Search

OBJECTIVE: Robotically assisted PCI offers a great alternative to S-PCI. This has gained even more relevance during the COVID-19 pandemic era however safety of R-PCI compared to S-PCI has not been studied well. This study explores the safety and efficacy of robotically assisted PCI (R-PCI) compared to standard PCI (S-PCI) for the treatment of coronary artery disease (CAD). METHODS: PubMed, Scopus, Ovid, and Google scholar databases were searched for studies comparing R-PCI to S-PCI. Outcomes included clinical success, procedure time, fluoroscopy time, contrast use and radiation exposure. RESULTS: Theauthors included 5 studies comprising 1555 patients in this meta-analysis. Clinical success was comparable in both arms (p = 0.91). Procedure time was significantly longer in R-PCI group (risk ratio: 5.52, 95% confidence interval: 1.85 to 9.91, p = 0.003). Compared to S-PCI, patients in R-PCI group had lower contrast use (meandifference: -19.88, 95% confidence interval: -21.43 to -18.33, p

Highlights • Prophylactic cranial irradiation (PCI) was more commonly used in younger patients. • PCI utilization rates did not change throughout our 20-year institutional experience. • PCI was associated with improved OS and lower brain metastasis risk, independent of MRI follow-up or era of treatment. • For LS-SCLC patients with good thoracic response, PCI remains the standard-of-care., Background & purpose Prophylactic cranial irradiation (PCI) is recommended for limited-stage small-cell lung cancer (LS-SCLC) patients with good response to concurrent chemoradiation. We report our institution’s 20-year experience with this patient population and associated clinical outcomes. Materials & methods A retrospective cohort of consecutive LS-SCLC patients treated with curative intent chemoradiation at our institution (1997–2018) was reviewed. Overall survival (OS) was calculated using the Kaplan-Meier method, and significant covariates determined by the Cox proportional hazards model. Covariates predictive of PCI were determined using Fisher's exact test and the Mann-Whitney test. Brain failure risk (BFR) was calculated using the cumulative incidence method treating death as a competing event. Treatment cohorts (historic vs. contemporary) were stratified by the median year of diagnosis (2005). Results A total of 369 patients with LS-SCLC were identified, of which 278 patients were notionally PCI eligible. PCI was given to 196 patients (71%). Younger age was associated with PCI utilization (p

Guide catheter extension system (GCES) is a valuable tool for interventional cardiologists, especially in complex cases. GCES increases guide back-up support and is crucial in complex PCI procedures, particularly in cases of severe calcification and tortuosity. Apart from their primary use to increase back-up support of guide by providing coaxial alignment, deep intubation and facilitation of stent delivery, GCES are now being increasingly used in different clinical indications including complex and high-risk coronary intervention interventions.

ObjectivesTo analyse whether (1) passive or active pain coping strategies and (2) presence of neuropathic pain component influences the change of Achilles tendinopathy (AT) symptoms over a course of 24 weeks in conservatively-treated patients.DesignProspective cohort study.MethodsPatients with clinically-diagnosed chronic midportion AT were conservatively treated. At baseline, the Pain Coping Inventory (PCI) was used to determine scores of coping, which consisted of two domains, active and passive (score ranging from 0 to 1; the higher, the more active or passive). Presence of neuropathic pain (PainDETECT questionnaire, −1 to 38 points) was categorized as (a) unlikely (≤12 points), (b) unclear (13–18 points) and (c) likely (≥19 points). The symptom severity was determined with the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire (0–100) at baseline, 6, 12 and 24 weeks. We analysed the correlation between (1) PCI and (2) PainDETECT baseline scores with change in VISA-A score using an adjusted Generalized Estimating Equations model.ResultsOf 80 included patients, 76 (95%) completed the 24-weeks follow-up. The mean VISA-A score (standard deviation) increased from 43 (16) points at baseline to 63 (23) points at 24 weeks. Patients had a mean (standard deviation) active coping score of 0.53 (0.13) and a passive score of 0.43 (0.10). Twelve patients (15%) had a likely neuropathic pain component. Active and passive coping mechanisms and presence of neuropathic pain did not influence the change in AT symptoms (p = 0.459, p = 0.478 and p = 0.420, respectively).ConclusionsContrary to widespread belief, coping strategy and presence of neuropathic pain are not associated with a worse clinical outcome in this homogeneous group of patients with clinically diagnosed AT.

Purpose To identify trajectories of cognitive performance up to five years since diagnosis and their predictors, in a cohort of patients with breast cancer (BCa). Methods A total of 464 women with BCa admitted to the Portuguese Institute of Oncology, Porto, during 2012, were evaluated with the Montreal Cognitive Assessment (MoCA) before any treatment, and after one, three and five years. Probable cognitive impairment (PCI) at baseline was defined based on normative age- and education-specific reference values. Mclust was used to define MoCA trajectories. Receiver Operating Characteristic curves were used to assess the predictive accuracy for cognitive trajectories. Results Two trajectories were identified, one with higher scores and increasing overtime, and the other, including 25.9% of the participants, showing a continuous decline. To further characterize each trajectory, participants were also classified as scoring above or below the median baseline MoCA scores. This resulted in four groups: 1) highest baseline scores, stable overtime (0.0% with PCI); 2) lowest baseline scores (29.5% with PCI); 3) mid-range scores at baseline, increasing overtime (10.5% with PCI); 4) mid-range scores at baseline, decreasing overtime (0.0% with PCI). Adding the change in MoCA during the first year to baseline variables significantly increased the accuracy to predict the downward trajectory (area under the curve [AUC] = 0.732 vs. AUC = 0.841, P, Highlights • 5-year cognitive trajectories since diagnosis of breast cancer were identified. • 25.9% of breast cancer survivors had a declining cognitive trajectory. • Cognitive performance during the 1st year predicted the 5-year trajectory.

Background: The management of atrial fibrillation and/or flutter (AF) patients requiring percutaneous coronary intervention (PCI) has evolved significantly. The Canadian Cardiovascular Society AF guidelines, last updated in 2020, seek to aid physicians in balancing both bleeding and thrombotic risks. Methods: A tertiary academic centre registry of patients with AF who had PCI was examined for the antithrombotic therapy at discharge in 4 time periods (cohort 2010–2011; cohort 2014–2015; cohort 2017; cohort 2019). Discharge prescription patterns were compared among the cohorts, using the χ2 test. In addition, antithrombotic management in cohorts 2017 and 2019 were compared to guideline-expected therapy, using the χ2 test. Results: A total of 576 AF patients undergoing PCI were included. Clinical and procedural characteristics were similar among cohorts, except for an increase in drug-eluting stent use in the most recent cohort (94% vs 99%; P = 0.04). The rate of oral anticoagulation increased over time (75% vs 89%; P < 0.01), driven primarily by an increase in direct oral anticoagulants prescription (63% vs 84%; P < 0.01). In contrast to previous cohorts, there was no significant difference between the observed and the guideline-expected anticoagulation rate in cohort 2019 (89% vs 94%; P = 0.23). Conclusions: A combination of expert guidance and educational initiatives in the past decade contributed to dramatic changes in the management of patients with AF undergoing PCI. Résumé: Introduction: La prise en charge des patients atteints de fibrillation auriculaire et/ou de flutter (FA) qui ont besoin d'une intervention coronarienne percutanée (ICP) a considérablement évolué. La dernière révision, en 2020, des lignes directrices sur la FA de la Société canadienne de cardiologie vise à aider les médecins à établir l’équilibre entre les risques d'hémorragie et de thrombose. Méthodes: Nous avons fouillé le registre d'un centre universitaire en soins tertiaires portant sur des patients atteints de FA qui avaient subi une ICP pour nous pencher sur le traitement antithrombotique offert à la sortie de l'hôpital de quatre périodes (cohorte 2010–2011; cohorte 2014–2015; cohorte 2017; cohorte 2019). Nous avons comparé les pratiques en matière d'ordonnances à la sortie de l'hôpital entre les cohortes à l'aide du test du χ2. De plus, nous avons comparé la prise en charge des cohortes de 2017 et de 2019 qui avaient reçu le traitement antithrombotique à celles qui avaient reçu le traitement prévu dans les lignes directrices à l'aide du test du χ2. Résultats: Nous avons sélectionné un total de 576 patients atteints de FA qui avaient subi une ICP. Les caractéristiques cliniques et interventionnelles étaient similaires entre les cohortes, à l'exception d'une augmentation de l'utilisation d'une endoprothèse médicamentée dans la plus récente cohorte (94 % vs 99 %; P = 0,04). Le taux d'anticoagulation par voie orale qui avait augmenté au fil du temps (75 % vs 89 %; P

