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This study focuses on identifying anatomical markers with predictive capacity for long-term myocardial infarction (MI) in focal coronary artery disease (CAD). Eighty future culprit lesions (FCL) and 108 non-culprit lesions (NCL) from 80 patients underwent 3D quantitative coronary angiography. The minimum lumen area (MLA), minimum lumen ratio (MLR), and vessel fractional flow reserve (vFFR) were evaluated. MLR was defined as the ratio between MLA and the cross-sectional area at the proximal lesion edge, with lower values indicating more abrupt luminal narrowing. Significant differences were observed between FCL and NCL in MLR (0.41 vs. 0.53, p < 0.001). MLR correlated inversely with translesional vFFR (r = − 0.26, p = 0.0004) and was the strongest predictor of MI at 5 years (AUC = 0.75). Lesions with MLR < 0.40 had a fourfold increased MI incidence at 5 years. MLR is a robust predictor of future adverse coronary events. The minimum lumen ratio (MLR) is defined as the ratio between the minimum lumen area (MLA) and the cross-sectional area at the proximal edge of the lesion (PROXA). A lower MLR suggests a more pronounced luminal narrowing upstream of the MLA. This specific anatomical lesion characteristic correlates with higher translesional pressure gradients and has been found to be highly predictive of lesion destabilization over a 5-year period. Notably, lesions exhibiting MLR values below 0.399 were associated with a fourfold increase in the incidence of myocardial infarction (MI) within the same timeframe. [ABSTRACT FROM AUTHOR]

Background/Objectives: Among patients with suspected severe aortic stenosis (AS), discordance between effective orifice area (EOA) and transvalvular gradients is frequent and requires a multiparametric workup including flow assessment and calcium-scoring to confirm true severe AS. The aim of this study was to assess direct planimetry, energy loss index (Eli) and dimensionless index (DI) as stand-alone parameters to identify non-severe AS in discordant cases. Methods: In this prospective cohort study, we included consecutive AS patients > 70 years with EOA < 1.0 cm2 referred for valve replacement between 2014 and 2017. AS severity was retrospectively reassessed using the multiparametric work-up recommended in the 2021 ESC/EACTS guidelines. DI and ELi were calculated, and valve area was measured by direct planimetry on transesophageal echocardiography. Results: A total of 101 patients (mean age 82 y; 57% male) were included. Discordance between EOA and gradients was observed in 46% and non-severe AS found in 24% despite an EOA < 1 cm2. Valve planimetry performed poorly, with an area under the ROC curve (AUC) of 0.64. At a cut-off value of >0.82 cm2, sensitivity and specificity to identify non-severe AS were 67 and 66%, respectively. DI and ELi showed a higher diagnostic accuracy, with an AUC of 0.77 and 0.76, respectively. Cut-off values of >0.24 and >0.6 cm2/m2 identified non-severe AS, with a high specificity of 79% and 91%, respectively. Conclusions: Almost one in four patients with EOA < 1 cm2 had non-severe AS according to guideline-recommended multiparametric assessment. Direct valve planimetry revealed poor diagnostic accuracy and should be interpreted with caution. Usual prognostic cut-off values for DI > 0.24 and ELI > 0.6 cm2/m2 identified non-severe AS with high specificity and should therefore be included in the assessment of low-gradient AS. [ABSTRACT FROM AUTHOR]

Background: The transcarotid (TC) vascular access for transcatheter aortic valve implantation (TAVI) has emerged as the first-choice alternative to the transfemoral access, in patients unsuitable for the latter. The use of both the left and right common carotid arteries (CCAs) for TC-TAVI has been described, but the optimal side is subject to debate. We conducted this pilot study to compare the level of vessel tortuosity and plaque burden from either the left CCA to the aortic annulus, or the right CCA to the aortic annulus, considering them as surrogates for technical and procedural complexity. Methods: Consecutive patients who underwent TC-TAVI between 2018 and 2021 in our institution were included. Using three-dimensional reconstruction, pre-TAVI neck and chest computed tomography angiography exams were reviewed to assess the tortuosity index (TI), sum of angles metric, as well as plaque burden, between each CCA and the aortic annulus. Results: We included 46 patients who underwent TC-TAVI. No significant difference regarding the mean TIs between the left and right sides (respectively 1.20 and 1.19, p = 0.82), the mean sum of angles (left side: 396°, right side: 384°, p = 0.27), and arterial plaque burden (arterial plaque found in 30% of left CCAs and 45% of right CCAs, p = 0.19) was found. Conclusions: We found no convincing data favoring the use of one particular access side over the other one. The choice of the CCA side in TC-TAVI should to be made on a case-by-case basis, in a multidisciplinary fashion, and may also depend on the operators' experience. [ABSTRACT FROM AUTHOR]

