Experience from a regional percutaneous coronary intervention center: Aiming to assess and improve quality of care.

INTRODUCTION AND OBJECTIVES: Ischemic heart disease is the single most common cause of death in Europe. Mortality in patients presenting with ST-elevation myocardial infarction (STEMI) is associated with many factors, one of which is the time delay to treatment. The purpose of this work is to analyze the coronary pathway in our region in terms of timing, taking into consideration the place of first medical contact (FMC). METHODS: Consecutive patients admitted to our center with STEMI to undergo percutaneous coronary intervention (PCI) between 2013 and 2022 were analyzed. Age, gender, and time delays were collected. Analysis was performed with IBM SPSS version 28 for a significance level of 0.05. RESULTS: We found that non-PCI centers had a significantly greater FMC to diagnosis delay and diagnosis to wire delay compared to other places of origin. Only 2.2% of patients met the 10-min FMC to diagnosis target; 44.8% met the target of 90 min from diagnosis to wire in transferred patients, while 40.6% met the 60-min target for patients admitted to a PCI center. Median patient, electrocardiogram (ECG) and logistic delays are 92.0±146.0 min, 19.0±146.0 min and 15.5±46.3 min, respectively. CONCLUSION: A significant difference between state-of-the-art targets and reality was found, depending on the place of FMC, with the worst delays in non-PCI centers. Patient delay, ECG delay, FMC to diagnosis and logistic delay are identified as key areas in which to intervene.

OPTImized coronary interventions eXplaIn the bEst cliNical outcomEs (OPTI-XIENCE) study. Rationale and study design.

INTRODUCTION: Clinical events may occur after percutaneous coronary intervention (PCI), particularly in complex lesions and complex patients. The optimization of PCI result, using pressure guidewire and intracoronary imaging techniques, may reduce the risk of these events. The hypothesis of the present study is that the clinical outcome of patients with indication of PCI and coronary stent implantation that are at high risk of events can be improved with an unrestricted use of intracoronary tools that allow PCI optimization. METHODS AND ANALYSIS: Observational prospective multicenter international study, with a follow-up of 12 months, including 1064 patients treated with a cobalt­chromium everolimus-eluting stent. Inclusion criteria include any of the following: Lesion length > 28 mm; Reference vessel diameter < 2.5 mm or > 4.25 mm; Chronic total occlusion; Bifurcation with side branch ≥2.0 mm;Ostial lesion; Left main lesion; In-stent restenosis; >2 lesions stented in the same vessel; Treatment of >2 vessels; Acute myocardial infarction; Renal insufficiency; Left ventricular ejection fraction <30 %; Staged procedure. The control group will be comprised by a similar number of matched patients included in the "extended risk" cohort of the XIENCE V USA study. The primary endpoint will be the 1-year rate of target lesion failure (TLF) (composite of ischemia-driven TLR, myocardial infarction (MI) related to the target vessel, or cardiac death related to the target vessel). Secondary endpoints will include overall mortality, cardiovascular mortality, acute myocardial infarction, TVR, TLR, target vessel failure, and definitive or probable stent thrombosis at 1 year. IMPLICATIONS: The ongoing OPTI-XIENCE study will contribute to the growing evidence supporting the use of intra-coronary imaging techniques for stent optimization in patients with complex coronary lesions.

Creatinine variation improves Zwolle score in selecting low-risk patients after ST-segment elevation myocardial infarction.

BACKGROUND: The Zwolle score is recommended to identify ST-segment elevation myocardial infarction (STEMI) patients with low-risk eligible for early discharge. Our aim was to ascertain if creatinine variation (Δ-sCr) would improve Zwolle score in the decision-making of early discharge after primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: A total of 3296 patients with STEMI that underwent primary PCI were gathered from the Portuguese Registry on Acute Coronary Syndromes. A Modified-Zwolle score, including Δ-sCr, was created and compared with the original Zwolle score. Δ-sCr was also compared between low (Zwolle score ≤3) and non-low-risk patients (Zwolle score >3). The primary endpoint is 30-day mortality and the secondary endpoints are in-hospital mortality and complications. Thirty-day mortality was 1.5% in low-risk patients (35 patients) and 9.2% in non-low-risk patients (92 patients). The Modified-Zwolle score had a better performance than the original Zwolle score in all endpoints: 30-day mortality (area under curve 0.853 versus 0.810, P < 0.001), in-hospital mortality (0.889 versus 0.845, P < 0.001) and complications (0.728 versus 0.719, P = 0.037). Reclassification of patients lead to a net reclassification improvement of 6.8%. Additionally, both original Zwolle score low-risk patients and non-low-risk patients who had a Δ-sCr ≥0.3 mg/dl had higher 30-day mortality (low-risk: 1% versus 6.6%, P < 0.001; non-low-risk 4.4% versus 20.7%, P < 0.001), in-hospital mortality and complications. CONCLUSION: Δ-sCr enhanced the performance of Zwolle score and was associated with higher 30-day mortality, in-hospital mortality and complications in low and non-low-risk patients. This data may assist the selection of low-risk patients who will safely benefit from early discharge after STEMI.