Background: Chronic kidney disease (CKD) is an independent risk factor for the development of coronary artery disease. We evaluated outcomes amongst patients of CKD undergoing percutaneous coronary intervention (PCI) as assessed on severity of CKD based on estimated glomerular filtration rate (eGFR) at the time of PCI. Method and materials: We analyzed 100 consecutive CKD patients who underwent PCI and were followed up for 1 year; an observational, prospective, open-label study. Multivariate and Receiver operator characteristics (ROC) analysis was used to determine the cut point ofeGFR for predicting 4-P major adverse cardiac events (MACE) outcomes defined as the composite of Cardiovascular (CV) mortality, heart failure hospitalization (HHF), repeat revascularization and non-fatal MI over 1 year follow up. Results: According to eGFR cut-off value derived from ROC, patients were divided in to two groups based on eGFR cut-off of 36.25 mL/min/1.73 m2. Majority of patients (79%) were in Group 1 (eGFR >36.25 mL/min/1.73 m2). Group 2 had Lower HbA1C, hemoglobin and elevated level of urea as compared to group:1 (p=0.002

Objectives: To analyse the feasibility, safety and procedural outcomes of percutaneous coronary intervention (PCI) for chronic total occlusions (CTO) through retrograde approach using single catheter. Methods: Our study was a retrospective observational study that enrolled patients who underwent retrograde CTO PCI using a single catheter between June 2016 and February 2020. Clinical success was defined as successful completion of CTO PCI without associated in-hospital major clinical complications like death, myocardial infarction, stroke or urgent revascularisation. Technical success was defined as successful completion of CTO PCI using single catheter and minimum diameter stenosis of

Background Management of ST-elevated myocardial infarction (STEMI) necessitates rapid reperfusion. Delays prolong myocardial ischemia and increase the risk of complications, including death. The COVID-19 pandemic may have impacted STEMI management. We evaluated the relative volume of hospitalizations and clinical time intervals within a regional STEMI system. Methods 494 patients with STEMI were grouped into pre-lockdown, lockdown and re-opening cohorts. Clinical, temporal and outcome data were collected and compared between groups for both urban and rural patients, receiving primary percutaneous coronary intervention (PCI) and pharmacoinvasive revascularization, respectively. Data was compared to a 10-year historical comparator. Results During pre-lockdown there was 238 cases versus 193 in lockdown; a 19.0% reduction in volume. When lockdown was compared to the median caseload from a 10-year historical cohort, a 19.8% reduction was observed. For patients treated with primary PCI during lockdown, median symptom-to-balloon time increased by 44-minutes [217 (IQR 157-387) vs. 261 (160-659) minutes; p=0.03]; driven by an increase in median symptom-to-door time of 41-minutes [136 (IQR 80-267) vs. 177 (IQR 90-569) minutes; p, Reports from Canadian cardiovascular centers have indicated that the COVID-19 lockdown may have had unintended affects on STEMI care. There is limited Canadian data providing granular details regarding the impact of the COVID-19 lockdown on STEMI care patterns. We present data from a large cardiac care institution that demonstrates patient and hospital transfer level delays in STEMI care during the COVID-19 lockdown. These challenges must be addressed in light of a second wave of COVID-19.

Introduction There are conflicting data on the clinical outcomes of percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) based on time of intervention. Concerns have been postulated regarding equally effective in-hospital outcomes for STEMI patients treated with PCI during normal working hours as compared to group treated off-hours. Purpose The aim of this study was to assess clinical outcomes in “real-world” patients with STEMI treated with PCI during off-hours and regular hours of work. Methods To avoid possible bias related to the non-randomized design, a propensity score was calculated to compare off- and on-hours groups. The study group consisted of 37, 469 matched pairs in STEMI treated with PCI and stent implantation between 2014 and 2018 during regular hours (weekdays 7:00 AM to 16:59 PM) and off-hours (weekdays between 17:00 PM and 06:59AM, weekends, and holidays) in 151 tertiary invasive cardiology centers in Poland (the ORPKI Polish National Registry). Results No differences were reported between both groups in baseline characteristics after the propensity score match (PSM). There were no differences in time from pain to first contact (p=0.2) and door to balloon time between both groups (p=0.7). After PSM higher radiation dose was observed in off-hours group (1055.18 (±1006.52) vs. 1081.59 (±1003.25)[mGy]; p=0.001). However, there was no difference in total amount of contrast (on-hours vs. off-hours: 175.69 (±74.71) vs. 176.48 (±74.41)[ml]; p=0.1, respectively). Similar rate of periprocedural complications was observed between both groups of patients, includind stroke, access-site-related bleeding, allergic reaction and coronary artery perforation. However, procedures performed during off-hours were associated with higher incidence of periprocedural death (1.17% (439) vs. 1.49% (559); p=0.001) and periprocedural cardiac arrest (1.76% (658) vs.1.97% (740); p=0.001) as compared to PCI conducted within normal working hours. Conclusions Percutaneous coronary intervention in STEMI performed durgin off-hours might be associated with higher rate of periprocedural mortality and higher radiation dose as compared to procedures conducted during regular working hours. Funding Acknowledgement Type of funding source: None

Background Distal transradial access (dTRA), through the anatomical snuffbox (AS) of the hand, is a novel, potentially beneficial, vascular access for patients undergoing coronary procedures. Method Consecutive patients with an indication for coronary angiography and/or percutaneous coronary intervention (PCI) were enrolled in our tertiary center, from November 2018 to March 2019. The success rate of the procedure, the incidence of local complications, the time required for hemostasis, and the incidence of radial artery occlusion (RAO) were evaluated. Results Α total of 167 patients were catheterized through the dTRA (79.6% men, 20.4% women), with a median age of 64 years. The indication for catheterization was ACS in 80 (47.9%) patients, stable coronary artery disease in 51 (30.5%) patients, and other reasons in 36 (21.6%) patients. Fifty patients (32.9%) underwent PCI. Successful sheath insertion was recorded in 152 (91.0%) patients. The mean time to hemostasis after sheath removal was 52 ± 11 min. Vascular access site complications were evaluated with ultrasound in 62 (40.8%) of the enrolled patients, 40 ± 15 days after the procedure. Among them, 2 (3.2%) patients presented with arteriovenous fistula, and 2 (3.2%) patients with local occlusion at the puncture site within the AS and distal to the transverse ligament, with preservation of the patency of the radial artery proximal to the radial styloid process. Conclusion The dTRA may be a feasible and safe access site for diagnostic and interventional coronary procedures, with decreased incidence of RAO and time required for hemostasis compared to classical radial artery access.

