and 30-day mortality in patients included in the Spanish TAVI registry who were treated by TXA or TFA access. Methods: We analyzed data from patients treated with TXA or TFA and who were included in the TAVI Spanish registry. In-hospital and 30-day events were defined according to the recommendations of the Valve Academic Research Consortium. The impact of the access route was evaluated by propensity score matching according to clinical and echocardiogram characteristics. Results: A total of 6603 patients were included; 191 (2.9%) were treated via TXA and 6412 via TFA access. After adjustment (n=113 TXA group and n=3035 TFA group) device success was similar between the 2 groups (94%, TXA vs 95%, TFA; P=.95). However, compared with the TFA group, the TXA group showed a higher rate of acute myocardial infarction (OR, 5.3; 95%CI, 2.0-13.8); P=.001), renal complications (OR, 2.3; 95%CI, 1.3-4.1; P=.003), and pacemaker implantation (OR, 1.6; 95%CI, 1.01-2.6; P=.03). The TXA group also had higher in-hospital and 30-day mortality rates (OR, 2.2; 95%CI, 1.04-4.6; P=.039 and OR, 2.3; 95%CI, 1.2-4.5; P=.01, respectively). Conclusions: Compared with ATF, TXA is associated with higher total mortality, both in-hospital and at 30 days. Given these results, we believe that TXA should be considered only in those patients who are not suitable candidates for TFA (AU)

Diseño y justificación del estudio clínico aleatorizado BA-SCAD (bloqueadores beta y agentes antiplaquetarios en pacientes con disección arterial coronaria espontánea) / Rationale and design of the BA-SCAD (Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection) randomized clinical trial

Introducción y objetivos: La disección coronaria espontánea (DCE) es una causa rara de síndrome coronario agudo. La mayor parte de los pacientes con DCE son tratados empíricamente con bloqueadores beta (BB) y antiagregantes plaquetarios (AP). El estudio BA-SCAD (bloqueadores beta y agentes antiplaquetarios en pacientes con disección coronaria espontánea) es un ensayo clínico académico, pragmático, diseñado con metodología PROBE (prospective randomized open blinded endpoint), con el patrocinio de la Sociedad Española de Cardiología, para conocer la eficacia del tratamiento farmacológico en pacientes con DCE. Métodos: Mediante un diseño factorial 2 × 2, se aleatorizará a 600 pacientes (1:1/1:1) a: a) BB (sí/no) y b) tratamiento con AP «corto» (1 mes) frente a tratamiento antiagregante plaquetario doble y «prolongado» (12 meses). Se aleatorizará a BB (sí/no) solo a los pacientes con fracción de eyección del ventrículo izquierdo conservada, ya que a los pacientes con fracción de eyección reducida se los tratará con BB de acuerdo con las guías actuales. De modo similar, se aleatorizará al estrato de AP solo a los pacientes en tratamiento conservador (sin revascularización), ya que los que requieran intervención coronaria recibirán tratamiento antiagregante plaquetario doble durante 1 año. El objetivo primario de valoración incluye muerte, infarto de miocardio, accidente cerebrovascular, revascularización coronaria, DCE recurrente y hospitalización no planeada por síndrome coronario agudo o insuficiencia cardiaca al año de seguimiento. El objetivo de seguridad es la hemorragia. Todos los pacientes serán seguidos anualmente. Se desarrollará un programa exhaustivo de subestudios adicionales (clínicos, de imagen, de revascularización, de biomarcadores, inflamatorios, inmunológicos, farmacogenéticos y genéticos) para garantizar una visión completa de esta entidad tan especial y compleja (AU)

introduction y objectives: Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome. Most patients are empirically treated with beta-blockers and antiplatelet drugs. The Beta-blockers and Antiplatelet agents in patients with Spontaneous Coronary Artery Dissection (BA-SCAD) is an academic, pragmatic, prospective, randomized, open-label, blinded-endpoint clinical trial, performed under the auspices of the Spanish Society of Cardiology, to assess the efficacy of pharmacological therapy in patients with SCAD. Methods: Using a 2 x 2 factorial design, 600 patients will be randomized (1:1/1:1) to: a) beta-blockers (yes/no) and b) “short” (1 month) vs “prolonged” (12 months) antiplatelet therapy. Only patients with preserved left ventricular ejection fraction will be randomized to beta-blockers (yes/no) because patients with reduced left ventricular ejection fraction will receive beta-blockers according to current guidelines. Similarly, only conservatively managed patients (ie, no coronary intervention) will be randomized to the antiplatelet stratum, as patients requiring coronary interventions will receive 1-year dual antiplatelet therapy. The primary efficacy endpoint includes a composite of death, myocardial infarction, stroke, coronary revascularization, recurrent SCAD, and unplanned hospitalization for acute coronary syndrome or heart failure at 1 year. The primary safety endpoint will be bleeding. All patients will be clinically followed up yearly. A comprehensive set of additional substudies (clinical, imaging, revascularization, biomarkers, inflammatory, immunologic, pharmacogenetics, and genetic) will be conducted to ensure a holistic view of this unique and challenging clinical entity.Conclusions: The results of the BA-SCAD randomized clinical trial will advance our knowledge in the treatment of patients with SCAD (AU)

Sex differences in treatment strategy for coronary artery aneurysms: Insights from the international Coronary Artery Aneurysm Registry.

