Interventional cardiology in cancer patients: A position paper from the Portuguese Cardiovascular Intervention Association and the Portuguese Cardio-Oncology Study Group of the Portuguese Society of Cardiology.

The field of Cardio-Oncology has grown significantly, especially during the last decade. While awareness of cardiotoxicity due to cancer disease and/or therapies has greatly increased, much of the attention has focused on myocardial systolic disfunction and heart failure. However, coronary and structural heart disease are also a common issue in cancer patients and encompass the full spectrum of cardiotoxicity. While invasive percutaneous or surgical intervention, either is often needed or considered in cancer patients, limited evidence or guidelines are available for dealing with coronary or structural heart disease. The Society for Cardiovascular Angiography and Interventions consensus document published in 2016 is the most comprehensive document regarding this particular issue, but relevant evidence has emerged since, which render some of its considerations outdated. In addition to that, the recent 2022 ESC Guidelines on Cardio-Oncology only briefly discuss this topic. As a result, the Portuguese Association of Cardiovascular Intervention and the Cardio-Oncology Study Group of the Portuguese Society of Cardiology have partnered to produce a position paper to address the issue of cardiac intervention in cancer patients, focusing on percutaneous techniques. A brief review of available evidence is provided, followed by practical considerations. These are based both on the literature as well as accumulated experience with these types of patients, as the authors are either interventional cardiologists, cardiologists with experience in the field of Cardio-Oncology, or both.

Acute total occlusion of the unprotected left main coronary artery: Patient characteristics and outcomes.

INTRODUCTION AND OBJECTIVES: Acute total occlusion of the unprotected left main coronary artery (LMCA) is a dramatic event. There are limited data regarding this population. We aimed to describe the clinical presentation and outcomes of patients and to determine predictors of in-hospital mortality. METHODS: This retrospective study included patients presenting with acute (<12 h) myocardial infarction due to total occlusion of the LMCA (TIMI flow 0) between January 2008 and December 2020 in three tertiary hospitals. RESULTS: During this period, 11036 emergent coronary angiographies were performed, 59 (0.5%) of which revealed acute total occlusion of the LMCA. Patients' mean age was 61.2 (SD±12.2) years and 73% were male. No patients had left dominance. At presentation, 73% were in cardiogenic shock, aborted cardiac arrest occurred in 27% and 97% underwent myocardial revascularization. Primary percutaneous coronary intervention was performed in 90% of cases and angiographic success was achieved in 56% of procedures, while 7% of patients underwent surgical revascularization. In-hospital mortality was 58%. Among survivors, 92% and 67% were alive after one and five years, respectively. After multivariate analysis, only cardiogenic shock and angiographic success were independent predictors of in-hospital mortality. Use of mechanical circulatory support and presence of well-developed collateral circulation were not predictive of short-term prognosis. CONCLUSION: Acute total occlusion of the LMCA is associated with a dismal prognosis. Cardiogenic shock and angiographic success play a major role in predicting the prognosis of these patients. The effect of mechanical circulatory support on patient prognosis remains to be determined.

Percutaneous versus surgical revascularization of unprotected left main coronary artery: Data from the Portuguese Registry of Acute Coronary Syndromes (ProACS).