Introduction: Cardiac magnetic resonance imaging (CMR) is vital, but claustrophobia affects 10% of patients. The metaverse, an immersive virtual and augmented reality environment, has healthcare potential. We present a metaverse-based CMR simulation for claustrophobic patients. Methods: Three cardiomyopathy patients, initially CMR-refusing due to claustrophobia, received training via a virtual reality headset in a metaverse-based virtual hospital. Training efficacy was assessed through questionnaires and anxiety scales. Results: The patients successfully completed metaverse-based training, adapting to the CMR simulation. On CMR day, all entered the machine without issues and with reduced anxiety. Patients found the training useful, suggesting platform familiarization. Discussion: Our study demonstrates the metaverse's potential in alleviating CMR-related claustrophobia. The immersive nature enhances patient preparation, although usability improvements are needed. Further research should compare this approach with alternatives. Cardiac magnetic resonance imaging (CMR) is a vital tool for diagnosing heart problems, but some patients cannot undergo it due to claustrophobia. To address this, researchers are exploring new methods like hypnosis and simulations. One emerging technology, the metaverse, a 3D virtual reality (VR) environment, is being tested in healthcare. This study created a metaverse-based simulation to help claustrophobic patients prepare for CMR. Three patients with heart issues were given VR headsets to access a virtual hospital in the metaverse. Inside, they were trained for CMR step by step, experiencing the process and sounds realistically. Training was done 1 week, 3 days, and 1 day before the real CMR. Anxiety levels were measured. All patients completed the virtual training without issues. During the first simulations, some could not complete entering the virtual CMR machine due to anxiety. However, by the final simulation, all succeeded. On CMR day, all completed the scan without problems, and their anxiety levels decreased significantly from the initial training. Patients found the training helpful, but the platform's usability needed improvement. The study demonstrates that metaverse-based simulations can help patients overcome claustrophobia to successfully undergo CMR. This technology holds promise for simulating medical situations, easing patient fears, and improving preparation. However, further work is needed to make it user-friendly and accessible without assistance. This study encourages more research to assess the usefulness of the metaverse for broader patient groups, comparing it with other methods like hypnosis or sedation. Metaverse VR eases CMR claustrophobia! Tech innovation reduces anxiety and boosts scan success. Exciting clinical support tool. More research ahead! #HealthTech #Innovation Article highlights Metaverse-based cardiac magnetic resonance imaging simulation The study explored using a metaverse-based simulation to help claustrophobic patients with cardiac magnetic resonance imaging (CMR). Virtual reality headsets and a metaverse hospital were used to simulate the CMR process, aiming to assess its feasibility, efficacy, and usability. Positive patient response Three patients with claustrophobia underwent metaverse-based CMR simulation before the actual exam. All patients completed simulations successfully, and on the exam day, they completed CMR without issues. Patients reported reduced anxiety, indicating the potential benefits of the approach. Potential of metaverse technology The study demonstrates how metaverse simulations can alleviate anxiety and improve patient readiness for CMR scans. While the simulation shows promise, further refinement of user-friendliness is needed. The technology's applicability across diverse patient groups compared with alternative methods warrants future investigation. [ABSTRACT FROM AUTHOR]

Background: Chronic coronary syndrome (CCS) patients have a high mortality rate globally. Atherosclerosis, a cause of CCS, is influenced by inflammation. Pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-α), interleukin-1 (IL-1), and interleukin-6 (IL-6) have a key role in the process of atherosclerosis. Moreover, gut microbiota dysbiosis can lead to leaky gut syndrome, subsequently triggering abnormal immune responses and contributing to diseases, including atherosclerosis and coronary artery disease (CAD). Objective: To study the relationship between pro-inflammatory cytokines and gut microbiome in CCS patients undergoing coronary angiography. Material and Methods: Participants were divided into two groups by using statistical matching techniques with age and gender, as CCS patients and healthy participants. Each patient's blood was collected on the day of the appointment. All patients' feces were collected one day before an appointment. The present research was a cross-sectional study. Results: Fifty-three patients, including 28 CCS patients and 25 healthy participants were enrolled. CCS patients had a higher level of TNF-α compared to healthy participants with statistical significance at 79.31 pg/mL. Phascolarctobacterium, Sutterella, and Prevotella could distinguish CCS patients from healthy participants based on receiver operating characteristic (ROC) analysis. Proteus and Phascolarctobacterium were positively correlated with TNF-α. Conclusion: There is a potential relationship between gut microbiome composition and inflammatory biomarkers in CCS patients. Pro-inflammatory cytokines and specific bacterial genera may be related to indicate significant CAD in CCS patients undergoing coronary angiography. [ABSTRACT FROM AUTHOR]

