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Introduction and objectives: Patients with left main coronary artery (LMCA) stenosis have been excluded from the trials that support the non-inferiority of the instantaneous wave-free ratio (iFR) compared to the fractional flow reserve (FFR) in the decision-making process of coronary revascularization. This study proposes to prospectively assess the concordance between the two indices in LMCA lesions and to validate the iFR cut-off value of 0.89 for clinical use. Methods: National, prospective, and observational multicenter registry of 300 consecutive patients with intermediate lesions in the LMCA (angiographic stenosis, 25% to 60%. A pressure gudiewire study and determination of the RFF and the iFR will be performed: in the event of a negative concordant result (FFR > 0.80/iFR > 0.89), no treatment will be performed; in case of a positive concordant result (FFR ≤ 0.80/iFR ≤ 0.89), revascularization will be performed; In the event of a discordant result (FFR> 0.80/iFR ≤ 0.89 or FFR ≤ 0.80/iFR> 0.89), an intravascular echocardiography will be performed and revascularization will be delayed if the minimum lumen area is > 6 mm2. The primary clinical endpoint will be a composite of cardiovascular death, LMCA lesion-related non-fatal infarction or need for revascularization of the LMCA lesion at 12 months. Conclusions: Confirm that an iFR-guided decision-making process in patients with intermediate LMCA stenosis is clinically safe and would have a significant clinical impact. Also, justify its systematic use when prescribing treatment in these potentially high-risk patients. Registered at ClinicalTrials.gov ( Identifier: NCT03767621).

Introduction and objectives: The COVID-19 epidemic and the declaration of the state of alarm have led to a decrease in healthcare activity in interventional cardiology units. The objective of this study is to quantify these changes in activity, with special interest in the treatment of patients with ST-segment elevation myocardial infarction (STEMI). Methods: A telematic survey of 81 centers involved in STEMI networks in the 17 autonomous communities of Spain. Information was collected on diagnostic activity, percutaneous coronary intervention (PCI), structural interventions, and PCI in STEMI on changes in the organization of STEMI networks, and on the prevalence of COVID-19 among interventional cardiologists. Data was compared for the week of February 24 through March 1 (before the outbreak) and for the week of March 16 through March 22 (during the outbreak). Results: Response has been obtained from 73 centers (90%). A very significant decrease in the number of diagnostic procedures (─56%), PCI (─48%), structural interventions (─81%) and PCI in STEMI (─40%) has been observed. A slight increase in the use of pharmacological thrombolysis has been reported, although primary angioplasty remains the leading reperfusion strategy. Up to 5% of interventional cardiologists (17) had COVID-19. Conclusions: An important reduction in the activity in interventional cardiology has been observed during the COVID-19 epidemic. Likewise, a great decrease has been detected in the number of patients treated in the STEMI networks, with the risk of increased morbidity and mortality that this represents. Scientific societies and health authorities have to promote that patients presenting STEMI compatible symptoms proceed with no delay to access the health system to receive reperfusion treatment in an appropriate way.

AIMS The aim of this study was to assess clinical and prognosis differences in patients with COVID-19 and STEMI. METHODS AND RESULTS Using a nationwide registry of consecutive patients managed within 42 specific STEMI care networks, we compared patient and procedure characteristics and in-hospital outcomes in two different cohorts, according to whether or not they had COVID-19. Among 1,010 consecutive STEMI patients, 91 were identified as having COVID-19 (9.0%). With the exception of smoking status (more frequent in non-COVID-19 patients) and previous coronary artery disease (more frequent in COVID-19 patients), clinical characteristics were similar between the groups, but COVID-19 patients had more heart failure on arrival (31.9% vs 18.4%, p=0.002). Mechanical thrombectomy (44% vs 33.5%, p=0.046) and GP IIb/IIIa inhibitor administration (20.9% vs 11.2%, p=0.007) were more frequent in COVID-19 patients, who had an increased in-hospital mortality (23.1% vs 5.7%, p