BACKGROUND: In acute coronary syndromes (ACS), the optimal revascularization strategy for unprotected left main coronary artery (ULMCA) culprit lesion has been under-investigated. Therefore, we compared clinical characteristics and short- and medium-term outcomes of percutaneous and surgical revascularization in ACS. METHODS AND RESULTS: Of 31886 patients enrolled in a multicenter, national, prospective registry study between October 2010 and December 2020, 246 (0.8%) had ULMCA as a culprit lesion and underwent percutaneous coronary intervention (PCI) alone (n=133, 54%) or coronary artery bypass grafting (CABG) alone (n=113, 46%). Patients undergoing PCI presented more frequently ongoing chest pain (68% versus 41%, p<0.001) and cardiogenic shock (25% versus 1%, p<0.001). Time from admission to revascularization was higher in surgical group with a median time to CABG of 4.5 days compared to 0 days to PCI (p<0.001). Angiographic success rate was 93.2% in patients who underwent PCI. Primary endpoint (all-cause death, non-fatal reinfarction and/or non-fatal stroke during hospitalization) occurred in 15.9% of patients and was more frequent in the PCI group (p<0.001). After adjustment, surgical revascularization was associated with better in-hospital prognosis (odds ratio (OR) 0.164; 95% confidence interval (CI), 0.04-0.64; p=0.009). Similar results were achieved after propensity score matching. No difference was found at one-year all-cause death. CONCLUSION: Percutaneous coronary intervention was the most common revascularization strategy in the ACS with ULMCA culprit lesion. PCI was preferred in unstable patients and presented a high angiographic success. CABG was often delayed and preferred in low-risk patients. At one-year follow-up, PCI and CABG conferred a similar prognosis. The two approaches appear complementary in this high risk cohort.

Spontaneous coronary artery dissection: A review for clinical and interventional cardiologists.

Spontaneous coronary artery dissection (SCAD) is an increasingly recognized cause of acute coronary syndrome, especially among young to middle-aged women with few traditional cardiovascular risk factors and low pretest probability for atherosclerotic coronary artery disease. Diagnosis by invasive coronary angiography is the gold standard and conservative therapy is generally recommended, with percutaneous or surgical revascularization being reserved for cases of clinical instability, high-risk anatomy or as bailout. Unlike atherothrombotic coronary artery disease, strong evidence on optimal medical therapy is scarce, posing unique challenges in cases of pregnancy-associated SCAD. The follow-up strategy is also of major importance, as recurrent SCAD is not infrequent, lifestyle changes and pharmacological therapy should be planned for the long term, and SCAD-associated conditions need to be addressed. This review aims to provide a practical management approach to SCAD patients for both clinical and interventional cardiologists.

Spontaneous coronary artery dissection: Ten years' experience of a tertiary center.

INTRODUCTION: Spontaneous coronary artery dissection (SCAD) represents 1-4% of all acute coronary syndromes (ACS), and is a particularly important cause among young women and individuals with few cardiovascular risk factors. OBJECTIVES: To characterize clinical background, therapeutic management and clinical outcomes in a SCAD population. METHODS: We retrospectively analyzed all consecutive patients diagnosed with SCAD at a tertiary center between August 2009 and May 2020, with a median follow-up of 40 months (IQR 14-95 months). SCAD was classified according to the Saw angiographic SCAD classification. RESULTS: A total of 36 patients were included, 94% female, mean age 51 years (±11 years). A trigger was only detected in 8% and associated conditions in 31% of patients, mainly inflammatory or autoimmune systemic diseases and migraine. Most patients had non-ST-elevation ACS and 33% presented with ST-elevation ACS. The most frequent culprit lesion was the left anterior descending (LAD) artery (67%); mid to distal segments were the most affected (94%) and type 2 dissection the most prevalent (60%). Almost all patients were successfully medically managed, with only four undergoing percutaneous intervention. During follow-up, ischemic events recurred in 15% of patients and no patient died. Patients with type 2 dissection exhibited lower risk of recurrence compared to type 1 (p=0.049, OR=0.13). CONCLUSION: SCAD patients were mainly young or middle-aged women; the LAD artery was the most affected vessel and type 2 dissection the most prevalent. This report showed for the first time a correlation between type 2 SCAD and lower risk of recurrence.

Acute coronary syndrome and stress: Is there a relationship?