The present study establishes a link between blood flow energy transformations in coronary atherosclerotic lesions and clinical outcomes. The predictive capacity for future myocardial infarction (MI) was compared with that of established quantitative coronary angiography (QCA)-derived predictors. Angiography-based computational fluid dynamics (CFD) simulations were performed on 80 human coronary lesions culprit of MI within 5 years and 108 non-culprit lesions for future MI. Blood flow energy transformations were assessed in the converging flow segment of the lesion as ratios of kinetic and rotational energy values (KER and RER, respectively) at the QCA-identified minimum lumen area and proximal lesion sections. The anatomical and functional lesion severity were evaluated with QCA to derive percentage area stenosis (%AS), vessel fractional flow reserve (vFFR), and translesional vFFR (ΔvFFR). Wall shear stress profiles were investigated in terms of topological shear variation index (TSVI). KER and RER predicted MI at 5 years (AUC = 0.73, 95% CI 0.65–0.80, and AUC = 0.76, 95% CI 0.70–0.83, respectively; p < 0.0001 for both). The predictive capacity for future MI of KER and RER was significantly stronger than vFFR (p = 0.0391 and p = 0.0045, respectively). RER predictive capacity was significantly stronger than %AS and ΔvFFR (p = 0.0041 and p = 0.0059, respectively). The predictive capacity for future MI of KER and RER did not differ significantly from TSVI. Blood flow kinetic and rotational energy transformations were significant predictors for MI at 5 years (p < 0.0001). The findings of this study support the hypothesis of a biomechanical contribution to the process of plaque destabilization/rupture leading to MI. [ABSTRACT FROM AUTHOR]

A growing body of evidence suggests that extrathoracic vascular accesses for transcatheter aortic valve replacement (TAVR) yield favorable outcomes and can be considered as primary alternatives when the gold-standard transfemoral access is contraindicated. Data comparing the transcaval (TCv) to supra-aortic (SAo) approaches (transcarotid, transsubclavian, and transaxillary) for TAVR are lacking. We aimed to compare the outcomes and safety of TCv and SAo accesses for TAVR as alternatives to transfemoral TAVR. A systematic review with meta-analysis was performed by searching PubMed/MEDLINE and EMBASE databases for all articles comparing TCv-TAVR against SAo-TAVR published until September 2023. Outcomes included in-hospital or 30-day all-cause mortality (ACM) and postoperative complications. A total of three studies with 318 TCv-TAVR and 179 SAo-TAVR patients were included. No statistically significant difference was found regarding in-hospital or 30-day ACM (relative risk [RR] 1.04, 95% confidence interval [CI] 0.47–2.34, p = 0.91), major bleeding, the need for blood transfusions, major vascular complications, and acute kidney injury. TCv-TAVR was associated with a non-statistically significant lower rate of neurovascular complications (RR 0.39, 95%CI 0.14–1.09, p = 0.07). These results suggest that both approaches may be considered as first-line alternatives to transfemoral TAVR, depending on local expertise and patients' anatomy. Additional data from long-term cohort studies are needed. [ABSTRACT FROM AUTHOR]

Cardiology's digital revolution: AI diagnoses, ChatGPT consults, Metaverse educates. Challenges & promises explored. #CardiologyTech #DigitalHealth [ABSTRACT FROM AUTHOR]

Purpose of Review: As TAVR is increasingly performed on younger patients with a longer life expectancy, the number of redo-TAVR procedures is likely to increase in the coming years. Limited data is currently available on this sometimes challenging procedure. We provide a summary of currently published literature on management of patients with a failed transcatheter aortic valve. Recent Findings: Recent registry data have increased the clinical knowledge on redo-TAVR. Additionally, numerous bench studies have provided valuable insights into the technical aspects of redo-TAVR with various combinations of valve types. Summary: Redo-TAVR can be performed safely in selected cases with a high procedural success and good short-term outcomes. However, at present, the procedure remains relatively infrequent and many patients are not eligible. Bench testing can be useful to understand important concepts such as valve expansion, neoskirt, leaflet overhang, and leaflet deflection as well as their potential clinical implications. [ABSTRACT FROM AUTHOR]