Resumen Introduccion y objetivos Los pacientes mayores de 75 anos con infarto agudo de miocardio con elevacion del segmento ST sometidos a angioplastia primaria en situacion de shock cardiogenico sufren una gran mortalidad. La identificacion previa al procedimento de variables predictoras de la posterior mortalidad seria muy util para guiar la toma de decisiones. Metodos Analisis del registro multicentrico de angioplastia primaria en pacientes mayores de 75 anos (ESTROFA MI + 75), que incluye a 3.576 pacientes. Se analizaron las caracteristicas y la evolucion clinica del subgrupo con shock cardiogenico para identificar predictores de supervivencia a 1 ano tras la angioplastia y elaborar un indice pronostico. Se valido el indice en una cohorte independiente. Resultados Se incluyo a 332 pacientes. Los predictores basales independientes fueron: la localizacion anterior (HR = 2,8; IC95%, 1,4-6,0; p = 0,005), una fraccion de eyeccion 6 h (HR = 3,2; IC95%, 1,6-7,5; p = 0,001). Se diseno un indice basado en estas variables (indice «6-ANT-40»). La supervivencia a 1 ano fue del 54,5% de aquellos con indice 0, el 32,3% con indice 1, el 27,4% con indice 2 y el 17% con indice 3 (p = 0,004, estadistico C = 0,70). En una cohorte independiente de 124 pacientes, las supervivencias a 1 ano fueron del 64,5, el 40,0, el 28,9 y el 22,2% respectivamente (p = 0,008; estadistico C = 0,68). Conclusiones Un indice basado en simples variables clinicas previas al procedimiento (localizacion anterior, fraccion de eyeccion 6 h) permite estimar la supervivencia tras una angioplastia primaria de los pacientes mayores con shock cardiogenico, y asi ayudar en la toma de decisiones.

QUESTION: Compared to the pressure guidewire what possible advantages does coronary angiography-derived fractional flow reserve (FFRangio) have and what is the current clinical evidence? ANSWER: Different physiological indices have been developed lately from the 3D reconstruction of the angiogram based on 2 projections and the application of fluid dynamics algorithms. These indices estimate fractional flow reserve (FFR) semi-invasively because, although they are based on percutaneous coronary angiography with contrast, pressure guidewires or drugs are not necessary in the coronary artery. The most widely studied software package to obtain these indices is the one designed by Medis (QAngio XA 3D, Medis Medical Imaging System, The Netherlands), but there are others in the pipeline.1 The actual software allows us to obtain the baseline quantitative flow ratio (QFR) (fixed QFR [fQFR]). There is another one that adds the speed of the flow of contrast to the estimate (contrast QFR [cQFR]) by quantifying the TIMI frame count. It can also obtain the adenosine-flow QFR (aQFR) with the administration of adenosine and the residual QFR after a hypothetic percutaneous treatment of the lesion. To this day, the current studies on FFRangio basically focus on analyzing its match (especially that of cQFR) with FFR or the instantaneous wave-free ratio...

To the Editor, We have read with great interest the results of the ISCHEMIA trial1 of 5179 patients with moderate or severe ischemia who were randomized to receive an early invasive strategy of angiography plus revascularization, when necessary, or a conservative strategy of early optimal medical therapy and angiography if the medical therapy failed. As already known, the conclusion is that an early invasive strategy does not reduce the risk of cardiovascular ischemic events or all-cause mortality at the follow-up. However, it had beneficial effects because it reduced the occurrence of spontaneous myocardial infarction at the expense of a number of peri-PCI myocardial infarctions. Currently, this observation is under discussion probably because a different result was expected by researchers. In an interesting article2 it has been argued that the ISCHEMIA trial did not compare the benefits of coronary revascularization vs medical therapy, but assessed an early strategy of medical therapy vs early invasive treatment with angiography. In this sense, 79.4% of the patients from the invasive group were percutaneous or surgically revascularized vs 21.0% of the patients from the conservative group. A careful review of the supplementary data of the original publication1 reveals interesting additional data that we wish to share. A...

Background: Statins are recommended for secondary prevention. Our aims were to describe the proportion of very elderly patients receiving statins after non-ST segment elevation acute coronary syndrome (NST-ACS) and to determine the prognostic implications of statins use. Methods: This prospective registry was performed in 44 hospitals that included patients ≥80 years discharged after a NST-ACS from April 2016 to September 2016. Results: We included 523 patients, the mean age was 84.2 ± 4.0 years and 200 patients (38.2%) were women. Previous statin treatment was recorded in 282 patients (53.4%), and 135 (32.5%) had LDL cholesterol levels >2.6 mmol/L. Mean LDL cholesterol levels during admission were 2.3 ± 0.9 mmol/L. Statins were prescribed at discharge to 474 patients (90.6%). Compared with patients discharged on statins, those that did not receive statins were more often frail (22 [47.8%] vs. 114 [24.4%], p < 0.01) and underwent an invasive approach less frequently (30 [61.2%] vs. 374 [78.9%], p = 0.01). During a 6-month follow-up, 50 patients died (9.5%). There was a nonsignificant trend to higher mortality in patients not treated with statins (6 [15%] vs. 44 [9.6%], p = 0.30), but statins were not independently associated with lower mortality (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.30–2.11, p = 0.65), nor with a reduction in the combined endpoint mortality/hospitalizations (HR 0.89; 95% CI 0.52–1.55, p = 0.69). Conclusions: Although most octogenarians presenting a NST-ACS are already on statins before the episode, their LDL cholesterol is frequently >2.6 mmol/L. Octogenarians who do not receive statins have a high-risk profile, with significant frailty and comorbidity.

