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Aims: Coronary artery ectasia (CAE) has been linked to the occurrence of adverse events in patients with ischemia/angina and no obstructive coronary arteries (INOCA/ANOCA), while the relationship between CAE and myocardial infarction with nonobstructive coronary arteries (MINOCA) has been poorly investigated. In our study we aimed at assessing differences in clinical, angiographic and prognostic features among patients with CAE and MINOCA vs. INOCA/ANOCA presentation., Methods: Patients with angiographic evidence of CAE were enrolled at the University Hospital of Parma and divided into MINOCA vs. INOCA/ANOCA presentation. Clinical and quantitative angiographic information was recorded and the incidence of major adverse cardiovascular events (MACE) was assessed at follow-up., Results: We enrolled a total of 97 patients: 49 (50.5%) with MINOCA and 48 (49.5%) with INOCA/ANOCA presentation. The presentation with MINOCA was associated with a higher frequency of inflammatory diseases ( P  = 0.041), multivessel CAE ( P  = 0.030) and thrombolysis in myocardial infarction (TIMI) flow < 3 ( P  = 0.013). At a median follow-up of 38 months, patients with MINOCA had a significantly higher incidence of MACE compared with those with INOCA/ANOCA [8 (16.3%) vs. 2 (4.2%), P  = 0.045], mainly driven by a higher rate of nonfatal MI [5 (10.2%) vs. 0 (0.0%), P  = 0.023]. At multivariate Cox regression analysis, the presentation with MINOCA ( P  = 0.039) and the presence of TIMI flow <3 ( P  = 0.037) were independent predictors of MACE at follow-up., Conclusion: Among a cohort of patients with CAE and nonobstructive coronary artery disease, the presentation with MINOCA predicted a worse outcome., (Copyright © 2024 Italian Federation of Cardiology - I.F.C. All rights reserved.)

Background: The aim was to assess whether periprocedural myocardial injury (PPMI) predicts outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). PPMI is a strong predictor of outcomes following coronary intervention, but its impact in the context of TAVR remains unclear. We performed a systematic review and meta-analysis to ascertain the association between PPMI and short- or long-term outcomes., Methods and Results: Electronic searches identified studies reporting PPMI following TAVR. Primary end point was 30-day all-cause mortality, with secondary end points, including 1-year all-cause mortality, neurological events, post-TAVR pacemaker implantation, and aortic regurgitation. Analyses were performed using random effects modeling and reported as summary odds ratio (OR) with 95% CI. Nine studies comprising 3442 patients (mean age 81.0±6.6 years, 51.2% female) were included. PPMI occurred in 25.5% of patients following TAVR. The pooled all-cause mortality at 30-days and 1-year was 5.2% and 18.6%, respectively. The occurrence of PPMI following TAVR was associated with significantly increased risk of both 30-day (OR, 4.23; CI, 1.95-9.19; P<0.001) and 1-year all-cause mortality (OR, 1.77; CI, 1.05-2.99; P<0.001). Similarly, PPMI was associated with post-TAVR neurological events (OR, 2.72; CI, 1.69-4.37; P<0.001) and post-TAVR permanent pacing (OR, 1.43; CI, 1.02-2.00; P=0.04) but not with a statistically significant increase in aortic regurgitation post-TAVR (OR, 1.39; CI, 0.93-2.08; P=0.11)., Conclusions: PPMI is common following TAVR and is strongly associated with 30-day and 1-year mortality. Detection of PPMI has potential to identify TAVR patients at highest risk of subsequent adverse events.