INTRODUCTION: Sex disparities exist in coronary artery disease (CAD) in terms of risk profile, clinical management and outcome. It is unclear if differences are also present in coronary aneurysms, a rare variant of CAD. METHODS: Patients were selected from the international Coronary Artery Aneurysm Registry (CAAR; ClinicalTrials.gov: NCT02563626), and differences between groups were analysed according to sex. The CAAR database is a prospective multicentre registry of 1565 patients with coronary aneurysms (336 females). Kaplan-Meier method was used for event-free survival analysis for death, major adverse cardiac events (MACE: composite endpoint of death, heart failure and acute coronary syndrome) and bleeding. RESULTS: Female patients were older, were more often hypertensive and less frequently smoker. They were treated conservatively more often compared to male patients and received significantly less frequently aspirin (92% vs 88%, p = 0.002) or dual antiplatelet therapy (DAPT) (67% vs 58%, p = 0.001) at discharge. Median DAPT duration was also shorter (3 vs 9 months, p = 0.001). Kaplan-Meier analysis revealed no sex differences in death, MACE or bleeding during a median follow-up duration of 37 months, although male patients did experience acute coronary syndrome (ACS) more often during follow-up (15% vs 10%, p = 0.015). CONCLUSIONS: These CAAR findings showed a comparable high-risk cardiovascular risk profile for both sexes. Female patients were treated conservatively more often and received DAPT less often at discharge, with a shorter DAPT duration. ACS was more prevalent among male patients; however, overall clinical outcome was not different between male and female patients during follow-up.

Long-Term (≥10 Years) Safety of Percutaneous Treatment of Unprotected Left Main Stenosis With Drug-Eluting Stents.

Percutaneous coronary intervention (PCI) of unprotected left main disease (ULM) with drug-eluting stents (DES) is hampered by lack of information on long-term (≥10 years) safety data. All patients treated with PCI on ULM in 9 international centers with at least 10 years follow-up were enrolled. Baseline and procedural features were recorded. Repeat PCI (re-PCI) on ULM at 10 years was the primary end point. Secondary end points included major adverse cardiac events and its components (cardiac and noncardiac death, myocardial infarction, re-PCI not on ULM, and stent thrombosis). Sensitivity analysis was performed according to the presence of isolated ULM disease: 284 patients were enrolled. A total of 70 patients (21%) performed a re-PCI on ULM, 39 in the first year, and 31 between 1 and 10 years (only 5 overall performed for acute coronary syndrome). Patients with re-PCI on ULM did not show differences in baseline and procedural features, or experience higher rates of cardiovascular death (12% vs 11%, p 0.65), myocardial infarction (11% vs 6%, p 0.56), or of re-PCI on non-ULM disease (31% vs 27%, p 0.76) compared with those without re-PCI on ULM. At Kaplan-Meier analysis, patients with PCI in other coronary vessels were at higher risk of major adverse cardiac events, driven by target vessel revascularization (20.4% vs 32.9%, p 0.009), as confirmed at multivariate analysis (stenosis other than LM; hazard ratio 2, 1.4 to 2.7, all CI 95%). In conclusion, despite of using first-generation stents, PCI on ULM is safe, with low rates of recurrent events due to index revascularization. Progression of atherosclerotic lesions on other coronary vessels represents the only independent predictive factor for prognosis.

The use of the acute Pd/Pa drop after intracoronary nitroglycerin infusion to rule out significant FFR: CANICA (Can intracoronary nitroglycerin predict fractional flow reserve without adenosine?) multicenter study.