Background: The most reliable quantitative variable on Rubidium-82 (82Rb) cardiac PET/CT for predicting major adverse cardiovascular events (MACE) has not been characterized with low-dose silicon photomultipliers (SiPM) technology, which allows halving injected activity and radiation dose delivering less than 1.0 mSv in a 70-kg individual. Methods and Results: We prospectively enrolled 234 consecutive participants with suspected myocardial ischemia. Participants underwent 82Rb cardiac SiPM PET/CT (5 MBq/kg) and were followed up for MACE over 652 days (interquartile range 559-751 days). For each participant, global stress myocardial blood flow (stress MBF), global myocardial flow reserve (MFR), and regional severely reduced myocardial flow capacity (MFCsevere) were measured. The Youden index was used to select optimal thresholds. In multivariate analysis after adjustments for clinical risk factors, reduced global stress MBF < 1.94 ml/min/g, reduced global MFR < 1.98, and regional MFCsevere > 3.2% of left ventricle emerged all as independent predictors of MACE (HR 4.5, 3.1, and 3.67, respectively, p < 0.001). However, only reduced global stress MBF remained an independent prognostic factor for MACE after adjusting for clinical risk factors and the combined use of global stress MBF, global MFR, and regional MFCsevere impairments (HR 2.81, p = 0.027). Conclusion: Using the latest SiPM PET technology with low-dose 82Rb halving the standard activity to deliver < 1 mSv for a 70-kg patient, impaired global stress MBF, global MFR, and regional MFC were powerful predictors of cardiovascular events, outperforming traditional cardiovascular risk factors. However, only reduced global stress MBF independently predicted MACE, being superior to global MFR and regional MFC impairments. [ABSTRACT FROM AUTHOR]

While technology has become integral to cardiovascular medicine and augmented and virtual reality (AR/VR) are bringing modern possibilities, healthcare is arriving closer than ever to the merge of virtual and real worlds. Digital health and telemedicine flourished during the recent pandemic and modified the traditional physical way of patient-doctor interaction by using digital means and internet. Why the Metaverse in healthcare and Cardiology Virtual reality, distant consultations, and telemedicine apps have already been introduced to healthcare with multiple different services. [Extracted from the article]

Background: Computed tomography angiography (CTA) is used to plan TAVI procedures. We investigated the performance of pre-TAVI CTA for excluding coronary artery disease (CAD). Methods: In total 127 patients were included. CTA images were analyzed for the presence of ≥ 50% (significant CAD) and ≥ 70% (severe CAD) diameter stenoses in proximal coronary arteries. Results were compared with invasive coronary angiography (ICA) at vessel and patient levels. Primary endpoint was the negative predictive value (NPV) of CTA for the presence of CAD. Results: A total of 342 vessels were analyzable. NPV of CTA was 97.5% for significant CAD and 96.3% for severe CAD. Positive predictive value and accuracy were 44.8% and 87.1% for significant CAD and 56.3% and 94.4% for severe CAD. At patient level, NPV for significant CAD was 88.6%. Conclusion: Pre-TAVI CTA shows good performance for ruling out CAD and could be used as a gatekeeper for ICA in selected patients. [ABSTRACT FROM AUTHOR]

Objective: The prognostic importance of a coronary stenosis depends on its functional severity and its depending myocardial mass. Functional severity can be assessed by fractional flow reserve (FFR), estimated non-invasively by a specific validated CT algorithm (FFRCT). Calculation of myocardial mass at risk by that same set of CT data (CTmass), however, has not been prospectively validated so far. The aim of the present study was to compare relative territorial-based CTmass assessment with relative flow distribution, which is closely linked to true myocardial mass.Methods: In this exploratory study, 35 patients with (near) normal coronary arteries underwent CT scanning for computed flow-based CTmass assessment and underwent invasive myocardial perfusion measurement in all 3 major coronary arteries by continuous thermodilution. Next, the mass and flows were calculated as relative percentages of total mass and perfusion.Results: The mean difference between CTmass per territory and invasively measured myocardial perfusion, both expressed as percentage of total mass and perfusion, was 5.3±6.2% for the left anterior descending territory, -2.0±7.4% for the left circumflex territory and -3.2±3.4% for the right coronary artery territory. The intraclass correlation between the two techniques was 0.90.Conclusions: Our study shows a close relationship between the relative mass of the perfusion territory calculated by the specific CT algorithm and invasively measured myocardial perfusion. As such, these data support the use of CTmass to estimate territorial myocardium-at-risk in proximal coronary arteries. [ABSTRACT FROM AUTHOR]