Background: The role of allergic inflammation in acute coronary syndromes (ACS) has not been clearly defined to date. Aim of this study was to assess eosinophil and basophil activation in ACS and the prognostic role of eosinophil cationic protein in ST-segment-elevation myocardial infarction., Methods and Results: In a cross-sectional study, we prospectively enrolled 51 patients undergoing percutaneous coronary intervention (60.8% patients with ACS and 39.2% with stable angina). Flow cytometry analysis assessed CD66b, CD69, and CD203c median fluorescence intensity expression. In a follow-up study, 181 patients presenting with ST-segment-elevation myocardial infarction, undergoing primary percutaneous coronary intervention, were prospectively enrolled with a follow-up of 24 months. Eosinophil activation (CD66b) was similar in patients with ACS and stable angina (6.61 [4.91-7.72] versus 6.62 [5.27-8.73], P=0.63), whereas eosinophil degranulation (CD69) and basophil activation (CD203c) were higher in ACS patients compared with stable angina patients (1.38 [1.16-1.52] versus 1.17 [1-1.31], P=0.01); 0.97 [0.89-1.11] versus 0.92 [0.87-0.95], P=0.03, respectively). Eosinophil cationic protein serum levels were significantly higher in ST-segment-elevation myocardial infarction patients with major adverse cardiac events as compared with those without (21.1 [10.37-25.65] versus 7.83 [3.37-12.8] μg/L, P=0.01) and in patients with thrombus score >3 compared with those with thrombus score ≤3 (15.0 [9.8-24.7] versus 5.2 [3.5-22.9] μg/L, P=0.006). Eosinophil cationic protein serum levels predicted major adverse cardiac events during follow-up (odds ratio =1.041, 95% confidence interval 1.012-1.071, P=0.005). C-reactive protein serum levels showed a borderline statistical significance (odds ratio =0.904, 95% confidence interval 0.806-1.014, P=0.085)., Conclusions: These findings are the first demonstration of in vivo eosinophil degranulation and basophil activation during ACS and of the prognostic role of eosinophil cationic protein in ST-segment-elevation myocardial infarction., (© 2015 American Heart Association, Inc.)

We describe a case of very late stent thrombosis with documentation of highly calcific restenosis at optical coherence tomography without clear signs of stent malapposition, neoatherosclerosis disruption, or vascular toxicity to stent polymer. To the best of our knowledge, this is one of the first reports dealing with highly calcific restenosis as a potential background to very late stent thrombosis.

Multiple plaque instability has been reported in about one-third of patients with ST elevation acute myocardial infarction (STEMI) and could be responsible for early recurrent instability after STEMI. Optical coherence tomography (OCT) is a high-resolution imaging technique that may help in detection and characterization of unstable coronary plaques. We present a case of multiple coronary instability in a patient with anterior STEMI where OCT has tailored an optimal diagnosis and treatment.

Very late stent thrombosis occurring after drug-eluting stent implantation is a rare complication. However, it is often associated with poor outcome. Manual thrombectomy has been shown to lower the rate of distal embolization in the case of ST-elevation myocardial infarction of native coronary arteries. However, the presence of abundant thrombus material may lead to manual thrombus aspiration failure. Here, we describe the case of a patient with acute myocardial infarction due to stent thrombosis of a sirolimus-eluting stent occurring 50 months after stent deployment showing abundant thrombus material, which led to manual thrombus aspiration failure and was then successfully treated by excimer laser coronary angioplasty. In these cases, excimer laser coronary angioplasty may be useful due to its ability to dissolve thrombus.

Background: Chrono Carbostent (CID, Saluggia, Italy) is characterized by a peculiar coating with Carbofilm which could reduce the risk of thrombosis as compared to other bare metal stents (BMS). This feature should be particularly useful in the setting of primary or rescue percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI)., Methods: We tested the efficacy and safety of this stent in patients with STEMI undergoing primary or rescue PCI. Inclusion criteria included the diagnosis of STEMI, a coronary anatomy suitable for stenting and no contraindications to dual antiplatelet therapy for at least 1 month. The primary endpoint was the composite of the following major adverse cardiac events (MACEs) at 12 months: death, recurrence of myocardial infarction and target vessel revascularization., Results: One hundred and seven STEMI patients treated with Chrono Carbostent implantation were enrolled. Eighty-three (77%) patients underwent primary and 24 (23%) rescue PCI. A total of 148 stents were successfully implanted. Cardiogenic shock was present in 12 (11%) patients and in-hospital mortality was 6.5%. Cumulatively, the rate of MACEs at 12 months was 17.7% (deaths 7.4%, target lesion revascularization 9.3%)., Conclusions: In unselected patients with STEMI treated by urgent PCI, the Chrono Carbostent showed a low rate of events in those patients surviving the acute phase of myocardial infarction. Unfortunately, and especially for patients in cardiogenic shock, survival continued to be relatively independent of interventional treatment, even when successfully completed, thus strictly linking prognosis of STEMI to severity of clinical presentation.

