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Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS) that is increasingly recognized in young to middle-aged women without typical coronary risk factors. This case report describes a 46-year-old male with a rare presentation of SCAD involving the left main (LM) coronary artery. The patient underwent an emergency coronary angiogram for high-risk ACS and had percutaneous coronary intervention (PCI) of LM due to active ischemia and hemodynamic instability. The extension of intramural hematoma after the LM coronary artery stent confirmed the initial suspicion of SCAD. The diagnosis of SCAD is crucial, as its management differs from other causes of ACS. Coronary angiography is the gold standard for diagnosing SCAD, with adjunctive imaging using optical coherence tomography (OCT) and intravascular ultrasound (IVUS). In this patient, his physical examination findings and further imaging raised a suspicion for systemic connective tissue disease. Genetic analysis was executed, but no reportable variants in any of the 29 genes studied were identified. This case highlights the importance of recognizing SCAD as a potential cause of ACS even in men and emphasizes the findings during coronary angiography that can aid in an accurate diagnosis and appropriate management., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Chopra et al.)

Background: Physiology-guided percutaneous coronary intervention (PCI) has demonstrated to improve clinical outcomes. Previous trials showed the agreement between iFR and FFR is approximately 80%, however the details of discordance pattern remain to be elucidated., Methods: We retrospectively reviewed 1024 consecutive intermediate stenotic lesions for which functional evaluation using both iFR and FFR were performed between January 2015 and June 2016. The lesions were classified into 4 groups according to iFR and FFR concordance [(iFR+/FFR+) and (iFR-/FFR-)] or discordance [(iFR+/FFR-) and (iFR-/FFR+)]., Results: Our study evaluated 451 lesions, 264 lesions (58.5%) from men and 187 lesions (41.5%) from women. iFR was similar between women and men, however FFR was significantly higher in women than men. The rate of discordance between iFR and FFR was 21.3% (iFR+/FFR- 12.4% and iFR-/FFR+ 8.9%) in overall cohort. The prevalence of overall concordance and discordance were similar between men and women, however iFR+/FFR- discordance was significantly higher in women (17.1% vs. 9.1%) whereas iFR-/FFR+ discordance was significantly higher in men (11.3% vs. 4.8%). In multivariable analysis, female sex and older age were significantly associated with iFR+/FFR- discordance (odds ratio 1.88 and 1.48, respectively). Conversely, younger age, higher stenosis, and concomitant chronic total occlusion were independent predictors for iFR-/FFR+ discordance (odds ratio 0.67, 1.82, and 4.32, respectively)., Conclusions: Despite similar prevalence of overall concordance and discordance between men and women, iFR+/FFR- discordance was higher in women and iFR-/FFR+ discordance was higher in men. Multivariable analysis showed female sex to be independent predictor of iFR+/FFR- discordance., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: We aimed to investigate the efficacy and safety of different antithrombotic strategies in patients undergoing transcatheter aortic valve implantation (TAVI) using network meta-analyses., Background: Meta-analyses comparing single antiplatelet therapy (SAPT) vs. dual antiplatelet therapy (DAPT), ± oral anticoagulant (OAC) was conducted to determine the appropriate post TAVI antithrombotic regimen. However, there was limited direct comparisons across the different therapeutic strategies., Methods: MEDLINE and EMBASE were searched through December 2018 to investigate the efficacy and safety of different antithrombotic strategies (SAPT, DAPT, OAC, OAC + SAPT, and OAC + DAPT) in patients undergoing TAVI. The main outcome were all-cause mortality, major or life-threatening bleeding events, and stroke., Results: Our search identified 3 randomized controlled trials and 10 nonrandomized studies, a total of 20,548 patients who underwent TAVI. All OACs were vitamin K antagonists. There was no significant difference on mortality except that OAC + DAPT had significantly higher rates of mortality compared with others (p < .05, I 2 = 0%). SAPT had significantly lower rates of bleeding compared with DAPT, OAC+SAPT, and OAC+DAPT (hazard ratio [HR]: 0.59 [0.46-0.77], p < .001, HR: 0.58 [0.34-0.99], p = .045, HR: 0.41 [0.18-0.93], p = .033, respectively, I 2 = 0%). There was no significant difference on stroke among all antithrombotic strategies., Conclusion: Patients who underwent TAVI had similar all-cause mortality rates among different antithrombotic strategies except OAC+DAPT. Patients on SAPT had significantly lower bleeding risk than those on DAPT, OAC + SAPT, and OAC + DAPT. Our results suggest SAPT is the preferred regimen when there is no indication for DAPT or OAC. When DAPT or OAC is indicated, DAPT + OAC should be avoided., (© 2019 Wiley Periodicals, Inc.)

Amputation has been known to be a rare adverse event of sodium glucose co-transporter-2 (SGLT2) inhibitors. It remains unclear whether the SGLT2 inhibitor as a class or specific categories of the SGLT2 inhibitors are linked with an increased risk of amputation. The objective of this meta-analysis was to investigate the association between the amputation risk and the use of SGLT2 inhibitors. The main outcome measure was the risk of amputation. Multiple databases were searched up to February 2020 and data extraction was performed. Inclusion criteria were randomized controlled trials (RCTs) which reported risk of amputation with SGLT2 inhibitors over non-SGLT2 inhibitors or placebo. The risk of bias was assessed by Cochrane bias tool. The initial search yielded 1,873 citations and a total of five RCTs were included in the meta-analysis. The five included studies evaluated a total of 39,067 patients with diabetes mellitus, including 21,395 patients on SGLT2 inhibitors. The incidence rate of amputation ranged from 0.36 to 3.18% in the SGLT2 inhibitor group and from 0% to 2.87% in the control group. Follow up duration ranged from 24 weeks to 4.2 years. Use of SGLT2 inhibitors was not associated with significant increase in the risk of amputation as compared with controls (OR: 1.31, 95% CI: 0.92-1.87, I 2  = 75%). Subgroup analysis showed that neither canagliflozin, empagliflozin, nor dapagliflozin was associated with increased risk of amputation. In conclusion, our meta-analysis showed that neither canagliflozin nor other SGLT2 inhibitors increase the risk of amputation., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Symmetrically inverted or biphasic T waves in anterior precordial leads, Wellens' sign, have been shown to represent impending infarction of left anterior descending (LAD) territory among unstable angina patients in the studies published more than 3 decades ago, when non-ST-segment elevation myocardial infarction (NSTEMI) was not a recognized entity. The clinical implication of Wellens' sign in the contemporary NSTEMI cohort has not been clarified., Methods: We performed a retrospective analysis of all NSTEMI patients who underwent coronary angiography between January 2013 and June 2014. Wellens' sign was defined as either symmetrically inverted T waves (≥ 0.10 mV) or biphasic T waves in both leads V2 and V3. Coronary angiograms were reviewed and culprit lesions were determined for each patient., Results: A total of 274 patients were included in the final analysis, of whom 24 (8.8%) had Wellens' sign. Among these 24 patients, 16 had a LAD culprit (eight proximal), two had a non-LAD culprit, and six had non-obstructive coronary artery disease. Patients with Wellens' sign were more likely to have LAD culprit (66.7% vs. 19.6%, P < 0.001) and proximal LAD culprit (33.3% vs. 14.4%, P = 0.035) than those without it. Wellens' sign had a sensitivity of 24.6% and a specificity of 96.2% to predict LAD culprit., Conclusions: Our study revealed that: 1) Wellens' sign was seen in 8.8% of the patients with NSTEMI; 2) Two-thirds of patients with Wellens' sign had LAD culprit and one-third had proximal LAD culprit; and 3) Sensitivity and specificity of Wellens' sign to predict LAD culprit were 24.6% and 96.2%, respectively., Competing Interests: None.