Introduction Coronary artery disease (CAD) is the most common cause of morbidity and mortality especially in the developing countries. Coronary artery measurements (CAM) are the most important factor affecting the procedure and outcome of coronary angioplasty (PCI) as well as coronary by-pass operations (CABG). In this study, we aimed to establish a database for the normal CAM as well as for gender difference among the Indian population using quantitative coronary angiography (QCA) with an objective of assessing normal coronary vessel morphology of patients with normal coronaries. Materials and Methods Four thousand angiograms from patients of Indian origin were studied prospectively after procuring the sanction for the same from the ethical committee of the pre-selected hospitals of four states in India. Informed consents were obtained. Post CABG, post PCI patients and patient being diabetic for ≥5 years were also excluded from the study. Results Ten segments from right and left coronary arteries were taken for diameter measurements. These coronary diameters were indexed to body surface area (BSA) (mean diameter mm/m2 BSA). Among, 4,000 patients, 933(23.3%) [M:F-521:412] had normal coronaries and 3,067 (76.7%) were diseased. Discussion and conclusion The dimensions of the coronary artery segments of Indians were smaller (in BSA indexed and non-indexed data), compared to studies from other continents which can be due to their smaller BSA.

Aim Coronary artery calcification is an important factor influencing revascularisation outcomes in patients with chronic kidney disease (CKD). Lesion preparation using rotational atherectomy (RA) may help adequately modify calcified plaques and facilitate the achievement of optimal clinical outcomes in these patients. In this study, we assessed the safety and effectiveness of percutaneous coronary intervention (PCI) using RA followed by new-generation drug-eluting stent (DES) implantation in patients with CKD and calcified coronary artery disease (CAD). Methods and results From November 2014 to October 2019, a total of 203 patients with calcified CAD who underwent RA followed by second- or third-generation DES implantation at our centre were included in the study. Mild, moderate, and severe CKD was present in 38%, 55.5%, and 6.5% of the patients, respectively. Diffused coronary calcifications were present in 85%. Procedural success was 97.5% with minimal periprocedural complications. In-stent restenosis occurred in one patient (0.5%); major adverse cardiovascular and cerebrovascular events were reported in 22 patients (10.8%); cardiac death occurred in eight patients during follow-up. Conclusion Percutaneous coronary intervention using RA followed by second- or third-generation DES implantation is feasible and safe with high procedural success and low in-stent restenosis in CKD patients with calcified coronary lesions.

Objectives The aim of this study is to determine the prevalence, clinical characteristics, angiographic profile and predictors of outcome for percutaneous coronary interventions (PCI) of coronary chronic total occlusions (CTO) in a tertiary referral centre of north India. Background There is no data on the prevalence and very few reports on clinical characteristics, angiographic profile and outcome of PCI in CTO from India. Methods Retrospective analysis was done for the data of 12,020 patients undergoing coronary angiography (CAG) between January 2018 to January 2019 at our centre. Detailed baseline clinical, angiographic and revascularization data was collected. Outcome of CTO PCI was also noted. All baseline parameters were analysed for predicting the outcome of CTO PCI. Results CTO was identified in 16.3% (1968) patients undergoing CAG and in 24.4% of patients with hemodynamically significant CAD. CTO was predominantly found in LAD (48%) followed by RCA (42.9%) and LCx (25.3%) arterial distribution. Mean JCTO score was 1.93 ± 0.7. PCI as a management strategy was adopted in 456 of 1968 patients (23.1%) and was successful in 340 of 456 (74.6%) of patients. Almost all CTO PCI were attempted by an antegrade approach only. Increasing age, male sex, CTO in LCx arterial distribution and higher J CTO score were associated with poorer outcome in CTO PCI. Conclusions CTO’s are commonly encountered during CAG procedures. In patients undergoing CTO PCI, a fair success rate can be achieved in a high volume experienced centre.

Objective To study the use of CYP2C19 genotyping to guide P2Y12 inhibitor selection to maximize efficacy, and attenuate risk in appropriate patients who underwent PCI for CAD. Methods We performed a retrospective analysis of 868 patients with CAD who received CYP2C19 genotyping after PCI and changed P2Y12 inhibitor based on the results. Patients were divided into two groups based on clopidogrel metabolizer status. Group I: Intermediate (IM) and poor metabolizers (PM). Group II: Ultra-rapid (UM), rapid (RM) and normal metabolizers (NM). Each group was then categorized to one of two treatment arms guided by CYP2C19 genotype. Category 1: IM/PM started on clopidogrel, switched to ticagrelor or prasugrel; 2:IM/PM started on ticagrelor/prasugrel, continued these medications; 3: UM/RM/NM started on ticagrelor/prasugrel, switched to clopidogrel; 4: UM/RM/NM started on clopidogrel, continued clopidogrel. Death due to cardiac causes, bleeding events, non-fatal MI, target vessel revascularization (TVR), and MACE in all four categories were considered at 1, 6 and 12 months. Results We did not observe significant difference between phenotypes for MACE at 1 (p = 0.274), 6 (p = 0.387), and 12 months (p = 0.083). Death due to cardiac causes, MI, and bleeding events were not significant at 1, 6, and 12 months. There was no significant difference in TVR at 6 (p = 0.491), and 12 months (p = 0.423) except at 1 month (p = 0.012). Conclusion CYP2C19 genotype-based intervention can be implemented effectively and reliably to guide selection of P2Y12 inhibitor to optimize patient quality and safety when appropriate in post PCI patients.

Background: Major bleeding (MB) is an independent predictor of mortality among ST-elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (pPCI). Prevention of access-site MB has received significant attention. However, limited data have been obtained on the influence of access-site MB vs non-access-site MB and association with subsequent adverse in-hospital outcomes in the STEMI population undergoing pPCI. Methods: We identified 1494 STEMI patients who underwent pPCI between 2012 and 2018. Unadjusted and adjusted differences among patients with no MB, access-site MB, non-access-site MB, and in-hospital clinical outcomes were assessed. The use of bleeding-avoidance strategies and their effects on MB were also evaluated. Results: MB occurred in 121 (8.1%) patients. Access-site MB occurred in 34 (2.3%) patients, and non-access-site MB occurred in 87 (5.8%). The median reduction in hemoglobin was 31 g/L (interquartile range: 19-43) with access-site MB, and 44 g/L (interquartile range: 29-62) with non-access-site MB. After multivariable adjustment, non-access-site MB was independently associated with in-hospital death (adjusted odds ratio [aOR] 4.21; 95% confidence interval [CI] 2.04-8.68), cardiogenic shock (aOR 10.91; 95% CI 5.67-20.98), and cardiac arrest (aOR 5.63; 95% CI 2.88-11.01). Conversely, access-site MB was not associated with adverse in-hospital outcomes. Bleeding-avoidance strategies were used frequently; however, after multivariable adjustment, no single bleeding-avoidance strategy was significantly associated with reduced MB. Conclusions: In STEMI patients undergoing pPCI, non-access-site MB was independently associated with adverse in-hospital outcomes, whereas access-site MB was not. Additional study of strategies to reduce the incidence and impact of non-access-site MB appears to be warranted. Résumé: Contexte: Le saignement majeur (SM) est un facteur prédictif indépendant de la mortalité chez les patients ayant eu un infarctus du myocarde avec élévation du segment ST (STEMI) qui subissent une intervention coronarienne percutanée primaire (ICPp). La prévention du SM lié à l'accès vasculaire a fait l'objet de nombreuses études. Toutefois, rares sont les données sur l'influence du SM lié à l'accès vasculaire par rapport au SM non lié à cet élément et sur son association avec des résultats indésirables intrahospitaliers subséquents chez des patients ayant subi une ICPp après un STEMI. Méthodologie: Nous avons répertorié 1 494 patients ayant subi une ICPp après un STEMI entre 2012 et 2018. Nous avons évalué les différences non ajustées et ajustées entre les cas sans SM, les cas de SM liés à l'accès vasculaire et les cas de SM non liés à l'accès vasculaire, et les résultats cliniques intrahospitaliers. L'utilisation de stratégies d'évitement des saignements et leurs effets sur le SM ont également été évalués. Résultats: Un SM a été observé chez 121 (8,1 %) patients. Le SM lié à l'accès vasculaire touchait 34 (2,3 %) patients, et le SM non lié à l'accès vasculaire 87 (5,8 %) patients. La réduction médiane du taux d'hémoglobine était de 31 g/L (intervalle interquartile : 19 à 43) dans le cas du SM lié à l'accès vasculaire, et de 44 g/L (intervalle interquartile : 29 à 62) pour le SM non lié à l'accès vasculaire. Après ajustement multivarié, une association indépendante a été observée entre le SM non lié à l'accès vasculaire et le décès (rapport de cotes ajusté [RRa] 4,21; intervalle de confiance [IC] à 95 % : de 2,04 à 8,68), le choc cardiogénique (RRa 10,91; IC à 95 % : de 5,67 à 20,98), et l'arrêt cardiaque (RRa 5,63; IC à 95 % : de 2,88 à 11,01) intrahospitaliers. Inversement, le SM lié à l'accès vasculaire n'était associé à aucun résultat indésirable intrahospitalier. Les stratégies d'évitement des saignements avaient été utilisées fréquemment; toutefois, après ajustement multivarié, aucune stratégie particulière d'évitement des saignements n'était associée de façon significative à une réduction du SM. Conclusions: Chez les patients subissant une ICPp après un STEMI, le SM non lié à l'accès vasculaire était associé de façon indépendante aux résultats indésirables intrahospitaliers, alors que le SM lié à l'accès vasculaire ne l'était pas. La poursuite des recherches sur les stratégies permettant de réduire l'incidence et les conséquences du SM non lié à l'accès vasculaire semble donc justifiée.