Discharge anaemia is common following acute coronary syndromes (ACS). However, it is unknown if chronic anaemia (CA) and hospital-acquired anaemia (HAA) are associated with similar outcomes. In this retrospective analysis of 4083 ACS admissions treated with percutaneous coronary intervention in Switzerland (SPUM-ACS registry), 1896 patients (46.4%) had discharge anaemia (CA: n = 643 (15.7%) vs. HAA: n = 1253 (30.7%)). Landmark analysis that matched patients with CA (n = 504) and HAA (n = 866) with non-anaemic patients found increased 1-year major adverse cardiovascular events (cardiovascular mortality, myocardial infarction, stroke) among patients with CA (6.9% vs. 3.0%, HR 2.073, 95% CI 1.039–4.134, p = 0.039) and HAA (3.8% vs. 2.3%, HR 1.772, 95% CI 1.002–3.232, p = 0.049). Only CA was associated with increased 1-year all-cause mortality (7.9% vs. 1.6%, HR 4.255, 95% CI 1.950–9.284, p < 0.001). CA and HAA were associated with poor 1-year cardiovascular outcomes. Only CA was associated with increased all-cause mortality suggesting that HAA and CA represent distinct subclinical entities. [ABSTRACT FROM AUTHOR]

Aims Fractional flow reserve (FFR) has never been investigated in patients with reduced ejection fraction and associated coronary artery disease (CAD). We evaluated the impact of FFR on the management strategies of these patients and related outcomes. Methods and results From 2002 to 2010, all consecutive patients with left ventricular ejection fraction (LVEF) ≤50% undergoing coronary angiography with ≥1 intermediate coronary stenosis [diameter stenosis (DS)% 50–70%] treated based on angiography (Angiography-guided group) or according to FFR (FFR-guided group) were screened for inclusion. In the FFR-guided group, 433 patients were matched with 866 contemporary patients of the Angiography-guided group. For outcome comparison, 617 control patients with LVEF >50% were included. After FFR, stenotic vessels per patient were significantly downgraded compared with the Angiography-guided group (1.43 ± 0.98 vs. 1.97 ± 0.84; P  < 0.001). This was associated with lower revascularization rate (52% vs. 62%; P  < 0.001) in the FFR-guided vs. the Angiography-guided group. All-cause death at 5 years of follow-up was significantly lower in the FFR-guided as compared with Angiography-guided group [22% vs. 31%. HR (95% CI) 0.64 (0.51–0.81); P  < 0.001]. Similarly, rate of major adverse cardiovascular and cerebrovascular events (MACCE: composite of all-cause death, myocardial infarction, revascularization, and stroke) was significantly lower in the FFR-guided group [40% vs. 46% in the Angiography-guided group. HR (95% CI) 0.81 (0.67–0.97); P  = 0.019]. Higher rates of death and MACCE were observed in patients with reduced LVEF compared with the control cohort. Conclusions In patients with reduced LVEF and CAD, FFR-guided revascularization was associated with lower rates of death and MACCE at 5 years as compared with the Angiography-guided strategy. This beneficial impact was observed in parallel with less coronary artery bypass grafting and more patients deferred to percutaneous coronary intervention or medical therapy. Open in new tab Download slide Open in new tab Download slide [ABSTRACT FROM AUTHOR]

Objective: To obtain a real-world perspective of the optimal timing of angiography performed within 24 hours of admission with non-ST elevation myocardial infarction (NSTEMI).Background: Current guidelines recommend angiography within 24 hours of hospitalisation with NSTEMI. The recent VERDICT trial found that angiography within 12 hours of admission with NSTEMI was associated with improved cardiovascular outcomes among high-risk patients. We compared the outcomes of real-world NSTEMI patients undergoing angiography within 12 hours of admission with those of patients undergoing angiography 12 to 24 hours after admission.Methods: NSTEMI patients without life-threatening features who received angiography within 24 hours of admission were obtained from the SPUM-ACS registry, a cohort of consecutive patients admitted with acute coronary syndromes to four university hospitals in Switzerland. Cox models assessed for an association between door-to-catheter time and one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, and stroke).Results: Of 2672 NSTEMI patients, 1832 met the inclusion criteria. Among them, 1464 patients underwent angiography within 12 hours (12 h group) compared with 368 patients between 12 and 24 hours (12-24 h group). Multiple logistic regression identified out-of-hours admission as the only factor associated with delayed angiography. After 2 : 1 propensity score matching, 736 patients from the 12 h group and 368 patients from the 12-24 h group demonstrated no significant difference in rates of one-year MACE (7.7% vs. 7.3%, HR: 1.050, 95% CI 0.637-1.733, p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (p=0.847). Stratification by GRACE score (>140 vs. ≤140) found no significant reduction in MACE among high-risk patients in the 12 h group (.Conclusions: In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of admission was not associated with improved one-year cardiovascular outcomes when compared with angiography 12 and 24 hours after admission, even among high-risk patients. [ABSTRACT FROM AUTHOR]

