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Background/Introduction Previously validated risk scores for identifying low-risk patients after ST-segment elevation myocardial infarction (STEMI) have led to acceptance of the safety and feasibility of discharge after 48–72 hours of hospitalization, reducing hospital length of stay and costs. With ongoing improvements in outcomes, it may be possible to select patients who are safe to discharge very early (24–48 hours) but this has never been evaluated. Purpose We sought to develop and validate a novel risk score for identifying low-risk patients suitable for very early discharge (≤48 hours of hospitalization) post-STEMI. Methods We derived a novel risk score using data from patients enrolled in the Trial of Routine Aspiration Thrombectomy with PCI versus PCI alone in Patients with STEMI (TOTAL). The TOTAL database was randomly divided into a derivation cohort with 2/3 of the composite events and non-events and remaining 1/3 as the internal validation cohort. Using the derivation cohort, we identified risk factors for cardiovascular death (CV) or non-fatal cardiac arrest by performing a univariate and multivariable stepwise regression analysis of baseline clinical and angiographic characteristics. Each co-variate was assigned an integer score based on regression coefficients and the novel TOTAL risk score was developed by adding points from each risk factor profile. We externally validated the TOTAL score using data from the Radial versus Femoral Access for Coronary Intervention (RIVAL) trial. Results The TOTAL derivation cohort included 6331 participants with 287 events (CV death/cardiac arrest). Twelve independent risk-factors associated with risk of CV death and non-fatal cardiac arrest at 1 year were selected and weighted for the TOTAL risk score (Table 1). In the TOTAL validation cohort (n=3166), patients with a TOTAL score of 0–4 points (n=779 (24.6%)) were categorized as very low risk with only a 0.1% risk of CV death/cardiac arrest observed within 24 hours of hospitalization, and no further events observed between 24 hours and 30 days post-STEMI. In the RIVAL validation dataset (n=1451), patients with a TOTAL score of 0–4 points (n=737 (50.7%)) had a 0.3% risk of CV death/cardiac arrest within 24 hours, with no further events observed between 24 hours and 72 hours of hospitalization. Conclusion The TOTAL risk score identified a very low risk subset of patients for whom early discharge, 24–48 hours post-STEMI, is likely safe. These findings have the potential to change practice and support early discharge after STEMI. Funding Acknowledgement Type of funding sources: None.

Background: The COMPLETE trial (Complete Versus Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI) demonstrated that staged nonculprit lesion percutaneous coronary intervention (PCI) reduced major cardiovascular events in patients with ST-segment–elevation myocardial infarction and multivessel coronary artery disease. It is unclear whether consistent benefit is observed in patients undergoing a pharmacoinvasive strategy compared with primary PCI. Methods: Following culprit lesion PCI, 4041 patients with ST-segment–elevation myocardial infarction and multivessel coronary artery disease were randomized to either routine nonculprit lesion PCI or culprit lesion only PCI. In a prespecified analysis, we determined the treatment effect in 303 patients undergoing a pharmacoinvasive strategy versus 3738 patients undergoing primary PCI on the first coprimary outcome of cardiovascular death or new myocardial infarction and the second coprimary outcome of cardiovascular death, new myocardial infarction, or ischemia-driven revascularization. Results: The first coprimary was reduced with complete revascularization both in the patients undergoing a pharmacoinvasive strategy (2.1%/y versus 4.7%/y, hazard ratio, 0.45 [95% CI, 0.21–0.97]) and in patients undergoing primary PCI (2.7%/y versus 3.6%/y, hazard ratio, 0.77 [95% CI, 0.62–0.95]; interaction P =0.18). The second coprimary outcome was reduced with complete revascularization in patients undergoing a pharmacoinvasive strategy (2.3%/y versus 8.5%/y, hazard ratio, 0.28 [95% CI, 0.14–0.56]), and in patients undergoing primary PCI (3.2%/y versus 6.0%/y, hazard ratio, 0.53 [95% CI, 0.44–0.64], interaction P =0.07). Conclusions: Among patients with ST-segment–elevation myocardial infarction and multivessel disease, complete revascularization with multivessel PCI consistently reduces major cardiovascular events in patients undergoing an initial pharmacoinvasive strategy as well as in those undergoing primary PCI. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01740479.

Background: Complete revascularization with routine percutaneous coronary intervention of nonculprit lesions after primary percutaneous coronary intervention improves outcomes in ST-segment–elevation myocardial infarction. Whether this benefit is associated with nonculprit lesion vulnerability is unknown. Methods: In a prospective substudy of the COMPLETEs trial (Complete vs Culprit-Only Revascularization to Treat Multi-Vessel Disease After Early PCI for STEMI), we performed optical coherence tomography of at least 2 coronary arteries before nonculprit lesion percutaneous coronary intervention in 93 patients with ST-segment–elevation myocardial infarction and multivessel disease; and the ST-segment–elevation myocardial infarction culprit vessel if there was unstented segment amenable to imaging. Nonculprit lesions were categorized as obstructive (≥70% stenosis by visual angiographic assessment) or nonobstructive, and as thin-cap fibroatheroma (TCFA) or non-TCFA by optical coherence tomography criteria. TCFA was defined as a lesion with mean fibrous cap thickness 90°. Results: On a patient level, at least one obstructive TCFA was observed in 44/93 (47%) of patients. On a lesion level, there were 58 TCFAs among 150 obstructive nonculprit lesions compared with 74 TCFAs among 275 nonculprit lesions (adjusted TCFA prevalence: 35.4% versus 23.2%, P =0.022). Compared with obstructive non-TCFAs, obstructive TCFAs had similar lesion length (23.1 versus 20.8 mm, P =0.16) but higher lipid quadrants (55.2 versus 19.2, P P P P P =0.11), but more lipid quadrants (36.4 versus 13.5, P P Conclusions: Among patients who underwent optical coherence tomography imaging in the COMPLETE trial, nearly 50% had at least one obstructive nonculprit lesion containing complex vulnerable plaque. Obstructive lesions more commonly harbored vulnerable plaque morphology than nonobstructive lesions. This may help explain the benefit of routine percutaneous coronary intervention of obstructive nonculprit lesions in patients with ST-segment–elevation myocardial infarction and multivessel disease. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01740479s.