Objective: To analyze changes in performance indicators five years after Portugal joined the Stent for Life (SFL) initiative. Methods: National surveys were carried out annually over one-month periods designated as study Time Points between 2011 (Time Zero) and 2016 (Time Five). In this study, 1340 consecutive patients with suspected ST-elevation myocardial infarction (STEMI) who underwent coronary angiography, admitted to 18 24/7 primary percutaneous coronary intervention (PCI) centers, were enrolled. Results: There was a significant reduction in the proportion of patients who attended primary healthcare centers (20.3% vs. 4.8%, p

Objective: To investigate the efficacy and safety of ticagrelor and different dosages of clopidogrel after acute coronary syndrome. Methods: We compared different antiplatelet strategies for the prevention of cardiovascular events in 1939 patients admitted to the hospital with an acute coronary syndrome undergoing percutaneous coronary intervention (PCI). Results: At 24 months, a survival analysis showed that ticagrelor and double-dose clopidogrel decreased the incidence of MACCE (a composite of all-cause death, myocardial infarction (MI), target vessel revascularization and stroke) (p

Background The initial enthusiasm for thrombectomy during percutaneous coronary intervention (PCI) of ST-elevation myocardial infarction (STEMI) patients has given way to restraint. There has been some limited interest whether it is beneficial in a few selected subgroups. Hence, we performed a network meta-analysis to compare conventional PCI (cPCI), Aspiration or manual thrombectomy (AT) and Mechanical thrombectomy (McT) for clarification. Methods Electronic databases were searched for randomized studies that compared AT, McT, or cPCI. A network meta-analysis was performed and odd’s ratio (OR) with 95% confidence intervals was generated for major adverse cardiac events (MACE), mortality, myocardial infarction (MI), target vessel revascularization (TVR), stent thrombosis (ST), stroke, left ventricular ejection fraction (LVEF), myocardial blush grade (MBG) and ST segment resolution (STR). Results A total of 43 randomized trials (n = 26,682) were included. The risk of MACE (OR 0.86 95% CI 0.73–1.00), Mortality (OR 0.85 95% CI 0.73–0.99), MI (OR 0.65, 95% CI: 0.44–0.95) and TVR (OR 0.86, 95% CI: 0.74–1.00) were lower with AT compared to cPCI. The risk of ST and stroke was no different with the use of adjunctive AT. MBG, STR, and LVEF improved with the use of AT while the infarct size was no different in the two groups. Conclusions Our comprehensive network meta-analysis suggests conflicting outcomes with AT. While Mortality, MACE, MI seem better, there is a suggestion that, Stroke and ST might be worse. Whether AT can still be pursued in any select cases should be further scrutinized.

STEMI is a major public health problem requiring timely reperfusion. Fibrinolysis remains prevalent reperfusion strategy where timely primary percutaneous coronary intervention (PCI) cannot be performed. Adjunctive antithrombotic agents are of utmost importance for maximizing the benefit of fibrinolysis. This prospective study evaluates the angiographic outcomes in STEMI patients receiving fibrinolysis with optimal antithrombotic therapy and reported TIMI 3 flow rates of 33.8% and 41.5% for streptokinase and reteplase respectively, that were significantly higher than various prior studies. This data reiterates the utility of thrombolysis in resource limited settings.

Objectives: The no-reflow phenomenon occurs in 25% of patients with ST elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), and may be associated with adverse outcomes. The aim of our study was to detect novel predictors of no-reflow phenomenon and the resulting adverse long term outcomes. Methods: We enrolled 400 STEMI patients undergoing primary PCI; 228 patients had TIMI flow 3 after PCI (57%) and the remaining 172 patients had TIMI flow 5.6 ng/mL (OR = 1.040, 95% CI: 1.001–1.080, P = 0.04), diabetes mellitus (OR = 4.401, 95% CI: 1.081–17.923, P = 0.04) and heavy thrombus burden (OR = 16.915, 95% CI: 5.055–56.602, P 0.21, FAR >11.56, and AIP >0.52 could be considered as novel powerful independent predictors (OR = 3.357, 95% CI: 2.288–4.927, P

Introduction and objectives: D-dimers are a determinant of hypercoagulable state and have been found to be related to acute coronary syndromes. We aimed to establish the association between increased D-dimer levels and coronary artery disease (CAD) severity using SYNTAX Score (SS) II in patients with ST elevation myocardial infarction (STEMI) who underwent primary percutaneous coronary intervention (PCI). Methods: This retrospective study included 300 consecutive patients (81.7% males, mean age 55±12 years) with STEMI who underwent a primary PCI. Patients were divided into two groups according to their median SSII [SSII

Large intracoronary thrombus has been reported in significant number of patients with STEMI. Primary PCI is the current standard of care in patients of STEMI. Despite the availability of dual antiplatelets, GP IIb/IIIa inhibitor and effective anticoagulation regimens, large intracoronary thrombus remains one of the biggest challenge to interventional cardiologists during primary PCI. Large intracoronary thrombus may lead to distal embolization, no/slow reflow or embolization into a non-culprit vessel and is associated with adverse cardiovascular outcome. There is no ideal management strategy. We hereby discuss the current available methods/strategies to deal with large thrombus burden encountered during primary PCI, in the current manuscript.

This report describes a case of a 35-year-old man who presented with acute coronary syndrome. An angiogram and intravascular ultrasound revealed atherosclerotic stenosis in the myocardial bridging segment of the mid-left anterior descending artery. The culprit lesion was treated using a drug-coated balloon, and no residual stenosis was observed, which was later confirmed by intravascular ultrasound and optical coherence tomography at a 1-year coronary angiographic follow-up. This case provides evidence that drug-coated balloon could be a potential treatment strategy for atherosclerosis located in the myocardial bridging segment and suggests advantages of the "leave nothing behind" strategy in such clinical scenarios.