Introduction and objectives Contemporary data on the incidence and prognosis of heart failure (HF) and the influence of left ventricular ejection fraction (LVEF) in the setting of acute coronary syndrome (ACS) are scant. The aim of this study was to examine the relationship between LVEF and HF with long-term prognosis in a cohort of patients with ACS. Methods This is a retrospective observational study of 6208 patients consecutively admitted for ACS to 2 different Spanish hospitals. Baseline characteristics were examined and a follow-up period was established for registration of death and HF rehospitalization as the primary endpoint. Results Among the study participants, 5064 had ACS without HF during hospitalization: 290 (5.8%) had LVEF < 40%, 540 (10.6%) LVEF 40% to 49%, and 4234 (83.6%) LVEF ≥ 50%. The remaining 1144 patients developed HF in the acute phase: 395 (34.6%) had LVEF < 40%, 251 (21.9%) LVEF 40% to 49%, and 498 (43.5%) LVEF ≥ 50%. Patients with LVEF 40% to 49% had a demographic and clinical profile with intermediate features between the LVEF < 40% and LVEF ≥ 50% groups. Kaplan-Meier curves showed that mortality and HF readmissions were statistically different depending on LVEF in the non-HF group but not in the HF group. Left ventricular ejection fraction ≥ 50% was an independent prognostic factor in the non-HF group only. Conclusions In ACS, long-term prognosis is considerably worse in patients who develop HF during hospitalization than in patients without HF, irrespective of LVEF. This parameter is a strong prognostic predictor only in patients without HF.

Background: A worse prognosis has been reported among women with acute coronary syndrome compared to men. Our aim was to address the role of frailty and sex in the management and prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome. Methods: A prospective registry in 44 Spanish hospitals including patients aged 80 years and older with non-ST-segment elevation acute coronary syndrome. Frailty assessment was performed using the FRAIL scale. Results: Of a total of 535 patients, 207 (38.7%) were women. Mean age was 84.8±4.0 years, similar in men and women. A prior history of coronary artery disease was more common in men (146, 44.9%) than in women (46, 22.2%), PConclusions: In octogenarians with acute coronary syndrome female sex was independently associated with death/hospitalisation at 6 months. Frailty was more common in women and was a predictor of poor prognosis. In men prefrailty also predicted a poor prognosis.

Aims: Current guidelines recommend an early invasive strategy in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). The role of an invasive strategy in frail elderly patients remains controversial. The aim of this substudy was to assess the impact of an invasive strategy on outcomes according to the degree of frailty in these patients. Methods and results: The LONGEVO-SCA registry included unselected NSTEACS patients aged =80 years. A geriatric assessment, including frailty, was performed during hospitalisation. During the admission, we evaluated the impact of an invasive strategy on the incidence of cardiac death, reinfarction or new revascularisation at six months. From 531 patients included, 145 (27.3%) were frail. Mean age was 84.3 years. Most patients underwent an invasive strategy (407/531, 76.6%). Patients undergoing an invasive strategy were younger and had a lower proportion of frailty (23.3% vs. 40.3%, p

Objectives To assess the efficacy and safety of the Xience Prime everolimus-eluting stent (EES) in long coronary lesions in a real-world population. Background Long lesions are considered difficult technically and in terms of achieving successful clinical outcomes. With first generation DES, MACE can be as high as 10% at a short-medium term follow-up. There are a few data available in this subset regarding the use of second generation DES METHODS: A prospective, multicenter registry of consecutive patients (aged 64.8 ± 11.2 years, 77% men and 33% diabetics) in 29 tertiary hospitals with de novo > 24 mm lesions in vessels of 2.25-4 mm was performed. The primary and secondary endpoints were major adverse cardiac events (MACE; cardiac death, myocardial infarction, and target lesion revascularization) and stent thrombosis (ST) at 1, 12, and 24 months. Patients were on dual antiplatelet therapy during 12 months. Results A total of 610 patients with 705 long lesions were included (1.2 per patient). Lesion length was 34.59 ± 11.17 mm and vessel size 2.93 ± 0.41 mm. Stented length was 39.83 ± 14.08 mm (1.4 stents per lesion). Predilatation/postdiltatation was performed in 75 and 33% of the cases, intravascular ultrasound in 15%. The device success rate was 99.1%. MACE and ST rates at 1, 12, and 24-months follow-up were 0.3, 2.1, and 5.4% and 0.2, 0.7, and 1.5%, respectively. Conclusion In this real-world population, the Xience Prime EES performs extremely well in long lesions, with a very low rate of both MACE and ST.