BACKGROUND Spontaneous coronary artery dissection (SCAD) is an important cause of acute coronary syndrome, yet its pathophysiology is only partially understood. We sought to assess the association between endothelial dysfunction (ED) and SCAD. METHODS We prospectively assessed patients presenting with acute coronary syndrome who were diagnosed with SCAD. The control arm had established coronary artery atherosclerotic disease (AD) according to previous coronary angiography. ED was assessed using the EndoPAT 2000 while patients returned to their steady state condition. A total of 16 patients with SCAD and 66 patients with AD were included. RESULTS Microvascular reactivity as assessed with the EndoPAT was significantly worse in the AD group compared to the SCAD group. The median RHI in the AD group was 1.76 (IQR 1.52, 2.2) vs. a median RHI of 2.08 (IQR 1.73, 2.79) in the SCAD group (p

Background Routine thrombus aspiration in patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) does not improve clinical outcomes. However, there is remaining uncertainty about the potential benefit in those patients with high thrombus burden, where there is a biological rationale for greater benefit. Objectives The purpose of this study was to evaluate the benefit of thrombus aspiration among STEMI patients with high thrombus burden. Methods TOTAL (ThrOmbecTomy with PCI vs. PCI ALone in patients with STEMI) was a randomized trial of routine manual thrombectomy versus PCI alone in patients with STEMI (n = 10,732). High thrombus burden (Thrombolysis In Myocardial Infarction thrombus grade ≥3) was a pre-specified subgroup. Results The primary outcome of cardiovascular (CV) death, MI, cardiogenic shock, or heart failure was not different at 1 year with thrombus aspiration in patients with high thrombus burden (8.1% vs. 8.3% thrombus aspiration; hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.84 to 1.13) or low thrombus burden (6.0% vs. 5.0% thrombus aspiration; HR: 1.22; 95% CI: 0.73 to 2.05; interaction p = 0.41). However, among patients with high thrombus burden, stroke at 30 days was more frequent with thrombus aspiration (31 [0.7%] thrombus aspiration vs. 16 [0.4%] PCI alone, HR: 1.90; 95% CI: 1.04 to 3.48). In the high thrombus burden group, thrombus aspiration did not significantly improve CV mortality at 30 days (HR: 0.78; 95% CI: 0.61 to 1.01; p = 0.06) and at 1 year (HR: 0.88; 95% CI: 0.72 to 1.09; p = 0.25). Irrespective of treatment assignment, high thrombus burden was an independent predictor of death (HR: 1.78; 95% CI: 1.05 to 3.01). Conclusions In patients with high thrombus burden, routine thrombus aspiration did not improve outcomes at 1 year and was associated with an increased rate of stroke. High thrombus burden is still an important predictor of outcome in STEMI. (A Trial of routine aspiration ThrOmbecTomy with PCI vs. PCI ALone in patients with STEMI [TOTAL]; NCT01149044)

BACKGROUND AND AIMS Lecithin:cholesterol acyltransferase (LCAT), a key enzyme in high-density lipoprotein (HDL) metabolism and reverse cholesterol transport (RCT), has been associated with atheroprotection. However, its relation to plaque characteristics has not been confirmed to date. We aimed to determine the relationship between plasma LCAT mass concentration and plaque burden in a multi-center imaging study. METHODS Two hundred sixty-seven patients with angiographically proven coronary artery disease (CAD) underwent intravascular ultrasonography (IVUS) imaging. Ninety-six patients without CAD served as controls for biochemistry assessments. RESULTS Plasma LCAT mass concentration was higher in CAD patients as compared to controls (8.94 ± 2.51 μg/mL vs. 7.89 ± 2.99 μg/mL, p = 0.003), while cholesterol esterification rate (CER) was downregulated (253.6 ± 83.9 μM/2 h vs. 315.3 ± 115.0 μM/2 h, p

Background Hybrid coronary revascularization ( HCR ) involves the integration of coronary artery bypass grafting ( CABG ) and percutaneous coronary intervention to treat multivessel coronary artery disease. Our objective was to perform a comparative analysis with long‐term follow‐up between HCR and conventional off‐pump CABG . Methods and Results We compared all double off‐pump CABG (n=216) and HCR (n=147; robotic‐assisted minimally invasive direct CABG of the left internal thoracic artery to the left anterior descending artery and percutaneous coronary intervention to one of the non–left anterior descending vessels) performed at a single institution between March 2004 and November 2015. To adjust for the selection bias of receiving either off‐pump CABG or HCR , we performed a propensity score analysis using inverse‐probability weighting. Both groups had similar results in terms of re‐exploration for bleeding, perioperative myocardial infarction, stroke, blood transfusion, in‐hospital mortality, and intensive care unit length of stay. HCR was associated with a higher in‐hospital reintervention rate ( CABG 0% versus HCR 3.4%; P =0.03), lower prolonged mechanical ventilation (>24 hours) rate (4% versus 0.7%; P =0.02), and shorter hospital length of stay (8.1±5.8 versus 4.5±2.1 days; P CABG and 96 (53–115) months for HCR , the HCR group of patients had a trend toward improved survival (85% versus 96%; P =0.054). Freedom from any form of revascularization was similar between the 2 groups (92% versus 91%; P =0.80). Freedom from angina was better in the HCR group (73% versus 90%; P Conclusions HCR seems to provide, in selected patients, a shorter postoperative recovery, with similar excellent short‐ and long‐term outcomes when compared with standard off‐pump CABG .

It is estimated that over one billion people worldwide are affected by hypertension (HTN) and that over nine million annual deaths can be attributed to complications of HTN such as myocardial infarction, stroke and renal disease. The prevalence of HTN is constantly rising and this trend is expected to continue unless appropriate measures are taken (1,2). Importantly, even very mild reductions in blood pressure were linked to a large effect on rates of cardiovascular events (3,4).

Spontaneous coronary artery dissection (SCAD) is a cause of about 4% of acute coronary syndrome. The pathophysiology of SCAD is not yet fully understood. Loeys-Dietz syndrome is a connective tissue disorder characterized by aortic aneurysms, arterial tortuosity, and aortic dissections. It is caused by mutations in the genes affecting the transforming growth factor β pathway. We describe a family with a SMAD3 gene mutation and Loeys-Dietz syndrome presenting with recurrent SCAD episodes.

We present two cases where fractional flow reserve (FFR) was utilised to guide management of coronary artery fistula (CAF), an approach advocated in recent case studies. CAF is a coronary anomaly that may present with a variety of syndromes though is frequently asymptomatic. When to exclude the fistula (surgically or percutaneously) is not always clear. A way to quantify if the fistula is physiologically meaningful would be advantageous. Our findings suggest FFR may only be assessing the concomitant epicardial coronary artery disease (CAD) rather than the degree of coronary steal and its routine use in this setting is not supported.

Summary Spontaneous coronary artery dissection (SCAD) is an under-recognised presentation of acute coronary syndrome. A high index of suspicion is essential. If diagnostic doubt is high, intracoronary imaging, performed carefully, can be useful, although it can result in worsening of the clinical condition. The current report exemplifies the complexity of diagnosis and management of SCAD in a patient with out-of-hospital cardiac arrest and non-diagnostic angiography.

