Young cryptogenic ischemic stroke: A descriptive analysis of clinical and laboratory characteristics, outcomes and stroke recurrence.

BACKGROUND AND PURPOSE: Ischemic strokes (IS) occur also in young adults and despite an extensive work-up the cause of IS remains very often cryptogenic. Thus, effectiveness of secondary prevention may be unclear. We aimed to analyze a relationship among vascular risk factors (VRF), clinical and laboratory parameters, outcomes and recurrent IS (RIS) in young cryptogenic IS (CIS) patients. SUBJECTS AND METHODS: The study set consisted of young acute IS patients < 50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). All analyzed patients underwent transesophageal echocardiography, 24-h and 3-week ECG-Holter to assess cause of IS according to the ASCOD classification. Recurrent IS (RIS) was recorded during a follow-up (FUP). RESULTS: Out of 294 young enrolled patients, 208 (70.7%, 113 males, mean age 41.6 ± 7.2 years) were identified as cryptogenic. Hyperlipidemia (43.3%), smoking (40.6%) and arterial hypertension (37.0%) were the most frequent VRF. RIS occurred in 7 (3.4%) patients during a mean time of FUP 19 ± 23 months. One-year risk of RIS was 3.4% (95%CI: 1.4-6.8%). Patients with RIS were older (47.4 vs. 41.1 years, p = 0.007) and more often obese (71.4 vs. 19.7%, p = 0.006), and did not differ in any of other analyzed parameters and VRF. Multivariate logistic regression analysis showed obesity (OR: 9.527; 95%CI: 1.777-51.1) and the previous use of antiplatelets (OR: 15.68; 95%CI: 2.430-101.2) as predictors of recurrent IS. CONCLUSION: Despite a higher presence of VRF in young CIS patients, the risk of RIS was very low. Obesity and previous use of antiplatelet therapy were found the only predictors of RIS.

Computed tomography versus invasive coronary angiography: design and methods of the pragmatic randomised multicentre DISCHARGE trial.

OBJECTIVES: More than 3.5 million invasive coronary angiographies (ICA) are performed in Europe annually. Approximately 2 million of these invasive procedures might be reduced by noninvasive tests because no coronary intervention is performed. Computed tomography (CT) is the most accurate noninvasive test for detection and exclusion of coronary artery disease (CAD). To investigate the comparative effectiveness of CT and ICA, we designed the European pragmatic multicentre DISCHARGE trial funded by the 7th Framework Programme of the European Union (EC-GA 603266). METHODS: In this trial, patients with a low-to-intermediate pretest probability (10-60 %) of suspected CAD and a clinical indication for ICA because of stable chest pain will be randomised in a 1-to-1 ratio to CT or ICA. CT and ICA findings guide subsequent management decisions by the local heart teams according to current evidence and European guidelines. RESULTS: Major adverse cardiovascular events (MACE) defined as cardiovascular death, myocardial infarction and stroke as a composite endpoint will be the primary outcome measure. Secondary and other outcomes include cost-effectiveness, radiation exposure, health-related quality of life (HRQoL), socioeconomic status, lifestyle, adverse events related to CT/ICA, and gender differences. CONCLUSIONS: The DISCHARGE trial will assess the comparative effectiveness of CT and ICA. KEY POINTS: • Coronary artery disease (CAD) is a major cause of morbidity and mortality. • Invasive coronary angiography (ICA) is the reference standard for detection of CAD. • Noninvasive computed tomography angiography excludes CAD with high sensitivity. • CT may effectively reduce the approximately 2 million negative ICAs in Europe. • DISCHARGE addresses this hypothesis in patients with low-to-intermediate pretest probability for CAD.

[Carotid artery stenting - history, trends and innovations]. / Karotický stenting - vývoj, trendy a inovace.

Surgical carotid endarterectomy is traditionally considered the standard approach for the treatment of atherosclerotic carotid artery disease based on its long history of favorable outcomes. Many of the patients could, however, be offered carotid artery stenting (CAS), which has over time evolved into an elaborate method. With proper selection of patients, CAS provides comparable long-term outcomes and very low risk of periprocedural complication. This article summarises the current knowledge, trends and innovations in CAS.