Rebound hyperthermia (RH) is frequently seen after completion of targeted temperature management (TTM) in comatose survivors of cardiac arrest. However, its clinical significance is not well understood. Previous studies analyzing the association of RH with clinical outcome have reported conflicting results. The purpose of this meta-analysis is to examine the impact of RH after completion of TTM in patients postcardiac arrest. We reviewed six studies that evaluated the incidence of RH (T > 38°C) with documentation of outcome based on the presence of hyperthermia. We reviewed all six articles and extracted the data for mortality and neurological outcome. A total of 729 patients were analyzed for neurological outcome and 950 patients were analyzed for mortality. RH was found to be associated with a significantly worse neurological outcome (odds ratio [OR] 1.55; 95% confidence interval [CI] 1.13-2.14). RH was not significantly associated with a higher mortality (OR 1.31; 95% CI 1.00-1.72). We also analyzed three studies totaling 206 patients for neurological outcomes and mortality that included patients with severe RH (T > 38.5°C). Severe RH was found to be associated with significantly worse neurological outcome (OR 1.92, 95% CI 1.28-1.90) and significantly worse mortality (OR 2.22, 95% CI 1.50-3.29). RH is common after completion of TTM in comatose patients because of cardiac arrest and is associated with poor neurological outcomes. The clinical impact of RH is likely proportional to the magnitude of RH.

Background: Low QRS voltage was reported to predict adverse outcomes in acute myocardial infarction in the pre-thrombolytic era. However, the association between low voltage and angiographic findings has not been fully addressed., Methods: We performed a retrospective analysis of patients with anterior ST-segment elevation myocardial infarction (STEMI). Low QRS voltage was defined as either peak to peak QRS complex voltage <1.0mV in all precordial leads or <0.5mV in all limb leads., Results: Among 190 patients, 37 patients (19%) had low voltage. Patients with low voltage had a higher rate of multi-vessel disease (MVD) (76% vs. 52%, p=0.01). Patients with low voltage were more likely to undergo coronary artery bypass grafting (CABG) during admission (11% vs. 2%, p=0.028). Low voltage was an independent predictor for MVD (OR 2.50; 95% CI 1.12 to 6.03; p=0.032)., Conclusion: Low QRS voltage was associated with MVD and in-hospital CABG in anterior STEMI., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Positive T wave in lead aVR has been shown to predict an adverse in-hospital outcome in patients with anterior wall ST-segment elevation myocardial infarction (STEMI). However, the prognostic value of positive T wave in lead aVR on a long-term outcome has not been fully explored., Methods: We performed a retrospective analysis of 190 consecutive patients with first anterior wall STEMI who underwent an emergent coronary angiogram. Patients were divided into those with positive T wave > 0 mV and those with negative T wave ≦ 0 mV in lead aVR. Baseline and angiographic characteristics, and in-hospital revascularization procedures were recorded. In addition, in-hospital and 1-year major adverse cardiac events (MACE) including death, recurrent myocardial infarction, and target vessel revascularization were recorded., Results: Among 190 patients, 37 patients (19%) had positive T wave and 153 patients (81%) had negative T wave in lead aVR. Patients with positive T wave had higher rate of left main disease defined as stenosis ≥50% (11% vs. 2%, p = .028) than those with negative T wave. Patients with positive T wave had higher rate of 1-year MACE (38% vs. 13%, p < .001) driven by higher all-cause mortality (27% vs. 5%, p < .001). Positive T wave was an independent predictor for 1-year MACE (OR 2.74; 95% CI 1.04-7.15; p = .04)., Conclusion: Positive T wave in lead aVR was an independent predictor for 1-year MACE in patients with first anterior wall STEMI., (© 2017 Wiley Periodicals, Inc.)

Therapeutic hypothermia is used in select patients after out-of-hospital cardiac arrest (OHCA) to improve neurologic outcome. Rebound hyperthermia (RH) is commonly observed post-treatment. Previous studies analyzing the association of RH with clinical outcome have reported conflicting results. The purpose of this study is to examine the impact of RH after completion of therapeutic hypothermia in patients postcardiac arrest. We analyzed a retrospective cohort from our institution. All adults who underwent therapeutic hypothermia post-OHCA were divided into two cohorts depending on the presence/absence of fever (T > 38°C) within 24 hours of completing hypothermia protocol. Clinical outcomes were analyzed at hospital discharge or death. Among 306 patients admitted with OHCA, 117 underwent hypothermia, 97 survived 24 hours postrewarming. Twenty-seven patients (50%) with RH died compared with 20 (47%) without RH (OR, 1.15; 95% CI, 0.52-2.57). Twenty-six patients (67%) with RH had a poor neurologic outcome compared with 27 (63%) without RH (OR 1.19, 95% CI, 0.51-2.74). RH is common after completion of therapeutic hypothermia in comatose patients due to cardiac arrest and is associated with poor neurologic outcomes. We found no significant clinical impact of rebound hypothermia on neurologic outcome or mortality, but our study was underpowered to reveal such impact if it exists.