The long-term pharmacodynamic effects of Ticagrelor versus Clopidogrel in patients undergoing early percutaneous coronary intervention (PCI) after fibrinolytic therapy is unknown. From May 2014 to August 2016, 212 patients undergoing PCI within 24 h of Tenecteplase (TNK), Aspirin, and Clopidogrel for ST-elevated myocardial infarction (STEMI) were randomized at four Canadian sites to receive additional Clopidogrel or Ticagrelor initiated prior to PCI. The platelet reactivity units (PRU) were measured with the VerifyNow Assay before study drug administration (baseline), at 4 and 24 h post PCI, and follow-up appointment. A mixed-model analysis with time as the repeated measure and drug as the between-subjects factor was calculated using 2 separate 1 × 4 ANOVAs, with students t-tests used to compare drugs within each time point. Complete clinical follow-up data (median 115.0 days; IQR 80.3–168.8) was available in 50 patients (23.6%) randomized to either Clopidogrel (n = 23) or Ticagrelor (n = 27). Analyses revealed significant decreases in PRU from baseline to 4 h (261.4 vs. 71.7; Mdiff = − 189.7; p

Advances in medical and interventional therapy over the last few decades have revolutionized the treatment of acute myocardial infarction. Despite the ability to restore epicardial coronary artery patency promptly through percutaneous coronary intervention, tissue level damage may continue. The reported 30-day mortality after all acute coronary syndromes is 2 to 3%, and around 5% following myocardial infarction. Post-infarct complications such as heart failure continue to be a major contributor to cardiovascular morbidity and mortality. Inadequate microvascular reperfusion leads to worse clinical outcomes and potentially strategies to reduce infarct size during periods of ischemia-reperfusion can improve outcomes. Many strategies have been tested, but no single strategy alone has shown a consistent result or benefit in large scale randomised clinical trials. Herein, we review the historical efforts, current strategies, and potential novel concepts that may improve myocardial protection and reduce infarct size.

Objective Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. Methods From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ±41.4 months. Results Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. Conclusions Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

The clinical value of ischemic conditioning during percutaneous coronary intervention (PCI) and mode of administration is controversial. Our aim was to assess the long-term effect of remote ischemic postconditioning among patients undergoing PCI. We randomized 360 patients undergoing PCI who presented with a negative troponin T at baseline into 3 groups: 2 groups received remote ischemic postconditioning (with ischemia applied to the arm in 1 group and to the thigh in the other group), and the third group acted as a control group. Remote ischemic postconditioning was applied during PCI immediately following stent deployment, by 3, 5-minute cycles of blood pressure cuff inflation to >200 mm Hg on the arm or thigh (20 mm Hg to the arm in the control), with 5-minute breaks between each cycle. There were no differences in baseline characteristics among the 3 groups. Periprocedural myocardial injury occurred in 33% (P = 0.64). After 1 year, there was no difference between groups in death (P = 0.91), myocardial infarction (P = 0.78), or repeat revascularization (P = 0.86). During 3 years of follow-up, there was no difference in death, myocardial infarction, and revascularization among the groups (P = 0.45). Remote ischemic postconditioning during PCI did not affect long-term cardiovascular outcome. A similar effect was obtained when remote ischemia was induced to the upper or lower limb. ClinicalTrials.gov Identifier: NCT00970827.

Radiotherapy can affect the electronic components of a cardiac implantable electronic device (CIED) resulting in malfunction and/or damage. We sought to assess the incidence, predictors, and clinical impact of CIED dysfunction (CIED-D) after radiotherapy for cancer treatment. Clinical characteristics, cancer, different types of CIEDs, and radiation dose were evaluated. The investigation identified 230 patients, mean age 78 ± 8 years and 70% were men. A total of 199 patients had pacemakers (59% dual chamber), 21 (9%) cardioverter-defibrillators, and 10 (4%) resynchronizators or defibrillators. The left pectoral (n = 192, 83%) was the most common CIED location. Sixteen patients (7%) experienced 18 events of CIED-D after radiotherapy. Reset to backup pacing mode was the most common encountered dysfunction, and only 1 (6%) patient of those with CIED-D experienced symptoms of atrioventricular dyssynchrony. Those who had CIED-D tended to have a shorter device age at the time of radiotherapy compared to those who did not (2.5 ± 1.5 vs 3.8 ± 3.4 years, p = 0.09). The total dose prescribed to the tumor was significantly greater among those who had CIED-D (66 ± 30 vs 42 ± 23 Gy, p0.0001). Multivariate logistic regression analysis identified the total dose prescribed to the tumor as the only independent predictor for CIED-D (odds ratio 1.19 for each increase in 5 Gy, 95% confidence interval 1.08 to 1.31, p = 0.0005). In conclusion, in this large population of patients with CIEDs undergoing radiotherapy for cancer treatment, the occurrence of newly diagnosed CIED-D was 7%, and the reset to backup pacing mode was the most common encountered dysfunction. The total dose prescribed to the tumor was a predictor of CIED-D. Importantly, although the unpredictability of CIEDs under radiotherapy is still an issue, none of our patients experienced significant symptoms, life-threatening arrhythmias, or conduction disorders.

Background and purpose In patients undergoing percutaneous coronary intervention (PCI) with implantation of coronary stents, the risk of stent thrombosis is mitigated with antiplatelet therapy. While current clinical practice is to treat patients with dual antiplatelet therapy (DAPT) combining aspirin with an adenosine diphosphate receptor inhibitor (ADPri), prolonged therapy is associated with heightened bleeding risk. Limiting DAPT to a shorter period after PCI, followed by ADPri monotherapy, may be an attractive strategy for optimizing the balance between thrombotic and bleeding risks. While several randomized controlled trials (RCTs) have been published examining this strategy, the optimal duration of abbreviated DAPT run-in and the ideal choice of ADPri remain uncertain. Methods We undertook a systematic review and meta-analysis of RCTs assessing abbreviated DAPT followed by ADPri monotherapy post coronary stenting. Our primary outcomes were defined as clinically important bleeding, major adverse cardiovascular events (MACE), and all-cause mortality. We searched Ovid MEDLINE and EMBASE from their inceptions to November 2019 with study selection and data extraction performed in duplicate. We pooled data at one year using random effects models; relative risks (RRs) with 95% confidence intervals (95% CIs) were generated using the inverse variance method. Pre-specified sub-group analyses were undertaken according to duration of DAPT and the primary ADPri employed. Results Four trials (n=29084) were eligible for inclusion. Mean age was 65 years and 51.5% of patients were recruited in the context of acute coronary syndrome. Following meta-analysis, the occurrence of clinically significant bleeding events was significantly lower in patients receiving ADPri monotherapy (4 studies; n=29084; RR=0.60; 95% CI, 0.43–0.83; I2=73%; Figure-A), with no significant difference in the rates of all-cause mortality (4 studies; n=29084; RR=0.87; 95% CI, 0.71–1.06; I2=0%; Figure-B) or MACE (4 studies; n=29084; RR=0.90; 95% CI, 0.79–1.03; I2=1%; Figure-C). In subgroup analysis, trends toward lower rates of both all-cause mortality (2 studies; n=23082 participants; RR=0.81; 95% CI, 0.65–1.01; I2=0%; Figure-B) and MACE (2 studies; n=23082 participants; RR=0.90; 95% CI, 0.79–1.03; I2=25%; Figure-C) were seen in the studies employing ticagrelor as opposed to clopidogrel; however, neither analysis reached statistical significance (p-values=0.06 and 0.19, respectively). There was no differential treatment effect based on the duration of abbreviated DAPT prior to ADPri monotherapy in sub-group analysis. Conclusions Following PCI in patients with coronary disease, an abbreviated course of DAPT followed by ADPri monotherapy significantly reduces rates of bleeding with no difference in rates of MACE or all-cause mortality. Future studies are required to conclusively determine whether the use of ticagrelor in this setting may also reduce rates of all-cause mortality. Meta-analysis of included studies Funding Acknowledgement Type of funding source: None