INTRODUCTION: Acute coronary syndrome (ACS) is the result of a complex pathophysiological process with various dynamic factors. The 10-item Perceived Stress Scale (PSS-10) is a validated instrument for estimating stress levels in clinical practice and may be useful in the assessment of ACS. METHODS: We carried out a single-center prospective study engaging patients hospitalized with ACS between March 20, 2019 and March 3, 2020. The PSS-10 was completed during the hospitalization period. The ACS group was compared to a control group (the general Portuguese population), and a subanalysis in the stress group were then performed. RESULTS: A total of 171 patients with ACS were included, of whom 36.5% presented ST-elevation myocardial infarction (STEMI), 38.1% were female and the mean PSS score was 19.5±7.1. Females in the control group scored 16.6±6.3 on the PSS-10 and control males scored 13.4±6.5. The female population with ACS scored 22.8±9.8 on the PSS-10 (p<0.001). Similarly, ACS males scored a mean of 17.4±6.4 (p<0.001). Pathological stress levels were not a predictor of major adverse cardiovascular events or severity at admission. CONCLUSIONS: ACS patients had higher perceived stress levels compared to the control group. Perceived stress level was not associated with worse prognosis in ACS patients.

Cancer patients with acute coronary syndrome have non-superior bleeding risk compared to patients with similar characteristics - a propensity score analysis from the ProACS registry.

INTRODUCTION: The management of acute coronary syndrome (ACS) in malignancy is challenging due to higher bleeding risk. METHODS: We analyzed patients with cancer (active or in the previous five years) prospectively included in the ProACS registry between 2010 and 2019. Our aim was to assess safety (major bleeding, primary endpoint) and secondary efficacy endpoints (in-hospital mortality and combined in-hospital mortality, reinfarction and ischemic stroke) of ACS treatment. Propensity score matching analysis (1:1) was further performed to better understand predictors of outcomes. RESULTS: We found 934 (5%) cancer patients out of a total of 18 845 patients with ACS. Cancer patients had more events: major bleeding (2.9% vs. 1.5%), in-hospital mortality (5.8% vs. 3.4%) and the combined endpoint (7.4% vs. 4.9%). The primary endpoint was related to cancer diagnosis (OR 1.97), previous bleeding (OR 7.09), hemoglobin level (OR 4.94), atrial fibrillation (OR 3.50), oral anticoagulation (OR 3.67) and renal dysfunction. Mortality and the combined secondary endpoint were associated with lower use of invasive coronary angiography and antiplatelet and neurohormonal blocker therapy. After propensity score matching (350 patients), there were no statistically significant differences in endpoints between the populations. CONCLUSION: Bleeding risk was not significant higher in the cancer population compared to patients with similar characteristics, nor were mortality or ischemic risk. The presence of cancer should not preclude simultaneous ACS treatment.

Androgen deprivation therapy mimicking acute coronary syndrome: A case report.

An 80-year-old man diagnosed with prostate cancer and under treatment with androgen deprivation therapy presented at the emergency room with chest pain, repolarization abnormalities and QT interval prolongation on electrocardiogram. An initial diagnosis of acute coronary syndrome was proposed, but biomarkers and coronary angiography were negative. Hydroelectrolyte balance and echocardiogram were also normal. Some weeks after drug withdrawal, repolarization changes reverted. A rare side effect of these drugs mimicking an acute coronary syndrome was the most probable diagnosis.

The impact of the COVID-19 pandemic on acute coronary syndrome admissions to a tertiary care hospital in Portugal.

INTRODUCTION AND OBJECTIVES: The coronavirus SARS-CoV-2 (COVID-19) pandemic has been an unmatched challenge to global healthcare. Although the majority of patients admitted with acute coronary syndrome (ACS) may not be infected with COVID-19, the quarantine and public health emergency measures may have affected this particular high risk group. The objective of this study is to assess the impact of the early period of the COVID-19 pandemic on ACS admissions and clinical course in a tertiary care hospital in Portugal's most affected region. METHODS: This retrospective, case-control study included patients admitted with a diagnosis of ACS during March and April 2020 (pandemic group) and in the same period in 2019 (control group). Clinical course and complications were also assessed. RESULTS: During the pandemic, there were fewer ACS admissions but presentation was more severe, with a larger proportion of acute ST-elevation myocardial infarctions (54.9% vs. 38.8%, p=0.047), higher maximum troponin levels and greater prevalence of left ventricular systolic dysfunction at discharge (58.0% vs. 35.0%, p=0.01). In this population, although not statistically significant, it was observed a delay between the onset of symptoms and percutaneous coronary intervention, which may traduce a deferred search for urgent medical care during the pandemic. CONCLUSION: The lockdown phase of COVID-19 pandemic was associated with fewer and more severe ACS in a Tertiary Care Hospital in Portugal's most affected region by the pandemic.