Background/purpose: Diabetes portends an increased risk of adverse early and late outcomes in patients undergoing PCI. In this study, we aimed to investigate if the adverse effect of diabetes mellitus (DM) on early and late PCI outcomes is reduced with drug-eluting (DES) compared to bare-metal (BMS) stents., Methods/materials: We reviewed the Mount Sinai Beth Israel Hospital first PCI experience for multivessel coronary artery disease (CAD, 1998-2009). Patients were excluded if they had single-vessel CAD, emergency, no stent, prior bypass graft or myocardial infarction <24h. Diabetes-effect was derived from 9-year all-cause mortality and re-intervention risk-adjusted hazard ratios [AHR (95% confidence intervals)] for DES (N=2679; 48% three-vessel; 39% DM) and BMS (N=2651; 40% three-vessel; 33% DM) and then stratified based on stent (DES/BMS) and vessel disease (two/three)., Results: Diabetes-effect on mortality was lower for DES (AHR DM/NoDM =1.41 [1.14-1.74]) versus BMS (AHR DM/NoDM =1.71 [1.50-2.01]), but this was predominantly driven by two-vessel patients. This diabetes effect was similar for first (DES1: AHR DM/NoDM =1.43 [1.14-1.79]) and second (DES2: AHR DM/NoDM =1.53 [0.77-3.07]) generation DES. Re-intervention comparisons were similarly increased by diabetes in all sub-cohorts., Conclusions: Our analysis of a large real-world PCI series indicates that diabetes is associated with worse 9-year mortality irrespective of stent type, albeit this is mitigated to varying degrees with DES, particularly in DES2 and in case of 2-vessel disease. A complementary stent-effect analysis confirmed DES-to-BMS and DES2-to-DES1 superiority in both diabetics and non-diabetics., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Stent thrombosis (ST) is a rare but devastating complication after percutaneous coronary intervention. Newer generation drug-eluting stents (DES) and newer antiplatelet therapies have been shown to decrease the incidence of ST, but we continue to observe ST-segment elevation myocardial infarction (STEMI) due to ST in contemporary practice. A retrospective analysis of 527 patients who presented with STEMI was performed; 57 patients (11%) with angiographically confirmed ST were compared with the patients with STEMI due to de novo lesion. The type of previous stent, the timing of ST, and the use of antiplatelet therapy were reviewed in patients with ST. Patients with ST had higher prevalence of comorbid conditions, such as hypertension, diabetes mellitus, and coronary artery disease, and had lower left ventricular ejection fraction (37 ± 5 vs. 44 ± 16%, p  = 0.0011). There was no difference in in-hospital mortality (2 vs. 4%, p  = 0.7082). ST was seen most commonly as "very late" (56%), and with previous second-generation DES (40%). Eighty-two percent of patients among early ST, compared with 22% of patients with very late ST were on dual antiplatelet therapy (DAPT). In 12% of patients, ST happened after DAPT was stopped by physician for procedures. ST is seen in a variety of clinical settings with the most common presentation being very late ST and in second-generation DES, which most likely represent the growing population with previous second-generation stents.

In the early days of coronary angioplasty, follow-up coronary angiography was often performed to assess restenosis. Angiographic restenosis has been shown to be associated with worse clinical outcomes, though the exact causality has yet to be determined. Numerous studies have repeatedly demonstrated that routine follow-up coronary angiography increases the incidence of target lesion revascularization without a clear reduction in mortality or myocardial infarction. Despite the lack of proven benefit of angiographic follow-up, routine follow-up coronary angiography is still being performed in certain countries and facilities. There are several factors that might explain the lack of benefit of angiographic follow-up: 1) lower incidence of stent failure in the current drug-eluting stent era has attenuated the net clinical benefit of follow-up angiography. 2) Angiographic restenosis might not lead to myocardial ischemia. 3) Patients that do have functionally significant restenosis are often referred for coronary angiography due to clinical indications such as intractable angina. 4) Absence of restenosis at the time of follow-up angiography does not exclude future restenosis. The absence of proven benefit in unselected populations does not necessarily preclude the presence of benefit in selected population, and there may be a subgroup of patients who can benefit from angiographic follow-up such as those with a large myocardial ischemic territory or those at very high risk of restenosis. Until there is more clinical evidence with respect to follow-up angiography, the decision of whether or not to perform it routinely in selected high-risk population should entail an in-depth discussion with the patient., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Competing Interests: The authors have no conflicts of interest to declare.

Background: Emergency medical services (EMS) transportation is associated with shorter door-to-balloon (DTB) time in patients with ST-segment elevation myocardial infarction (STEMI). In addition to EMS transportation, prehospital notification of STEMI by EMS to receiving hospital might be able to further shorten DTB time. We evaluated the impact of STEMI notification on DTB time as well as infarct size., Methods: We performed a retrospective analysis of consecutive patients with anterior wall STEMI who underwent emergent coronary angiography. We excluded patients who presented with cardiac arrest and those who were transferred from non-percutaneous coronary intervention-capable hospitals. Mode of transportation were categorized into the 3 groups: (1) EMS transport with STEMI notification, (2) EMS transport without STEMI notification, and (3) self-transport. Baseline characteristics, laboratory data, left ventricular ejection fraction (LVEF), and DTB time were compared among the 3 groups., Results: A total of 148 patients were included in the final analysis. Of the 148 patients, 56 patients arrived by EMS transport with STEMI notification, 56 patients arrived by EMS transport without STEMI notification, and 36 patients arrived by self-transport. Patients who arrived by EMS transport with STEMI notification had the shortest DTB time among the 3 groups. Patients who arrived by EMS transport with STEMI notification had smaller infarct size, as indicated by lower peak creatine kinase value and higher LVEF, compared with those who arrived by EMS transport without STEMI notification., Conclusion: Emergency medical services transport with STEMI notification was associated with shorter DTB time and smaller infarct size in patients with anterior wall STEMI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background/purpose: Shock index (SI), a ratio of heart rate/systolic blood pressure, has been reported to predict increased mortality in patients with ST-segment elevation myocardial infarction. However, the prognostic value of SI has not been fully elucidated in patients with non-ST-segment elevation myocardial infarction (NSTEMI)., Methods/materials: We performed a retrospective analysis of 481 consecutive NSTEMI patients who underwent coronary angiography from January 2013 to June 2014. Systolic blood pressure and heart rate on presentation were recorded, and SI was calculated as heart rate/systolic blood pressure. Patients were divided into those with SI≧0.7 and those with SI<0.7. Baseline and angiographic characteristics were recorded. In addition, cardiogenic shock and in-hospital mortality were recorded and compared between the two groups., Results: Among 481 patients, 103 patients (21.4%) had SI≧0.7. No statistically significant difference was observed in baseline characteristics between the two groups. Patients with SI≧0.7 had a lower left ventricular ejection fraction than those with SI<0.7 (56 [35-60] % vs. 60 [45-64] %, p=0.035). Patients with SI≧0.7 had a higher rate of cardiogenic shock on admission (2.9% vs. 0.3%, p=0.032). Patients with SI≧0.7 had a higher, albeit statistically insignificant, incidence of cardiogenic shock after admission (5.0% vs. 1.9%, p=0.074). The total incidence of cardiogenic shock was higher in patients with SI≧0.7 (7.8% vs. 2.1%, p=0.001). Patients with SI≧0.7 had higher in-hospital mortality (4.9% vs. 0.5%, p=0.006) than those with SI<0.7., Conclusion: Elevated SI was associated with higher in-hospital mortality in patients with NSTEMI., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: The effect of oral beta-blocker therapy on long-term mortality in patients with ST-segment elevation myocardial infarction (STEMI) who are treated with primary percutaneous coronary intervention (PCI) and who have preserved left ventricular ejection fraction (LVEF) remains unclear., Methods: We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials for studies evaluating the effect of oral beta-blocker therapy in patients with STEMI who underwent primary PCI and who had preserved LVEF. The primary outcome was all-cause mortality. Randomized controlled trials and the observational studies that reported an adjusted hazard ratio (or hazard ratio in the propensity score-matched patients) with follow-up duration equal to or more than 6 months were included. Pooled hazard ratio with 95% confidence interval (CI) was calculated using a random effect model., Results: No randomized controlled trials met the inclusion criteria. Seven observational studies totaling 10 857 patients met the inclusion criteria. Follow-up duration ranged from 6 months to 5.2 years. Preserved LVEF was defined as 40% in 4 studies and 50% in 3 studies. Based on the pooled estimate, oral beta-blocker therapy was associated with a reduction in all-cause mortality (combined hazard ratio 0.79, 95% CI 0.65-0.97)., Conclusion: This meta-analysis demonstrates that oral beta-blocker therapy is associated with decreased all-cause mortality in patients with STEMI who are treated with primary PCI and who have preserved LVEF. This supports the current American College of Cardiology Foundation/American Heart Association 2013 Guideline for the Management of STEMI., (© The Author(s) 2015.)