Resumen Introduccion y objetivos Las neoplasias malignas son la segunda causa de muerte en los paises desarrollados, por detras de las enfermedades cardiovasculares, y ambas entidades tienen factores en comun. Metodos Estudio prospectivo de todos los pacientes ingresados por un sindrome coronario agudo en el que se evaluo la prevalencia de neoplasias y la incidencia tras el alta. Resultados La prevalencia de neoplasias en los 1.819 pacientes incluidos fue del 3,4% y el 41,9% de los casos se consideraron libres de enfermedad. Entre los 1.731 pacientes dados de alta, la incidencia fue 3,1% (53 casos) y las localizaciones mas frecuentes fueron colon, pulmon, vejiga y pancreas. Los pacientes con neoplasias prevalentes presentaron mas edad, comorbilidades y complicaciones. No se observaron diferencias en el porcentaje de revascularizacion, pero si menor uso de stents farmacoactivos en los pacientes con neoplasias prevalentes. Durante el seguimiento, la mediana de tiempo hasta el diagnostico de nuevas neoplasias fue de 25 meses y el analisis multivariante identifico como factores independientes la edad y el ser fumador o exfumador. La mortalidad por cualquier causa tras el alta fue muy superior en los pacientes con neoplasias incidentes (64,2%) o prevalentes (40,0%). El analisis multivariante mostro que en las neoplasias prevalentes e incidentes se multiplicaba por 4 el riesgo de mortalidad por cualquier causa. Conclusiones El 3,8% de los pacientes tuvieron neoplasias prevalentes y menos del 50% se consideraban curadas en el momento del ingreso. La incidencia de nuevas neoplasias fue del 3,4% y ambas formas de neoplasias empeoraron mucho el pronostico a largo plazo.

Introduction: HF remains a frequent complication following MI and adversely affects prognosis. The objective of this study was to identify predictors of HF following MI and to design a risk score for its prediction. Methods: Retrospective study of all consecutive patients admitted forMI. Primary end pointwas time to incident HF. Patients with previous history of HF were excluded. Death was modelled as competing risk. Results: 5737 patients were included. Mean age was 66.32 +/- 12.80. During a median follow-up of 47.0 months (23.0-73.0), 686 patients (12%) developed HF. Age, diabetes mellitus, peripheral artery disease, renal insufficiency, chronic obstructive pulmonary disease, persistent atrial fibrillation, haemoglobin, troponin peak, diuretic at admission, ventricular function, and revascularizationwere independent predictors for HF development. According to this multivariate regression analysis, we developed a novel score that allows for the identification of patients at high (>= 16), medium (9-15) and low risk (

Background: Intravenous infusion of adenosine is considered standard practice for fractional flow reserve (FFR) assessment but is associated with adverse side-effects and is time-consuming. Intracoronary bolus injection of adenosine is better tolerated by patients, cheaper, and less time-consuming. However, current literature remains fragmented and modestly sized regarding the equivalence of intracoronary versus intravenous adenosine. We aim to investigate the relationship between intracoronary adenosine and intravenous adenosine to determine FFR. Methods: We performed a lesion-level meta-analysis to compare intracoronary adenosine with intravenous adenosine (140 µg/kg per minute) for FFR assessment. The search was conducted in accordance to the Preferred Reporting for Systematic Reviews and Meta-Analysis statement. Lesion-level data were obtained by contacting the respective authors or by digitization of scatterplots using custom-made software. Intracoronary adenosine dose was defined as; low: Results: We collected 1972 FFR measurements (1413 lesions) comparing intracoronary with intravenous adenosine from 16 studies. There was a strong correlation (correlation coefficient =0.915; P P Conclusions: The present study documents clinically irrelevant differences in FFR values obtained with intracoronary versus intravenous adenosine. Intracoronary adenosine hence confers a practical and patient-friendly alternative for intravenous adenosine for FFR assessment.