Acute coronay syndrome in a patient with severe hemophilia A: Dificult decisions.

Hemophilia A is an inherited coagulation disease characterized by factor VIII (FVIII) deficiency and is associated with high hemorrhagic risk, especially in its severe forms. As the average life expectancy of patients with hemophilia has increased, so has the prevalence of acute coronary events. There is however limited experience in dealing with them. The strategy of acting on acute coronary events in patients with hemophilia, as demonstrated in the present case, is a real challenge, not only due to the need for antiplatelet therapy (which is essential in the prevention of stent thrombosis, but increases hemorrhagic risk), but also due to the lack of specific recommendations related to the most adequate and safe replacement therapy in these situations. The authors describe the case of a 48-year-old man with unstable angina and a previous diagnosis of severe hemophilia A who underwent percutaneous coronary intervention under FVIII therapy without hemorrhagic complications.

Treinamento de Não-Cardiologistas pode Melhorar os Resultados do Tratamento de Infarto Agudo do Miocárdio com Supra de ST / Training Non-Cardiologists Could Improve the Treatment Results of ST Elevation Myocardial Infarction

Resumo Fundamento De acordo com a Organização Mundial da Saúde, países emergentes terão um crescimento considerável no número de ataques cardíacos e mortes relacionadas. Um dos principais problemas médicos no Brasil é a mortalidade causada por infarto agudo do miocárdio com supra de ST (IAMCSST). A Sociedade de Cardiologia do Estado de São Paulo nunca treinou não-cardiologistas para atendimentos de emergência. Os pacientes normalmente buscam ajuda em prontos-socorros, em vez de chamar a ambulância. Objetivo Nosso objetivo foi reduzir as taxas de mortalidade hospitalar causada por infarto agudo do miocárdio ao treinar profissionais da emergência na cidade de São Paulo. Métodos Utilizamos um programa de treinamento para as equipes de cinco hospitais com > 100 pacientes internados com IAMCSST por ano, e pelo menos 15% de mortes hospitalares relacionadas ao IAMCSST. Realizamos treinamentos online, organizamos de dois a quatro eventos para até 400 participantes, fizemos folders e panfletos informativos. A análise estatística utilizou o teste para comparação de duas proporções, com p <0,05. Resultados Quase 200 médicos e 350 enfermeiros participaram de pelo menos um treinamento de maio de 2010 até dezembro de 2013. Inicialmente, muitos médicos da emergência não reconheciam um infarto agudo do miocárdio no eletrocardiograma, mas a tele-ecocardiografia é usada em alguns departamentos da emergência para determinar o diagnóstico. A taxa de mortalidade nos cinco hospitais caiu de 25,6%, em 2009, para 18,2%, em 2010 (p=0,005). Depois da conclusão do período de treinamento, as mortes relacionadas ao IAMCSST em todos os hospitais públicos de São Paulo diminuíram de 14,31%, em 2009, para 11,25%, em 2014 (p<0,0001). Conclusão Mesmo programas simplificados de treinamento de pessoal da emergência pode reduzir muito as taxas de morte por infarto agudo do miocárdio em países em desenvolvimento.