In patients with a ST-segment elevation myocardial infarction (STEMI), the prevalence of chronic total occlusion (CTO) in a non–infarct-related artery (non-IRA) is 8% to 15% [(1)][1] with 2-fold greater morbidity and mortality than in those with single-vessel disease (SVD) [(2)][2]. The TOTAL (

Introduction Hypertrophic cardiomyopathy is often associated with myocardial ischemia despite lack of focal epicardial coronary stenoses and this is partially attributable to microvascular dysfunction. The index of microvascular resistance (IMR) is a hemodynamic index that is independent of epicardial stenoses and reflects coronary microvascular function. Purpose To investigate the relationship between microvascular dysfunction and the degree of hypertrophy in hypertrophic cardiomyopathy patients. Methods We performed a prospective study to assess epicardial and microvascular coronary hemodynamics in 12 subjects with hypertrophic cardiomyopathy undergoing diagnostic coronary angiography. A pressure-temperature sensor coronary guidewire was used with intracoronary injections of room-temperature saline to measure mean coronary transit time during rest and hyperemia induced with intravenous adenosine. IMR was calculated by multiplying mean coronary transit time during hyperemia by distal coronary pressure in each subject. Left ventricular mass was calculated from baseline echocardiographic studies using established methods. Continuous variables are shown as mean ± standard deviation. Results Six subjects were male; mean age was 59.8±11.6 years. Baseline body mass index was 30.5±6.1 kg/m2 and left ventricular ejection fraction was 76.7% ± 11.0% with mean left ventricular mass 230.1±76.6 grams by echocardiography. Ten subjects had asymmetric septal hypertrophy; one subject had marked apical hypertrophy and one subject had asymmetric septal and inferolateral hypertrophy. Resting left ventricular outflow tract gradient was 59.4±37.8 mmHg and increased to 90.0±54.1 mmHg with Valsalva maneuver. Systolic anterior motion of the mitral valve was present in 10 subjects. Hemodynamic variables included coronary flow reserve (2.1±1.2); hyperemic mean transit time (0.29±0.15 sec.), and IMR (21.7±10.2). Index of microvascular resistance was strongly positively correlated with left ventricular mass (Figure 1; Pearson r=0.68, p=0.021). Figure 1. IMR is correlated with LV mass Conclusion(s) Microvascular dysfunction as assessed by IMR is strongly correlated with left ventricular mass and may contribute to symptoms in patients with hypertrophic cardiomyopathy.

Objectives To assess the relationship between preprocedural anticoagulation use and clinical and angiographic outcomes. Background For patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), the optimal timing of anticoagulant administration remains uncertain. Methods Patients enrolled in the TOTAL trial were stratified based on whether or not they had received any parenteral anticoagulant prior to randomization and PCI. Baseline and procedural characteristics were compared. For one-year clinical outcomes, Cox proportional modeling adjusted on a propensity score was used to analyze differences between groups. Angiographic endpoints were analyzed by logistic regression models adjusted for propensity scores. Results In the trial, 10,064 patients were enrolled and underwent PCI. Preprocedural anticoagulation was used in 6,381 patients (63%).The most common anticoagulant was intravenous unfractionated heparin (5,188, 81%). Patients who received preprocedural anticoagulation had higher rates of TIMI-2-3 or TIMI-3 flow and lower grades of thrombus prior to PCI. Pretreatment with anticoagulation was associated with lower use of bailout thrombectomy, GP IIb/IIIa inhibitors, and intra-aortic balloon pump. After adjustment, preprocedural anticoagulation was associated with lower rates of CABG and minor bleeding at 1 year but there were no significant differences in death, stroke, recurrent MI, cardiogenic shock, or congestive heart failure. Conclusions Preprocedural anticoagulation is associated with improved flow and reduced thrombus in the IRA prior to PCI, less bailout thrombectomy during PCI but no difference in death, recurrent infarction, or heart failure at 1 year.

Robust comparisons between oral P2Y12 inhibitors (clopidogrel, prasugrel, ticagrelor) in ST-elevation myocardial infarction (STEMI) patients who undergo primary percutaneous coronary intervention are lacking. We sought to evaluate outcomes on the basis of P2Y12 inhibitor therapy in patients from the Thrombectomy With PCI Versus PCI Alone in Patients With STEMI Undergoing Primary PCI (TOTAL) trial.We grouped 9932 patients according to P2Y12 inhibitor at hospital discharge: clopidogrel (n = 6500; 65.5%), prasugrel (n = 1244; 12.5%), or ticagrelor (n = 2188; 22.0%). The primary composite end point of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or New York Heart Association class IV heart failure was examined at 1 year. Secondary efficacy and safety end points were also assessed. Cox proportional hazard ratios were determined and adjusted for confounders via propensity scoring.Baseline characteristics differing between the 3 groups were mainly age 75 years or older, diabetes, and previous stroke. After adjustment, ticagrelor use was associated with a lower rate of the primary composite outcome compared with clopidogrel (adjusted hazard ratio [aHR], 0.72; 95% confidence interval [CI], 0.57-0.91; P0.02) and prasugrel (aHR, 0.65; 95% CI, 0.48-0.89; P = 0.02). Prasugrel use was not associated with a lower rate of the primary outcome compared with clopidogrel (aHR, 1.09; 95% CI, 0.86-1.39; P 0.99). Neither prasugrel nor ticagrelor were associated with increased risk of stroke compared with clopidogrel. Compared with clopidogrel, ticagrelor was associated with significantly lower rates of major bleeding.In this observational analysis of STEMI patients who underwent primary percutaneous coronary intervention, ticagrelor was associated with improved outcomes compared with clopidogrel and prasugrel. An appropriately powered randomized trial is needed to confirm these findings.