Alternative accesses for transcatheter aortic valve replacement (TAVR) are needed in a certain number of patients, who present contraindications to the standard transfemoral access. We present the transcervical approach, which allows to access the aortic valve via supra-aortic vessels, namely, the brachiocephalic trunk, carotid artery, or subclavian artery. This approach is interesting because it avoids thoracotomy, which is necessary with some other alternative approaches for TAVR, such as the transaortic or transapical ones. Although some points still need clarification, such as the best anesthesia modality (general or local) or the optimal side for vessel access, data suggest the transcervical access might yield similar periprocedural and 30-day outcomes compared with the transfemoral access. Herein, we describe the surgical technique that was developed in our institution for transcervical access. [ABSTRACT FROM AUTHOR]

In an era where transcatheter aortic valve implantation (TAVI) indications and utilization are expanding beyond high-risk patients, paravalvular leak remains the intervention's Achilles heel. Effective reduction of paravalvular leak is important in order to ensure an optimal clinical outcome. We present here the first case report in which percutaneous valvular closure using Amplatzer plugs followed by a TAV-in-TAV intervention during the same procedure managed to resolve a severe paravalvular leak with haemodynamic instability, after TAVI for a bicuspid aortic stenosis. [ABSTRACT FROM AUTHOR]

Aims To assess the effect of fractional flow reserve (FFR)-guided percutaneous coronary intervention (PCI) with contemporary drug-eluting stents on the composite of cardiac death or myocardial infarction (MI) vs. medical therapy in patients with stable coronary lesions. Methods and results We performed a systematic review and meta-analysis of individual patient data (IPD) of the three available randomized trials of contemporary FFR-guided PCI vs. medical therapy for patients with stable coronary lesions: FAME 2 (NCT01132495), DANAMI-3-PRIMULTI (NCT01960933), and Compare-Acute (NCT01399736). FAME 2 enrolled patients with stable coronary artery disease (CAD), while the other two focused on non-culprit lesions in stabilized patients after acute coronary syndrome. A total of 2400 subjects were recruited from 54 sites world-wide with 1056 randomly assigned to FFR-guided PCI and 1344 to medical therapy. The pre-specified primary outcome was a composite of cardiac death or MI. We included data from extended follow-ups for FAME 2 (up to 5.5 years follow-up) and DANAMI-3-PRIMULTI (up to 4.7 years follow-up). After a median follow-up of 35 months (interquartile range 12–60 months), a reduction in the composite of cardiac death or MI was observed with FFR-guided PCI as compared with medical therapy (hazard ratio 0.72, 95% confidence interval 0.54–0.96; P  = 0.02). The difference between groups was driven by MI. Conclusion In this IPD meta-analysis of the three available randomized controlled trials to date, FFR-guided PCI resulted in a reduction of the composite of cardiac death or MI compared with medical therapy, which was driven by a decreased risk of MI. [ABSTRACT FROM AUTHOR]

Clinical benefit of invasive functionally guided revascularization has been mostly investigated and proven for percutaneous coronary intervention. It has never been prospectively evaluated whether a systematic fractional flow reserve (FFR) assessment is also beneficial in guiding coronary artery bypass graft surgery (CABG). The objective of the GRAft patency after FFR-guided versus angiography-guIded CABG (GRAFFITI) trial was to compare an FFR-guided revascularization strategy to the traditional angiography-guided revascularization strategy for patients undergoing CABG. Patients were enrolled with significantly diseased left anterior descending or left main stem and at least one major coronary artery with angiographically intermediate stenosis (30-90% diameter stenosis) that was assessed by FFR. Thereafter, while the FFR values were kept concealed, cardiac surgeons decided their intended procedural strategy based on the coronary angiography alone. At this point, patients underwent 1:1 randomization to either an FFR-guided or an angiography-guided CABG strategy. In case the patient was randomized to angiography-guided arm, cardiac surgeons kept their intended procedural strategy, i.e., CABG was guided solely on the basis of the coronary angiography. In case the patient was randomized to the FFR-guided arm, FFR values were disclosed to the surgeons who revised the surgical protocol according to the functional significance of each coronary stenosis. The primary endpoint of the trial was the rate of graft occlusion at 12 months, assessed by coronary computed tomography or coronary angiography. The secondary endpoints were (1) length of postoperative hospital stay; (2) changes in surgical strategy depending upon FFR results (in FFR-guided group only); and (3) rate of major adverse cardiac and cerebrovascular events, i.e., composite of death, myocardial infarction, stroke, and any revascularization during the follow-up period. This study is the first prospective randomized trial investigating potential clinical benefits, associated with FFR-guided surgical revascularization. Trial registration: NCT01810224 [ABSTRACT FROM AUTHOR]