Abstract Background According to the World Health Organization, emerging countries will have an enormous growth in the number of heart attacks and related deaths. The main medical issue in Brazil is mortality caused by acute ST elevation myocardial infarction (STEMI). The Society of Cardiology in the State of São Paulo has never trained non-cardiologists as emergency personnel. Patients usually seek help from emergency departments instead of calling for an ambulance. Objectives We aimed at reducing in-hospital death rates from acute myocardial infarction by training emergency personnel in the city of Sao Paulo. Methods We used a training program for the personnel of five hospitals with >100 patients admitted with STEMI per year, and at least 15% in-hospital STEMI-associated mortality rate. We performed internet training, biannual-quarterly symposia for up to 400 participants, informative folders and handouts. Statistical analysis used the two proportion comparison test with p <0.05. Results Nearly 200 physicians and 350 nurses attended at least one training from May 2010 to December 2013. Initially, many emergency physicians could not recognize an acute myocardial infarction on the electrocardiogram, but tele-electrocardiography is used in some emergency departments to determine the diagnosis. The death rate in the five hospitals decreased from 25.6%, in 2009, to 18.2%, in 2010 (p=0.005). After the entire period of training, the STEMI-associated death rate in all public hospitals of São Paulo decreased from 14.31%, in 2009, to 11.25%, in 2014 (p<0.0001). Conclusion Even simple training programs for emergency personnel can greatly reduce acute myocardial infarction death rates in undeveloped countries.

Estratégias de Revascularização em Doentes com Infarto Agudo do Miocárdio em Choque Cardiogênico - Resultados do Registo Português de Síndromes Coronárias Agudas / Revascularization Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock: Results from the Portuguese Registry on Acute Coronary Syndromes

Resumo Fundamento: Em doentes com infarto agudo do miocárdio (IAM), choque cardiogênico (CC) e doença multivaso (DMV) persistem dúvidas sobre a intervenção nas artérias não responsáveis. Objetivos: 1) caracterizar a amostra de doentes com IAM, CC e DMV incluídos no Registo Nacional Português de Síndromes Coronárias Agudas (RNSCA); 2) comparar os eventos associados a diferentes estratégias de revascularização; e 3) identificar preditores de mortalidade intra-hospitalar nesta amostra. Métodos: Estudo observacional retrospetivo de doentes com IAM, CC e DMV incluídos no RNSCA entre 2010 e 2018. Compararam-se duas estratégias de revascularização: completa durante o procedimento índice (grupo 1); e completa diferida ou incompleta durante o internamento (grupo 2-3). O endpoint primário foi a ocorrência de reinfarto ou morte intra-hospitalar. A significância estatística foi definida por um valor p < 0,05. Resultados: Identificaram-se 127 doentes com IAM, CC e DMV (18,1% no grupo 1 e 81,9% no grupo 2-3), com idade média de 70 ± 12 anos e 92,9% com IAM com supradesnivelamento do segmento ST. O endpoint primário ocorreu em 47,8% dos doentes do grupo 1 e em 37,5% do grupo 2-3 (p = 0,359). As taxas de mortalidade intra-hospitalar, reinfarto, acidente vascular cerebral e hemorragia major foram também semelhantes nos dois grupos. Os preditores de mortalidade intra-hospitalar nesta amostra foram a presença na admissão de disfunção ventricular esquerda (OR 16,8), bloqueio completo de ramo direito (OR 7,6) e anemia (OR 5,2), (p ≤ 0,02). Conclusões: Entre os doentes com IAM, CC e DMV, incluídos no RNSCA, não se verificou diferença significativa entre revascularização completa no evento índex e completa diferida ou incompleta durante o internamento, relativamente à ocorrência de morte intra-hospitalar ou reinfarto. (Arq Bras Cardiol. 2021; 116(5):867-876)