Key Points Question Is thrombus aspiration beneficial for patients who present early with ST-segment elevation myocardial infarction (STEMI)? Findings In this post hoc analysis of a randomized clinical trial, thrombus aspiration was associated with a greater reduction in distal embolization in patients who presented early with STEMI; however, it was not associated with improved clinical outcomes irrespective of time. Total ischemic time and door-to-device time were also important factors associated with mortality among patients with STEMI. Meaning This analysis suggests that thrombus aspiration does not appear to be associated with a benefit irrespective of ischemic time among patients with STEMI., Importance Patients with shorter ischemic times have a greater viable myocardium and may derive greater benefit from thrombus aspiration. Objective To study the association of thrombus aspiration with outcomes among patients presenting with ST-segment elevation myocardial infarction (STEMI) based on time. Design, Setting, and Participants The TOTAL (Thrombectomy With PCI vs PCI Alone in Patients with STEMI) trial was an international randomized clinical trial of 10 732 patients with STEMI undergoing primary percutaneous coronary intervention (PCI) within 12 hours of symptom onset. Patients were recruited between August 5, 2010, and July 25, 2014, and were followed up for 1 year. Data analysis was performed from February 22, 2019, to January 5, 2021. Interventions Thrombus aspiration vs PCI alone. Main Outcomes and Measures Post hoc subgroup analyses were performed for total ischemic time and first medical contact (FMC)–to–device time for the primary outcomes (cardiovascular [CV] mortality, myocardial Infarction [MI], cardiogenic shock, and New York Heart Association class IV heart failure) and angiographically determined distal embolization. In addition, a multivariable analysis was performed to assess the association of total ischemic time and FMC-to-device time with CV mortality at 1 year. Results The study randomized 10 732 patients, and 9986 underwent primary PCI and had time data available (7737 men [77.5%]; mean [SD] age, 61.0 [12.0] years). For the randomized comparison of thrombus aspiration, there was a reduction in angiographic distal embolization with thrombus aspiration that was more pronounced in patients with short ischemic times (6 hours: OR, 0.70 [95% CI, 0.33-1.50]; P = .12 for interaction). However, for the primary composite outcome, there was no benefit based on (1) total ischemic time (6 hours: HR, 0.87 [95% CI, 0.60-1.27]; P = .46 for interaction) or (2) FMC-to-device time (90-120 minutes: HR, 1.19 [95% CI, 0.85-1.67]; >120 minutes: HR, 0.89 [95% CI, 0.70-1.14]; P = .54 for interaction). In a multivariable analysis, both total ischemic time (>2 hours: HR, 1.26 [95% CI, 1.00-1.58) and FMC-to-device time (>120 minutes: HR, 1.45 [95% CI, 1.18-1.79]) were independently associated with CV mortality. Conclusions and Relevance This analysis suggests that thrombus aspiration does not appear to be associated with an improvement in clinical outcomes regardless of ischemic time. In the current STEMI era, both total ischemic time and FMC-to-device times continue to be important factors associated with mortality. Trial Registration ClinicalTrials.gov Identifier: NCT01149044, This post hoc analysis of a randomized clinical trial studies the association of thrombus aspiration with outcomes among patients presenting with ST-segment elevation myocardial infarction based on time.

Background Contemporary use of dual antiplatelet therapy and consistency with guideline recommendations in acute coronary syndrome patients undergoing percutaneous coronary intervention (PCI) have not been well characterized. Methods The COAPT was a prospective, observational, multicenter, longitudinal study of patients with myocardial infarction (MI) undergoing PCI. Baseline characteristics, treatment patterns, processes of care, factors associated with switching to and from novel adenosine diphosphate receptor inhibitors (ADPris), and in-hospital outcomes are described. Results Among 2,179 MI patients undergoing PCI during their index hospitalization, 1,328 (60.9%) had ST elevation. Initial ADPri use included clopidogrel in 1,812 (83.2%), prasugrel in 125 (5.7%), and ticagrelor in 242 (11.1%). At discharge, 1,597 patients (73.4%) were prescribed clopidogrel, 220 (10.1%) prasugrel, and 358 (16.5%) ticagrelor. Switching between ADPri therapies during the index hospitalization occurred in 15.3%, 22.4%, and 25.2% of patients initially started on clopidogrel, prasugrel, and ticagrelor, respectively. Most switches over the 15-month study period occurred during the index admission (16.8% of patients vs 4.4% switches postdischarge). Major adverse cardiovascular events occurred in 7.5% of patients during the index hospitalization. In-hospital bleeding events occurred in 6.0% of patients and most were mild. Conclusions Despite randomized trial evidence and guideline recommendations, only a minority of Canadian MI patients undergoing PCI initially received or were discharged on one of the newer ADPri agents. These findings suggest an opportunity to improve upon the appropriate selection of the ADPris at index hospitalization and discharge in Canadian MI patients undergoing PCI.

Radial artery occlusion is the most common complication following trans-radial approach (TRA) for cardiac catheterization. Our aim was to compare short durations of compression hemostatic device (CHD) application post TRA in patients not receiving anticoagulation. Patients (n=450) undergoing

Patients diagnosed with ST-segment elevation myocardial infarction (STEMI) are occasionally found to have no culprit lesion on coronary angiography and are classified as presenting with false-positive STEMI. The clinical presentation and outcomes of these patients need to be further explored. In this case-controlled study, 259 consecutive patients with true code STEMI were compared to 104 consecutive STEMI patients without culprit lesions on emergent coronary angiography. We compared the clinical presentation, electrocardiographic features, etiology, and outcomes of the two groups. STEMI patients without culprit lesions were less likely to have typical chest pain (46% vs. 79%, P < 0.01). The ST-elevation in the group without culprit lesion was more likely to be concave (56% vs. 31%, P < 0.01), with less reciprocal ST-depression (19% vs. 71%, P < 0.01). The group without culprit lesions had a higher rate of ventilator support requirement (12.4% vs. 5.4%, P = 0.02), and higher rate of 30-day mortality (11.0% vs. 5.9%, P = 0.02). However, after excluding the patients with out-of-hospital cardiac arrests from both groups, the difference was no longer significant (P = 0.40 and 0.34 respectively). The relative poor outcomes of patients with false-positive code STEMI reflect the severity of their underlying medical condition. Careful history and review of ECG may help differentiate this group from true STEMI.

Rotational atherectomy (RA) performed during percutaneous coronary intervention is commonly associated with distal embolization of calcific particles resulting in conduction abnormalities. As a result, temporary pacing is often used during these procedures. It is unknown whether temporary pacing should be routinely used.We performed an analysis of 134 consecutive patients who underwent RA at our institution between January 2011 and September 2013 for the presence of intraprocedural heart block or pacemaker activation.A temporary pacemaker was inserted in 50% of cases. Forty-two (31%) patients experienced either heart block (n = 16) or pacemaker activation (n = 26). There was no difference in baseline characteristics between those who experienced heart block or required temporary pacing, and those who did not. Interventional characteristics including burr size, maximum rotations per minute used, and maximum run duration were also similar among the groups. Only target RA vessel was associated with the presence of heart block or temporary pacing in multivariate analysis (P0.0001). Heart block or temporary pacing occurred in 28 (53%) of RA to the right coronary artery, 2 (5%) of the left anterior descending artery, 8 (62%) of the left-dominant circumflex artery, and 2 (18%) with RA to the circumflex artery with right-dominant circulation. Asystole occurred only in patients who underwent RA to the right coronary artery.Heart block or temporary pacing was more commonly associated with right coronary artery and left-dominant circumflex lesions. Prophylactic pacemaker insertion might be avoided with RA to other vessels.

This clinical trial assesses ticagrelor administration and endothelial function and arterial stiffness in patients with coronary artery disease.

The safety and efficacy of drug eluting stents (DES) in the setting of ST elevation myocardial infarction (STEMI) is not well established.In the TOTAL trial, patients presenting with STEMI were randomized to routine thrombectomy versus PCI alone. In this post-hoc analysis, propensity matching was used to assess relative safety and efficacy according to type of stent used.Each propensity-matched cohort included 2313 patients. The composite primary outcome of cardiovascular death, recurrent MI, cardiogenic shock or class IV heart failure within one year was lower in the DES group (HR 0.67; 95% CI 0.54 to 0.84, p=0.0004). Cardiovascular death (HR 0.61; 95% CI 0.43 to 0.86, p=0.005), recurrent MI (HR 0.51; 95% CI 0.35 to 0.75, p=0.0005), target vessel revascularization (HR 0.47; 95% CI 0.36 to 0.62, p0.0001) and stent thrombosis (HR 0.60; 95% CI 0.40 to 0.89, p=0.01) were lower in the DES group. There was no difference in major bleeding between groups.In this observational analysis, the use of DES was associated with improvement in cardiovascular outcomes compared to the use of BMS. These results support the use of DES during primary PCI for STEMI.

