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Background: The 2018 World Symposium on Pulmonary Hypertension (WSPH) changed the definition of pulmonary hypertension (PH) with a new threshold of mean pulmonary artery pressure (mPAP) above 20 mmHg., Objective: To evaluate the profile and prognosis of patients with chronic heart failure (HF) considered for heart transplantation with the new definition of PH., Methods: Patients with chronic HF considered for heart transplantation were classified as mPAP ≤20mmHg , mPAP 20 - 25 mmHg , and mPAP ≥25mmHg . Using a multivariate Cox model, we compared the mortality of patients with mPAP 20 - 25mmHg , and mPAP ≥25mmHg versus those with mPAP ≤20mmHg ., Results: Of 693 patients with chronic HF considered for heart transplantation, 12.7%, 77.5% and 9.8% were classified as mPAP 20 - 25mmHg , mPAP ≥ 25mmHg and mPAP ≤20mmHg . Patients of mPAP ≥  25mmHg and mPAP 20 - 25 mmHg categories were older than mPAP ≤  20 mmHg (56 versus 55 and 52 year-old, p = 0.02) with more frequent co-morbidities. Within 2.8 years, the mPAP 20 - 25mmHg category displayed a higher risk of mortality compared with those of the mPAP ≤20mmHg category (aHR 2.75, 95% CI 1.27-5.97, p = 0.01). Overall, the new PH definition using a threshold of mPAP >20 mmHg was associated with a higher risk of death (adj HR 2.71, 95% CI 1.26-5.80) than the previous definition (mPAP >25 mmHg, aHR: 1.35 95% CI 1.00-1.83, p = 0.05)., Conclusions: One out of 8 patients with severe HF are reclassified as having PH following the 2018 WSPH. Patients with mPAP 20 - 25 evaluated for heart transplantation displayed significant co-morbidities and high mortality rates., Competing Interests: Declaration of Competing Interest Gilles Montalescot reports research grants, funding or consulting fees from Abbott, Amgen, AstraZeneca, Axis, Bayer, BMS, Boehringer-Ingelheim, Boston-Scientific, Cell Prothera, CSL Behring, Idorsia, Leo-Pharma, Lilly, Medtronic, Novartis, Pfizer, Quantum Genomics, Sanofi, Terumo; Michel Zeitouni reports research grants, funding or consulting fees from Fédération Française de Cardiologie, Institut Servier, BMS/Pfizer, AstraZeneca and Amgen; Johanne Silvain reports reports research grants, funding or consulting fees from AstraZeneca, Bayer HealthCare SAS, Abbott Medical France SAS, Biotronik, Boehringer Ingelheim France, CSL Behring SA, Gilead Science, Sanofi-Aventis France, Stockholder of Pharmaseeds, Terumo France SAS, Zoll; Mathieu Kerneis reports research grants, funding or consulting fees from Fédération Française de Cardiologie, du Programme PHRC N, de l'Institut Servier et des honoraires de Bayer, Sanofi, Servier; Jean Philippe Collet reports research grants, funding or consulting fees from AstraZeneca, Boston Scientific, Bristol-Myers Squibb, COR2ED, Lead-Up, Medtronic, WebMD; Quentin Morlon, Stéphane Hatem, Nadjib Hammoudi, Claude Le Feuvre, Gérard Helft, Paul Guedeney, Guillaume Lebreton, Pascal Leprince, Shaida Varnous and Niki Procopi report no conflict of interests., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Despite the overall neutral results of the GLOBAL-LEADERS trial, results from a prespecified subgroup analysis showed that patients from Western Europe had a significantly lower rate of the primary endpoint when treated with ticagrelor monotherapy. Therefore, we aimed to examine the regional disparities in patients' baseline characteristics and their response to ticagrelor monotherapy., Methods: Patients' baseline characteristics and the treatment effects of ticagrelor combined with aspirin for 1 month, followed by ticagrelor monotherapy for 23-months versus 12-months of standard dual antiplatelet therapy (DAPT) were compared according to participating countries. The primary endpoint was a composite endpoint of all-cause death or new Q-wave myocardial infarction at two years., Results: Significant variances in patients' baseline characteristics were found between participating countries. The primary endpoint varied significantly according to the country (P interaction  = 0.027). Patients from France (1.6% versus 5.2%, HR: 0.31, 95%CI: 0.13-0.73) and The Netherlands (2.4% versus 4.8%, HR, 0.50, 95%CI: 0.26-0.94) had lower rates of the primary endpoint when allocated to ticagrelor monotherapy, compared with the