Comparison of myocardial perfusion study and invasive hemodynamic measurement of the significance of non-infarct-related residual stenoses in ST elevation myocardial infarction patients.

BACKGROUND: Nearly 50% of ST elevation myocardial infarction (STEMI) patients have multivessel coronary artery disease. The optimal selection of non-culprit lesions for complete revascularization is a matter of current debate. Little is known about the predictive value of myocardial perfusion study (MPS) in this scenario. METHODS: We enrolled 49 STEMI patients (61.5 ± 10.3 years) with at least one major non-culprit lesion (50-90%) other than left main coronary artery lesions. Overall 63 non-infarct- related artery (IRA) stenoses (65.2 ± 11.9%) were recommended for further evaluation using Fractional Flow Reserve (FFR) measurement as is standard in our institution. Prior to FFR, all patients were scheduled for non-invasive MPS using single-photon emission computed tomography (SPECT). Both FFR and MPS were performed 4-8 weeks after STEMI with MPS preceding FFR within no more than 48 hours. An FFR value of ≤0.80 was considered significant and guided the final revascularization strategy. The results of MPS were correlated to FFR as well as to the clinical and angiographic characteristics of both culprit and non-infarct-related lesions. RESULTS: Based on FFR, 30 out of 63 stenoses (47.6%) in 27 patients were considered hemodynamically significant (FFR 0.69 ± 0.08, range 0.51-0.79) compared to residual 33 stenoses considered negative (FFR 0.87 ± 0.04, range 0.81-0.96). The MPS revealed abnormal myocardium (23.6% average, range 5-56%) in 21 patients (42.8%). Among those patients, only 9 showed the evidence of ischemic myocardium (average 10.8%, range 4-18%) with low sensitivity of MPS in predicting positive FFR. Besides that, higher proportion of patients (71.4% vs. 42.9%, P=0.047) with overall lower FFR values (0.73 vs. 0.80, P=0.014, resp.) in non-IRAs as well as higher proportion of patients with more severely compromised flow in IRAs (P=0.048) during STEMI had MPS-detected abnormal myocardium. CONCLUSION: In STEMI patients with multivessel coronary artery disease, we observed rather weak correlation between MPS using SPECT and invasive hemodynamic measurement using FFR in ischemia detection.

Complete revascularization of multivessel coronary artery disease in patients with ST elevation acute coronary syndrome - for whom and when? A comprehensive review.

Atherosclerosis is the most common cause of coronary steno-occlusive disease and acute myocardial infarction is the leading cause of death in industrialized countries. In patients with acute ST elevation myocardial infarction (STEMI), there is unquestionable evidence that primary percutaneous coronary intervention providing recanalization of the infarct related artery (IRA) is the preferred reperfusion strategy. Nevertheless, up to 50% of patients with STEMI have multivessel coronary artery disease defined as at least 50% stenosis exclusive of IRA. There is conflicting data regarding the optimal treatment strategy and timing in such patients. Currently, it is assumed that stable patients might benefit from complete revascularization particularly in reducing the need for future unplanned procedures but only culprit lesion should be treated during index procedure in unstable patients. In this article, we provide a comprehensive overview of this important and currently highly debated topic.

Comparison of angiographic estimation and invasive hemodynamic measurement of the significance of non-infarct-related residual stenoses in ST-elevation myocardial infarction patients.