Abstract Background: In patients with acute myocardial infarction (MI), cardiogenic shock (CS), and multivessel disease (MVD) questions remain unanswered when it comes to intervention on non-culprit arteries. Objective: This article aims to 1) characterize patients with MI, CS and MVD included in the Portuguese Registry on Acute Coronary Syndromes (ProACS); 2) compare different revascularization strategies in the sample; 3) identify predictors of in-hospital mortality among these patients. Methods: Observational retrospective study of patients with MI, CS and MVD included in the ProACS between 2010 and 2018. Two revascularization strategies were compared: complete during the index procedure (group 1); and complete or incomplete during the index hospitalization (groups 2-3). The primary endpoint was a composite of in-hospital death or MI. Statistical significance was defined by a p-value <0.05. Results: We identified 127 patients with MI, CS, and MVD (18.1% in group 1, and 81.9% in groups 2-3), with a mean age of 7012 years, and 92.9% of the sample being diagnosed with ST-segment elevation MI (STEMI). The primary endpoint occurred in 47.8% of the patients in group 1 and 37.5% in group 2-3 (p = 0.359). The rates of in-hospital death, recurrent MI, stroke, and major bleeding were also similar. The predictors of in-hospital death in this sample were the presence of left ventricle systolic dysfunction on admission (OR 16.8), right bundle branch block (OR 7.6), and anemia (OR 5.2) (p ≤ 0.02 for both). Conclusions: Among patients with MI, CS, and MVD included in the ProACS, there was no significant difference between complete and incomplete revascularization during the index hospitalization regarding the occurrence of in-hospital death or MI. (Arq Bras Cardiol. 2021; 116(5):867-876)

Novedades de las guías de la Sociedad Europea de Cardiología 2020 sobre manejo del síndrome coronario agudo sin elevación persistente del segmento ST / News from the European Society of Cardiology 2020 guidelines on the management of acute coronary syndrome without persistent ST-segment elevation / Novidades da Sociedade Europeia de Cardiologia 2020 diretrizes sobre o tratamento da síndrome coronariana aguda sem elevação persistente do segmento ST

Las enfermedades cardiovasculares representan la primera causa de muerte en el mundo. El manejo de los síndromes coronarios ha avanzado formidablemente en los últimos 50 años, reduciendo el riesgo isquémico, a expensas del consiguiente aumento del riesgo hemorrágico. La Sociedad Europea de Cardiología publicó en el año 2020 la guía sobre el manejo de síndrome coronario agudo sin elevación del segmento ST, donde se destacan cambios en los algoritmos de estratificación de riesgo y la terapia antiplaquetaria y anticoagulante como dos de los aspectos principales. En el presente editorial se resumen las principales novedades publicadas en este documento.

Cardiovascular disease is the leading cause of death worldwide. The management of coronary syndromes has advanced dramatically in the last 50 years, reducing ischemic risk, but observing an increase in bleeding risk. The European Society of Cardiology published in 2020 the guideline on the management of acute coronary syndrome without ST-segment elevation, where changes in risk stratification algorithms and antiplatelet and anticoagulant therapy are highlighted as two of the main aspects. This editorial summarizes the main developments published in this document.

A doença cardiovascular é a principal causa de morte em todo o mundo. O manejo das síndromes coronarianas avançou dramaticamente nos últimos 50 anos, reduzindo o risco isquêmico, mas observando um aumento no risco de sangramento. A Sociedade Europeia de Cardiologia publicou em 2020 a diretriz sobre o manejo da síndrome coronariana aguda sem supradesnivelamento do segmento ST, onde as alterações nos algoritmos de estratificação de risco e na terapia antiplaquetária e anticoagulante são destacadas como dois dos principais aspectos. Este editorial resume os principais desenvolvimentos publicados neste documento.

Kounis syndrome - Report of 4 cases / Síndrome de Kounis - Relato de 4 casos

Kounis syndrome is described as the occurrence of myocardial injury following a hypersensitivity reaction triggered by allergen exposure. The actual incidence is unknown, as most of the information comes from case reports and there are no international recommendations. Kounis syndrome does not seem to be rare but rather underdiagnosed. We report and discuss the clinical presentation and management of 4 cases of Kounis syndrome. All patients presented with anaphylaxis and chest pain. Patient age ranged from 44 to 83 years. Anaphylaxis triggers were nonsteroidal anti-inflammatory drugs and antibiotics. It is important to recognize Kounis syndrome in order to conduct an adequate investigation and prevent further events. A major difficulty is that the treatment of the 2 entities (hypersensitivity reaction and acute coronary syndrome) may worsen each other. Large prospective studies are needed to establish definitive treatment guidelines for these patients.