Left ventricular hypertrophy (LVH) can lead to subendocardial ischemia by altering the coronary blood flow and its transmural myocardial distribution in the setting of increased oxygen demand. We hypothesized that electrocardiographic LVH predicts nonsignificant coronary artery disease (CAD) in patients with non-ST-segment elevation myocardial infarction (NSTEMI). We performed a retrospective analysis of 406 consecutive patients with NSTEMI who underwent coronary angiography. The LVH was diagnosed using Sokolow-Lyon and Cornell voltage criteria. Nonsignificant CAD was defined as stenosis less than 50% in the left main and 70% in any other coronary arteries. Of the 406 patients, 100 (25%) patients had electrocardiographic LVH and 99 (24%) patients had nonsignificant CAD. Patients with electrocardiographic LVH had a higher prevalence of nonsignificant CAD (32% vs 22%, P = .04) and a lower rate of in-hospital revascularization (45% vs 69%, P < .001) than those without LVH. On multivariate analysis, electrocardiographic LVH was an independent predictor of nonsignificant CAD (odds ratio 1.94; 95% confidence interval 1.12-3.35; P = .02). In conclusion, electrocardiographic LVH is an independent predictor of nonsignificant CAD and associated with a lower rate of in-hospital revascularization in patients with NSTEMI., (© The Author(s) 2015.)

Background: ST-segment elevation in lead aVR predicts left main and/or three-vessel disease (LM/3VD) in patients with acute coronary syndromes. ST-segment elevation in lead aVR is generally reciprocal to and accompanied by ST-segment depression in precordial leads. Previous studies have assessed the independent predictive value of ST-segment elevation in lead aVR for LM/3VD in non-ST-segment elevation acute coronary syndrome and have reported conflicting results., Methods: We performed a retrospective analysis of 379 patients with non-ST-segment elevation myocardial infarction (NSTEMI). Electrocardiograms on presentation were reviewed especially for ST-segment elevation ≥0.05 mV in lead aVR and ST-segment depression ≥0.05 mV in more than two contiguous leads in any other leads., Results: Among 379 patients, 97 (26%) patients had ST-segment elevation in lead aVR and 88 (23%) patients had LM/3VD. Patients with ST-segment elevation in lead aVR had a higher rate of LM/3VD (39% vs. 18%; P < 0.001) and in-hospital revascularization (73% vs. 60%; P = 0.02) driven by a higher rate of in-hospital coronary artery bypass grafting (19% vs. 7%; P < 0.001) than those without ST-segment elevation in lead aVR. On multivariate analysis, ST-segment elevation in lead aVR (odds ratio [OR] 2.05; 95% confidence interval [CI] 1.10-3.77; P = 0.02) and ST-segment depression in leads V1 -V4 (OR 2.99; 95% CI 1.46-6.15; P = 0.003) were independent predictors of LM/3VD., Conclusion: This study demonstrates that ST-segment elevation in lead aVR is an independent predictor of LM/3VD in patients with NSTEMI., (© 2015 Wiley Periodicals, Inc.)

Background: The prognostic value of ST-segment elevation in lead V1 (STE in V1) in anterior ST-segment elevation myocardial infarction (STEMI) has not been elucidated., Methods: We performed a retrospective analysis of 190 consecutive first anterior STEMI patients. STE in V1 ≥0.1mV was recorded. Major adverse cardiac events (MACE) were defined as a composite of all-cause death, recurrent myocardial infarction, or target vessel revascularization., Results: Among 190 patients, 42 patients did not have STE in V1. The patient without STE in V1 had a higher peak creatine kinase value and a higher incidence of 1-year MACE (36% vs. 13%, p<0.001), driven by a higher mortality (24% vs. 5%, p<0.001). The absence of STE in V1 was an independent predictor for 1-year MACE (odds ratio 3.16; 95% confidence interval 1.28-7.83; p=0.01)., Conclusion: The absence of STE in V1 was an independent predictor for worse long-term outcomes in patients with first anterior STEMI., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Elevated left ventricular end-diastolic pressure (LVEDP) has been reported to predict an increased mortality in patients with ST-segment elevation myocardial infarction. However, its prognostic value in patients with non-ST-segment elevation myocardial infarction (NSTEMI) remains unclear., Methods: We performed a retrospective analysis of NSTEMI patients who underwent coronary angiography between January 2013 and June 2014. We excluded patients who did not undergo LVEDP measurements. Baseline and angiographic characteristics, in-hospital heart failure as well as in-hospital mortality were recorded., Results: After exclusion, 367 patients were included in the final analysis. The median (interquartile range) LVEDP was 19 mm Hg (14 - 24 mm Hg). By receiver operating characteristic curve analysis, the optimal cutoff value for predicting in-hospital mortality was 22 mm Hg (area under the curve 0.80, sensitivity 80%, and specificity 71%). Of 367 patients, 109 patients (29.7%) had LVEDP > 22 mm Hg. Patients with LVEDP > 22 mm Hg had a greater number of comorbidities. There was no statistically significant difference in the rate of multi-vessel disease. Patients with LVEDP > 22 mm Hg had a significantly higher rate of in-hospital heart failure (22.0% vs. 13.2%, P = 0.03) and in-hospital mortality (3.7% vs. 0.4%, P = 0.03) than those with LVEDP ≤ 22 mm Hg., Conclusion: Elevated LVEDP was significantly associated with a higher in-hospital mortality in patients with NSTEMI.