Introduction: Up to 50% of patients with ST elevation myocardial infarction (STEMI) have ≥ 50% stenosis in a major non-infarct-related artery. Several studies have evaluated the prognostic value of the completion of revascularization with overall inconclusive results. Selection of the stenoses was based on the angiographic evaluation, invasive hemodynamic measurement or the combined approach. It is unknown whether such a selection provides correlation of comparable patient groups. Material and methods: We enrolled 51 patients (62.7 ±10.2 years) with acute STEMI and at least one residual (50-90%) stenosis in a non-infarct-related major coronary artery (excluding left main coronary artery). Overall 65 stenoses (67.9 ±10.7%) were evaluated angiographically following primary percutaneous coronary intervention and the hemodynamic significance was estimated with respect to the stenosis severity, caliber of the arterial segment, localization of the stenosis (proximity) as well as the estimated size of the supplied vascular territory. During subsequent hospitalization, invasive measurement of the hemodynamic significance using fractional flow reserve (FFR) was performed to guide the final revascularization strategy (FFR value of ≤ 0.80 considered significant). Results: Based on angiographic evaluation, a total of 44 stenoses would be recommended for treatment, whereas only 31 stenoses were revascularized based on FFR measurement. Moreover, visual evaluation and hemodynamic measurement were discrepant in 27 of 65 (41.5%) stenoses. Conclusions: We observed a weak correlation between visual angiographic evaluation and invasive hemodynamic measurement. More stents would be implanted based on angiographic evaluation compared to FFR measurement.

Determination of the prevalence and predictors of ventricular thrombus with assessment of the risk of systemic embolization to the CNS in patients after acute myocardial infarction using magnetic resonance imaging, echocardiography and cardiac markers - a prospective, unicentric, observational study.

BACKGROUND: Left ventricular thrombus (LVT) formation is one of the well-known and serious complications of acute myocardial infarction (AMI) due to the risk of systemic arterial embolization (SE). To diagnose LVT, echocardiography (TTE) is used. Late gadolinium-enhanced cardiovascular magnetic resonance (DE-CMR) is the gold standard for diagnosing LVT. OBJECTIVES: The aim of this observational study was to determine the role of transthoracic echocardiography and cardiac markers in predicting the occurrence of LVT compared with a reference cardiac imaging (DE-CMR) and to determine the risk of systemic embolization to the CNS using brain MRA. METHODS: Seventy patients after MI managed by percutaneous coronary intervention (localization: 92.9% anterior wall, 7% other; median age 58.7 years) were initially examined by transthoracic echocardiography (TTE, n=69) with a focus on LVT detection. Patients were then referred for DE-CMR (n=55). Laboratory determination of cardiac markers (Troponin T and NTproBNP) was carried out in all. Brain MRA was performed 1 year apart (n=51). RESULTS: The prevalence of LVT detected by echocardiography: (n=11/69, i.e. 15.9%); by DE-CMR: (n=9/55, i.e. 16.7%). Statistically significant parameters to predict the occurrence of LVT after AMI (cut off value): (a) detected by echocardiography: anamnestic data - delay (≥ 5 hours), echocardiographic parameters - left atrial volume index (LAVI≥ 32 mL/m2), LV EF Simpson biplane and estimated (≤ 42%), tissue Doppler determination of septal A wave velocity (≤ 7.5cm/s); (b) detected by DE-CMR: anamnestic data - delay (≥ 13 hours), DE-CMR parameters - left ventricular end-diastolic diameter (≥ 54mm). The value of cardiac markers (Troponin T and NTproBNP in ng/L) in LVT detected by echocardiography did not reach statistical significance. In LVT detected by DE-CMR, NTproBNP was statistically significantly increased at 1 month after AMI onset (no optimal cut-off value could be determined). There was no statistically significant association between the LVT detection (both modalities) and the occurrence of clinically manifest and silent cardioembolic events. CONCLUSION: Our study confirmed a relatively high prevalence of LVT in the high-risk group of patients with anterior wall STEMI. Due to the low prevalence of thromboembolic complications, no significant association between the LVT detection and the occurrence of a cardioembolic event was demonstrated.

Mid-term outcomes of carotid artery stenting in patients with angiographic string sign.