Aims Survivors of out-of-hospital cardiac arrest (OHCA) have a high rate of morbidity and mortality. Invasive cardiac assessment with coronary angiography offers the potential for improving outcomes by facilitating early revascularization. The aim of the present study was to review the published data on early coronary angiography for survivors of OHCA, and its impact on survival and neurological outcomes. Methods Medline, Embase and PubMed were searched with a structured search query. The primary outcome was in-hospital (or if not available, 30 day or 6 month) survival. Rates of survival with good neurological outcome were a secondary endpoint. The time period of the search was from 1 January 1980 to 1 January 2014. Data was pooled with means and 95% CI interval calculated. Meta-analysis of the main outcomes was performed using a weighted random effects model. Results Following review of all identified records, 105 relevant full text articles were retrieved. Fifty had adequate outcome information stratified by the use of coronary angiography for analysis. In studies where a control group was available for comparison, the overall survival in the acute angiography group was 58.8% versus 30.9% in the control group (Odds ratio 2.77, 95% CI 2.06–3.72). Survival with good neurological outcome (as per the Utstein framework) in the early angiography group was 58% versus 35.8% in the control group (Odds ratio 2.20, 95% CI 1.46–3.32). Conclusions Early coronary angiography in patients following OHCA is associated with improved outcome and better survival.

Background— Remote ischemic preconditioning may result in reduction in infarct size during percutaneous coronary intervention (PCI). It is unclear whether remote ischemic postconditioning (RIPost) will reduce the incidence of myocardial injury after PCI, and whether ischemic conditioning of a larger remote organ (thigh versus arm) would provide further myocardial protection. Methods and Results— We randomized 360 patients presenting with stable or unstable angina (28% of patients) and negative Troponin T at baseline to 3 groups: 2 groups received RIPost (induced by ischemia to upper or lower limb), and a third was the control group. RIPost was applied during PCI immediately after stent deployment, by three 5-minute cycles of blood pressure cuff inflation to >200 mm Hg in the arm or thigh (20 mm Hg in the control) with 5-minute breaks between each cycle. The primary end-point was the proportion of patients with Troponin T levels >3×ULN postprocedure (at 6 or 18–24 hours), where ULN stands for upper limit of normal. A total of 120 patients were randomized to each group. There were no differences in baseline characteristics between the 3 groups. The primary outcome occurred in 30%, 35%, and 35% of the arm, thigh, and control groups, respectively ( P =0.64). There were no differences in creatine kinase or high sensitivity C-reactive protein levels after PCI or in the incidence of acute kidney injury between the groups. Conclusions— RIPost during PCI did not reduce the incidence of periprocedural myocardial injury. Similar effect was obtained when remote ischemia was induced to the upper or lower limb. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00970827.

This study sought to determine the incidence, predictors, and prognostic value of heart failure (HF) during and after primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. The TOTAL trial was an international randomized trial (N = 10,732) comparing thrombus

The mechanism by which depression affects postoperative outcome may involve arrhythmias. The purpose of this study was to evaluate whether untreated depression is associated with an increased incidence of postoperative arrhythmias in patients undergoing coronary artery bypass graft surgery (CABG).One hundred seven patients were assessed for signs of depression with the Prime-MD Patient Health Questionnaire (brief PHQ) one week before surgery and subsequently underwent Holter monitoring for 48-72 hr postoperatively. The incidences of atrial fibrillation (AF); supraventricular tachycardia (SVT); ventricular tachycardia (VT), defined as three or more consecutive beats at a cycle length less than 600 msec; ventricular fibrillation (VF); and average heart rate (HR) were recorded in patients with and without signs of depression.The incidence of preoperative untreated depression was 27% (29/107). Twenty patients had mild depression (brief PHQ score of 5-9), seven patients had moderate depression (a score of 10-14), and two patients had severe depression (a score of 20). The incidences of postoperative AF, SVT, and non-sustained VT in depressed and non-depressed patients were 37.9% vs 35.9%, respectively (P = 0.50), 34.4% vs 52.5%, respectively (P = 0.07), and 17.2% vs 37.1%, respectively (P = 0.04). The average (SD) postoperative HR was similar in both groups [95 (12) beats·min(-1) in depressed patients and 92 (10) beats·min(-1) in non-depressed patients, (P = 0.25)]. Multivariate regression analysis showed that older age, but not depression, was a risk factor for postoperative arrhythmia.Preoperative untreated depression is not related to postoperative arrhythmia in the early postoperative period in patients undergoing elective CABG. This trial was registered at clinicaltrials.gov (number: NCT00622024).

Aims: There is a paucity of real-world, contemporary data of practice patterns and clinical outcomes following dual-antiplatelet therapy (DAPT) in acute myocardial infarction (AMI) patients treated with percutaneous coronary intervention (PCI). Methods and Results: The Canadian Observational Antiplatelet Study (COAPT) was a prospective, multicenter, cohort study examining adenosine diphosphate (ADP) receptor antagonist use following PCI for AMI. We compared practice patterns, patient characteristics, and clinical outcomes in relation to DAPT duration (

Background Coronary no-reflow during primary percutaneous coronary intervention (PPCI) is a predictor of poorer cardiovascular outcome. Both endothelial dysfunction and no-reflow involves abnormal vascular function and hemostasis. Our aim was to assess the association between endothelial dysfunction and no reflow during primary PCI. Methods Thirty consecutive patients with ST elevation myocardial infarction (STEMI) and normal flow during primary PCI were compared to 19 consecutive patients who had no reflow. All subjects underwent assessment of peripheral endothelial function by reactive hyperemia index (RHI) 48–72 h post PCI using the EndoPAT device. Results Age, sex and hypertension were similar in both groups. Smokers were less likely to have no-reflow. Post PPCI there was less ST segment resolution in the no-reflow group (48% ± 7 vs. 81% ± 6; p = 0.001). Patients who had no reflow had subsequently lower ejection fraction (39% ± 10 vs. 47% ± 10; p = 0.015). There was no difference in vascular function (RHI), between the no-reflow and normal flow groups (1.91 ± 0.3 vs. 2.09 ± 0.11; p = 0.24). Conclusions Systemic peripheral endothelial function does not differ between STEMI patients with and without no reflow during primary PCI.