standard DAPT regimen. Of the 26 baseline and post-randomization factors explored, variance in the rate of complex PCI between countries was identified as the top contributor to this regional interaction., Conclusions: Patients' baseline characteristics varied between participating countries in the GLOBAL-LEADERS trial. There is a significant regional variance in the treatment effect of ticagrelor monotherapy, which could partly be explained by the differences in complex PCI being performed., Clinical Trial Registration: ClinicalTrials.gov (NCT01813435)., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: Copeptin - the C-terminal section of vasopressin precursor - is a novel biomarker, that has been shown to be a useful prognostic factor in heart failure, ischemic stroke and in acute myocardial infarction (MI) but with restricted population and follow-up in ST-segment elevation MI (STEMI) setting. We evaluated in this study the hypothesis that copeptin measured on admission is an independent predictor of one-year all-cause mortality after a STEMI., Methods: Copeptin was measured immediately on arrival in the catheterization laboratory in a cohort of unselected STEMI patients and was compared to the peak of cardiac troponin I as a prognosis marker. One-year follow-up was performed., Results: We included 401 STEMI patients (77% of men, mean age 64 ± 14 years) treated by primary percutaneous coronary intervention. Copeptin on admission was significantly higher in patients who died during the one-year follow-up than in survivors (154.8 pmol/L; IQR [63.9-304.8] vs 30.3 pmol/L; IQR [10.8-93.5]); p < 0.0001). There was an increase in mortality at one year from the lowest to the highest quartile of copeptin. After Cox regression analysis, copeptin was an independent predictor of death at one year (adjHR 3.1, 95% CI [1.5-6.2], p = 0.001). When compared to the peak value of cardiac troponin I, copeptin measured on admission had a better prognostic value to predict one-year mortality (AUC of 0.74 vs 0.60, p = 0.022)., Conclusion: Copeptin measured on admission is a reliable and independent prognostic biomarker of one-year mortality in acute myocardial infarction patients., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Background: The prevalence and associated-risk of asymptomatic multisite artery disease (MSAD) in high risk coronary patients are unknown. Whether systematic identification and aggressive management of asymptomatic MSAD is clinically relevant in high risk coronary patients has not been evaluated., Methods: We randomly assigned 521 high risk coronary patients defined by the presence of three-vessel coronary disease (n=304) or recent acute coronary syndrome beyond the age of 75years (n=215) to either a strategy of systematic detection of asymptomatic MSAD combined with an aggressive secondary prevention (n=263) or to a more conventional strategy based on treatment of coronary artery disease only with standard of care (n=258). The primary end point was the time to first occurrence of death, any organ failure or ischemic event leading to re-hospitalization through two years of follow-up., Results: The pro-active strategy identified asymptomatic MSAD in 21.7% of patients with few revascularizations (3.6%); the pro-active pharmacological secondary prevention was obtained in >85% of patients and life-style changes in <60% of patients. At 2-year follow-up, the primary end point occurred in 44.9% of patients in the pro-active group and 43.0% of patients in the conventional group (HR 1.03; 95% confidence interval [CI], 0.80 to 1.34]. The rate of major bleeding did not differ significantly between groups (4.6% vs 5.0%; HR, 0.97; 95% CI, 0.40 to 1.91)., Conclusion: In high risk coronary patients, there is no apparent benefit of a systematic detection of asymptomatic extra-coronary atherothrombotic disease and intensified treatment over a 2-year follow-up period. (Funded by the Academic Allies in Cardiovascular Trials Initiatives and Organized Networks and Institut de l'Athérothrombose; AMERICA ClinicalTrials.gov number, NCT00445835)., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Background: ATLANTIC was a randomized study comparing pre- and in-hospital treatment with a ticagrelor loading dose (LD) in ongoing ST-segment elevation