OBJECTIVES: To report on early and mid-term outcomes of carotid artery stenting (CAS) in patients with angiographic string sign (SS). BACKGROUND: Little is known about the prognosis of patients with carotid SS treated by CAS. METHODS: We retrospectively evaluated early and mid-term outcomes, together with ultrasound findings, in patients with SS treated by CAS at our institution. RESULTS: Of 308 CAS procedures, SS was diagnosed in 6.2% (19 patients, 58% symptomatic). Carotid stent implantation was successful in 18 patients (success rate 95%). There were no peri-procedural adverse events. One patient suffered from a transient ischemic attack during hospitalization and died of pneumonia. All remaining patients completed a 30-day follow-up, and no complications were reported (asymptomatic restenosis was diagnosed in 1 patient and successfully redilated). Six patients died of causes unrelated to CAS (pneumonia, decompensated heart failure, and contralateral stroke) before completing a 6-month follow-up. However, these patients presented with more pronounced, unfavorable clinical and angiographic characteristics compared to the rest of the patients. CONCLUSIONS: We suggest that CAS might be performed with acceptable procedural risk in patients presenting with SS, which is unsuitable for surgery. However, patients' clinical and angiographic characteristics must be carefully evaluated when considering interventional therapy, regardless of the favorable procedural outcomes.

Carotid artery stenting without post-dilation.

INTRODUCTION: The aim of this study is to report the feasibility, safety, and 1-year restenosis rate of carotid artery stenting (CAS) without post-dilation. METHODS: Between April 2006 and November 2009, 254 consecutive patients (68.7 ± 8.5 years old, 31% symptomatic) underwent 308 CAS procedures with the intention of avoiding post-dilation (eligibility criteria were stenosis of less than 30% after stent placement with no overt signs of calcification). Comparison and analysis of mid-term clinical outcomes and restenosis rates of CAS with or without post-dilation was performed retrospectively. RESULTS: Overall, 27 patients (study group) were eligible for treatment without post-dilation. No significant difference in adverse events was found between the study and control group. In the study group, 2 transient ischemic attacks (7.4%) occurred immediately after the procedure and no other neurological complications were reported during the 30-day, 6-month, and 1-year follow-ups (3 patients died from causes unrelated to the procedure). Two asymptomatic restenosis cases were diagnosed in the study group within the first 12-months after the procedure compared to 16 significant restenosis cases diagnosed in the control group (7.4% vs 5.7%, NS). All of them were successfully treated with repeated intervention. CONCLUSION: We suggest that CAS without post-dilation is feasible and probably safe with a low rate of cerebrovascular events and restenosis in a selected group of patients. We also suggest that CAS with postdeployment stenosis of less than 20% and without overt signs of severe calcification might be performed without post-dilation.

Comparison of carotid artery stenting in patients with single versus bilateral carotid artery disease and factors affecting midterm outcome.

BACKGROUND: Carotid artery stenting (CAS) is the method of choice for carotid artery revascularization of patients at high risk for carotid endarterectomy. In this study, we compared the midterm results of CAS in patients with unilateral versus bilateral carotid artery disease. METHODS AND RESULTS: This is a retrospective analysis of 1-year outcome of 273 consecutive patients in whom 342 CAS procedures were performed. The incidence of periprocedural transient ischemic attacks (TIAs) differed significantly (8% vs. 1%; p = 0.01) among patients with and without bilateral internal carotid disease, and a tendency to a lower occurrence of early adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction) was subsequently shown (11% vs. 5%; p = 0.12). At 1-year follow-up, there was a high incidence of adverse events (death, stroke, periprocedural TIA, periprocedural myocardial infarction, restenosis) in patients with bilateral carotid artery disease (40% vs. 14%; p < 0.01), which was mainly driven by a higher incidence of death, periprocedural TIA, and restenosis (p ≤ 0.02 for all). According to multivariate analysis, the independent predictors of midterm adverse events were left ventricular dysfunction, male gender, bilateral carotid artery disease, renal insufficiency, cerebral symptoms within the last 6 months before the intervention, and low-density lipoprotein cholesterol level. CONCLUSIONS: At midterm follow-up, patients with bilateral carotid artery disease treated by CAS have significantly more adverse events than those with unilateral disease.

Long-term positive remodeling of the right coronary artery after reimplantation from the pulmonary artery to the ascending aorta.

A 53-year-old woman, nonsmoking patient, with a history of surgically corrected anomalous origin of the right coronary artery from the pulmonary artery 17 years prior to admission, presented to our department complaining of mild, left-sided exertional chest pain for the past 3 months. She underwent a computed tomography examination of the heart and coronary angiography revealing postsurgical changes to the coronary vasculature and severe stenosis of the left circumflex artery, which was successfully treated by percutaneous stent implantation.

