Implementation of Microcirculation Examination in Clinical Practice-Insights from the Nationwide POL-MKW Registry.

Background and Objectives: The assessment of coronary microcirculation may facilitate risk stratification and treatment adjustment. The aim of this study was to evaluate patients' clinical presentation and treatment following coronary microcirculation assessment, as well as factors associated with an abnormal coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) values. Materials and Results: This retrospective analysis included 223 patients gathered from the national registry of invasive coronary microvascular testing collected between 2018 and 2023. Results: The frequency of coronary microcirculatory assessments in Poland has steadily increased since 2018. Patients with impaired IMR (≥25) were less burdened with comorbidities. Patients with normal IMR underwent revascularisation attempts more frequently (11.9% vs. 29.8%, p = 0.003). After microcirculation testing, calcium channel blockers (CCBs) and angiotensin-converting enzyme inhibitors were added more often for patients with IMR and CFR abnormalities, respectively, as compared to control groups. Moreover, patients with coronary microvascular dysfunction (CMD, defined as CFR and/or IMR abnormality), regardless of treatment choice following microcirculation assessment, were provided with trimetazidine (23.2%) and dihydropyridine CCBs (26.4%) more frequently than those without CMD who were treated conservatively (6.8%) and by revascularisation (4.2% with p = 0.002 and 0% with p < 0.001, respectively). Multivariable analysis revealed no association between angina symptoms and IMR or CFR impairment. Conclusions: The frequency of coronary microcirculatory assessments in Poland has steadily increased. Angina symptoms were not associated with either IMR or CFR impairment. After microcirculation assessment, patients with impaired microcirculation, expressed as either low CFR, high IMR or both, received additional pharmacotherapy treatment more often.

Influence of heart rate on FFR measurements: An experimental and clinical validation study.

BACKGROUND: Functional lesion assessment in stable coronary disease is considered the gold standard. The result of fractional flow reserve (FFR) in stable coronary disease is often a decision-maker for patient qualification. Taking into account the paramount position of FFR, it is crucial to acknowledge and reduce all potential bias. AIMS: In the present study, we quantified the influence of elevated HR on FFR results using a preclinical model and then validated the results in a clinical setting. METHODS AND RESULTS: The relationship between FFR and HR was first explored experimentally in a porcine model. A clinical validation study was conducted in patients with isolated moderate lesions in the left anterior descending artery (LAD) or right coronary artery (RCA). In both the experimental and clinical arms, FFR was measured at resting HR and with pacing at 100, 130, 160, and 180 (for pigs) beats per minute. In the porcine model and in the clinical settings, a significant correlation between FFR and HR was confirmed in the LAD (r = 0.89, p < .0001; r = 0.53, p = .00002), but not in the RCA (r = -0.19, p = .5; r = 0.14, p = .3). Post hoc analyses revealed that the FFR values in the LAD at 130/min and above tended to be significantly different from the baseline HR. CONCLUSIONS: The results of this study indicate that in an experimental setting, tachycardia might be responsible for an overestimation of FFR results in LAD lesions.

TIMI myocardial perfusion grade and ST-segment resolution in the assessment of coronary reperfusion after primary angioplasty.