myocardial infarction (STEMI). We sought to compare patient characteristics and clinical outcomes in France with other countries participating in ATLANTIC., Methods: The population comprised 1862 patients, 660 (35.4%) from France and 1202 from 12 other countries. The main endpoints were reperfusion (≥70% ST-segment elevation resolution) and TIMI flow grade 3 before (co-primary endpoints) and after percutaneous coronary intervention (PCI). Other endpoints included a composite ischaemic endpoint (death/myocardial infarction/stroke/urgent revascularization/definite stent thrombosis) and bleeding events at 30days., Results: In France, median times from first LD to angiography and between first and second LDs were 49 and 35min, respectively, and were similar to other countries. French patients were younger (mean 58.7 vs 61.9years, p<0.0001) and characterized by a higher rate of radial access (89.9% vs 54.8%, p<0.0001), more frequent use of pre-hospital glycoprotein (GP) IIb/IIIa inhibitors (14.1% vs 3.1%, p<0.0001) and intravenous enoxaparin (57.3% vs 10.1%, p<0.0001). In France, as in other countries, the co-primary endpoints did not differ between the two randomization groups. The composite ischaemic endpoint was numerically lower in France (3.3% vs 5.1%, p=0.07), with a lower mortality (1.4% vs 3.3%, p=0.01). PLATO major bleeding was numerically less frequent in France (1.8% vs 3.2%, p=0.07)., Conclusions: The French population appears to have better outcomes than the rest of the study population, and seems related to differences in demographics and management characteristics., Trial Registry: ClinicalTrials.gov (NCT01347580)., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Acute coronary syndrome (ACS) mortality increases when the culprit lesion is in the left anterior descending (LAD) artery. We investigated the effects of prasugrel versus clopidogrel according to site of culprit lesion causing ACS treated with percutaneous coronary intervention (PCI) in the TRITON-TIMI 38 study., Methods: Patients were divided into three groups based on the native coronary artery culprit lesion location. The LAD artery group included also patients with the culprit lesion in the left main (LM) artery., Results: In the whole ACS population, prasugrel recipients had lower rates of the primary endpoint that included cardiovascular (CV) death, non-fatal myocardial infarction (MI) or non-fatal stroke without significant differences across vessel groups. CV death was significantly decreased with prasugrel in the whole ACS population (p=0.03) and in ST-elevation MI (STEMI) patients undergoing primary PCI (p=0.04), with pronounced differences in favour of prasugrel versus clopidogrel when the LAD-LM was the culprit vessel (relative risk reduction 50% in the whole ACS population, 57% in STEMI treated with primary PCI, p for interaction 0.07 and 0.08 respectively)., Conclusions: Prasugrel effects were particularly favourable when LAD-LM was the culprit vessel, resulting in CV mortality reduction in the whole ACS population and in STEMI patients when treated with primary PCI., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Consistent evidence of benefit exists for radial access (RA) in ST-elevation acute myocardial infarction (STEMI). Patients with non ST-elevation acute coronary syndrome (NSTE-ACS) have a more varied ischemic and bleeding profile. No randomized trial of vascular access ever focused on NSTE-ACS and landmark studies did not provide conclusive results in this heterogeneous subset of patients., Methods: We assessed in a meta-analysis whether RA is associated with improved outcomes in NSTE-ACS patients. Included studies had to meet the following criteria: 1) enrolling patients with NSTE-ACS undergoing invasive management; 2) reporting outcomes with respect to RA as compared with femoral access (FA); 3) reporting short-term (procedural, in-hospital and up to 30-day) or long-term clinical outcomes. Studies were pooled with fixed and random effects models and heterogeneity was investigated by weighted meta-regression., Results: Eleven studies were included encompassing 131.339 patients, 46.451 receiving RA and 84.888 receiving FA. Thirty-day mortality and MACE were lower with RA (p<0.001 with fixed effects, p=NS with random effects model), but