A síndrome de Kounis caracteriza-se pela ocorrência de uma síndrome coronária aguda no contexto de uma reação alérgica concomitante desencadeada por exposição a um alergênio. A sua incidência real é desconhecida e não há consenso relativamente à abordagem, uma vez que a maioria dos dados provem de relatos de casos. A síndrome de Kounis não parece ser uma entidade rara, mas é infrequentemente diagnosticada. Apresentamos quatro casos, a sua apresentação clínica e abordagem diagnóstica e terapêutica. Todos os doentes, com idades entre os 44 e os 83 anos, se apresentaram com anafilaxia e dor torácica. Os fatores desencadeantes foram fármacos: anti-inflamatórios não esteroides e antibióticos. Torna-se importante reconhecer a síndrome de Kounis, de modo a que possa ser feita investigação adequada e prevenidos novos eventos. A grande dificuldade reside no fato de que o tratamento das duas entidades (Reação de hipersensibilidade e Síndrome coronária aguda), pode agravar uma à outra. São necessários estudos prospetivos alargados de modo a estabelecer diretrizes definitivas para o tratamento destes doentes.

Dual antiplatelet therapy in myocardial infarction with non-obstructive coronary artery disease - insights from a nationwide registry.

INTRODUCTION AND OBJECTIVES: Dual antiplatelet therapy (DAPT) is a mainstay for myocardial infarction (MI) therapy. However, in patients with myocardial infarction with non-obstructive coronary artery disease (MINOCA), clear recommendations are lacking in the literature. This study aims to identify the cases in which DAPT is currently prescribed at discharge for MINOCA. METHODS: The authors analyzed a cohort of patients from a multicenter national registry enrolling patients who suffered their first MI between 2010 and 2017, and underwent coronary angiography revealing absence of stenosis ≥50%. Individual antithrombotic therapy was identified. A logistic regression analysis was applied to search for predictors of DAPT. RESULTS: From a total of 16 237 patients analyzed, 709 (4.4%) were categorized as MINOCA. Mean age was 64±13 years, 46.3% (n=409) were females. 390 (55.0%) of MINOCA patients were discharged on DAPT. Males (OR 1.67, CI 95 [1.05-2.38], p=0.027), active smokers (OR=1.82, CI 95 [1.05-3.16], p=0.033), previous percutaneous intervention (OR 3.18, CI 95 [1.48-6.81], p=0.003), ST elevation MI (OR 2.70, CI 95 [1.59-4.76], p<0.001) and sinus rhythm at admission (OR=3.94, CI 95 [2.07-7.48], p<0.001) were independent predictors of DAPT use. CONCLUSION: In this nationwide registry, DAPT was prescribed at discharge in 55% of MINOCA patients. Beyond sinus rhythm, the variables presented as independent predictors for DAPT use identify subgroups of patients who are classified as more prone to thrombotic events. The issue of how to handle antithrombotic agents in MINOCA patients is a topic open for discussion.

Eligibility for extended antithrombotic therapy for secondary prevention of acute coronary syndrome.

INTRODUCTION AND OBJECTIVES: Recent randomized controlled trials have evaluated the benefit of extended antithrombotic therapy in secondary prevention of acute coronary syndrome (ACS). However, the numerous and strict enrollment criteria may limit the validity and reproducibility of the published results in clinical practice. Our goal was to estimate the eligibility for participation in two randomized clinical trials in a group of patients followed for ACS. METHODS: We applied the enrollment criteria of two randomized clinical trials (PEGASUS and COMPASS) to consecutive patients who underwent percutaneous coronary intervention in an ACS registry between January 2016 and June 2017. RESULTS: A total of 780 patients were included in the final analysis. The proportion of patients fulfilling the trial enrollment criteria was 35.9% for PEGASUS and 32.1% for COMPASS. The proportion of patients eligible for both trials was 17.7% and 49.7% of patients were eligible for at least one trial. The need for anticoagulant therapy was the most common reason for exclusion on the PEGASUS criteria (46.2%) and the presence of high bleeding risk was the most common reason for exclusion on the COMPASS criteria (61.5%). CONCLUSIONS: Approximately 50% of real-world patients are not eligible for the antithrombotic strategies applied in these trials. Since this non-eligible population is at greater risk of events, further studies are needed to confirm the applicability of these strategies.