OBJECTIVE: Functional assessment of coronary artery stenosis is performed by measuring the fractional flow reserve (FFR) under hyperemic conditions (Adenosine). However, the use of adenosine portends limitations. OBJECTIVE: We sought to investigate the relationship and correlation between FFR and the Pd/Pa value obtained just after the intracoronary infusion (acute drop) of nitroglycerin (Pd/Pa-NTG) and if this parameter enhances diagnostic accuracy for FFR prediction compared to the resting baseline Pd/Pa. METHODS: We conducted a multicenter study including prospectively patients presenting intermediate coronary artery stenosis (30-70%) evaluated with pressure wire. Resting baseline Pd/Pa, Pd/Pa-NTG and FFR were measured. RESULTS: 283 patients (335 lesions) were included. Resting baseline Pd/Pa value was 0.72 to 1.0 (0.93 ± 0.04), Pd/Pa-NTG was 0.60 to 1.0 (0.87 ± 0.07) and FFR 0.55 to 1.0 (0.83 ± 0.08). The ROC curves for resting baseline Pd/Pa and for Pd/Pa-NTG, using a FFR ≤ 0.80 showed an AUC of 0.88 (95% CI: 0.84-0.92, P < 0.001) and 0.94 (95% CI: 0.92-0.96, P < 0.001) respectively. The optimal cutoff values of resting baseline Pd/Pa and Pd/Pa-NTG for an FFR > 0.80, were >0.96 and >0.88, respectively. These values were present in a 29.8% (n = 100) and a 47.1% (n = 158), of the total lesions. Scatter plots showed a better correlation and agreement points with Pd/Pa-NTG than resting baseline Pd/Pa. The cutoff value of Pd/Pa-NTG > 0.88 showed an excellent NPV (96.2% for FFR > 0.8 and 100% for FFR > 0.75) and sensitivity (95% for FFR > 0.8 and 100% for FFR > 0.75) which were consistently high across all the subgroups analysis. CONCLUSION: The cutoff value of acute Pd/Pa-NTG > 0.88 has a high NPV meaning adenosine-FFR can be avoided in almost half of lesions.

[Unstable angina in octogenarians: is an invasive approach feasible and effective?]. / Angina inestable en el paciente octogenario: ¿es factible y eficaz el abordaje invasivo?

BACKGROUND AND OBJECTIVE: Octogenarian patients with unstable angina are usually managed more conservatively despite having a worse prognosis. Studies of balloon angioplasty in the elderly have demonstrated a higher incidence of adverse events but the new advances (mainly stenting) have improved the results. We evaluated the efficacy and safety of an invasive approach in octogenarians with unstable angina. PATIENTS AND METHOD: From January 1996 to October 1999, 100 patients at least 80 years old with unstable angina were admitted to our unit and among these, 74 (74%) underwent percutaneous revascularization. We evaluated immediate results, in-hospital events and clinical follow-up. RESULTS: A total of 145 lesions were treated in 74 patients. The stent implantation rate was 79%. The success rate was 92%. Two patients died during hospitalization due to cardiac causes and 1 patient had a non-Q infarction. At follow-up, 24 +/- 12 months (range: 4 -50 months) 14 patients died (19.4%). New revascularization was performed in 10 patients (13.5%), 9 with PTCA and 1 with surgery. The survival rate free of death and infarction in the first year was 89.2%. At the end of follow-up 58 patients were alive (78.4%), 45 asymptomatic and 13 had stable angina, class I or II. CONCLUSIONS: The results of stent implantation in octogenarians were good with a 92% procedural success. Ninety-six percent of patients were free of death and infarction during hospitalization and 78.4% of the patients remained alive, most of them asymptomatic at the end of follow-up.

[Intravascular ultrasonographic evaluation of direct stents, implanted without predilatation. Comparison of results according to lesion types]. / Evaluación con ultrasonografía intravascular de stents implantados sin predilatación (stents directos). Comparación de resultados según el tipo de lesión.

INTRODUCTION AND OBJECTIVES: Direct stenting is a safe and feasible technique in selected lesions yielding excellent angiographic results. However, there are no studies providing intravascular ultrasonographic examination after direct stenting. The aim of this study was to evaluate direct stent expansion with ultrasonography and to know whether there are differences in the results based on lesion types. METHODS: Patients with amenable lesions for direct stenting were enrolled; including patients with no occlusion, no calcification, no significant tortuosity or angulation, a length 15 mm and a reference lumen diameter 2.5 mm. Intravascular ultrasonography was performed after stent implantation. The ultrasonographic criteria for optimal expansion were: complete apposition and a minimal intrastent lumen area > 80% of the average reference luminal area and 90% of the distal reference lumen area. RESULTS: We included 40 patients (50 lesions). The final angiographic result was good in all the patients but in one case an additional stent was used due to dissection. The ultrasonographic examination did not show significant differences between type A and B lesions. Optimal expansion was achieved in 14/21 (66%) of type A lesions and 17/29 (58%) of type B lesions (p = 0.5). The balloon/artery ratio was the only factor significantly related to ultrasonographic results. When this ratio was 1.1-1.2 (25 cases), 76% of the stents were optimally expanded and when the ratio was < 1. 1 (25 cases) only in a 48% an optimal result was achieved (p < 0.05). CONCLUSIONS: Direct stenting in selected lesions provides ultrasonographic results comparable to those expected with conventional stenting and these results could be even improved if a balloon artery ratio 1.1-1.2 is used. Taking into consideration the selection criteria the differences observed between lesion types A and B are not significant.