Background The clinical benefit of manual thrombus aspiration (TA) during primary percutaneous coronary intervention (PPCI) in patients with ST-segment elevation myocardial infarction (STEMI) remains uncertain. This study assessed the impact of circadian rhythms on the effectiveness of manual TA. Methods and results We conducted an observational study of patients enrolled in the Acute Myocardial Infarction in Switzerland Plus registry. STEMI patients undergoing PPCI with (TA group) or without (PCI-alone group) manual TA were divided based on time-of-day symptom onset: group 1 (00:00-05:59), group 2 (06:00-11:59), group 3 (12:00-17:59) and group 4 (18:00-23:59). The primary endpoint was circadian variation of myocardial infarction (MI) size. The secondary endpoint was in-hospital all-cause mortality. Between 2009 and 2014, 3648 patients underwent PPCI (TA, 49%). After propensity-score matching, 2860 patients were included. Minimal myocardial Injury was observed in groups 2 and 3 (peak creatine kinase level group 1, 2723 ± 148 U/l; group 2, 2493 ± 105 U/l; group 3, 2550 ± 106 U/l; group 4, 2952 ± 144 U/l; p = 0.044) in the TA group, whereas no time-of-day dependence was found in PCI-alone group. After periodic sinusoidal regression analysis, a circadian relationship between time-of-day symptom onset and MI size was demonstrated in the TA group (p < 0.001). In-hospital all-cause mortality was 3.4% in the TA group and 4.3% in the PCI-alone group (p = 0.20). Conclusions In this large registry of STEMI patients, manual TA did not reduce in-hospital all-cause mortality. Nonetheless, there was a circadian dependence of TA effectiveness with greatest myocardial salvage for patients with symptom onset between 06:00 and 17:59. [ABSTRACT FROM AUTHOR]

Introduction: High-sensitivity cardiac troponin assays have significantly improved the sensitivity of myocardial infarction detection by using cutoff values and early absolute changes. However, variation in repeated measures also depends on biological variability. This study aimed to assess the potential circadian component of this biological variability. Methods: 17 healthy volunteers were recruited, and standardized conditions for physical activity, meals, exposure to light and duration of sleep were imposed. Blood samples were collected every 4 h and high-sensitivity troponin T assay with a limit of detection of 3 ng/l and a 99th percentile of 14 ng/l were used. Circadian variations were analyzed using the cosinor method. Results: Statistically significant circadian variations were observed for body temperature, heart rate, and systolic/diastolic arterial blood pressures ( p < 0.01 using both a non-adjusted cosinor model and a gender- and BMI-adjusted cosinor model). The amplitudes of the circadian variations were 18.93, 6, 15.35, and 1.92%, respectively. A statistically significant circadian biological variation of troponin blood concentrations was evidenced ( p < 0.01 in both the non-adjusted cosinor model and the gender- and BMI-adjusted cosinor), with an amplitude of 20.5% (average: 4.39 ng/l; amplitude: 0.9 ng/l; peak at 06:00 and nadir at 18:00). Discussion: This study demonstrates a circadian biological variation in blood troponin concentration in a healthy population. The amplitude of this variation challenges the cutoff value for instant rule-out of the rapid rule-in/rule-out of the recent European guidelines for the management of acute coronary syndromes. These findings deserve further investigation in a population at risk of myocardial infarction. [ABSTRACT FROM AUTHOR]