these results depended on one large observational database. Major bleeding was consistently reduced by RA (p<0.001), albeit an inverse relationship with the proportion of patients in each study receiving FA and experiencing major bleeding was evident. The association of RA with reduced long-term mortality was of borderline significance (p=0.054 with random-effects, p=0.001 with fixed-effect model) and also depended on major bleeding in FA patients., Conclusions: RA is associated with better outcomes as compared with FA in NSTE-ACS, although this observation is influenced by nonrandomized comparisons. Large heterogeneity exists among studies., Registration: This study is registered in the PROSPERO database (CRD42015029459)., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: No-reflow in ST-segment elevation acute myocardial infarction (STEMI) is associated with a poor clinical prognosis. Its pathophysiological mechanisms are not fully elucidated yet but enhanced vascular permeability plays a key role in this phenomenon. Angiopoietin-like 4 (ANGPTL4) has been implicated in vascular permeability in experimental models of acute myocardial infarction (AMI). We therefore sought to investigate whether baseline ANGPTL4 serum levels are associated with no-reflow after primary percutaneous coronary intervention (PPCI)., Methods: We studied a group of 41 patients presenting with a first STEMI within 12h of onset of symptoms and who underwent successful PPCI. Blood samples were obtained from all patients on admission before the start of the procedure, for ANGPTL4 level measurement. No-reflow was assessed by cardiac magnetic resonance imaging (MRI), the reference method., Results: MRI-detected no-reflow was observed in 20 patients (48.8%). Variables independently associated with no-reflow on multivariate logistic regression analysis were: lower ANGPTL4 serum levels (odds ratio 0.82, 95% CI 0.70-0.98, P=0.02), higher troponin T peak (odds ratio 1.03, 95% CI 1.00-1.05, P=0.03), higher incidence of left anterior descending coronary artery (LAD) as culprit artery (odds ratio 14.61, 95% CI 1.24-172.49, P=0.03), and higher C-reactive protein levels (odds ratio 1.18, 95% CI 1.00-1.39, P=0.05)., Conclusion: ANGPTL4 serum levels predict MRI-detected no-reflow after successful PPCI in STEMI patients. Given the recently demonstrated therapeutic role of ANGPTL4 in diminishing no-reflow and limiting infarct size in pre-clinical animal models, these findings in humans may open up new possibilities in the field of research., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Background and Aims: Plasma aldosterone has been associated with all-cause and cardiovascular mortality in high-risk cardiovascular populations, including patients with heart failure, myocardial infarction and high-risk coronary artery disease (CAD) patients. In the present study, we evaluated the association of plasma aldosterone levels with vascular events in a large prospective cohort of stable CAD patients recruited in an outpatient setting. Moreover, we investigated the relationship between aldosterone and atherosclerotic burden., Methods and Results: Baseline plasma aldosterone levels were measured in 2699 subjects with CAD (mean age 60 ± 10 years, 82% male). During a median follow-up of 4.7 years, 308 (11%) patients died, of which 203 were from a vascular cause. Vascular endpoints of myocardial infarction, ischemic stroke or vascular death occurred in 355 (13%) patients. Multivariable Cox regression analysis was performed, adjusting for multiple confounders. Aldosterone (median 96 pg/mL, interquartile range 70-138 pg/mL, normal range 58-362 pg/mL) was independently associated with major vascular events (hazard ratio (HR) 1.56, 95% confidence interval (CI) 1.13-2.15) and vascular mortality (HR 1.95, 95% CI 1.27-3.00). By multivariable regression analysis, aldosterone was also associated with the presence of atherosclerosis in additional vascular territories (cerebrovascular disease and/or peripheral artery disease) (p=0.026)., Conclusions: In patients with stable coronary artery disease, plasma aldosterone is independently associated with the risk of major vascular events and vascular mortality and with atherosclerotic burden., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Aldosterone