Evaluation of direct stent implantation without predilatation by intravascular ultrasound.

The present study shows that direct stent implantation without predilatation in selected lesions provides angiographic and ultrasonographic results that could be comparable to those expected with conventional stenting. These results may even safely improve if a balloon-artery ratio of 1.1 to 1.2 is used in combination with implantation pressures of 12 to 16 atm.

[A direct stent without predilatation. Our experience in 300 lesions]. / Stent directo sin predilatación. Experiencia en 300 lesiones.

INTRODUCTION: The stent alone technique, direct stenting without predilatation, aims to reduce cost and procedural time. Other potential benefits are the avoidance of abrupt vessel closure after balloon angioplasty and lessening of the restenosis rate due to the reduced arterial injury. We present our experience with this therapeutic approach in a long series of patients. PATIENTS AND METHODS: 230 patients referred to our unit were included with 300 non-occlusive stenotic lesions without excessive tortuosity, calcification, length or angulation and with a reference vessel diameter > or = 2.5 mm. In these patients stent implantation without predilatation was attempted. The immediate angiographic results and procedural related complications were evaluated. RESULTS: The stent alone technique succeeded in 256 (85%) among the 300 lesions treated. In 43 (14.3%) lesions predilatation was required and in one case the stent could not be positioned. A new dilatation after deployment was required due to suboptimal stent expansion in 27/256 (10.5%) lesions. Stent embolization occurred in 5 patients, 4 stents were retrieved and there were no clinical sequelae. The best results were obtained in non-subtotal and non-bifurcated lesions type A or B1 without moderate calcification, tortuosity or angulation. CONCLUSIONS: Direct stenting is feasible in a large number of patients with a high success rate after an appropriate selection. The most optimal lesions to be treated with this technique are < or = 90% stenotic non-bifurcated lesions type A or B1 without moderate calcification, tortuosity or angulation.

[The induction of a septal infarct as a therapeutic alternative in hypertrophic obstructive cardiomyopathy: new observations apropos a case]. / Inducción de infarto septal como alternativa terapéutica en la miocardiopatía hipertrófica obstructiva: nuevas observaciones a propósito de un caso.

The hypertrophic cardiomyopathy may be associated with a variable degree of left ventricular outflow tract obstruction. There are several available therapeutic strategies for treatment: pharmacological, dual-chamber pacing, surgery and induced septal infarction. This last one is a novel technique with less experience in practice. We present the clinical case of a patient which showed persistent and severe obstruction in spite of the medications and dual-chamber pacing, and who underwent this novel technique. The results were optimal but new observations arise from this particular case.

[Symptomatic ischemia in a patient with a single right coronary artery without lesions]. / Isquemia sintomática en un paciente con coronaria derecha única sin lesiones.

Coronary artery anomalies are not a frequent finding, and a single right coronary artery is extremely rare. This anomaly has been included among the potentially serious ones because its association with infarction and sudden death has been reported. We present the case of a female patient who complained of chest pain, showed a positive exercise treadmill test and had a single right coronary artery in the angiography with no stenotic lesions. The pathophysiology and the clinical implications are discussed.

[Early discharge in uncomplicated acute myocardial infarction]. / Alta precoz en el infarto agudo de miocardio no complicado.

INTRODUCTION AND OBJECTIVES: The length of hospital stay for uncomplicated myocardial infarction is still a debatable issue. Our study tries to establish the rate of patients amenable early discharged and the safety of this practice. PATIENTS AND METHODS: We studied retrospectively the clinical features, in-hospital events and 30-day follow up of 238 patients discharged early (5 or 6 days) during the last three years. These patients were compared with the remaining group of 929 patients discharged after a conventional stay (mean 10.4 days) in the same time frame. RESULTS: The mean hospital stay in the early discharged group was 5.4 days. They had no ischemic, arrhythmic or haemodynamic complications in the acute phase. In the 30-day follow up there was only one death (at the 14 th post-myocardial infarction day) and 17 readmissions to the hospital, none with re-infarction. By contrast, there were 14 deaths and 43 readmissions among the patients with the standard stay at the hospital. CONCLUSIONS: At least 20% of patients with uncomplicated myocardial infarction can be discharged early. This practice seems to be safe in low risk groups, and is not associated with a higher rate of complications when compared with longer hospital stays.

[A false aneurysm with a double entry orifice]. / Falso aneurisma con doble orificio de entrada.

A case of a 64-year-old man is described, who was diagnosed as having a false aneurysm of the left ventricle, or pseudoaneurysm, a year following an inferior wall myocardial infarction. The echocardiogram demonstrated the presence of two ways of entry which communicated the inferior wall of the left ventricle to the false aneurysm. The patient was taken to surgery, where the diagnosis was confirmed. Aspects related to the diagnosis, treatment and prognosis of this case are discussed.