© 2020 Sociedade Portuguesa de Cardiologia. Published by Elsevier España, S.L.U. This is an open access article under the CC-BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/)., Introduction: Patient selection for percutaneous coronary intervention (PCI) in chronic total occlusions (CTOs) is crucial to procedural success. Our aim was to identify independent predictors of success in CTO PCI in order to create an accurate score. Methods: In a single-center observational registry of CTO PCI, demographic and clinical data and anatomical characteristics of coronary lesions were recorded. Linear and logistic regression analysis were used to identify predictors of success. A score to predict success was created and its accuracy was measured by receiver operating curve analysis. Results: A total of 377 interventions were performed (334 patients, age 68±11 years, 75% male). The success rate was 65% per patient and 60% per procedure. Predictors of success in univariate analysis were absence of active smoking (OR 2.02, 95% CI 1.243-3.29; p=0.005), presence of tapered stump (OR 5.2, 95% CI 2.7-10.2; p8 with high probability (95%). Conclusion: In our sample only anatomical characteristics were predictors of success. The creation of a score to predict success, with good accuracy, may enable selection of cases that can be treated by any operator, those in which a dedicated operator will be desirable, and those with an extremely low probability of success, which should be considered individually for conservative management, surgical revascularization or PCI by a team experienced in CTO.

Introduction and objectives: In ST-segment elevation myocardial infarction (STEMI) the benefit of dual antiplatelet therapy is unequivocal, but the optimal time to administer the loading dose (LD) of a P2Y12 inhibitor is the subject of debate and disagreement. The main aim of this study was characterize current practice in Portugal and to assess the prognostic impact of P2Y12 inhibitor LD administration strategy, before versus during or after primary percutaneous coronary intervention (PCI). Methods: This multicenter retrospective study based on the Portuguese National Registry on Acute Coronary Syndromes included patients with STEMI and PCI performed between October 1, 2010 and September 19, 2017. Two groups were established: LD before PCI (LD-PRE) and LD during or after PCI (LD-CATH). Results: A total of 4123 patients were included, 66.3% in the LD-PRE group and 32.4% in the LD-CATH group. Prehospital use of a P2Y12 inhibitor was a predictor of the composite bleeding endpoint (major bleeding, need for transfusion or hemoglobin [Hb] drop >2 g/dl), Hb drop >2 g/dl and reinfarction. There were no differences between groups in major adverse events (MAE) (in-hospital mortality, reinfarction and stroke) or in-hospital mortality. Conclusions: Prehospital use of a P2Y12 inhibitor was associated with an increased risk of bleeding, predicting the composite bleeding outcome and Hb drop>2 g/dl, with no differences in mortality or MAE, calling into question the benefit of this strategy. Resumo: Introdução e objetivos: No enfarte agudo do miocárdio com supra desnivelamento do segmento ST (EAMcST) é inequívoco o benefício do uso de dupla anti-agregação plaquetar. O tempo ideal para administrar a dose de carga do inibidor do recetor P2Y12 (DC-iP2Y12) é pouco consensual e motivo de debate. O principal objetivo do trabalho foi caracterizar a prática usada em Portugal e avaliar o impacto prognóstico da estratégia de administração da DC-iP2Y12, se antes ou durante/após angioplastia primária (AP). Métodos: Estudo multicêntrico, retrospetivo, baseado no Registo Nacional de Síndromes Coronárias Agudas, com inclusão de doentes com EAMcST e AP realizada de 1/10/2010 a 19/09/2017. Estabelecidos dois grupos: DC-iP2Y12 pré-AP (PRE-DC-iP2Y12) e DC-iP2Y12 durante ou após AP (CAT-DC-iP2Y12). Resultados: Incluídos 4123 doentes, 66,3% do grupo PRE-DC-iP2Y12 e 32,4% do grupo CAT-DC-iP2Y12. Numa análise multivariada o uso de PRE-DC-iP2Y12 foi preditor de HEMATS (endpoint composto por hemorragia major, transfusão de sangue e queda de hemoglobina (Hb)>2 g/dL), queda de Hb>2 g/dL e re-enfarte. Não se verificaram diferenças entre grupos no MACE (endpoint composto por morte hospitalar, acidente vascular cerebral e re-enfarte) e morte hospitalar. Conclusões: O uso de PRE-DC-iP2Y12 associou-se a um aumento do risco hemorrágico, sendo preditor do outcome composto de hemorragia (HEMATS) e de queda de Hb>2 g/dL, sem diferenças significativas na mortalidade e no MACE, o que coloca em questão o benefício desta estratégia.

Background: This study aimed to investigate the effect of ticagrelor combined with omeprazole on patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI). Methods: Eighty-six patients with AMI who underwent primary PCI in Xinxiang Central Hospital between July 2015 and December 2016 were included and divided randomly into the observation group and the control group by the draw, with 43 patients in each group. All patients were routinely treated with dual antiplatelet therapy with aspirin plus ticagrelor. Omeprazole was used in the observation group and placebo was used in the control group. Data of baseline patient characteristics, platelet response index (PRI), ADP-induced platelet aggregation (ADP-Ag), major adverse cardiac events (MACE), and incidence of bleeding events were recorded and compared between both groups. Results: PRI and ADP-Ag at 7 days, 1 month, and 6 months after operation in both groups were significantly lower than those in the same group before administration (p

Objective To estimate the incidence of major adverse cardiovascular events (MACE) with genotype test-guided antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome. Methods Patients who had undergone PCI for acute coronary syndrome as well as stable coronary artery disease were recruited. Salivary samples were obtained from these patients and genotyped for CYP2C19*2, CYP2C19*3 variations by sequencing method (GAAP x method). Patients were categorized as normal (GG, GG) (29%), intermediate (AG) (52%) or poor metabolizers (homozygous variant AA) (19%). Dual antiplatelets were given based on the genotyping data. Poor metabolizers received newer agent (ticagrelor), intermediate metabolizers received double-dose of clopidogrel and normal metabolizers received therapeutic doses of clopidogrel. All subjects were followed-up for six months. Results Based on the genotyping data of CYP2C19*2 and CYP2C19*3 variations, it was found that most patients were categorized as ‘intermediate’ (78, 51.65%), followed by ‘normal’ (43, 28.48%) and ‘poor’ metabolizers (30, 19.87%). Only 3 (1.5%) of 151 patients reported MACE at follow-up. Conclusions Genotyping for CYP2C19 variations to assess clopidogrel resistance in patients undergoing PCI and subsequent drug selection helps reduce MACE after coronary intervention.

Arteriovenous (AV) fistulae for hemodialysis in patients with end-stage renal disease usually prevents ipsilateral transradial access (TRA) for coronary angiography. We present a case of coronary angiography and percutaneous coronary intervention via left TRA with navigation through a dormant AV fistula in a patient with limited vascular access. (Level of Difficulty: Intermediate.), Graphical abstract, Arteriovenous (AV) fistulae for hemodialysis in patients with end-stage renal disease usually prevents ipsilateral transradial access (TRA) for…

Background A recent clinical trial demonstrated that optical frequency domain imaging (OFDI) guidance in percutaneous coronary intervention (PCI) is noninferior to intravascular ultrasound (IVUS) guidance in patients with coronary artery disease with regard to target vessel failure (composed of cardiac death, myocardial infarction attributed to the target vessel, and clinically-driven target vessel revascularization) at 12 months. The impact of OFDI guidance in PCI for patients with acute coronary syndrome (ACS) remains uncertain. Methods OPINION ACS is a multicenter, prospective, randomized, controlled, open-label, parallel group, non-inferiority trial in Japan. Eligible patients will be randomly assigned to receive either OFDI- or IVUS-guided PCI. PCI is performed using the sirolimus-eluting stent in accordance with certain OFDI and IVUS criteria for optimal stent deployment. All patients will undergo follow-up angiography and OFDI imaging at 8 months. The primary endpoint is the minimum lumen area, as measured by OFDI at 8 months. Conclusion The OPINION ACS trial outcomes will provide insights regarding the impact of OFDI-guided PCI on in-stent restenosis at 8 months in patients with ACS.