Background: Up-sloping ST-segment depression has not been historically considered as representing ischemia as this electrocardiographic change can be seen in normal subjects during exercise stress testing or tachycardia. We aimed to clarify the prevalence and clinical significance of up-sloping ST-segment depression in patients with non-ST-segment elevation myocardial infarction (NSTEMI)., Methods: We performed a retrospective analysis of 330 consecutive patients with NSTEMI who underwent coronary angiography. ST-segment depression ≥ 0.05 mV in more than two contiguous leads was recorded and categorized as being up-sloping or non-up-sloping., Results: Of 330 patients, 109 patients (33%) had ST-segment depression; six of these patients had up-sloping ST-segment depression. All six patients with up-sloping ST-segment depression had a culprit lesion and underwent in-hospital revascularization. Three of these six patients had a culprit lesion in the left anterior descending artery; the culprit lesion in two others was in the left circumflex artery, while one patient had severe three-vessel disease. No statistically significant difference was found in the rate of in-hospital revascularization between patients with up-sloping and non-up-sloping ST-segment depression (100% vs. 75%, P = 0.33)., Conclusions: Patients with up-sloping ST-segment depression had a comparable rate of in-hospital revascularization compared to those with non-up-sloping ST-segment depression, suggesting that up-sloping ST-segment depression should be recognized as a manifestation of ischemia in NSTEMI.

Background: The association between preinfarction angina and angiographic findings has not been elucidated in patients with non-ST-segment elevation myocardial infarction (NSTEMI)., Hypothesis: Patients with preinfarction angina have favorable angiographic findings., Methods: This retrospective study analyzed 481 patients who underwent coronary angiography within 5 days of presenting NSTEMI. Preinfarction angina was defined as experiencing ≥1 chest-pain episode within 7 days prior to admission. Infarct size was measured as the peak cardiac troponin I (cTnI) level, and large myocardial infarction (MI) was defined as a peak cTnI level >85th percentile value in the study population. Infarct-related artery (IRA) patency was defined as Thrombolysis In Myocardial Infarction grade 2 or 3 flow. Clinical and angiographic characteristics and in-hospital mortality were compared between patients with and without preinfarction angina., Results: Among 481 patients, 200 (42%) had preinfarction angina. Preinfarction angina was associated with smaller infarct size, indicated by lower peak cTnI levels (P = 0.006) and lower incidence of large MI (P = 0.02), and IRA patency (P = 0.03). There was no significant difference in in-hospital mortality. On multivariate analysis, both preinfarction angina (odds ratio: 0.53, 95% confidence interval: 0.29-0.94, P = 0.03) and IRA patency (odds ratio: 0.30, 95% confidence interval: 0.17-0.52, P < 0.001) were independent negative predictors of large MI., Conclusion: Our study demonstrates that preinfarction angina is a predictor of smaller infarct size and infarct-related artery patency in NSTEMI patients, suggesting that NSTEMI patients presenting without preinfarction angina are at increased risk of developing a large MI., (© 2015 Wiley Periodicals, Inc.)

Background/purpose: Patients with acute coronary syndrome due to left main and/or three-vessel disease (LM/3VD) are at the highest risk of short- and long-term adverse cardiovascular events. Neutrophil-to-lymphocyte ratio (NLR) has been shown to predict the severity of coronary artery disease in various clinical settings, but its independent predictive value for LM/3VD has not been investigated in patients with non-ST-segment elevation myocardial infarction (NSTEMI). We aimed to evaluate the independent predictive value of NLR for LM/3VD in NSTEMI patients., Methods/materials: We performed a retrospective analysis of consecutive NSTEMI patients who underwent coronary angiography. NLR was calculated as the ratio of neutrophil to lymphocyte based on the laboratory data on admission. The primary outcome was the presence of LM/3VD., Results: In all, 396 patients were included in the final analysis. Median NLR in the entire study population was 3.43 (interquartile range, 2.12-5.51). By receiver operating characteristics curve analysis, the optimal cutoff value of NLR in predicting LM/3VD was 2.80 (area under the curve 0.60, sensitivity 73%, specificity 43%). Of the 396 patients, 244 patients (62%) had NLR ≥2.8. Patients with NLR ≥2.8 were older and had a higher prevalence of LM/3VD (30 % vs. 18%, p=0.005). According to multivariate logistic regression analysis, NLR ≥2.8 was an independent predictor of LM/3VD after adjusting for other clinical variables including ST depression and ST elevation in lead aVR (odds ratio 1.83, 95% confidence interval 1.07-3.21, p=0.03)., Conclusion: Our study demonstrates that NLR ≥2.8 is an independent predictor of LM/3VD in patients with NSTEMI., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objectives: The neutrophil-to-lymphocyte ratio (NLR) predicts short-term and long-term mortalities in patients with stable and unstable coronary artery disease. However, it has been reported that white blood cell and neutrophil counts vary considerably among different races. We aimed to assess the impact of racial difference on NLR in our diverse population with non-ST-segment elevation myocardial infarction (NSTEMI)., Methods: We carried out a retrospective analysis of 456 consecutive NSTEMI patients who had undergone coronary angiography. The patients were divided into four groups on the basis of self-reported race: White, Hispanic, African-American, and Asian. NLR was compared among the four groups. Univariate and multivariate linear regression analyses were carried out between NLR and baseline clinical characteristics and angiographic findings. The primary outcome was inhospital mortality., Results: The median NLR in the entire study population was 3.47 (interquartile range, 2.16-5.57). NLR differed significantly among the four groups according to the Kruskal-Wallis test (P=0.03). NLR was significantly lower in the African-American group compared with the White group according to the Steel-Dwass test (P=0.03). Multivariate analysis revealed that African-American ethnicity was negatively associated with NLR (P=0.04). The second multivariate analysis using the White group as a reference also revealed that African-American ethnicity was negatively associated with NLR (P=0.04). There was no significant difference in inhospital mortality among the four groups., Conclusion: The present study demonstrated an independent association between race and NLR in patients with NSTEMI, suggesting that a tailored cutoff value according to race would provide more precise prognostic information.