Background Highly sensitive troponin T (hs-TnT) assay has improved clinical decision-making for patients admitted with chest pain. However, this assay's performance in detecting myocardial ischaemia in a lowrisk population has been poorly documented. Purpose To assess hs-TnT assay's performance to detect myocardial ischaemia at positron emission tomography/CT (PET-CT) in low-risk patients admitted with chest pain. Methods Patients admitted for chest pain with a nonconclusive ECG and negative standard cardiac troponin T results at admission and after 6 hours were prospectively enrolled. Their hs-TnT samples were at T0, T2 and T6. Physicians were blinded to hs-TnT results. All patients underwent a PET-CT at rest and during adenosine-induced stress. All patients with a positive PET-CT result underwent a coronary angiography. Results Forty-eight patients were included. Six had ischaemia at PET-CT. All of them had ≥1 significant stenosis at coronary angiography. Areas under the curve (95% CI) for predicting significant ischaemia at PET-CT using hs-TnT were 0.764 (0.515 to 1.000) at T0, 0.812(0.616 to 1.000) at T2 and 0.813(0.638 to 0.989) at T6. The receiver operating characteristicbased optimal cut-off value for hs-TnT at T0, T2 and T6 needed to exclude significant ischaemia at PET-CT was <4 ng/L. Using this value, sensitivity, specificity, positive and negative predictive values of hs-TnT to predict significant ischaemia were 83%/38%/16%/94% at T0, 100%/40%/19%/100% at T2 and 100%/43%/20%/100% at T6, respectively. Conclusions Our findings suggest that in low-risk patients, using the hs-TnT assay with a cut-off value of 4 ng/L demonstrates excellent negative predictive value to exclude myocardial ischaemia detection at PET-CT, at the expense of weak specificity and positive predictive value. [ABSTRACT FROM AUTHOR]

Background: Different studies have shown circadian variation of ischemic burden among patients with ST-Elevation Myocardial Infarction (STEMI), but with controversial results. The aim of this study was to analyze circadian variation of myocardial infarction size and in-hospital mortality in a large multicenter registry. Methods: This retrospective, registry-based study was based on data from AMIS Plus, a large multicenter Swiss registry of patients who suffered myocardial infarction between 1999 and 2013. Peak creatine kinase (CK) was used as a proxy measure for myocardial infarction size. Associations between peak CK, in-hospital mortality, and the time of day at symptom onset were modelled using polynomial-harmonic regression methods. Results: 6,223 STEMI patients were admitted to 82 acute-care hospitals in Switzerland and treated with primary angioplasty within six hours of symptom onset. Only the 24-hour harmonic was significantly associated with peak CK (p = 0.0001). The maximum average peak CK value (2,315 U/L) was for patients with symptom onset at 23:00, whereas the minimum average (2,017 U/L) was for onset at 11:00. The amplitude of variation was 298 U/L. In addition, no correlation was observed between ischemic time and circadian peak CK variation. Of the 6,223 patients, 223 (3.58%) died during index hospitalization. Remarkably, only the 24-hour harmonic was significantly associated with in-hospital mortality. The risk of death from STEMI was highest for patients with symptom onset at 00:00 and lowest for those with onset at 12:00. Discussion: As a part of this first large study of STEMI patients treated with primary angioplasty in Swiss hospitals, investigations confirmed a circadian pattern to both peak CK and in-hospital mortality which were independent of total ischemic time. Accordingly, this study proposes that symptom onset time be incorporated as a prognosis factor in patients with myocardial infarction. [ABSTRACT FROM AUTHOR]

Objectives: To test if the time of day significantly influences the occurrence of type 4A myocardial infarction in elective patients undergoing percutaneous coronary intervention (PCI). Background: Recent studies have suggested an influence of circadian rhythms on myocardial infarction size and mortality among patients with ST-elevation myocardial infarction. The aim of the study is to investigate whether periprocedural myocardial infarction (PMI) is influenced by the time of day in elective patients undergoing PCI. Methods: All consecutive patients undergoing elective PCI between 2007 and 2011 at our institutions with known post-interventional troponin were retrospectively included. Patients ( n = 1021) were divided into two groups according to the starting time of the PCI: the morning group ( n = 651) between 07:00 and 11:59, and the afternoon group ( n = 370) between 12:00 and 18:59. Baseline and procedural characteristics as well as clinical outcome defined as the occurrence of PMI were compared between groups. In order to limit selection bias, all analyses were equally performed in 308 pairs using propensity score (PS) matching. Results: In the overall population, the rate of PMI was statistically lower in the morning group compared to the afternoon group (20% vs. 30%, p < 0.001). This difference remained statistically significant after PS-matching (21% vs. 29%, p = 0.03). Multivariate analysis shows that being treated in the afternoon independently increases the risk for PMI with an odds ratio of 2.0 (95%CI: 1.1-3.4; p = 0.02). Conclusions: This observational PS-matched study suggests that the timing of an elective PCI influences the rate of PMI. [ABSTRACT FROM AUTHOR]