Aims Anemia is associated with poorer outcomes in patients with acute coronary syndromes (ACS), but the magnitude of this association in elderly patients remains poorly understood. No study has assessed the prognostic impact of anemia according to frailty status in this setting. Methods The LONGEVO-SCA registry included unselected ACS patients aged at least 80 years. A geriatric assessment was performed during hospitalization, including frailty assessment using the FRAIL scale. Anemia was defined by the WHO criteria. We evaluated the impact of anemia on 6-month mortality according to the presence of frailty. Results A total of 517 patients were assessed. Mean age was 84.3 years, and a total of 236 patients (45.6%) had anemia. Patients with anemia had a higher prevalence of comorbidities and higher prevalence of frailty (30.6 vs. 22.3%, P = 0.007). A total of 60 patients (12.1%) died at 6 months [40 with anemia (17.5%) and 20 without anemia (7.5%), P = 0.001]. Anemia was independently associated with mortality at 6 months in the whole cohort (hazard ratio 2.28, 95% CI 1.13-457, P = 0.021). The association of anemia and mortality was different according to frailty status, being significant in patients without frailty (hazard ratio 3.94, 95% CI 1.84-8.45, P = 0.001), but not in frail patients (hazard ratio 1.17, 95% CI 0.53-2.57, P = 0.705), (P value for interaction = 0.035). Conclusion A high proportion of elderly patients with ACS have anemia, leading to a worse prognosis in the whole cohort. The association between anemia and mortality was especially significant in robust patients, whereas the poorer prognosis in frail patients was not modified by the presence of anemia.

Resumen Introduccion y objetivos La proporcion de pacientes de edad avanzada que se someten a angioplastia primaria esta creciendo. Este estudio describe el perfil clinico, las caracteristicas de los procedimientos, la evolucion y los predictores pronosticos. Metodos Registro en 31 centros de pacientes consecutivos mayores de 75 anos tratados con angioplastia primaria. Se recogieron variables clinicas y del procedimiento y se efectuo seguimiento clinico. Resultados Se incluyo a 3.576 pacientes (el 39,3% mujeres, el 48,5% con insuficiencia renal, el 11,5% en Killip III o IV y el 29,8% con mas de 6 h de dolor). El 55,4% presentaba enfermedad multivaso y al 24,8% se les trato ademas lesiones no culpables. Se utilizo via radial en el 56,4%, bivalirudina en el 11,8%, aspiracion de trombo en el 55,9% y stents farmacoactivos en el 26,6%. La incidencia de muerte cardiaca al mes era del 10,1% y a los 2 anos, del 14,7%. A los 2 anos la trombosis definitiva o probable era del 3,1%; la revascularizacion de lesion tratada, del 2,3% y las hemorragias BARC > 2, del 4,2%. Los predictores pronosticos fueron: diabetes mellitus, insuficiencia renal, fibrilacion auricular, retraso > 6 h, fraccion de eyeccion III - IV , via radial, bivalirudina, stents farmacoactivos, flujo final TIMI III y revascularizacion incompleta al alta. Conclusiones En este registro destaca el frecuente retraso en la presentacion y la alta prevalencia de factores adversos como la insuficiencia renal o la enfermedad multivaso. Se identificaron como factores protectores relacionados con el procedimiento el menor retraso, el uso de via radial, la bivalirudina, los stents farmacoactivos y la revascularizacion completa antes del alta.

Background Cangrelor, an intravenous, reversible P2Y12 antagonist, is approved for use in patients undergoing percutaneous coronary intervention (PCI). Objectives This study sought to evaluate the efficacy and safety of cangrelor compared with clopidogrel in subgroups that did and did not receive glycoprotein IIb/IIIa inhibitors (GPIs). Methods This pooled, patient-level analysis of the 3 CHAMPION (Cangrelor versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition) trials analyzed all randomized patients who underwent PCI and received the study drug (n = 24,902). Only bailout/rescue GPI use was permitted, except in CHAMPION PCI, in which routine or bailout/rescue GPI use was at the site investigator’s discretion. The primary efficacy endpoint was the composite of all-cause mortality, myocardial infarction, ischemia-driven revascularization, or stent thrombosis at 48 h after randomization. Results Overall, 3,173 patients (12.7%) received a GPI, most commonly eptifibatide (69.4%). Despite variation in indications for GPIs, baseline characteristics were well balanced between the cangrelor and clopidogrel arms in subsets receiving and not receiving GPIs. Rates of the primary composite endpoint were lower with cangrelor compared with clopidogrel in patients who did (4.9% vs. 6.5%; odds ratio [OR]: 0.74; 95% confidence interval [CI]: 0.55 to 1.01) or did not receive a GPI (3.6% vs. 4.4%; OR: 0.82; 95% CI: 0.72 to 0.94; Pint = 0.55). Cangrelor did not increase the primary safety endpoint, GUSTO-defined severe/life-threatening bleeding, in patients who did (0.4% vs. 0.5%; OR: 0.71; 95% CI: 0.25 to 1.99) or did not receive GPIs (0.2% vs. 0.1%; OR: 1.56; 95% CI: 0.80 to 3.04; Pint = 0.21). GPI use was associated with increased risk of bleeding in both treatment arms. Conclusions Cangrelor’s efficacy in reducing ischemic complications in patients undergoing PCI was maintained irrespective of GPI administration. GPI use was associated with substantially higher bleeding rates, regardless of the randomization to cangrelor or clopidogrel. (A Clinical Trial to Demonstrate the Efficacy of Cangrelor [PCI]: NCT00305162 ; Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition [PLATFORM]: NCT00385138 ; A Clinical Trial Comparing Cangrelor to Clopidogrel Standard Therapy in Subjects Who Require Percutaneous Coronary Intervention [PCI] [CHAMPION PHOENIX] [CHAMPION]: NCT01156571 )