levels are high early after admission for ST elevation myocardial infarction (STEMI) concomitantly with high risk of sudden death and life-threatening ventricular arrhythmia., Methods: We assessed the hypothesis that early aldosterone blockade on admission for primary percutaneous coronary intervention (PCI) may be associated with a reduction of life-threatening ventricular arrhythmia in a prospective cohort-nested case (n=159) versus historical control (n=623) study. All cases were treated on admission by 200mg IV bolus of potassium canrenoate, followed by 25mg PO spironolactone daily during the coronary care unit stay. The primary endpoint--in-hospital composite of death, resuscitated cardiac arrest and ventricular tachycardia--was assessed by logistic regression models adjusted on major pre-specified variables and validated by a bootstrap procedure and propensity-score based analyses., Results: Aldosterone blockade was associated with lower risks of the primary endpoint (adjusted ORs 0.26, 95% CI [0.13-0.57]), resuscitated cardiac arrest (adjusted OR 0.39, 95% CI [0.16-0.94]), ventricular tachycardia or fibrillation (adjusted ORs 0.23, 95% CI [0.12-0.45]), as well as ventricular arrhythmia requiring resuscitation or anti-arrhythmic therapy (adjusted OR 0.41, 95% CI [0.19-0.88]). All findings were confirmed by the bootstrap procedure. The benefit on death or resuscitated cardiac arrest seemed sustained at 6month follow-up., Conclusions: Early aldosterone blockade in patients presenting for primary PCI for STEMI is associated with significant reductions in rates of life-threatening arrhythmia and cardiac arrest independent of the initial risk profile, heart failure or hemodynamic status. These findings support the concept of aldosterone blockade early after STEMI, warranting further confirmation by ongoing randomized trials., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Drug-eluting stents are the default treatment for acute coronary syndromes, unless concerns or contraindications preclude dual antiplatelet therapy (DAPT). Platelet microemboli and mediators from activated platelets can undermine the restoration of perfusion. Therefore, ST-segment elevation MI (STEMI) patients should receive antiplatelet treatments regardless of reperfusion strategy. This review offers an evidence-based comparison of the P2Y12 antagonists that have been evaluated in STEMI. While several studies support clopidogrel in STEMI, the benefits emerge several hours after administration and vary considerably reflecting genetic, cellular and clinical inter-individual differences. Although higher clopidogrel loading doses may improve outcomes, ticagrelor and prasugrel are more potent, produce less inter-individual variability, and show a faster onset of action. Ticagrelor and prasugrel improve outcomes compared to clopidogrel, with manageable bleeding risks, although further studies with a longer follow up are needed. Studies directly comparing ticagrelor and prasugrel are now needed. In the meantime, most current guidelines focus on clopidogrel and, therefore, need revision. While several polymorphisms influence platelet activity, CYP2C19 variants are the most consistently linked to clopidogrel responsiveness. Consensus groups should consider the studies needed to allow routine pharmacogenomic testing. The evidence-based use of P2Y12 antagonists in DAPT should further reduce the morbidity and mortality associated with STEMI., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: We aimed to assess whether the use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with an increased risk of cardiovascular (CV) events in stable patients with established atherothrombosis or multiple risk factors., Methods: We analysed the 23,728 European patients of the REACH Registry; 20,588 (86.8%) had established atherothrombotic disease and 3140 (13.2%) had multiple risk factors only. Aspirin (ASA) and/or NSAIDs use was determined at enrolment and ischemic events were recorded over two years of follow-up. cMACCE was defined as the composite of CV death, MI or stroke. Bleeding was defined as any bleeding leading to both hospitalisation and transfusion., Results: The mean age of population was 67.2±9.8years. At baseline, 1573 patients (6.6%) received NSAIDs and 