Background: Frequency-domain optical coherence tomography (FD-OCT) is easily able to define both pre- and post-stenting features of the atherosclerotic plaque that can potentially be related to periprocedural complications. We sought to examine which FD-OCT-defined characteristics, assessed both before and after stent deployment, predicted periprocedural (type IVa) myocardial infarction (MI)., Methods and Results: FD-OCT was performed before and after coronary stenting in 50 patients undergoing percutaneous coronary intervention (PCI) for either non-ST segment elevation MI (NSTEMI) or stable angina. All patients underwent single-vessel stenting, and only drug-eluting stents were implanted. Troponin T was analyzed on admission, before PCI, and at 12 and 24 hours after PCI, and type IVa MI was defined in stable angina as a rise of at least 3× upper reference limit and in NSTEMI as a pre-PCI troponin T fall, followed by post-PCI troponin T rise >20%. Type IVa MI was diagnosed in 21 patients, while the remaining 29 represented the control group. FD-OCT analysis showed that thin-cap fibroatheroma (76.2% versus 41.4%; P=0.017) prior to PCI, intrastent thrombus (61.9% versus 20.7%; P=0.04), and intrastent dissection (61.9% versus 31%; P=0.03) after PCI were significantly more frequent in type IVa MI than in the control group. Multivariate logistic regression analysis confirmed thin-cap fibroatheroma (OR 29.7, 95% CI 1.4 to 32.1), intrastent thrombus (OR 5.5, CI 1.2 to 24.9) and intrastent dissection (OR 5.3, CI 1.2 to 24.3) as independent predictors of type IVa MI., Conclusions: In conclusion, presence of thin-cap fibroatheroma at pre-PCI FD-OCT and of intrastent thrombus and intrastent dissection at post-PCI FD-OCT predict type IVa MI in a contemporary sample of patients treated with second-generation drug-eluting stents. Interestingly, 2 of the 3 predictors of type IVa MI were not apparent at pre-PCI FD-OCT.

Background: No reflow after primary percutaneous coronary intervention is a dynamic process and its reversibility may affect left ventricular (LV) remodeling. We aimed at assessing in-hospital evolution of angiographic no reflow, predictors of its reversibility, and its impact on LV function at follow-up (FU)., Methods: Fifty-three consecutive patients (age, 60±10 years; male sex, 79%) presenting with ST-elevation myocardial infarction and undergoing primary percutaneous coronary intervention within 12 h of symptom onset were enrolled. No reflow was defined as a final thrombolysis in myocardial infarction (TIMI) flow of 2 or final TIMI flow of 3 with myocardial blush grade (MBG) of less than 2. The evolution of angiographic no reflow was assessed by repeat in-hospital coronary angiography. Patients with no reflow found to have an improvement of TIMI and/or MBG leading to a final TIMI 3 and MBG of greater than or equal to 2 were classified as reversible no reflow; the remaining patients were classified as sustained no reflow. Variables predicting the patterns of no reflow, recorded on admission, were assessed among clinical, angiographic and laboratory data. FU echocardiographic data (at 6 months) were compared with those obtained in-hospital according to no reflow evolution., Results: Thirty-six patients (68%) exhibited myocardial reperfusion; 17 patients (32%) showed no reflow. Among these, six patients (age, 58±10 years; male sex, 83%) showed sustained no reflow, whereas 11 patients (age, 55±8 years; male sex, 82%) showed reversible no reflow. Patients with sustained no reflow had longer time to percutaneous coronary intervention (261±80 min) compared with those with myocardial reperfusion (216±94 min) or reversible no reflow (237±76 min; P=0.008 and 0.05, respectively). Moreover, patients with sustained no reflow had a higher peak troponin-T levels (14.5 ng/ml; range, 7.5-20.2 ng/ml) compared with those presenting with myocardial reperfusion (3.9 ng/ml; range, 3.3-9.1 ng/ml) and reversible no reflow (7.7 ng/ml; range, 3.6-29.9 ng/ml; P=0.03 and 0.07, respectively). At multivariate ordinal logistic regression, time pre-PCI retained its statistical significant association with angiographic no reflow evolution (odds ratio=2.54; 95% confidence interval: 1.45-6.53; P=0.04), with troponin T levels showing a borderline statistical significance (odds ratio=3.12; 95% confidence interval: 1.07-6.23; P=0.09). Finally, in patients with sustained no reflow only both end-diastolic and end-systolic volumes significantly increased at FU (P<0.001 and 0.001, respectively)., Conclusion: Sustained no reflow is associated with a longer ischemic time and predicts worse LV remodeling. No reflow, however, shows an in-hospital reversibility calling for therapeutic interventions when its prevention fails.