Resumen Introduccion y objetivos Los sistemas de atencion urgente del infarto se han creado para mejorar su tratamiento y la revascularizacion, pero pueden mejorar el manejo de todos los pacientes con sindrome coronario agudo. Metodos Estudio comparativo de todos los pacientes ingresados por sindrome coronario agudo antes y tras la implantacion de un codigo infarto. Resultados Se incluyo a 1.210 pacientes, y aunque la media de edad fue igual en ambos periodos, los pacientes ingresados tras la implantacion del codigo infarto presentaron menor prevalencia de diabetes mellitus e hipertension pero mas tabaquismo activo y mayor GRACE. Se observo un incremento significativo en el porcentaje de pacientes ingresados por sindrome coronario agudo con elevacion del segmento ST (29,8-39,5%) y de revascularizaciones coronarias (82,1-90,1%), asi como la generalizacion de la angioplastia primaria (51,9-94,9%), ademas de una reduccion en el tiempo hasta el cateterismo e incremento de la revascularizacion precoz. La estancia hospitalaria media fue significativamente mas corta tras la implantacion del codigo infarto. No se observaron diferencias en la mortalidad hospitalaria, salvo entre los pacientes de alto riesgo (38,8-22,4%). Tras el alta no se observan diferencias entre ambos periodos en mortalidad cardiovascular, mortalidad por cualquier causa, reinfarto o complicaciones cardiovasculares mayores. Conclusiones La implantacion del codigo infarto conllevo un incremento de pacientes ingresados por sindrome coronario agudo con elevacion del segmento ST y mayor GRACE. Se redujo la estancia hospitalaria, se generalizo la angioplastia primaria y se redujo la mortalidad hospitalaria de los pacientes de alto riesgo. El pronostico tras el alta fue igual en ambos periodos.

Resumen Introduccion y objetivos La valoracion angiografica visual sigue utilizandose para decidir la revascularizacion de lesiones coronarias dudosas. Multiples factores, distintos del grado de estenosis, se han asociado con la repercusion funcional de una lesion coronaria. El objetivo de este estudio es analizar la capacidad de predecir visualmente la repercusion funcional de una lesion coronaria y los condicionantes clinicos y angiograficos asociados con el error en la prediccion. Metodos Estudio de concordancia entre la prediccion de repercusion funcional realizada por intervencionistas expertos y el valor de reserva fraccional de flujo obtenido mediante guia intracoronaria de presion en 665 lesiones intermedias (estenosis del 40–70% del diametro) en 587 pacientes. Se determinaron los factores independientemente asociados a un error en la prediccion. Resultados Se observo una discordancia del 30,1% (sobrestimacion, 11,3%; subestimacion, 18,8%) entre el valor de reserva fraccional de flujo predicho ≤ 0,80 y el observado. La localizacion en el stent, en una arteria distinta de la descendente anterior y en una bifurcacion se asocio a sobrestimacion. El sexo masculino, la calcificacion grave y el mayor territorio miocardico distal a la lesion se asociaron significativamente con importancia funcional de la lesion subestimada. Conclusiones Incluso integrando caracteristicas angiograficas y clinicas, la estimacion visual de la importancia funcional de estenosis coronarias intermedias se asocia a una alta tasa de discrepancias respecto a su determinacion real. Determinadas caracteristicas angiograficas y clinicas se asocian especificamente con mayor tendencia a sobrestimar o subestimar la importancia de la lesion.