15,395 (64.9%) received ASA. Four groups were defined: 1) no ASA/no NSAIDs, 2) ASA only, 3) NSAIDs only, 4) NSAIDs+ASA, with 7722 (32.5%), 14,433 (60.8%), 611 (2.6%) and 962 (4.1%) patients in these groups, respectively. Among the 22,028 (92.8%) with complete 2-year follow-up, 683 (3.2%) died from CV causes, while 395 (1.9%) had MI, 665 (3.1%) stroke, 1651 (7.6%) cMACCE and 199 (1.0%) bleeding. After adjustment, NSAID use was independently associated with an increased risk of stroke (OR 1.635; 95% CI 1.239-2.159, p<0.001), and a trend towards an increased bleeding rate (OR 1.554; CI 95% 0.960-2.51, p=0.07). No association was found between NSAID use and MI or MACCE., Conclusions: In stable atherothrombosis patients, the use of NSAIDs appears to be independently associated with an increased cerebrovascular event risk., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: Upper Gastrointestinal Symtoms (UGS) is a reason for discontinuation in patients treated by Low Dose Aspirin (LDA). The nationwide UGLA survey was designed to evaluate the prevalence and the pattern of UGS in patients on LDA, to assess the independent correlates of UGS and finally to determine their impact on treatment compliance., Methods: The UGLA survey was carried out on a representative sample of 10,000 subjects aged 50 or over. Prevalence and clinical impact of UGS related to LDA was appraised by standardised multi-choice questions., Results: A total of 8106 propositus (8106/10,000) accepted to participate in the survey. Among them, 986 (12.2%) were treated with LDA. The prevalence of UGS was 15.4% in subjects on chronic LDA (152/986), 70% being gastroesophageal reflux (GER) (heartburn and/or regurgitation). UGS was reported to occur at least once a week in 60% of propositus (91/152) and daily life was reported to be moderately and severely impaired in 53% (81/152) and 20% (30/152) of them, respectively. UGS impacted compliance to treatment in 12% of propositus with UGS. A prior history of dyspeptic symptoms was predictive of LDA-related UGS (OR: 17.60; CI 95%: 11.52-26.88) whereas neither, gender nor aspirin dosage (ranging from 75 and 325 mg) predicted the occurrence of UGS., Conclusions: Fifteen percent of patients treated with LDA suffered UGS, mostly GER symptoms which had a negative impact on daily life in 3 out of 4 patients and on treatment compliance in 1 out of 8 patients., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Accurate estimation of bleeding risk in patients undergoing elective percutaneous coronary intervention (PCI) is difficult and not based on widely accepted scores or characteristics. We developed and validated a simple prediction model for major bleeding using the SafeTy and Efficacy of Enoxaparin in PCI patients, an internationaL randomized Evaluation (STEEPLE) trial, which demonstrated the superior safety of enoxaparin over unfractionated heparin (UFH) in 3528 patients undergoing elective PCI., Methods and Results: Independent predictors of non-coronary artery bypass graft (CABG)-related major bleeding events were determined using stepwise multivariate logistic regression analysis from a development dataset using bootstrap resampling. These predictors were assigned an integer coefficient (risk score) proportional to the estimated coefficient from the logistic model. Risk scores were tested in a validation cohort. Female sex, use of unfractionated heparin (vs. enoxaparin), and use of a glycoprotein IIb/IIIa inhibitor (vs. nonuse) were the strongest independent predictors of bleeding. Extensive testing found that the final model performed well with bootstrap resampling in the development set (c-statistic 0.75; 95% CI: 0.70-0.82; Hosmer-Lemeshow p = 0.29), validation set (c-statistic 0.67; Hosmer-Lemeshow p = 0.12), and subgroups of high-risk patients analysed from the validation set (c-statistic ≥ 0.67)., Conclusions: Our model for evaluating the risk of non-CABG-related major bleeding in patients undergoing elective PCI identified sex, the type of antithrombin used, and glycoprotein IIb/IIIa inhibitor use as important indicators of bleeding risk, and accurately predicted the incidence of non-CABG-related major bleeding in patients undergoing elective PCI in the STEEPLE trial., (Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.)