Background/purpose: Stent thrombosis is an infrequent yet one of the most feared complications after stent implantation. Stent thrombosis most commonly manifests as ST-segment elevation myocardial infarction, thus the data regarding non-ST-segment elevation myocardial infarction (NSTEMI) resulting from stent thrombosis are still sparse. The aim of the study is to evaluate the prevalence and outcomes of NSTEMI resulting from stent thrombosis., Methods/materials: We performed a retrospective analysis of 378 consecutive NSTEMI patients who underwent coronary angiography. Patients were divided into those with and without stent thrombosis. The primary outcome was in-hospital mortality. Secondary outcome was the incidence of large myocardial infarction defined as a peak troponin I value greater than 90th percentile of the entire study population (26.5 μg/L)., Results: Among 378 patients with NSTEMI, 12 (3.2%) patients had angiographically confirmed definite stent thrombosis. With respect to the timing of stent thrombosis, 2 patients had early, 3 had late and 7 had very-late stent thrombosis. Patients with stent thrombosis had a higher incidence of large myocardial infarction (33% vs. 9%, p = 0.02) and a higher albeit statistically insignificant peak troponin value (interquartile, 4.62 [0.19-64.0] μg/L vs. 1.21 [0.14-7.12] μg/L, p = 0.25) compared to those without stent thrombosis. There was no significant difference in in-hospital mortality between the two groups (8% vs. 2%, p = 0.2)., Conclusions: Stent thrombosis accounted for 3.2% cases of NSTEMI in our cohort of patients and patients with NSTEMI resulting from stent thrombosis had a higher incidence of large myocardial infarction., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Radial artery access is a mainstay in the diagnosis and treatment of coronary artery disease. However, there is uncertainty on the comparison of right versus left radial access for coronary procedures. We thus undertook a systematic review and meta-analysis comparing right versus left radial access for coronary diagnostic and interventional procedures., Methods: Pertinent studies were searched in CENTRAL, Google Scholar, MEDLINE/PubMed, and Scopus, together with international conference proceedings. Randomized trials comparing right versus left radial (or ulnar) access for coronary diagnostic or interventional procedures were included. Risk ratios (RR) and weighted mean differences (WMD) were computed to generate point estimates (95% confidence intervals)., Results: A total of 5 trials (3210 patients) were included. No overall significant differences were found comparing right versus left radial access in terms of procedural time (WMD=0.99 [-0.53; 2.51]min, p=0.20), contrast use (WMD=1.71 [-1.32; 4.74]mL, p=0.27), fluoroscopy time (WMD=-35.79 [-3.54; 75.12]s, p=0.07) or any major complication (RR=2.00 [0.75; 5.31], p=0.49). However, right radial access was fraught with a significantly higher risk of failure leading to cross-over to femoral access (RR=1.65 [1.18; 2.30], p=0.003) in comparison to left radial access., Conclusions: Right and left radial accesses appear largely similar in their overall procedural and clinical performance during transradial diagnostic or interventional procedures. Nonetheless, left radial access can be recommended especially during the learning curve phase to reduce femoral cross-overs., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Bifurcation lesions at the time of emergent PCI for STEMI are relatively common. However, there are little data regarding their significance. The objective of this study is to evaluate the impact of bifurcation lesions in the setting of emergent percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI)., Methods: In 391 patients who underwent primary and rescue PCI, the clinical characteristics, procedural success, and in-hospital cardiac events were compared retrospectively between the patients with and without bifurcation lesions. The PCI strategy was at the discretion of the operator., Results: The culprit artery involved a bifurcation lesion in 54/391 (14%) patients. The baseline clinical characteristics between the groups with and without bifurcation lesions were similar. The majority of bifurcation lesions (81%) were seen in the left anterior ascending (LAD) artery. All lesions were treated with the provisional stenting approach, and only 2 (3%) patients required 2 stents. There were no difference in the procedural success and the final TIMI-3 flow, but PCI of bifurcation lesion required higher amount of contrast use. There was no in-hospital MACE in the bifurcation group. The peak cardiac enzyme, left ventricular function, and length of stay were similar in these 2 groups., Conclusions: Bifurcation lesions are relatively common in emergent PCI for STEMI involving the LAD. It can be safely treated with a provisional stenting approach, and the immediate outcome is similar to non-bifurcation lesions., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Introduction: Terminal T wave inversions (TTWI) indicate advanced stages of ST-elevation myocardial infarction (STEMI). The present study investigated whether TTWI predict unfavorable in-hospital outcomes in STEMI patients treated with urgent percutaneous coronary intervention (PCI)., Methods: A retrospective cohort study was performed with consecutive 188 STEMI cases undergoing urgent PCI. The primary endpoint was in-hospital major adverse cardiac event (MACE), and the secondary endpoints were ST resolution (STR) after PCI and length of stay (LOS)., Results: TTWI on presentation were independently associated with higher incidence of in-hospital MACE (adjusted OR 2.8; 95% CI 1.1-7.0; p=0.03), inadequate STR (adjusted OR 5.5; 95% CI 2.1-14.3; p=0.01), and longer LOS (adjusted mean increase 4.1 days; 95% CI 0.3-7.9; p=0.03). TTWI predicted these outcomes better than patient-reported ischemic time or pathologic Q waves., Conclusions: TTWI on presentation are an independent risk factor for poor inpatient prognosis among patients presenting with STEMI undergoing urgent PCI., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Abciximab is a glycoprotein IIb/IIIa receptor inhibitor that has been shown to improve outcomes in patients with ST-segment elevation myocardial infarction who undergo primary percutaneous coronary intervention (pPCI). An earlier study reported better efficacy with intracoronary (IC) compared to intravenous (IV) administration, but this finding has not been duplicated in other studies, thus leaving a great deal of uncertainty as to the most efficacious route of administration. To investigate if IC abciximab compared to IV administration decreases mortality and major adverse cardiac events in patients with ST-segment elevation myocardial infarction who undergo pPCI, a meta-analysis was performed consisting only of prospective randomized controlled trials. Subgroup analysis was performed to investigate the source of difference in efficacy between the 2 strategies. A meta-analysis of 4 trials including 1,148 subjects revealed that IC abciximab significantly reduced mortality compared to IV administration (1.5% vs 3.6%, odds ratio 0.44, 95% confidence interval 0.20 to 0.95, p = 0.04). Major adverse cardiac events were also reduced in a subgroup in which <30% of patients received aspiration thrombectomy (6.1% vs 16.2%, odds ratio 0.33, 95% confidence interval 0.18 to 0.61, p = 0.0004). In conclusion, the totality of the data available from relatively small but high-quality studies shows a significant mortality reduction associated using IC abciximab for pPCI compared to IV abciximab. IC abciximab in the setting of pPCI for ST-segment elevation myocardial infarction may be beneficial for patients with higher risk profiles., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background: Red blood cell distribution width (RDW) is a measure of heterogeneity in erythrocyte size used in the differential diagnosis of anemia. High levels are associated with elevated cardiovascular biomarkers and increased mortality. The hypothesis of this study is that high RDW levels on admission are associated with higher recourse to coronary artery bypass graft (CABG) in unstable angina (UA) or non-ST-elevation myocardial infarction (NSTEMI) patients., Methods: An observational, cross-sectional study of all adult patients undergoing coronary angiography admitted to an urban tertiary care center in 2007 with UA or NSTEMI was conducted. Data was gathered by review of inpatient charts. RDW was considered 'high' if it exceeded the 95th percentile (16.3%)., Results: Among the 503 subjects included in the analysis, high RDW was independently associated with higher recourse to CABG versus a nonsurgical approach [OR = 2.39 (1.04-5.50); p = 0.041] but not with conservative management [OR = 0.97 (0.51-1.84); p = 0.922] or percutaneous coronary intervention [OR = 0.67 (0.36-1.25); p = 0.208]., Conclusions: This study of patients with UA or NSTEMI demonstrated an independent association of elevated RDW with higher recourse to CABG. RDW should be considered in the stratification of patients presenting with UA or NSTEMI., (Copyright © 2012 S. Karger AG, Basel.)