Introduction and objectives: Elective percutaneous coronary intervention (PCI) has become an increasingly safe procedure. However, same day discharge (SDD) has yet to become standard practice. Our aim is to characterize the patients who underwent elective PCI and compare outcomes between the overnight stay (ONS) patient group and the group that was discharged on the same day at 24 hours and at 30 days. Methods: One-year registry of patients who underwent an elective PCI. The possibility of SDD was established by the operator. Appropriate candidates were discharged at least four hours after the end of the intervention. The primary endpoints were defined as: Major adverse cardiac and cerebrovascular events (MACCE) — death, myocardial infarction (MI) stroke or transient ischemic attack (TIA), non-planned re-intervention — and vascular complications. Secondary endpoints were any unplanned hospital visit, readmission and re-catheterization. Results: We performed 155 elective PCIs. One patient was admitted to the coronary care unit; 111 patients stayed overnight (ONS Group); 43 patients were discharged the same day (SDD Group). Three patients had early (

Highlights • Pneumatosis cystoides intestinalis is a rare condition with a broad spectrum of clinical symptoms. • Images are typically striking, which can confuse the medical team and lead to unnecessary procedures. • Close follow up is needed as complications can lead to a troublesome outcome., Background Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas infiltration into the intestine wall. When gas is seen in the intestinal wall, it is usually a sign of bowel wall infarction and a surgical emergency; therefore, an adequate differentiation of benign and urgent conditions of pneumatosis intestinalis is necessary to prevent misdiagnosis and inadequate therapies. Case presentation We present the case of a 79-year-old male with past medical history of Alzheimer’s, cholecystectomy, and umbilical hernia. PCI was identified, and conservative therapy was started. Since the patient's pain persisted, a complication was suspected, and surgery was decided. After successful treatment, the patient completely recovered. Conclusion There are many benign and life-threatening causes of pneumatosis intestinalis, the imaging appearance of both may look very similar. Therefore, clinical history, physical examination, and laboratory test results are the best indicators of whether it is due to a benign or life-threatening cause. PCI must be managed with a multidisciplinary team of clinicians, radiologists, and surgeons to achieve better results for our patients.

Cardiac rehabilitation (CR) is underutilised across the world and India. The use of simple algorithms is one way to facilitate CR, however, these algorithms need to be feasible to use across low resource settings. The objectives were to assess the feasibility of a CR algorithm following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). A single group, pre-post study on 50 participants undergoing PCI for ACS found significant improvement in various feasibility metrics at discharge and 30-days, with no major adverse events. The proposed CR algorithm was safe and feasible for low and moderate risk patients with ACS undergoing PCI.

Aims To study the incidence, clinical and angiographic characteristics, management and outcomes of coronary artery perforation (CAP) during percutaneous coronary intervention (PCI) at a high volume center in South-east Asia. Methods Data from patients who had CAP during PCI from January 2016 to December 2019 at our center were collected. Clinical features, angiographic and procedural characteristics, their management and outcomes were analyzed retrospectively. Results A total of 40,696 patients underwent PCI during the study period and the incidence of CAP was 0.13% (n = 51). Mean age was 60.0 ± 10.8 years and 69% were males. CAP cases involved complex type B2/C lesions in 73%, calcified lesions in 58%, and chronic total occlusions in 25%. Majority of patients presented as acute coronary syndrome (65%) and STEMI was the most frequent indication for PCI (33%). Most of the CAPs were Ellis type II (33%) and III (55%). CAP most frequently occurred during post dilation (n = 20) and wire manipulation (n = 17). Majority were treated by prolonged balloon inflation (53%) and covered stents (33%). Pericardiocentesis was required in 19 patients to alleviate tamponade. In one patient coil embolisation was done and two patients required bail-out emergency cardiac surgery. Periprocedural myocardial infarction occurred in 6% and in-hospital mortality was 10%. All-cause mortality accrued to 14% at 30 days and 16% at 6 months. Conclusion Although incidence of CAP in contemporary interventional practice remains low, the morbidity and mortality are considerable. Early recognition and management strategies tailored to the severity of perforation play a key role in achieving better outcomes.

Aim The aim of this study was to evaluate the feasibility of heparinised saline as flushing media for frequency-domain optical coherence tomography (FD-OCT) image acquisition during percutaneous coronary intervention (PCI) optimisation. Methods and results Twenty-seven patients undergoing FD-OCT–guided PCI were enrolled. Heparinised saline was injected into the coronary during FD-OCT image acquisition. A total of 118 runs were analysed for image quality and diagnostic value. FD-OCT runs were categorised as follows: good runs (GRs), clinically usable runs (CURs) and clinically not usable runs (NURs); GRs and CURs were combined as clinically effective runs (ERs). Saline FD-OCT enabled visualisation of all possible coronary lesions. Of the 118 runs analysed, 61%, 27.1%, 11.9% and 88.1% were GRs, CURs, NURs and ERs, respectively. Sixty-one percent of total runs were left coronary system (LCS) and 39% were right coronary system (RCS) runs. Among LCS runs, 55.6%, 30.6%, 13.8% and 86.2% were GRs, CURs, NURs and ERs, respectively. Among RCS runs, 69.6%, 21.7%, 8.7% and 91.3% were GRs, CURs, NURs and ERs, respectively. Conclusion This is the first study to demonstrate the technical feasibility of isolated saline FD-OCT for PCI optimisation.

Background: The residual burden of coronary artery disease after percutaneous coronary intervention (PCI) has been associated with worse ischemic outcome. However, data are conflicting in elderly patients. The aim of our study was to verify the incremental value of the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (rSS) over clinical variables and baseline SYNTAX score (bSS) in predicting 1-year mortality or cardiovascular events. Methods: A post hoc analysis of data collected in the Elderly-ACS 2 multicenter randomized trial was performed. We included 630 patients aged > 75 years with multivessel coronary disease undergoing PCI for acute coronary syndrome (ACS). The primary outcome was a composite of death, recurrent myocardial infarction, and stroke at 1-year follow up. Change in c-statistic and standardized net benefit were used to evaluate the incremental value of the rSS. Results: Event rates were significantly higher in patients with incomplete revascularization (rSS > 8). When the rSS was included in a core Cox regression model containing age, previous myocardial infarction, and ACS type, the hazard ratio for patients with score values > 8 was 2.47 (95% confidence interval, 1.51-4.06). However, the core model with rSS did not increase the c-statistic compared with the core model with the bSS (from 0.69 to 0.70) and gave little incremental value in the standardized net benefit. Conclusions: In elderly patients with ACS with multivessel disease undergoing PCI, incomplete revascularization was associated with worse outcome at 1-year follow-up. However, there was no clear incremental value of the rSS in the prediction of 1-year adverse outcome compared with a model including clinical variables and bSS. Résumé: Contexte: Le fardeau résiduel de la coronaropathie après une intervention coronarienne percutanée (ICP) a été associé à de moins bons résultats sur le plan ischémique. Les données recueillies chez les patients âgés sont toutefois contradictoires. Cette étude avait donc pour objectif de valider la valeur ajoutée du score SYNTAX (SYNergy between percutaneous coronary intervention with TAXus and cardiac surgery) résiduel (SSr) par rapport aux paramètres cliniques et au score SYNTAX initial (SSi) pour prédire la mortalité à 1 an et les manifestations cardiovasculaires. Méthodologie: Une analyse a posteriori des données de l’étude multicentrique avec répartition aléatoire Elderly-ACS 2 a été effectuée. Pour ce faire, 630 patients âgés de plus de 75 ans, atteints d’une coronaropathie multitronculaire et ayant subi une ICP pour traiter un syndrome coronarien aigu (SCA) ont été retenus. Le critère d’évaluation principal était composé du décès, de l’infarctus du myocarde récurrent et de l’accident vasculaire cérébral (AVC) au moment du suivi à 1 an. La variation de la statistique C et le bénéfice net normalisé ont servi à évaluer la valeur ajoutée du SSr. Résultats: Les manifestations étaient significativement plus fréquentes chez les patients dont la revascularisation était incomplète (SSr > 8). Lorsque le SSr a été pris en compte dans un modèle de régression de Cox de base ayant pour facteurs l’âge, les antécédents d’infarctus du myocarde et le type de SCA, le rapport des risques instantanés pour les patients ayant un score > 8 était de 2,47 (intervalle de confiance à 95 % : 1,51-4,06). L’intégration du SSr dans le modèle de base n’a toutefois pas donné lieu à une statistique C plus élevée que celle du SSi (0,70 vs 0,69) et conférait peu de valeur ajoutée sur le plan du bénéfice net normalisé. Conclusions: Chez les patients âgés présentant un SCA et une atteinte multitronculaire, et subissant une ICP, la revascularisation incomplète a été associée à de moins bons résultats au moment du suivi à 1 an. Le SSr n’a toutefois pas été clairement associé à une valeur ajoutée pour prédire une issue défavorable à 1 an comparativement à un modèle reposant sur des paramètres cliniques et le SSi.