Since the introduction of newer, more potent P2Y12 receptor inhibitors (P2Y12ris), practice patterns and associated clinical outcomes in patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) and also requiring oral anticoagulation (OAC) have not been fully characterized.The Canadian Observational Antiplatelet Study was a prospective, multicenter, longitudinal, observational study (26 hospitals, December 2011 to May 2013) describing P2Y12ri treatment patterns and outcomes in patients with ST-elevation and non-ST-elevation MI undergoing PCI. We describe the clinical characteristics, treatment patterns, bleeding, and ischemic outcomes over the 15-month follow-up within and between the subgroups of patients discharged on either dual-antiplatelet therapy (DAPT) (acetyl salicylic acid [ASA]+P2Y12ri) or triple therapy (ASA+P2Y12ri+OAC).Of the 2,034 patients at discharge, 86% (n = 1,757) were on DAPT, whereas 14% (n = 277) were on triple therapy (50% warfarin, 50% non-vitamin K OAC [NOAC]). The frequency of newer P2Y12ri use (prasugrel or ticagrelor) was similar in the DAPT and triple therapy groups (28% vs 26%, respectively). In the triple therapy group, NOAC use was higher in those receiving a new P2Y12ri compared to those receiving clopidogrel (75% vs 41%, respectively, P.0001). The unadjusted and adjusted events of major cardiovascular event (MACE) and bleeding were higher in the triple therapy group. For patients on triple therapy, the bleeding or MACE events were not significantly different between those on clopidogrel versus those on ticagrelor or prasugrel.In this observational study of MI patients requiring PCI, 1 in 8 were discharged on triple antithrombotic therapy, of whom 26% were on newer P2Y12ris. Patients on triple therapy had higher risk at baseline, with higher unadjusted and adjusted MACE and bleeding events compared to those on DAPT alone. Among triple therapy-treated patients, there was no difference in the MACE and bleeding events regardless of the P2Y12ri used.

c SURGICAL REVASCULARIZATION for coronary artery disease is one of the most common surgeries performed. ith constant aging of the world’s population and the increase n the number and complexity of percutaneous coronary interentions (PCIs), there is a shift toward performing coronary rtery bypass graft (CABG) surgery among an elderly and icker patient population. To reduce the risk of cardiovascular vents in these higher-risk patients, there is a need for more ntensive medical therapy, including the use of antiplatelet gents. The caveat is that these patients are also at an increased isk for adverse events and complications related to medical herapy. Antiplatelet medications are the most important drug therapy or patients with acute and chronic cardiovascular disease.1,2 Although their use has proven to be beneficial in reducing cardiovascular events, the administration of these medications also is associated with an increased risk of bleeding, which is an important factor in cardiovascular outcome.3,4 Because antiplatelet agents commonly are used in patients undergoing cardiovascular surgery, bleeding often occurs in these patients during the perioperative period, which significantly affects morbidity and mortality, reoperation rates, blood transfusions, intensive unit and in-hospital length of stay, and the incidence of associated complications. With the recent introduction of newer and more potent antiplatelet agents, it is particularly important to have clear guidelines for the use of these medications in patients undergoing cardiac surgery during the perioperative period.

Background Inflammation plays an important role in the pathophysiology of atherosclerosis and endothelial dysfunction, and occurs after percutaneous coronary intervention (PCI). We evaluated whether endothelial function is attenuated after PCI and if inhibition of secretory phospholipase A 2 (sPLA 2 ) activity augments endothelial function and coronary flow reserve (CFR) in these patients. Methods In the sPLA 2 Inhibition to Decrease Enzyme Release After Percutaneous Coronary Intervention (SPIDER-PCI) study, patients undergoing elective PCI were randomized to receive Varespladib (Anthera Pharmaceuticals Inc, San Mateo, CA), an inhibitor of sPLA 2 , or placebo 3-5 days prior to PCI and for 5 days after PCI. In this substudy, endothelial function was assessed in 31 patients by flow-mediated dilation (FMD) before treatment and on the day after PCI, while taking study medication. During the PCI procedure, CFR was assessed using a Doppler guide wire. Results Baseline and procedural characteristics were comparable in both groups and sPLA2 activity was similar at baseline. After PCI, sPLA 2 activity decreased only in the Varespladib group (2.9 ± 0.9 to 0.5 ± 0.4 ng/mL), and high-sensitivity C-reactive protein (hsCRP) increased by more than 100% in both groups. FMD at baseline was 3.66 ± 2.45% (Varespladib) and 3.37 ± 1.73% (placebo) with nonsignificant increase in both groups after PCI. The effect of Varespladib on FMD, adjusted for pre-PCI FMD by linear regression, was −1.16 ± 1.68%; P = 0.5. CFR was 2.45 ± 0.66 and 2.77 ± 0.85 in the Varespladib and placebo groups, respectively ( P = 0.36). Conclusions Systemic endothelial function is not reduced after elective PCI despite eliciting acute inflammatory response. Acute inhibition of sPLA 2 activity with Varespladib does not affect endothelial or microvascular function after PCI.

Ischemic preconditioning is a natural protective mechanism by which brief episodes of ischemia protect the heart or other organs from the deleterious effects of ischemia-reperfusion injury. Ischemic preconditioning was demonstrated in animals more than 20 years ago, and subsequent studies in humans showed a dramatic protective effect on the heart. This method did not translate into clinical practice partially due to difficulty in application of conditioning. At the same time, multiple drugs were assessed, but none proved to be beneficial in large scale studies for myocardial protection. Although multicenter studies are still lacking, it was recently demonstrated in reasonable sized studies that in patients undergoing percutaneous coronary interventions or suffering from myocardial infarction, remote ischemic conditioning has beneficial protective effect. With more studies we may see translation into clinical practice in the near future.

Obstructive coronary artery disease involving the left main coronary artery (LMCA) is found during cardiac catheterization in 4%-6% of patients. Randomized trials performed in the 1970s included small subgroups of patients with unprotected LMCA (ULMCA) and demonstrated the superiority of coronary artery bypass grafting (CABG) compared with medical management, which led to recommending CABG for those patients. Although technically, LMCA percutaneous coronary intervention (PCI) is often feasible, the outcome with balloon angioplasty or bare metal stenting was initially disappointing. In fact, the first patient who underwent PCI to the LMCA by Andreas Gruentzig in 1978, died within a year. CABG remained the preferred approach for this subset of patients. Advances in the realm of interventional cardiology, including the advent of the drugeluting stent (DES), have made the treatment of ULMCA disease with PCI a more acceptable treatment as an alternative to CABG. There is a growing body of evidence to support the treatment of ULMCA disease with PCI as opposed to CABG. However, because of the common assumption that withholding surgery is unethical, patients have usually been excluded from randomized clinical trials (RCTs) comparing PCI and CABG. Only a few RCTs to date have compared the efficacy of CABG and PCI in this setting, and even then most did not specifically target this population but reported subgroup results. The Synergy Between Percutaneous Coronary Intervention with TAXus and Cardiac Surgery (SYNTAX) trial randomized 1800 patients with 3-vessel or ULMCA disease, or both, to CABG or PCI using a first-generation DES. Among the 750 patients in the ULMCA disease subgroup, 1-year major adverse cardiovascular and cerebrovascular event (MACCE) rates were similar for PCI and CABG

There is growing need for the identification of novel non-invasive methodologies for the identification of individuals at risk for adverse cardiovascular (CV) events. We examined whether endothelial dysfunction, as detected by non- invasive peripheral arterial tonometry (EndoPAT), can predict late CV events. Methods and results Reactive hyperaemia (RH) was induced following upper arm occlusion of systolic blood pressure in 270 outpatients (54+ 12 years, 48% female). The natural logarithmic scaled RH index (L_RHI) was calculated from the ratio between the digital pulse volume during RH and at baseline. The patients were followed for CV adverse events (AE: cardiac death, myocardial infarction, revascularization or cardiac hospitalization) during a 7-year follow-up (inter-quartile range ¼ 4.4-8). Cox models were used to estimate the association of EndoPAT results with AE adjusted for age. During the follow-up, AE occurred in 86 patients (31%). Seven-year AE rate was 48% in patients with L_RHI , 0.4 vs. 28% in those with L_RHI � 0.4 (P ¼ 0.03). Additional univariate predictors of AE were advancing age (P ¼ 0.02) and prior coronary bypass surgery (P ¼ 0.01). The traditional Framingham risk score was not higher in patients with AE. Multivariate analysis identified L_RHI , 0.4 as an independent predictor of AE (P ¼ 0.03). Conclusion A low RH signal detected by EndoPAT, consistent with endothelial dysfunction, was associated with higher AE rate during follow-up. L_RHI was an independent predictor of AE. Non-invasive assessment of peripheral vascular func- tion may be useful for the identification of patients at risk for cardiac AEs.