Background: Limited data is available on the long-term outcome after sirolimus-eluting stent (SES) implantation for in-stent restenosis., Methods: In 3 centers, consecutive patients (n=100) with percutaneous coronary intervention (PCI) for in-stent restenosis (n=110) were treated with SES: 28 lesions were focal, 40 diffuse, 17 proliferative, and 15 totally occluded (reference vessel diameter: 3.0+/-0.2 mm, lesion length: 13.8+/-5.7 mm)., Results: SES implantation was successful in all patients. The mean follow-up was 50+/-12 months. The main univariate predictive factor of definite (4%) or probable (4%) SES thrombosis was revascularization without SES in a non-target site during the initial procedure (p<0.01). Repeated target lesion revascularization (TLR) was performed in 8 patients (8%) at 1 year, in 10 patients (10%) at 4 years. A cardiac event related to the SES occurred in 14 patients (14%) at one year, 17 patients (17%) at 4 years, and were associated with unstable angina (p<0.05), multivessel disease (p<0.02) and revascularization without SES in another site of the target vessel during the initial procedure (p<0.01)., Conclusions: SESs are effective at 4 years in the treatment of high risk patients with complex in-stent restenosis, with a low risk of TLR but a high risk of stent thrombosis. Most of cardiac events related to the target vessel occur during the first year, and are associated to a revascularization without SES in another site during the first procedure., (Copyright 2008 Elsevier Ireland Ltd. All rights reserved.)

Most guidelines recommend indefinite use of aspirin in patients at increased atherothrombotic risk. Dual antiplatelet therapy (aspirin/clopidogrel) is significantly more effective than aspirin monotherapy in reducing cardiovascular risk in a number of patient populations. As a result, dual therapy is recommended in many patient groups, including those with acute coronary syndromes and those who have undergone percutaneous coronary intervention. The recommended duration of clopidogrel/aspirin treatment is generally less than one year and, in some cases, as little as one month. However, there is evidence from a range of patient populations that more prolonged clopidogrel/aspirin therapy may be more effective than short-term treatment in reducing cardiovascular risk in some patients. The effects of discontinuing clopidogrel after an event-free period of one year require examination in clinical trials. Trial data are also needed to guide management of patients in whom early antiplatelet withdrawal is being considered (e.g. those who require non-cardiac surgery). This review discusses the benefits and risks of long-term dual antiplatelet therapy in a range of clinical situations.

Background: Limited information is available about clinical outcomes following routine percutaneous coronary intervention (PCI) in the current era. This study aimed to identify predictors of adverse clinical or angiographic complications following PCI in patients from many different countries., Methods: RIVIERA is a multinational, prospective, observational study in patients undergoing elective or primary PCI. Consecutive patients (n=7962) were enrolled in 144 hospitals from 23 countries in four different continents. Primary outcome was death or myocardial infarction (MI). The mean age of the patients was 59 years and 77% were men; 92% of patients underwent elective and 8% primary PCI., Results: The rate of in-hospital outcomes was low: death 0.3%, MI 1%, any bleeding 3.4%. Angiographic complications occurred in 8.7% of patients, mainly coronary dissection (3.7%) and no reflow (2%). After multivariable analysis, the strongest independent predictors of death or MI were clinical presentation with non-ST-segment elevation acute coronary syndrome or ST-segment elevation myocardial infarction and administration of a glycoprotein (GP) IIb/IIIa inhibitor. Radial access, thienopyridine pretreatment and anticoagulation with enoxaparin were associated with a lower risk of death or MI. Female gender, PCI of coronary artery bypass graft, administration of a GP IIb/IIIa inhibitor and combined use of enoxaparin and unfractionated heparin were significantly associated with more bleeding. Radial access was the only variable associated with less bleeding., Conclusions: Routine PCI appears to be a relatively safe revascularization procedure. Many of the variables identified as predictors of adverse cardiac outcomes confirm results obtained in recent randomized PCI trials and are modifiable, suggesting that further improvements can be made.