Background: Patients with ST-elevation myocardial infarction (STEMI) presenting to percutaneous coronary intervention (PCI)-capable hospitals often experience delays for primary PCI (pPCI). We sought to describe the effect of specific delay intervals and patient/system-level factors on STEMI reperfusion times. Methods: We analyzed all consecutive patients with STEMI who presented to 2 PCI-capable hospital emergency departments (EDs) between June 2007 and March 2016 who received successful pPCI. We excluded patients with prehospital cardiac arrest. We compared specific system delay intervals, patient characteristics, and in-hospital outcomes among patients who received timely (first medical contact-device ≤90/≤120 minutes) vs delayed >90/>120 minutes) pPCI. Results: Of 1936 patients with STEMI, 1127 (58%) presented directly to a PCI-capable hospital via emergency health services (EHS), 499 (26%) were transferred from the ED of a non-PCI hospital, and 310 (16%) self-presented to the ED of a pPCI-capable hospital. Guideline-recommended reperfusion times were met in 47% of direct-EHS, 42% of transfers, and 33% of self-presenters. Each time interval from first medical contact to device deployment was significantly prolonged in the delayed vs timely reperfusion cohorts across all 3 groups, excepting vascular access time. ED dwell time contributed the most to the difference in median reperfusion time within each group. Time of presentation, comorbidities, and sex were each significantly associated with delayed reperfusion. Within the EHS-direct group, prolonged reperfusion and ED dwell times were significantly associated with increased mortality, major bleeding, and cardiogenic shock. Conclusion: Ongoing efforts to identify and reduce ED dwell time and other systemic pPCI delays may improve STEMI outcomes, including mortality. Résumé: Contexte: Les patients en infarctus du myocarde avec élévation du segment ST (STEMI) qui se présentent dans un hôpital en mesure d’effectuer une intervention coronarienne percutanée (ICP) doivent souvent attendre pour subir une ICP primaire (ICPP). Nous avons tenté de décrire les effets de différents temps d’attente et facteurs relevant des patients ou du système de santé sur le délai avant la reperfusion lors d’un STEMI. Méthodologie: Nous avons analysé tous les cas consécutifs de patients en STEMI admis entre juin 2007 et mars 2016 au service des urgences de deux hôpitaux en mesure d’effectuer une ICP, et qui ont effectivement subi une ICPP. Les patients qui avaient subi un arrêt cardiaque avant leur arrivée à l’hôpital ont été exclus. Nous avons comparé les temps d’attente à des étapes particulières relevant du système de santé, les caractéristiques des patients et les issues de l’hospitalisation chez les patients qui ont subi une ICPP rapidement (intervalle entre la première prise de contact avec les services médicaux et la pose d’un dispositif ≤ 90/≤ 120 minutes) ou tardivement (intervalle > 90/> 120 minutes). Résultats: Sur les 1 936 patients ayant subi un STEMI, 1 127 (58 %) ont été conduits par l’entremise des services d’urgences de santé (SUS) directement dans un hôpital en mesure d’effectuer une ICP, 499 (26 %) ont été transférés depuis le service des urgences d’un hôpital n’étant pas en mesure d’effectuer une ICP et 310 (16 %) se sont présentés eux-mêmes au service des urgences d’un hôpital en mesure d’effectuer une ICPP. Les délais avant la reperfusion recommandés dans les lignes directrices ont été respectés dans 47 % des cas où le patient a été conduit par l’entremise des SUS, dans 42 % des cas de transfert et dans 33 % des cas où le patient s’est présenté lui-même. À l’exception du temps écoulé entre l’arrivée au laboratoire de cathétérisme et la création d’un accès vasculaire, les temps d’attente à chacune des étapes entre la première prise de contact avec les services médicaux et la pose d’un dispositif étaient significativement plus longs chez les patients ayant subi une reperfusion tardive que chez ceux ayant subi rapidement une ICPP, et ce, dans les trois groupes de patients. C’est le temps d’attente au service des urgences qui a le plus contribué à la différence entre les groupes en ce qui concerne le délai médian avant la reperfusion. L’heure de l’arrivée au service des urgences, la présence d’affections concomitantes et le sexe étaient tous des facteurs associés de manière significative à une reperfusion tardive. Chez les patients conduits par l’entremise des SUS directement dans un hôpital en mesure d’effectuer une ICP, un délai avant la perfusion et un temps d’attente au service des urgences plus longs étaient associés de manière significative à une hausse de la mortalité, des hémorragies majeures et des chocs cardiogéniques. Conclusion: Les efforts actuellement déployés pour reconnaître les sources de retard et réduire les temps d’attente au service des urgences et aux autres étapes avant la réalisation de l’ICPP pourraient permettre d’améliorer l’issue d’un STEMI, y compris la mortalité.

Background: This study was conducted with the aim of providing a quantitative appraisal of clinical outcomes of trans-radial access for primary percutaneous coronary interventions (PCI) in patients with ST-segment evaluation myocardial infarction (STEMI). Methods: In this study, we compared two propensity-matched cohorts of patients who underwent primary PCI via trans-radial (TRA) and trans-femoral access (TFA) in a 1:1 ratio. The profile of two cohorts was matched for gender, age, and body mass index, diabetes, hypertension, family history, and smoking. The outcomes of primary PCI were compared for the two cohorts which included all-cause in-hospital mortality, heart failure, re-infarction, cardiogenic shock, bleeding, transfusion, cerebrovascular accident, and dialysis. Results: This analysis was performed on a total of 2316 patients with 1158 patients each in the TRA and TFA group. We observed significantly lower rates of mortality, 0.8% (9) vs. 3.5% (41); p