The incidence of acute coronary syndromes (ACS) is high in the elderly. Despite a high prevalence of frailty and other aging-related variables, little information exists about the optimal clinical management in patients with coexisting geriatric syndromes. The aim of the LONGEVO-SCA registry (Impacto de la Fragilidad y Otros Sindromes Geriatricos en el Manejo y Pronostico Vital del Anciano con Sindrome Coronario Agudo sin Elevacion de Segmento ST) is to assess the impact of aging-related variables on clinical management, prognosis, and functional status in elderly patients with ACS. A series of 500 consecutive octogenarian patients with non-ST-segment elevation ACS from 57 centers in Spain will be included. A comprehensive geriatric assessment will be performed during the admission, assessing functional status (Barthel Index, Lawton-Brody Index), frailty (FRAIL scale, Short Physical Performance Battery), comorbidity (Charlson Index), nutritional status (Mini Nutritional Assessment-Short Form), and quality of life (Seattle Angina Questionnaire). Patients will be managed according to current recommendations. The primary outcome will be the description of mortality and its causes at 6 months. Secondary outcomes will be changes in functional status and quality of life. Results from this study might significantly improve the knowledge about the impact of aging-related variables on management and outcomes of elderly patients with ACS. Clinical management of these patients has become a major health care problem due to the growing incidence of ACS in the elderly and its particularities.

Resumen Introduccion y objetivos El periodo de uso recomendado del tratamiento antiagregante plaquetario combinado doble tras implante de stents farmacoactivos va de los 6 a los 12 meses o mas. Ensayos recientes indican que es seguro utilizar un tratamiento antiagregante plaquetario combinado doble durante 6 meses, si bien ciertas limitaciones de estos estudios hacen que sea escasa la aplicabilidad de esta estrategia de tratamiento antiagregante plaquetario combinado doble de menor duracion en la practica clinica real. Metodos Se puso en marcha un registro con la inscripcion de pacientes consecutivos a los que se habia implantado stent farmacoactivo de nueva generacion seguido de una prescripcion de 6 meses de tratamiento antiagregante plaquetario combinado doble. Se realizo una igualacion por puntuacion de propension con una cohorte historica de pacientes tratados con stents farmacoactivos de segunda generacion que recibieron luego 12 meses de tratamiento antiagregante plaquetario combinado doble del registro ESTROFA-2. El tamano muestral se calculo para el criterio de no inferioridad y el objetivo principal fue la combinacion de muerte cardiaca, infarto de miocardio, revascularizacion o hemorragia mayor a los 12 meses. Resultados Se incluyo en el analisis a 1.286 pacientes de cada grupo, que no presentaban diferencias significativas en sus caracteristicas basales. Se produjeron episodios del objetivo principal en el 5,0 y el 6,6% de los pacientes en los grupos de 6 y de 12 meses respectivamente (p = 0,001 para no inferioridad). La incidencia de trombosis del stent definitiva o probable fue del 0,5 y el 0,7% en los grupos de tratamiento de 6 y 12 meses respectivamente (p = 0,4). Los episodios de hemorragia mayor fueron menos en el grupo de 6 meses que en el de 12 (el 0,8 y el 1,4%; p = 0,2). Conclusiones En pacientes seleccionados de este amplio estudio multicentrico, la seguridad y la eficacia de 6 meses de tratamiento antiagregante plaquetario combinado doble despues del implante de stents farmacoactivos de nueva generacion fueron no inferiores a las observadas con 12 meses de tratamiento antiagregante plaquetario combinado doble.

Objective Functional assessment of coronary artery stenosis is performed by measuring the fractional flow reserve (FFR) under hyperemic conditions (Adenosine). However, the use of adenosine portends limitations. Objective We sought to investigate the relationship and correlation between FFR and the Pd/Pa value obtained just after the intracoronary infusion (acute drop) of nitroglycerin (Pd/Pa-NTG) and if this parameter enhances diagnostic accuracy for FFR prediction compared to the resting baseline Pd/Pa. Methods We conducted a multicenter study including prospectively patients presenting intermediate coronary artery stenosis (30–70%) evaluated with pressure wire. Resting baseline Pd/Pa, Pd/Pa-NTG and FFR were measured. Results 283 patients (335 lesions) were included. Resting baseline Pd/Pa value was 0.72 to 1.0 (0.93 ± 0.04), Pd/Pa-NTG was 0.60 to 1.0 (0.87 ± 0.07) and FFR 0.55 to 1.0 (0.83 ± 0.08). The ROC curves for resting baseline Pd/Pa and for Pd/Pa-NTG, using a FFR ≤ 0.80 showed an AUC of 0.88 (95% CI: 0.84–0.92, P 0.80, were >0.96 and >0.88, respectively. These values were present in a 29.8% (n = 100) and a 47.1% (n = 158), of the total lesions. Scatter plots showed a better correlation and agreement points with Pd/Pa-NTG than resting baseline Pd/Pa. The cutoff value of Pd/Pa-NTG > 0.88 showed an excellent NPV (96.2% for FFR > 0.8 and 100% for FFR > 0.75) and sensitivity (95% for FFR > 0.8 and 100% for FFR > 0.75) which were consistently high across all the subgroups analysis. Conclusion The cutoff value of acute Pd/Pa-NTG > 0.88 has a high NPV meaning adenosine-FFR can be avoided in almost half of lesions. © 2015 Wiley Periodicals, Inc.