Acute myocardial infarction, intraventricular thrombus and risk of systemic embolism.

The development of left ventricular thrombus (LVT) is a well-known and serious complication of acute myocardial infarction (AMI) due to the risk of systemic arterial embolism (SE), which is variable in its clinical picture and has potentially serious consequences depending on the extent of target organ damage. SE results in an increase in mortality and morbidity in these patients. LVT is one of the main causes of the development of ischaemic cardio-embolic cardiovascular events (CVE) after MI and the determination of the source of cardiac embolus is crucial for the initiation of adequate anticoagulant therapy in secondary prevention. Echocardiography holds an irreplaceable place in the diagnosis of LVT, contrast enhancement provides higher sensitivity. The gold standard for LVT diagnosis is cardiac magnetic resonance imaging, but it is not suitable as a basic screening test. In patients with already diagnosed LVT, it is necessary to adjust antithrombotic therapy by starting warfarin anticoagulation for at least 6 months with the need for echocardiographic follow-up to detect thrombotic residues. The effect of prophylactic administration of warfarin in high-risk patients after anterior AMI does not outweigh the risk of severe bleeding complications and does not result in a decrease in mortality and morbidity. At the present time, there is not enough evidence to use direct oral anticoagulants in this indication.

Vulnerable atherosclerotic plaque - a review of current concepts and advanced imaging.

Atherosclerosis is the most common cause of both carotid and coronary steno-occlusive disease. Rupture of an atherosclerotic plaque may lead to the formation of an overlying thrombosis resulting in complete arterial occlusion or downstream embolism. Clinically, this may manifest as a stroke or acute myocardial infarction, the overall leading causes of mortality and disability in developed countries. In this article, we summarize current concepts of the development of vulnerable plaque and provide an overview of commonly used imaging methods that may suggest/indicate atherosclerotic plaque vulnerability.

Arteria Lusoria and Superdominant Right Coronary Artery: Two Rare Arterial Anomalies Diagnosed during Transradial Coronary Catheterization.

We present a case report of two rare arterial anomalies diagnosed during transradial coronary catheterization-arteria lusoria (aberrant right subclavian artery) and superdominant right coronary artery. Importantly, these anomalies may cause difficulty in performance or interpretation of catheterization procedure, especially in urgent situation and with wide acceptance of transradial approach. To the best of our knowledge, the combination of these anomalies has never been described in the literature.

The role of near-infrared spectroscopy in the detection of vulnerable atherosclerotic plaques.

Coronary artery disease is the leading cause of mortality worldwide. Most acute coronary syndromes are caused by a rupture of a vulnerable atherosclerotic plaque which can be characterized by a lipid-rich necrotic core with an overlying thin fibrous cap. Many vulnerable plaques can cause angiographically mild stenoses due to positive remodelling, which is why the extent of coronary artery disease may be seriously underestimated. In recent years, we have witnessed a paradigm shift in interventional cardiology. We no longer focus solely on the degree of stenosis; rather, we seek to determine the true extent of atherosclerotic disease. We seek to identify high-risk plaques for improvement in risk stratification of patients and prevention. Several imaging methods have been developed for this purpose. Intracoronary near-infrared spectroscopy is one of the most promising. Here, we discuss the possible applications of this diagnostic method and provide a comprehensive overview of the current knowledge.

Near-infrared spectroscopy combined with intravascular ultrasound in carotid arteries.