Visual Abstract, Highlights • Our study supports the feasibility of using rapid CYP2C19 genotyping among both patients with stable and acute coronary syndrome undergoing diagnostic coronary angiography, with intent to undergo ad hoc PCI, in real-world clinical practice. • Rapid bedside genetic testing assay allows for very rapid turnaround times of results, with patients approached the same day of their procedure and availability of CYP2C19 genotypes within 1 h of sampling and before patients undergoing PCI. • Among carriers of CYP2C19 loss-of-function alleles undergoing PCI there were no differences in levels of platelet inhibition between prasugrel and ticagrelor (loading and maintenance dosing)., Summary The feasibility of rapid genetic testing in patients undergoing percutaneous coronary intervention (PCI) and the comparison of the pharmacodynamic effects of prasugrel versus ticagrelor among carriers of cytochrome P450 2C19 loss-of-function alleles treated with PCI has been poorly explored. Rapid genetic testing using the Spartan assay was shown to be feasible and provides results in a timely fashion in a real-world setting of patients undergoing coronary angiography (n = 781). Among patients (n = 223, 28.5%), carriers of at least 1 loss-of-function allele treated with PCI (n = 65), prasugrel, and ticagrelor achieve similar levels of platelet inhibition. (A Pharmacodynamic Study Comparing Prasugrel Versus Ticagrelor in Patients Undergoing PCI With CYP2C19 Loss-of-function [NCT02065479])

Background: Sex-based differences have been found in outcomes following ST-segment myocardial infarction (STEMI). Studies assessing sex-based differences in STEMI among Indian patients have reported conflicting results. Methods: A prospective multicenter registry of consecutive patients with STEMI who presented to percutaneous coronary intervention (PCI)–capable hospitals in the Indian state of Kerala between June 2013 and March 2017 was used to assess 1-year outcomes. The primary endpoint was a composite of major adverse cardiac events (MACE), including death, stroke, nonfatal myocardial infarction, and rehospitalization for heart failure. Outcomes of 2 sex-based propensity score–matched groups were compared. Results: We included 3194 patients (19.4% women). Women presenting with STEMI were older, had more traditional cardiovascular risk factors, and were more likely to be classified as living in poverty. After propensity-score matching, women experienced greater incidence of MACE (20.9% vs 14.3%, P < 0.01), primarily driven by increased 1-year mortality (14.3% vs 8.6%, P < 0.01). Women were more likely to experience prehospital delays, compared with men. Although reperfusion rates were similar between the groups, men were more likely than women to undergo reperfusion within the first 12 hours of chest pain onset. Among patients undergoing primary PCI, women were more likely to have delayed PCI than were men (80.2% vs 72.9%, P = 0.03). Procedural characteristics were similar between groups. Conclusions: Women in this cohort experienced higher incidence of MACE at 1 year, compared to men, primarily owing to increased mortality. Timeliness of reperfusion appears to be the primary factor impacting differences in outcomes between the 2 groups and may represent an attractive target for quality-improvement initiatives. Résumé: Contexte: Des différences entre les sexes ont été constatées dans les résultats obtenus à la suite d’un infarctus du myocarde avec élévation du segment ST (STEMI). Des études évaluant les différences entre les sexes parmi des patients indiens ayant subi un STEMI ont produit des résultats contradictoires. Méthodologie: Un registre multicentrique et prospectif de patients consécutifs qui ont subi un STEMI et se sont présentés dans des hôpitaux où pouvait être pratiquée une intervention coronarienne percutanée (ICP) dans l’État indien du Kerala entre juin 2013 et mars 2017 a été utilisé pour évaluer les résultats à 1 an. Le paramètre d’évaluation principal regroupait des événements cardiaques indésirables majeurs (ECIM) comprenant le décès, l’accident vasculaire cérébral, l’infarctus du myocarde non fatal et la réhospitalisation pour cause d’insuffisance cardiaque. Les résultats de deux groupes appariés selon les scores de propension en fonction du sexe ont été comparés. Résultats: Nous avons inclus 3 194 patients (19,4 % de femmes). Les femmes qui avaient subi un STEMI étaient plus âgées, présentaient des facteurs de risque cardiovasculaire plus classiques et étaient plus susceptibles d’appartenir à la catégorie des personnes vivant dans la pauvreté. Après l’appariement selon les scores de propension, l’incidence des ECIM était plus élevée chez les femmes (20,9 % vs 14,3 %, p < 0,01), surtout en raison d’une mortalité accrue à 1 an (14,3 % vs 8,6 %, p < 0,01). Les femmes étaient plus susceptibles de subir des retards avant l’hospitalisation que les hommes. Bien que les taux de reperfusion étaient semblables dans les groupes étudiés, les hommes étaient plus susceptibles que les femmes de subir une reperfusion dans les 12 premières heures suivant l’apparition de la douleur thoracique. Parmi les patients ayant subi une ICP primaire, les femmes étaient plus susceptibles d’être touchées par un retard d’intervention que les hommes (80,2 % vs 72,9 %, p = 0,03). Les caractéristiques de l’intervention étaient similaires dans les groupes étudiés. Conclusions: L’incidence des ECIM à 1 an au sein de cette cohorte était plus élevée chez les femmes que chez les hommes, surtout en raison d’une mortalité accrue. La rapidité de la reperfusion semble être le principal facteur ayant des répercussions sur les différences de résultats entre les deux groupes et pourrait représenter une cible intéressante dans le cadre d’initiatives d’amélioration de la qualité.

Arterial access site complications are the important predictor of successful percutaneous coronary interventions (PCI). We prospectively studied 722 consecutive PCI patients for access site complications. A total of 303 trans-femoral access (TFA) patients who had suture based vascular closure devices (VCD) were compared with 419 transradial access (TRA) patients. Incidence of hematoma was more in TFA (2.3% vs 0.23%, p 0.01). Median ambulation time (4 h vs 1 h, p, Graphical abstract Image 1

Corresponding Author

Percutaneous coronary intervention (PCI) in patients with chronic kidney disease is associated with a high-risk of contrast-induced nephropathy. We describe a case of ultra-low contrast PCI guided using optical coherence tomography using normal saline for clearance complicated by distal wire perforation treated with embolization. (Level of Difficulty: Intermediate.), Graphical abstract

Despite the seminal trials on radial versus femoral access for percutaneous coronary intervention (PCI) in ST elevation myocardial infarction (STEMI) showing reduced bleeding, major adverse cardiovascular events and mortality; these outcomes were attributed by some to low usage of bivalirudin and an unnecessarily higher dose of Heparin, combined with high usage of GP IIb/IIIa inhibitors, as well as to the use of larger bore catheters in the femoral groups. To prove the point, a study comparing TF with TR access was mooted( Lee et al., 2013) 3; with bivalirudin instead of heparin, preferably with use of potent oral anti-platelets instead of GP IIb/IIIa inhibitors; and femoral vascular closure devices, ostensibly, to assess outcomes based on ‘access-site alone’. With this intent, the SAFARI STEMI study was designed. In this article we discuss some of the major short-comings of this trial which raise significant questions on its results.

Summary Fibromuscular dysplasia is often present in patients with Spontaneous Coronary artery dissection (SCAD). Amphetamine associated SCAD is rare and there are currently only 2 cases reported. We present the first OCT images of Amphetamine associated SCAD in the literature and highlight the importance of OCT in making the diagnosis and guiding the PCI.

The use of mechanical circulatory support to maintain appropriate hemodynamics in high risk percutaneous coronary intervention cases is a new frontier. Treatment of cases that were once considered prohibitive may now be possible. Due to a paucity of data, guidelines offer no guidance about the use of mechanical circulatory support in such cases. This case, the first documented case of extracorporeal membrane oxygenation support for percutaneous coronary intervention (PCI) of a vein graft supplying the entire coronary circulation, adds to the medical literature demonstrating a likely benefit in the use of mechanical support during high risk PCI in patients without shock. (Level of Difficulty: Intermediate.), Graphical abstract, The use of mechanical circulatory support to maintain appropriate hemodynamics in high risk percutaneous coronary intervention cases is a new frontier…