Drug Coated Balloon-Only Strategy in De Novo Lesions of Large Coronary Vessels.

OBJECTIVES: We analyzed the efficacy of drug coated balloons (DCB) as a stand-alone-therapy in de novo lesions of large coronary arteries. DCBs seem to be an attractive alternative for the stent-free interventional treatment of de novo coronary artery disease (CAD). However, data regarding a DCB-only approach in de novo CAD are currently limited to vessels of small caliber. METHODS: By means of propensity score (PS) matching 234 individuals with de novo CAD were identified with similar demographic characteristics. This patient population was stratified in a 1:1 fashion according to a reference vessel diameter cut-off of 2.75 mm in small and large vessel disease. The primary endpoint was the rate of clinically driven target lesion revascularization (TLR) at 9 months. RESULTS: Patients with small vessel disease had an average reference diameter of 2.45 ± 0.23 mm, while the large vessel group averaged 3.16 ± 0.27 mm. Regarding 9-month major adverse cardiac event (MACE), 5.7% of the patients with small and 6.1% of the patients with large vessels had MACE (p=0.903). Analysis of the individual MACE components revealed a TLR rate of 3.8% in small and 1.0% in large vessels (p=0.200). Of note, no thrombotic events in the DCB treated coronary segments occurred in either group during the 9-month follow-up. CONCLUSIONS: Our data demonstrate for the first time that DCB-only PCI of de novo lesions in large coronary arteries (>2.75 mm) is safe and as effective. Interventional treatment for CAD without permanent or temporary scaffolding, demonstrated a similar efficacy for large and small vessels.

Spontaneous coronary artery dissection: Still a lot to learn.

Non-atherosclerotic spontaneous coronary artery dissection (SCAD) is an uncommon but probably underdetected pathological substrate for acute coronary syndrome. Clinical associations have been noted, like female gender and young age, but its pathophysiology is not yet fully understood. In this report we describe the case of a 50-year-old woman, without cardiovascular risk factors presenting with non-ST segment elevation myocardial infarction, in whom SCAD was diagnosed. Treatment was initially conservative but due to aggravation of the dissection she eventually underwent a complex percutaneous coronary intervention, requiring implantation of multiple stents, but with a good clinical outcome. The procedure was guided by optical coherence tomography (OCT). Carefully analyzing the combined pictures of OCT and angiography, the dissection appeared to be filled with a clear fluid, but not contrast.

Spontaneous Coronary Dissection: "Live Flash" Optical Coherence Tomography Guided Angioplasty.

Optical Coherence tomography (OCT) is a light-based imaging modality which shows tremendous potential in the setting of coronary imaging. Spontaneous coronary artery dissection (SCAD) is an infrequent cause of acute coronary syndrome (ACS). The diagnosis of SCAD is made mainly with invasive coronary angiography, although adjunctive imaging modalities such as computed tomography angiography, IVUS, and OCT may increase the diagnostic yield. The authors describe a clinical case of a young woman admitted with the diagnosis of ACS. The ACS was caused by SCAD detected in the coronary angiography and the angioplasty was guided by OCT. OCT use in the setting of SCAD has been already described and the true innovation in this case was this unique use of OCT. The guidance of angioplasty with live and short images was very useful as it allowed clearly identifying the position of the guidewires at any given moment without the use of prohibitive amounts of contrast.

Multivessel approach in ST-elevation myocardial infarction: impact on in-hospital morbidity and mortality.