Limited insights into the pathophysiology of the atherosclerotic carotid stenosis are available in vivo. We conducted a prospective study to assess safety and feasibility of intravascular ultrasound (IVUS) combined with near-infrared spectroscopy (NIRS) in carotid arteries. In addition, we described the size and the distribution of lipid rich plaques in significant atherosclerotic carotid stenoses. In a prospective single centre study 45 consecutive patients (mean age 66 ± 8 years) with symptomatic (≥50 %) or asymptomatic (≥70 %) stenosis of internal carotid artery (ICA) amendable to carotid stenting were enrolled. A 40 mm long NIRS-IVUS pullback through the stenosis was performed. IVUS and NIRS data were analyzed to assess minimal luminal area (MLA), plaque burden (PB), remodeling index (RI), calcifications, lipid core burden index (LCBI), maximal LCBI in any 4 mm segment of the artery (LCBImx) and LCBI in the 4 mm segment at the site of minimal luminal area (LCBImxMLA). NIRS-IVUS pullbacks were safely performed without overt clinical events. LCBImx was significantly higher than LCBImxMLA (369.1 ± 221.1 vs. 215.7 ± 2589; p = 0.004). Conversely, PB was significantly larger at the site of MLA (87.4 ± 4.8 % vs. 58.3 ± 18.2 %; p < 0001). Distance of the NIRS-IVUS frame with the highest LCBI from the site of MLA was 6.5 ± 7.7 mm. Eighty percent of frames with maximal LCBI were localized within 10 mm from the site of MLA and 67 % proximally to or at the site of MLA. This study suggested safety and feasibility of the NIRS-IVUS imaging of the carotid stenosis and provided insights on the distribution of lipids in the carotid stenosis. Lipid rich plaques were more often located in the sites with a milder stenosis and smaller plaque burden than at the site of MLA.

Impact of coexisting multivessel coronary artery disease on short-term outcomes and long-term survival of patients treated with carotid stenting.

INTRODUCTION: Systemic atherosclerosis can result in both coronary artery disease (CAD) and carotid artery disease. Recently it has been shown that patients with CAD have a higher incidence of microembolization during carotid artery stenting (CAS), and it has been hypothesized that they could be at higher risk in this intervention. MATERIAL AND METHODS: We retrospectively evaluated an institutional registry with 437 consecutive patients who underwent coronary angiography and CAS to evaluate their short-term outcomes and long-term survival with regard to the presence of coexisting multivessel coronary artery disease (MVD). RESULTS: We performed 220 CAS procedures in MVD patients and 318 CAS procedures in non-MVD patients. The incidence of in-hospital CAS-related adverse events was 2.7% and 2.5% in the MVD and non-MVD groups, respectively (p = 0.88). At 30 days, there was no significant difference between the groups in terms of the number of patients with adverse events (hierarchically death/stroke/myocardial infarction; 8.8% vs. 5.5%; p = 0.18). The median duration of follow-up was 4.23 years. Survival free of all-cause mortality at 1, 3 and 5 years was 90% (95% CI: 86-94%), 79% (95% CI: 73-85%) and 70% (95% CI: 64-77%), and 92% (95% CI: 89-95%), 85% (95% CI: 80-90%) and 76% (95% CI: 70-82%) for the MVD and non-MVD groups (p = 0.02), respectively. CONCLUSIONS: These results suggest that patients with MVD combined with carotid artery disease are probably not at higher risk of early post-CAS adverse clinical events, but they have significantly worse long-term survival rates.

Carotid Artery Stenting-Historical Context, Trends, and Innovations.

Surgical carotid endarterectomy (CEA) has been proven effective in both primary and secondary stroke prevention and, until recently, has been considered the standard treatment approach for patients with severe carotid artery disease. Because of its technical limitations and less favorable outcomes, carotid artery stenting (CAS) has been offered preferably to patients considered to be too comorbid to undergo surgical treatment. However, CAS has evolved over time into a reliable method and is currently considered an alternative to CEA. The aim of this review was to discuss the historical aspects, trends, and innovations in CAS.

The Paramount Role of the Anterior Communicating Artery in the Collateral Cerebral Circulation.

Clinical manifestation of carotid occlusive disease is largely dependent on the severity of stenosis and the capability of collateral circulation. However, due to the complexity and difficulty in evaluation, cerebral collateral circulation has, so far, remained underappreciated. We report a patient with advanced extracranial arterial disease (including the right subclavian steal, occlusion of the right external carotid artery, and severe stenosis of the left vertebral artery), who underwent transient right internal carotid artery occlusion during carotid intervention. Throughout the occlusion, the flow into the right hemisphere (monitored by transcranial Doppler ultrasound in the right middle cerebral artery) was sufficient despite almost totally dependent on the anterior communicating artery, which highlights its role as the most potent collateral pathway.