Background: We speculated that elevated admission cardiac troponin T (cTnT) could predict worse microvascular function in patients with ST-elevation myocardial infarction who are managed with emergency percutaneous coronary intervention., Methods: In 27 patients with ST-elevation myocardial infarction, we obtained admission cTnT, angiography at the time of intervention, and cardiovascular magnetic resonance after 3 days., Results: Elevated admission cTnT was associated with a higher corrected Thrombolysis In Myocardial Infarction frame count (P = 0.04) and with a trend toward worse myocardial blush grade at the end of the procedure (P = 0.069), indicating a higher degree of microvascular obstruction. This was confirmed by its correlation with the size of perfusion defect seen at first-pass cardiovascular magnetic resonance (rho = 0.42, P = 0.028). In contrast, admission cTnT did not correlate with the amount of muscle necrosis as seen by delayed-enhancement cardiovascular magnetic resonance (rho = 0.12, P = 0.55)., Conclusion: Elevated admission cTnT predicts worse microvascular function in ST-elevation myocardial infarction patients managed with emergency percutaneous coronary intervention. Measuring admission cTnT might provide the interventionalist with useful information for selecting additional therapies that benefit coronary microcirculation.

Background: Thrombus aspiration improves microvascular obstruction in patients with acute myocardial infarction treated by percutaneous coronary intervention. However, drugs such as nitroprusside and adenosine have not yet been tested as adjuncts to thrombus aspiration. Therefore, we designed a placebo-controlled, randomized, open-label, blind-examination, multicenter trial assessing the effects of intracoronary nitroprusside or adenosine on microvascular obstruction in patients undergoing primary or rescue percutaneous coronary intervention and thrombus aspiration., Methods and Results: Six hospitals in Italy participate in the REOPEN-AMI study. Two hundred and forty consecutive patients with acute myocardial infarction undergoing primary or rescue percutaneous coronary intervention and thrombus aspiration are randomly allocated 1: 1: 1 to receive either intracoronary nitroprusside, adenosine or placebo. The primary end-point is the incidence of ST resolution greater than 70% on surface ECG at 90 min after the procedure. Secondary end-points are: incidence of angiographic no-reflow (thrombolysis in myocardial infarction flow < or =2 or 3 with a myocardial blush grade <2); changes of left ventricular volumes at follow-up (at bidimensional echocardiography); rate of major adverse cardiac events (cardiac death, myocardial infarction, target lesion revascularization and heart failure requiring hospitalization)., Conclusions: REOPEN-AMI will provide important data on the efficacy and safety of intracoronary nitroprusside and adenosine as an adjunctive treatment to percutaneous coronary intervention after thrombus aspiration for patients with acute myocardial infarction.