Transradial catheterization (TRC) has been associated with a lower incidence of major access site related complications as compared to the transfemoral approach. With the increased adoption of transradial access, it is essential to understand the potential major and minor complications of TRC. The most common complication is asymptomatic radial artery occlusion, which rarely leads to clinical events, owing to the dual collateral perfusion of the hand. Adequate anticoagulation, appropriate compression techniques, and smaller sheath size can minimize the risk of radial artery occlusion. Hand ischemia with necrosis has never been reported during TRC with thorough pre-examination of intact collateral circulation. Radial artery spasm is relatively common, and can result in access and procedural failure. It can be prevented by the use of vasodilator cocktails and hydrophilic sheaths. Radial artery perforation can lead to severe forearm hematoma and compartment syndrome if not managed promptly. Careful observation, prompt detection of the hematoma, and management with a pressure bandage dressing are critical to avoid serious complications. Pseudoaneurym and arteriovenous fistula are rare complications, which can likely be managed conservatively without surgical intervention. Nerve injury occurring during access has been reported. Close observation for improvement is necessary, although symptoms usually improve over time. In summary, to prevent access site complications, avoidance of multiple punctures, gentle catheter manipulation, use of guided compression, coupled with careful observation for adverse warning signs such as hematoma, loss of pulse, pain, are critical for safe and effective TRC., (Copyright © 2011 Wiley Periodicals, Inc.)

The incidence of contrast-induced nephropathy (CIN) in primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) was previously reported to be as high as 19%. Iso-osmolar contrast has frequently been used for populations at high risk for CIN, but a recent meta-analysis did not show a significant benefit of using iso-osmolar contrast in preventing CIN. The aim of our study is to evaluate the impact of iso-osmolar contrast use in patients undergoing emergent PCI. We performed a retrospective analysis of patients who underwent primary and rescue PCI for STEMI. The PCI strategy, including the contrast choice, was left at the discretion of the operator. CIN was defined as an increase in creatinine of more than 0.5 mg or 25% from the baseline within 72 hours. Among 212 patients, CIN was seen in 33 patients (16%). Patients who received iso-osmolar contrast were older, and included more patients at risk for CIN. The incidence of CIN was 14% in the low-osmolar contrast group and 17% in the iso-osmolar contrast group (P=.799). After logistic regression analysis, CIN was seen more frequently in patients who had lower ejection fraction, post-PCI TIMI flow <3, and lower hemoglobin. The use of iso-osmolar contrast was not associated with a lower incidence of CIN in patients undergoing emergent PCI for STEMI.

Objectives: Our purpose was to describe the contemporary utilization, clinical outcomes and complication rates of intra-aortic balloon pump (IABP) therapy in this current age., Background: IABP use and outcomes, in the setting of modern antiplatelet therapy and primary percutaneous coronary intervention and the use of drug-eluting stents as we know them today, have not been clearly established., Methods: We performed a retrospective cohort study by collecting detailed clinical and device data from all 150 consecutive patients who received IABP therapy in our institution between 2004 and 2009., Results: Thrombocytopenia occurred in 50%, fever in 36%, bleeding in 27%, and vascular embolic events in 1%. Thrombocytopenia was the most common adverse event and was not significantly associated with the use of antiplatelet agents. The presence of diabetes mellitus, elevated white blood cells at presentation, and longer duration of IABP were significantly associated with the development of fever. Furthermore, those who developed fever had higher in-hospital mortality (31% versus 16%; p = 0.0487)., Conclusions: In this contemporary cohort of IABP patients, complication rates of thrombocytopenia, fever and bleeding were relatively high but similar to prior studies, even in this current era of revascularization and antiplatelet medications.

Previous studies have shown that the right radial approach encounters more tortuosity than the left radial approach during transradial coronary angiography. The objective of this study was to compare the procedural difficulty of the right and left radial approaches in the modern era with dedicated transradial catheters. One hundred ninety-three patients scheduled for transradial coronary angiography with normal Allen test results and without histories of coronary artery bypass grafting were randomized to the right or left radial approach. The choice of catheter was left to the discretion of the operator, with the preferred catheter being a dedicated transradial Optitorque catheter. The primary end point was procedural difficulty, defined as (1) hydrophilic or coronary wire use for tortuosity, (2) stiff wire use for the coronary engagement, (3) multiple catheters used, or (4) nonselective injection. The clinical characteristics were similar between the 2 groups. Procedural success was achieved in 98 of 101 (98%) in the right radial group and 91 of 92 (99%) in the left radial group. Procedural difficulty, fluoroscopy time, and contrast use were similar between the 2 groups. The use of a single catheter was more common in the right radial group (73% vs 18%, p <0.001). In conclusion, procedural success and difficulty were similar in the comparison groups. The right and left radial approaches are feasible and effective to perform coronary angiography and intervention., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: In acute inferior ST-segment elevation myocardial infarction (STEMI), multiple electrocardiographic algorithms have been proposed to predict the culprit artery. Our purpose is to review these and compare them to ST depression in lead aVR to predict culprit artery in inferior STEMI., Methods: In 106 patients with acute inferior STEMI who underwent emergent coronary angiography, we correlated electrocardiographic and angiographic findings pertaining to the culprit artery. We then reviewed the algorithms proposed by Fiol et al and Tierala et al, and applied them and our own from Kanei et al using ST depression in aVR for predicting the left circumflex artery (LCx) as the culprit, to the population. Finally, we compared the sensitivities and specificities of the respective algorithms for predicting the culprit artery., Results: The sensitivity and specificity of ST depression in lead aVR to predict LCx as the culprit were 53% and 86%, respectively, and 86% and 55%, respectively for predicting the right coronary artery (RCA) as the culprit. When their algorithms were applied to our population, the sensitivities and specificities of Fiol et al and Tierala et al were slightly higher., Conclusion: Compared to other proposed algorithms, ST depression in aVR is a simple method with satisfactory sensitivity and specificity to predict the culprit artery in inferior STEMI., (Copyright © 2011 Elsevier Inc. All rights reserved.)

There are little long-term clinical data regarding the safety and efficacy of using 2 drug-eluting stents (DESs) to treat coronary bifurcation lesions. We obtained clinical follow-up for 124 consecutive patients who underwent bifurcation stenting with 2 DESs. Major adverse cardiac events (MACEs) were defined as cardiac death, acute myocardial infarction (AMI), and target vessel revascularization (TVR). Sixty-four (52%) patients underwent ''crush,'' 42 (34%) patients underwent T stent, and 18 (14%) patients underwent kissing stent. Major adverse cardiac events were observed in 19 patients (17%) at 1 year: 6 (5%) AMI, 13 (12%) TVR, and no deaths, and 29 patients (26 %) at a mean follow-up of 22 months: 7 (6%) AMI, 21 (19%) TVR, and 1 (1%) death. No statistically significant risk factors for long-term MACEs were identified. It appears that treating bifurcation lesions with 2 DESs when necessary can be performed with an acceptable MACE rate.