Double coronary thrombosis in a patient with Behçet's disease.

Behçet's disease is a chronic relapsing multisystem autoinflammatory condition, in which cardiac involvement is rare, but among the most life-threatening complications. Treatment is largely empirical, and is aimed at suppressing vasculitis. In this role glucocorticoids and colchicine are frequently used. We present the case of a 42-year-old male with previously diagnosed Behçet's disease presenting to our emergency department with an anterior-inferior STEMI. He presented combined thrombosis of the distal anterior descending coronary artery and proximal right coronary artery, and was treated with sequential primary percutaneous coronary interventions and implantation of drug-eluting stents, but required two interventions due to high thrombotic load. His clinical course during hospitalization was good, with no systolic dysfunction at discharge. During follow-up, he has so far had no new cardiovascular events.

The prognostic value of elevated matrix metalloproteinase-9 in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: A two-year prospective study.

INTRODUCTION: Increased matrix metalloproteinase-9 (MMP-9) levels in ST-elevation myocardial infarction (STEMI) are well established; however, existing data on MMP-9 values as a prognostic marker after STEMI are limited and have been conflicting. OBJECTIVE: This study aimed to assess the clinical significance of MMP-9 in predicting two-year adverse cardiovascular events in patients who underwent primary percutaneous coronary intervention (PCI) after STEMI. METHODS: In this prospective study, 204 patients with STEMI undergoing PCI were included. Participants were classified as high MMP-9 (n=102) or low MMP-9 (n=102) based on a cutoff of 12.92 ng/ml. Both groups were assessed at one and two years after STEMI. RESULTS: Higher cardiovascular mortality at one year was observed in the high MMP-9 group (13.7% vs. 4.9% in the low MMP-9 group, p=0.03). When the follow-up period was extended to two years, the difference in cardiovascular mortality between the groups was more significant (17.6% vs. 4.9%, p=0.004). There was no significant difference at one-year follow-up in rates of advanced heart failure, however at the end of the second year, advanced heart failure was more prevalent in the high MMP-9 group (16.7% vs. 5.9%, p=0.015). After adjustment for potential confounders, a high MMP-9 value had 3.5-fold higher odds for cardiovascular mortality at two-year follow-up than low MMP-9. CONCLUSION: These results suggest that high MMP-9 levels are a strong predictor of cardiovascular mortality and advanced heart failure at two-year follow-up in STEMI patients.

Patient and system delays in the treatment of acute coronary syndrome.

INTRODUCTION: Early reperfusion for patients with ST-segment elevation myocardial infarction (STEMI) is indicated by the European Society of Cardiology, while a timely invasive strategy is recommended for patients with high-risk and intermediate-risk non-ST-elevation acute coronary syndromes (NSTE-ACS). This study aims to assess patient and system delays according to diagnosis and risk profile, and to identify predictors of prolonged delay. METHODS: We assembled a cohort of patients (n=939) consecutively admitted to the cardiology department of two hospitals, one in the metropolitan area of Porto and one in the north-east region of Portugal, between August 2013 and December 2014. RESULTS: The proportion of patients with time from symptom onset to first medical contact (FMC) ≥120 min was highest among high-risk NSTE-ACS (57.7%), followed by intermediate-risk NSTE-ACS (52.1%) and STEMI (43.3%). Regardless of diagnosis and risk stratification, use of own transportation and inability to interpret cardiac symptoms correctly were associated with prolonged delays. Regarding system delays, we found that 78.0% of patients with STEMI and 65.8% of patients with high-risk NSTE-ACS were treated in a timeframe exceeding the recommended limits. Admission to a non-percutaneous coronary intervention-capable hospital, admission on weekends and complications at admission were associated with prolonged delays to treatment. CONCLUSIONS: Due to both patient and system delays, a large proportion of STEMI and high-risk NSTE-ACS patients still fail to have access to timely reperfusion.