BACKGROUND: Angiographic coronary flow parameters and resolution of ST segment changes play an important role in the evaluation of reperfusion in patients with acute ST segment elevation myocardial infarction (STEMI). In previous studies on the relation between angiographic and electrocardiographic (ECG) parameters of coronary reperfusion, several alternative methods to assess ST segment resolution were used. Thus, the relation between the TIMI Myocardial Perfusion Grade (TMPG) and different methods to evaluate ST segment resolution seems to be of interest. AIM: To evaluate the relationship between TMPG and absolute and relative ST segment resolution after successful primary percutaneous coronary intervention (pPCI). METHODS: We studied a population of STEMI patients successfully treated with pPCI. Reperfusion of the coronary microcirculation was determined using 4-grade TMPG scale in coronary angiography performed after successful pPCI. ST segment resolution was analysed in two manners: 1) by calculating the sum of ST segment elevation in infarct leads and depression in reciprocal leads after pPCI (absolute resolution, SSTD); 2) as a percent reduction of summed ST segment deviation from the baseline value (relative resolution, SSTD%). Maximum ST segment elevation in a single lead on the postprocedural ECG was measured to categorise the risk of death. ST segment elevation > 1 mm for an inferior infarct or > 2 mm for an anterior infarct was considered the criterion of high risk (high risk ECG). RESULTS: The study population included 183 patients treated with pPCI. We found a significant but weak negative correlation between TMPG and SSTD (r = -0.27, p = 0.0002). Significant differences in median SSTD were observed between TMPG 0 vs. TMPG 2 and TMPG 3 groups (p = 0.0034 and 0.0121, respectively) and also between TMPG 1 and TMPG 2 (p = 0.02). A significant but very weak positive correlation was found between TMPG and SSTD% (r = 0.16,p = 0.0286). However, further analyses showed that differences in median SSTD% between patients with different TMPG values were statistically insignificant (p = 0.1756). In patients with TMPG 2/3, a high risk ECG was absent considerably more often (p = 0.0007). However, angiographic features of successfully vs. unsuccessfully reperfused microcirculation did not correspond to the presence of a high risk ECG in about 34% of cases. CONCLUSIONS: TMPG is more closely related to absolute compared to relative ST segment resolution. A high risk ECG was absent in most patients with TMPG 2 or 3. However, in about one third of cases TMPG did not correspond to the presence of ECG high risk features. These data suggest that TMPG is complementary to ST segment resolution in the assessment of coronary reperfusion.

Unstable angina in a young woman with Hodgkin's lymphoma.

We present the case of a 30 year-old woman - 16 months after successful treatment of Hodgkin's lymphoma (chest location) with chemotherapy (including doxorubicin) and radiotherapy - with recurrent chest pain and dyspnea. In ambulatory event telemetry, she reported nocturnal chest pain with transient ST elevation characteristic for acute cardiac ischemia. Urgent coronary angiography with intravascular ultrasound and virtual histology visualization revealed 70% fibrotic stenosis in the proximal segment of the left anterior descending artery successfully treated with a drug-eluting stent implantation. This case is especially noteworthy because of the short period from initial therapy to the symptomatic coronary artery disease that is entirely unlike the reported mean latency period of several years.

Comparison of angiographically guided direct stenting technique with direct stenting and optimal balloon angioplasty guided with intravascular ultrasound. The multicenter, randomized trial results.

AIM: The primary objective of the trial was to test the hypothesis that intravascular ultrasound (IVUS) guidance for coronary angioplasty is superior to the quantitative coronary angiography approach both during stenting and plain balloon angioplasty. METHODS: Two hundred fifty-nine patients (70 females, 189 males; mean age, 54 +/- 9) were enrolled into our study. They were randomized into 3 groups: group 1--direct stenting guided with quantitative coronary angiography; group 2--direct stenting guided with IVUS; group 3--optimal balloon angioplasty guided with IVUS. At 6-month follow-up, we recorded evidence of major adverse cardiac events (death, myocardial infarction, repeat coronary revascularization). RESULTS: Procedural success was achieved in 95% of cases. At 6-month follow-up, the evidence of composite end point (major adverse cardiac events) was 16.2%, 7.3%, and 21.8% in groups 1, 2, and 3, respectively (P < .05). Use of IVUS led to 55% reduction of the primary end point between group 1 and group 2. The same when compared to the balloon angioplasty group assumed 66% reduction. CONCLUSION: Ultrasound guidance for direct stenting is the most effective for long-term outcome in comparison with other strategies. It is very likely that bigger lumen gain due to appropriate device sizing is responsible for better outcome. Direct stenting guided with IVUS might be an alternative option for patients requiring coronary revascularization and have contraindications to prolonged antiplatlet therapy as is mandatory for drug-eluting stent implantation.

Mean platelet volume on admission predicts impaired reperfusion and long-term mortality in acute myocardial infarction treated with primary percutaneous coronary intervention.