Background: The significance of ischemic ECG changes during adenosine infusion in patients with normal myocardial perfusion imaging (MPI) is controversial. We evaluated the prevalence of, and defined the predictors for, severe coronary artery disease (CAD) in patients with such discordant findings., Methods: The findings of 3700 adenosine MPI studies performed at our institution between June 2005 and March 2009 were reviewed., Results: Data for 76 patients who had not previously undergone coronary revascularization and who had sufficient follow-up were analyzed; 22 (29%) were referred for coronary angiography and 10 (13%) underwent revascularization. None had left main disease and only three (14%) had multivessel disease. Diabetes mellitus was more prevalent (70% vs. 23%; P = .010) and ischemic ST-segment depressions more often lasted >5 minutes (50% vs. 15%; P = 0.021) in patients undergoing revascularization. During a 24 ± 13 month follow-up period, there were no deaths or myocardial infarctions, while an eleventh patient underwent revascularization 19 months after MPI., Conclusions: In the presence of normal MPI, the specificity of ischemic ECG changes during adenosine infusion for the detection of severe obstructive CAD is poor, although patients with multiple coronary risk factors, particularly diabetes mellitus, should undergo further investigation.

Although the provisional stenting technique to treat coronary bifurcation lesions is the preferred method, many bifurcation lesions still require a two-stent technique to optimize the result and clinical outcome. This manuscript summarizes the tips and tricks of bifurcation stenting with cases illustrations. As interventionists are encountering more complex and difficult cases, one may find the tips and tricks in this manuscript helpful in daily practice.

Radial artery pseudoaneurysm is an extremely rare complication associated with transradial catheterization. We report 2 cases of pseudoaneurysm of the radial artery that were successfully treated using the Terumo TR band. We believe that the safety, efficiency, speed and minimal invasiveness of this method make it feasible for use as a treatment for peripheral pseudoaneurysm in such patients.

Myocardial bridging is a common congenital coronary anomaly that is clinically silent in the majority of cases. Case reports suggest myocardial ischemia and infarction can be caused by myocardial bridging. The proposed mechanisms by which myocardial bridging causes myocardial ischemia include compromised coronary blood flow, endothelial dysfunction, thrombus formation and a strong association with coronary vasospasm. We reported a case of myocardial infarction caused by both myocardial bridging and coronary vasospasm. We reviewed the literature and suggest that coronary stenting may have a role in treating myocardial ischemia due to myocardial bridging and coronary spasm that is refractory to medical management.

Background: ST-segment depression in lead aVR in acute inferior wall ST-segment elevation myocardial infarction (STEMI) has recently been suggested as a predictor of left circumflex (LCx) artery involvement. The purpose of this study is to evaluate the clinical significance of aVR depression during inferior wall STEMI., Methods: This study included 106 consecutive patients who presented with inferior wall STEMI and underwent urgent coronary angiogram. Clinical and angiographic findings were compared between patients with and without aVR depression > or = 0.1 mV., Results: The sensitivity and specificity of aVR depression as a predictor of LCx infarction were 53% and 86%, respectively. In patients with right coronary artery infarction, aVR depression was associated with increased cardiac enzymes and the involvement of a large posterolateral branch, which may explain the larger infarction., Conclusions: ST-segment depression in lead aVR in inferior wall STEMI predicts LCx infarction or larger RCA infarction involving a large posterolateral branch., (2010 Elsevier Inc. All rights reserved.)

A weight-adjusted bolus of heparin (70 to 100 IU/kg) is recommended to achieve adequate anticoagulation during percutaneous coronary intervention (PCI). Proper dosing is mandatory to avoid bleeding and thrombotic complications. We investigated whether sensitivity to heparin is affected by difference in race. We performed a retrospective study with 874 consecutive PCI cases in our catheterization laboratory. The amount of initial heparin bolus (international units) per weight and subsequent activated clotting time (ACT; seconds) were obtained. Patients were divided into 4 categories based on race: Asian, African-American, European-American, and Hispanic. Multiple regression analysis was performed to validate the variables that determine the ACT. After adjusting for these variables, analysis of variance revealed the presence of a significant racial difference in ACT (p = 0.002). Successively, Student-Newman-Keuls test and Bonferroni t test revealed that Asian patients have higher ACT levels compared to other racial groups (p <0.03 for Asian vs others, p >0.26 between non-Asian groups). There was a positive relation between ACT and Asian race (p = 0.0004). Further analyses showed that Asians require 10 IU/kg less heparin per weight than other racial groups to achieve the same goal of ACT. In conclusion, decreased heparin dosing should be considered for Asian patients undergoing PCI., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Contrast-induced nephropathy (CIN) continues to be a common cause of acute renal failure in high-risk patients undergoing radiocontrast studies. However, there is still a lack of consensus regarding the most effective measures to prevent CIN., Methods: ONE HUNDRED EIGHTEEN PATIENTS WITH DIABETES MELLITUS AND/OR RENAL INSUFFICIENCY, SCHEDULED FOR CORONARY ANGIOGRAPHY OR INTERVENTION, WERE RANDOMLY ASSIGNED TO ONE OF FOUR TREATMENT GROUPS: intravenous (IV) 0.9% NaCl alone, IV 0.9% NaCl plus N-acetylcysteine (NAC), IV 0.9% sodium bicarbonate (NaHCO(3)) alone or IV 0.9% NaHCO(3) plus NAC. All patients received IV hydration as a preprocedure bolus and as maintenance. Iso-osmolar contrast was used in all patients. CIN was defined as an increase of greater than 25% in the serum creatinine concentration from baseline to 72 h., Results: The overall incidence of CIN was 6%. There was no statistically significant difference in the incidence of CIN among the groups. There was a CIN incidence of 7% in the NaCl only group, 5% in the NaCl/NAC group, 11% in the NaHCO(3) only group and 4% in the NaHCO(3)/NAC group (P=0.86). The maximum increase in serum creatinine was 14.14±12.38 μmol/L in the NaHCO(3) group, 10.60±29.14 μmol/L in the NaCl only group, 9.72±13.26 μmol/L in the NaCl/NAC group and 0.177±15.91 μmol/L for the NaHCO(3)/NAC group (P=0.0792)., Conclusion: CIN in high-risk patients may be effectively minimized solely through the use of an aggressive hydration protocol and an iso-osmolar contrast agent. The addition of NaHCO(3) and/or NAC did not have an effect on the incidence of CIN.