Endothelial dysfunction and atherosclerosis are systemic disorders, but are often characterised by segmental involvement and complications. A potential mechanism for local involvement early in the disease process may be related to plaque composition. This study was designed to test the hypothesis that in patients with minimal coronary atherosclerosis, coronary artery segments with abnormal endothelial function have specific plaque characteristics.Intravascular ultrasound (IVUS) images were obtained from 30 patients who underwent coronary endothelial function assessment. Spectral analysis of the IVUS radiofrequency data was used for assessment of plaque composition. IVUS findings of the coronary sections were compared according to the corresponding endothelial response to acetylcholine.Sections with a decrease epicardial coronary arterial diameter in response to acetylcholine had smaller baseline lumen (7.5 (2.4) mm(2) vs 8.8 (3.3) mm(2), p = 0.006) but larger plaque burden (37.1% (9.4%) vs 31% (7%), p = 0.003) than sections with normal endothelial response. Sections with endothelial dysfunction had larger necrotic core plaques: 0.13 (0.03-0.33) mm(2) vs 0.0 (0.0-0.07), p0.001 and more dense calcium: 0.03 (IQR 0.0-0.13) mm(2) vs 0.0 (0.0-0.10) mm(2), p0.01), than those with normal endothelial response. Only necrotic core area was associated with endothelial dysfunction (p0.001) after adjusting for other measures.This study suggests that local coronary endothelial dysfunction in patients with minimal coronary atherosclerosis is associated with plaque characteristics that are typical of vulnerable plaques.

Our objective was to assess the differences in systemic vascular and endothelial function in response to acute mental stress between men and women. The endothelium plays a pivotal role in vascular homeostasis and the development of atherosclerotic heart disease. The mechanism and presentation of cardiovascular events show a sex-based difference, although the sex difference in the vascular and endothelial response to mental stress is not known.Male (n = 34) and female (n = 53) subjects participated in a series of three different mental stress tasks during which vascular response was measured non-invasively using peripheral arterial tonometry. Endothelial function was assessed using reactive hyperemia peripheral arterial tonometry. Double product (systolic blood pressure x heart rate) was calculated.Males had a greater double product response (27.2 + 3.6% increase in double product vs. 19.2 + 1.7%; P = 0.01), and a greater vascular reactivity to mental stress. Females demonstrated a reduced response to reactive hyperemia (-0.47 vs. 13.74%; P = 0.01). Furthermore, a subgroup of females who showed the least vaso-reactivity to mental stress showed the greatest decline in endothelial function (-10.5 + 4% vs. 17.4 + 6.3%; P0.001).This study demonstrates sex-based differences in the vascular and endothelial responses to mental stress. The mental stress-induced reduction in endothelial function and increased double product seen in the females might manifest clinically as contributing to the pathophysiology of mental stress-mediated cardiovascular events in female patients and provide further information regarding the potential mechanism for sex differences in cardiac events.

Transient hyperglycemia is common during acute myocardial infarction in non-diabetic patients and is associated with a worse outcome. There is limited data on the outcome of patients who undergo primary percutaneous coronary intervention and have transient hyperglycemia.Fasting plasma glucose was measured in 431 consecutive acute myocardial infarction patients who underwent primary percutaneous coronary interventions. Patients were classified into three groups: non-diabetics/non-hyperglycemic (NDNH, glucose126 mg/dL; n=224); non-diabetics/hyperglycemic (NDH, glucoseor = 126 mg/dL; n=119); and diabetics (n=88). Data were analyzed according to the different groups and according to exact glucose levels.In-hospital mortality was significantly lower in NDNH (1%) compared to NDH (8%) and diabetic (5%) patients (p=0.01). One-year cumulative mortality was highest (10%) in patients with NDH (p0.001). One year target lesion revascularization rates were identical in NDNH and NDH patients (6% vs. 8%) and higher in diabetic patients (19%, p=0.001). In a multivariate model, a striking increase in the risk of death (0.6%, p=0.05) and target lesion revascularization (2%, p0.0001) was found for every increment of 1 mg/dL in glucose level.Transient hyperglycemia in non-diabetic acute myocardial infarction patients who undergo primary percutaneous coronary interventions is associated with high one-year mortality. One year target lesion revascularization rates were significantly higher in diabetics compared to non-diabetics with normoglycemia or transient hyperglycemia.

Background— Lipoprotein-associated phospholipase A 2 (Lp-PLA 2 ) is a novel marker and participant in vascular inflammation. Inflammation also is associated with coronary atherosclerosis. We tested the hypothesis that local coronary production of Lp-PLA 2 is enhanced in patients with early coronary atherosclerosis and associated with local endothelial function. Methods and Results— Coronary angiography, blood flow, flow reserve, endothelial function assessment, and intravascular ultrasound with volumetric analysis were performed in 15 patients with mild coronary atherosclerosis and in 15 control subjects. Plasma samples were collected simultaneously from the left main coronary artery and coronary sinus for measurement of Lp-PLA 2 , lysophosphatidylcholine (a product of Lp-PLA 2 ), and C-reactive protein. Hemodynamic parameters and cholesterol were similar in both groups. Arterial Lp-PLA 2 levels were similar in patients and control subjects: 225 ng/mL (interquartile range [IQR], 196 to 273 ng/mL) versus 221 ng/mL (IQR, 177 to 294 ng/mL). Lp-PLA 2 net production in the coronary circulation was higher in patients compared with control subjects: 519 ng/min (IQR, 198 to 1276 ng/min) versus −529 ng/min (IQR, −872 to −79 ng/min; P =0.001) and correlated with percent atheroma volume ( r s =0.37, P =0.04). Net production of lysophosphatidylcholine was higher in patients compared with control subjects: 199 ng/min (IQR, −592 to 470 ng/min) versus −505 ng/min (IQR, −1119 to 0 ng/min; P =0.03) and correlated with coronary endothelial dysfunction ( r s =0.5, P =0.005). C-reactive protein was not significantly different between the groups. Conclusions— Early coronary atherosclerosis in humans is characterized by local production of Lp-PLA 2 . Local coronary production of lysophosphatidylcholine, the active product of Lp-PLA 2 , is associated with endothelial dysfunction. These results support the role for Lp-PLA 2 in the mechanism of regional vascular inflammation and atherosclerosis in humans.