Objective: To investigate the determinants and prognostic value of heart rate variability (HRV) in acute myocardial infarction (AMI) patients treated by percutaneous coronary intervention (PCI)., Methods: We studied 64 patients with AMI (58.4 +/- 10 years, 56 men), treated by PCI within 12 h of symptom onset. Patients underwent 24-h electrocardiographic Holter recording before discharge. HRV was measured in the time- and frequency-domain. Cardiac events were assessed at 6 months., Results: At univariate analysis, Thrombolysis in Myocardial Infarction (TIMI) flow grade < 3 was significantly predictive of reduced frequency-domain variables. On multivariate analysis, diabetes and pre-PCI time > 6 h were the strongest predictors of depressed HRV, with peak creatine kinase myocardial-type and lower left ventricular ejection fraction being also variably correlated with impaired HRV. At 6-month follow-up, seven patients (10.1%) had cardiac events (one AMI, six revascularization procedures). A low standard deviation of RR intervals was a significant predictor of events (P = 0.009), although only age was associated with the endpoint (P = 0.05) on multivariate analysis., Conclusions: Our study shows that, in AMI patients treated by primary PCI, a delay in coronary revascularization and AMI extension are key factors for determining depressed HRV.

Inflammation is an important player both for the initiation and progression of coronary artery disease and for coronary plaque instability. Moreover, inflammation contributes to stent thrombosis and in-stent restenosis after percutaneous coronary intervention. In the past several decades, most studies evaluated the involvement of cellular effectors of classic inflammatory responses, such as monocytes/macrophages, neutrophils, and T cells. Yet, besides classic inflammation, mounting evidence derived from both experimental and clinical studies suggests an important, often unrecognized, role for effector cells of allergic inflammation in both the pathogenesis of coronary artery disease and adverse events following stent implantation. In this review, we discuss the role of effector cells of allergic inflammation in the setting of coronary artery disease progression and instability, and in the occurrence of adverse events following stent implantation, as well. Moreover, we discuss possible therapeutic approaches targeting different specific pathways of allergic inflammatory activation. [ABSTRACT FROM AUTHOR]

Background: Bioresorbable coronary stents have been introduced into clinical practice to improve the outcomes of patients treated with percutaneous coronary intervention. The everolimus-eluting bioresorbable vascular scaffold (BVS) is the most studied of these stent platforms; however, recent trials comparing BVS with everolimus-eluting metallic stents (EES) raised concerns about BVS safety. We aimed to assess the efficacy and safety of BVS versus EES in patients undergoing percutaneous coronary intervention.Methods: We searched Medline, Embase, the Cochrane Central Register of Controlled Trials, scientific sessions abstracts, and relevant Web sites for randomized trials with a follow-up of ≥2 years investigating percutaneous coronary interventions with BVS versus EES. The primary outcomes of our analysis were definite/probable stent thrombosis (ST) and target lesion failure (TLF; device-oriented composite end point of cardiac death, target vessel myocardial infarction, or ischemia-driven target lesion revascularization [TLR]). Secondary outcomes were target vessel myocardial infarction, TLR, and cardiac death. We calculated the risk estimates for main outcomes according to a fixed-effect model.Results: We included 7 trials comprising data for 5583 patients randomized to receive either a BVS (n=3261) or an EES (n=2322). Median follow-up was 24 months (range, 24-36 months). Patients treated with BVS had a higher risk of definite/probable ST compared with patients treated with EES (odds ratio, 3.33; 95% confidence interval, 1.97-5.62; P<0.00001). In particular, patients with BVS had a higher risk of subacute, late, and very late ST, whereas the risk of acute ST was similar. Patients treated with BVS compared with EES had a higher risk at 2 years of TLF (odds ratio, 1.47; 95% confidence interval, 1.14-1.90; P=0.003), driven mainly by an increased risk of target vessel myocardial infarction (odds ratio, 1.73; 95% confidence interval, 1.31-2.28; P=0.0001; I2=0%) and of TLR (odds ratio, 1.27; 95% confidence interval, 1.00-1.62; P=0.05). Of importance, the risk of TLF and TLR for patients with BVS was higher between 1 and 2 years, whereas there was no difference in the first year. Risk of cardiac death was similar between the 2 groups.Conclusions: Our meta-analysis of randomized trials with a follow-up of ≥2 years demonstrated a higher risk of ST and of TLF in patients treated with BVS compared with EES. Of note, BVS had a higher risk of subacute, late, and very late ST, whereas the risk of TLF and TLR was higher between 1 and 2 years. [ABSTRACT FROM AUTHOR]