Aims: To evaluate the diagnostic performance of a portable semi-quantitative whole blood immunoassay measuring soluble human fatty acid-binding protein [H-FABP] (CardioDetect) for the pre-hospital detection of myocardial infarction (MI)., Methods and Results: We enrolled prospectively 108 consecutive patients with acute ischemic type chest pain in whom the first medical care was delivered by a mobile intensive care unit (MICU). CTnI, myoglobin, CK-MB and CardioDetect were first assessed in the MICU before hospital admission using point-of-care assays and then cTnI was serially measured during the hospital stay. MI was defined as a positive cTnI in any sample over the first 24 h. The vast majority of the patients (77/108) were admitted <3 h of symptoms onset. Pre-hospital cTnI sample was normal in 96 patients (88.9%) of whom 43 had subsequent cTnI elevation. A positive H-FABP using the CardioDetect assay had a significantly better sensitivity than cTnI, myoglobin and CK-MB (87.3% vs 21.8%, 64.2% and 41.5%, respectively) to identify MI. The significant better sensitivity of the CardioDetect assay was also observed among patients who presented <3 h of symptom onset. The specificity of the CardioDetect assay was significantly better than that of myoglobin, irrespective of the time delay from symptom onset to measurement. In patients with normal pre-hospital cTnI and no ST-elevation (n=63), assessment based only on a positive H-FABP had 83.3% sensitivity, 93.3% specificity for the diagnosis of an evolving MI., Conclusion: Early assessment of H-FABP in patients presenting with chest pain improves the diagnosis of ongoing MI.

Background: The factors associated with recurrent restenosis after SES implantation for in-stent restenosis are unknown. This study aimed to assess the clinical outcome and to analyse predictive factors of cardiac events in patients with in-stent restenosis treated with Sirolimus-eluting stent (SES)., Methods: In 3 centers, consecutive patients (n = 100) with elective indication to percutaneous coronary intervention (PCI) for in-stent restenosis (n = 110) were treated with SES: 28 lesions were focal, 40 diffuse, 17 proliferative, and 15 showed total occlusion., Results: SES implantation was successful in all patients, without complication during the first hospital stay. The mean follow-up was 15 (10-24) months. A cardiac event related to the target vessel occurred in 24 (24%) patients, and was associated with dialysis status (p < 0.05), lower ejection fraction (p < 0.05) and revascularization without SES in another site (p < 0.0001). A cardiac event related to the SES occurred in 11 (11%) patients, secondary to an acute or sub-acute thrombosis of the SES (2%), to a late occlusion of the target vessel (4%) or to a non-occlusive restenosis of the SES (5%), and was associated with unstable angina (p < 0.01), multivessel disease (p < 0.03) and revascularization without SES in another site (p < 0.03). No cardiac event related to the SES occurred in patients with direct stenting. Target lesion revascularization for in-SES restenosis or occlusion of the target vessel was performed in 7 (7%) patients, and was associated with unstable angina (p < 0.01) and revascularization without SES in another site (p < 0.01). Target vessel revascularization was needed in 20 patients (20%), related to dialysis status (p < 0.01) and a revascularization without SES in another site (p < .0001)., Conclusions: SESs are effective in the treatment of high risk patients with complex in-stent restenosis. Most of cardiac events during follow-up are related to a revascularization without SES in another site.

We studied an exceptional case of a patient showing serious sinus node dysfunction during lithium treatment with levels constantly within the therapeutic range. After two endocardial explorations we found that the sinus node dysfunction was due to lithium and reversible after its withdrawal.