INTRODUCTION: Multivessel disease in ST-elevation myocardial infarction (STEMI) is associated with a worse prognosis. A multivessel approach at the time of primary percutaneous coronary intervention (PCI) is the subject of debate. OBJECTIVE: To assess the impact of a multivessel approach on in-hospital morbidity and mortality in patients with STEMI undergoing primary PCI. METHODS: We studied patients from the Portuguese Registry of Acute Coronary Syndromes with STEMI and multivessel disease who underwent primary PCI. The 257 patients were divided into two groups: those who underwent PCI of the culprit artery only and those who underwent multivessel PCI. Cardiovascular risk factors, STEMI location, in-hospital treatment, number and type of diseased and treated arteries, type of stent implanted and ejection fraction were recorded. The primary end-point was defined as in-hospital mortality and the secondary end-point as the presence of at least one of the following complications: major bleeding, need for transfusion, invasive ventilation, heart failure and reinfarction. RESULTS: Multivessel disease was found in 43.3% of the study population and a multivessel approach was adopted in 19.2% of these patients. There were no differences between the groups in cardiovascular risk factors or electrocardiographic presentation of STEMI. Patients undergoing multivessel PCI were more likely to be treated with drug-eluting stents and glycoprotein IIb/IIIa inhibitors, and less likely to receive heparin therapy. There were no differences between the groups with regard to in-hospital mortality or the incidence of complications. CONCLUSION: In our population of patients with STEMI, a multivessel approach appears to be safe and not associated with increased in-hospital mortality or morbidity.

Non-cardiac comorbidities in the very elderly with acute myocardial infarction: prevalence and influence on management and in-hospital mortality.

INTRODUCTION: Acute myocardial infarction (AMI) in the very elderly is common and is associated with increased mortality. Despite this, the majority of such patients do not receive the most effective cardiovascular therapies. The presence of non-cardiac comorbidities constitutes an additional challenge to the management of AMI in very elderly patients. OBJECTIVE: To determine the prevalence of non-cardiac comorbidities in the very elderly (age > or = 80 years) with AMI and how it influences their management and in-hospital mortality. METHODS: A total of 132 patients consecutively admitted with a diagnosis of AMI from January 2005 to December 2007 were analyzed retrospectively. Two groups were considered: patients with non-cardiac comorbidities (group 1) and those without non-cardiac comorbidities (group 2). Cardiovascular risk factors and non-cardiac comorbidities (anemia, chronic obstructive pulmonary disease, chronic renal failure, cancer, neurologic or psychiatric disorders, and prostatic hyperplasia in men) were recorded. Use of an invasive strategy and the therapy prescribed at discharge were compared between the groups. RESULTS: Non-cardiac comorbidities were found in 56.8% of patients, with the following prevalences: anemia 18.2%; chronic obstructive pulmonary disease 11.4%; chronic renal failure 25.8%; cancer 3.0%; neurologic or psychiatric disorders 11.4%; and prostatic hyperplasia 20.5%. Patients with comorbidities had longer hospital stay than those without (12.1 +/- 5.5 and 10.1 +/- 3.5 days, respectively; p = 0.014). An invasive strategy, with coronary angiography, was used in 12.1% of patients, with no differences between groups (12.3% in patients without comorbidities and 12.0% in those with, p = 0.82). At discharge, more than 70% of the patients were prescribed aspirin, statins and nitrates. With the exception of non-dihydropyridine calcium antagonists, which were more frequently prescribed in patients with comorbidities (15.9% vs. 2.2%; p = 0.04), no other differences in therapy were observed between the two groups. CONCLUSION: In our population of very elderly patients, the prevalence of non-cardiac comorbidities was high (56.8%), but this did not significantly influence the management of these patients.

[Troponins can fool]. / As troponinas também enganam! A propósito de um caso clínico.

The development of troponins dramatically changed the diagnosis of cardiac injury. Cardiac troponins are the most sensitive and specific biochemical markers of myocardial damage. In 2000. it was elaborated the new definition of miocardial infarction that reflected the importance of that biomarker. The rationale of including troponin assay in the diagnosis pathway was based on the assumption that myocardial necrosis, regardless of its magnitude, should be characterized as myocardial infarction. However, if the patient's clinical picture do no match an elevated troponin result we shoud suspect a false positive value caused by analytical interferences. This article ilustrates, by presentation of a case report, that in spite of its importance in the diagnosis of myocardial infarction, troponin positivity should't be the sole criterion for establishing such a diagnosis.

[Pheocromocytoma with negative MIBG]. / Feocromocitoma com MIBG negative.

Pheochomocytomas are catecholamine-releasing tumors derived from chromaffin cells. These kind of tumors occur in less than 1% of the patients evaluated for hypertension. The authors present a case of pheochomocytoma difficult to localize because MIBG scintigraphy was negative and elaborate a review about that subject.