OBJECTIVES: We sought to determine the prognostic value of mean platelet volume (MPV) for angiographic reperfusion and six-month mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). BACKGROUND: Mean platelet volume is predictive of unfavorable outcome among survivors of STEMI when measured after the index event. No data are available for the value of admission MPV in patients with STEMI treated with primary PCI. METHODS: Blood samples for MPV estimation, obtained on admission in 398 consecutive patients presenting with STEMI, were measured before primary PCI. Follow-up up to six months was performed. RESULTS: No-reflow was significantly more frequent in patients with high MPV (> or =10.3 fl) compared with those with low MPV (<10.3 fl) (21.2% vs. 5.5%, p < 0.0001). The MPV was correlated strongly with corrected Thrombolysis In Myocardial Infarction frame count (CTFC) (r = 0.698, p < 0.0001). Kaplan-Meier survival analysis showed six-month mortality rate of 12.1% in patients with high MPV versus 5.1% in low MPV group (log rank = 6.235, p = 0.0125). After adjusting for baseline characteristics, high MPV remained a strong independent predictor of no-reflow (odds ratio [OR] 4.7, 95% confidence interval [CI] 2.3 to 9.9, p < 0.0001), CTFC > or =40 (OR 10.1, 95% CI 5.7 to 18.1, p < 0.0001), and mortality (OR 3.2, 95% CI 1.1 to 9.3, p = 0.0084). Abciximab administration resulted in significant mortality reduction only in patients with high MPV values (OR 0.02, 95% CI 0.01 to 0.48, p = 0.0165). CONCLUSIONS: Mean platelet volume is a strong, independent predictor of impaired angiographic reperfusion and six-month mortality in STEMI treated with primary PCI. Apart from prognostic value, admission MPV may also carry further practical, therapeutic implications.

Serum B-type natriuretic peptide levels on admission predict not only short-term death but also angiographic success of procedure in patients with acute ST-elevation myocardial infarction treated with primary angioplasty.

BACKGROUND: B-type natriuretic peptide (BNP) levels are predictive of short-term death in patients with acute coronary syndromes. Few data are available for BNP levels obtained on admission in patients with acute ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention (PCI). METHODS: Blood samples for BNP estimation, obtained on admission in 126 consecutive patients (mean age, 58.8 +/- 10.7 years) with STEMI, were measured at the bedside by using a simple point-of-care test in a 15-minute period before PCI. Follow-up up to 42 days was performed. RESULTS: A baseline BNP value of 331 pg/mL had a sensitivity of 87.9% and a specificity of 90% for predicting death in a follow-up study. There was no difference in subgroups by median BNP (100 pg/mL) in Thrombolysis In Myocardial Infarction (TIMI) flow grade 3 before PCI, although higher BNP levels were observed among patients with TIMI <3 after PCI than among those with TIMI 3 (356.7 +/- 350.8 vs 144.9 +/- 191.2 pg/mL; P <.0001). In multivariate logistic regression analysis, admission BNP was the independent predictor for the following: death (odds ratio [OR], 16.3; 95% confidence interval [CI], 1.4 to 186.7; P =.03), TIMI grade <3 after PCI (OR, 3.4; 95% CI, 1.2 to 9.6; P =.02), and the no-reflow phenomenon (OR, 6.2; 95% CI, 1.7 to 23; P =.007) after adjusting for other variables. CONCLUSIONS: BNP levels obtained on admission are a powerful, independent predictor of short-term death and angiographic success after PCI in patients with STEMI. The no-reflow phenomenon may be predicted in STEMI on the basis of high serum BNP values on admission.

[Patient with stable ischaemic heart disease and essential thrombocythemia in Invasive Cardiology Laboratory -- role of the automated systems for estimation of platelet aggregation]. / Chory ze stabilna choroba wiencowa i wspólistniejaca nadplytkowoscia samoistna w pracowni kardiologii inwazyjnej. Rola zautomatyzowanych systemów oceny stopnia agregacji plytek.

Patient with stable ischaemic heart disease and essential thrombocythemia in Invasive Cardiology Laboratory -- role of the automated systems for estimation of platelet aggregation. A case of a 63-year-old male patient with essential thrombocythemia and coronary artery disease is presented. The patient underwent elective coronary angiography and subsequent angioplasty of the intermediate branch. The procedure was complicated by a massive thrombosis of the right coronary artery. Tirofiban and subsequent stenting relieved anginal symptoms. Next, platelet activity was monitored using the platelet function analyser PFA-100 which enabled optimisation of the antiplatelet agent dosages. The usefulness of this device in the catheterisation laboratory is discussed.