Objectives The purpose of this study was to assess the diagnostic accuracy of the instantaneous wave-free ratio (iFR) to characterize, outside of a pre-specified range of values, stenosis severity, as defined by fractional flow reserve (FFR) ≤0.80, in a prospective, independent, controlled, core laboratory–based environment. Background Studies with methodological heterogeneity have reported some discrepancies in the classification agreement between iFR and FFR. The ADVISE II (ADenosine Vasodilator Independent Stenosis Evaluation II) study was designed to overcome limitations of previous iFR versus FFR comparisons. Methods A total of 919 intermediate coronary stenoses were investigated during baseline and hyperemia. From these, 690 pressure recordings (n = 598 patients) met core laboratory physiology criteria and are included in this report. Results The pre-specified iFR cut-off of 0.89 was optimal for the study and correctly classified 82.5% of the stenoses, with a sensitivity of 73.0% and specificity of 87.8% (C statistic: 0.90 [95% confidence interval (CI): 0.88 to 0.92, p < 0.001]). The proportion of stenoses properly classified by iFR outside of the pre-specified treatment (≤0.85) and deferral (≥0.94) values was 91.6% (95% CI: 88.8% to 93.9%). When combined with FFR use within these cut-offs, the percent of stenoses properly classified by such a pre-specified hybrid iFR-FFR approach was 94.2% (95% CI: 92.2% to 95.8%). The hybrid iFR-FFR approach obviated vasodilators from 65.1% (95% CI: 61.1% to 68.9%) of patients and 69.1% (95% CI: 65.5% to 72.6%) of stenoses. Conclusions The ADVISE II study supports, on the basis rigorous methodology, the diagnostic value of iFR in establishing the functional significance of coronary stenoses, and highlights its complementariness with FFR when used in a hybrid iFR-FFR approach. (ADenosine Vasodilator Independent Stenosis Evaluation II–ADVISE II; NCT01740895)

Background Fractional flow reserve (FFR) has become an established tool for guiding treatment, but its graded relationship to clinical outcomes as modulated by medical therapy versus revascularization remains unclear. Objectives The study hypothesized that FFR displays a continuous relationship between its numeric value and prognosis, such that lower FFR values confer a higher risk and therefore receive larger absolute benefits from revascularization. Methods Meta-analysis of study- and patient-level data investigated prognosis after FFR measurement. An interaction term between FFR and revascularization status allowed for an outcomes-based threshold. Results A total of 9,173 (study-level) and 6,961 (patient-level) lesions were included with a median follow-up of 16 and 14 months, respectively. Clinical events increased as FFR decreased, and revascularization showed larger net benefit for lower baseline FFR values. Outcomes-derived FFR thresholds generally occurred around the range 0.75 to 0.80, although limited due to confounding by indication. FFR measured immediately after stenting also showed an inverse relationship with prognosis (hazard ratio: 0.86, 95% confidence interval: 0.80 to 0.93; p Conclusions FFR demonstrates a continuous and independent relationship with subsequent outcomes, modulated by medical therapy versus revascularization. Lesions with lower FFR values receive larger absolute benefits from revascularization. Measurement of FFR immediately after stenting also shows an inverse gradient of risk, likely from residual diffuse disease. An FFR-guided revascularization strategy significantly reduces events and increases freedom from angina with fewer procedures than an anatomy-based strategy.

Objectives The aim of this study was to determine whether drug-eluting stents (DES) are superior to bare-metal stents (BMS) in octogenarian patients with angina. Background Patients ≥80 years of age frequently have complex coronary disease warranting DES but have a higher risk of bleeding from prolonged dual antiplatelet therapy. Methods This multicenter randomized trial was conducted in 22 centers in the United Kingdom and Spain. Patients ≥80 years of age underwent stent placement for angina. The primary endpoint was a 1-year composite of death, myocardial infarction, cerebrovascular accident, target vessel revascularization, or major hemorrhage. Results In total, 800 patients (83.5 ± 3.2 years of age) were randomized to BMS (n = 401) or DES (n = 399) for treatment of stable angina (32%) or acute coronary syndrome (68%). Procedural success did not differ between groups (97.7% for BMS vs. 95.4% for DES; p = 0.07). Thirty-eight percent of patients had ≥2-vessel percutaneous coronary intervention, and 66% underwent complete revascularization. Patients who received BMS had shorter stent implants (24.0 ± 13.4 mm vs. 26.6 ± 14.3 mm; p = 0.01). Rates of dual antiplatelet therapy at 1 year were 32.2% for patients in the BMS group and 94.0% for patients in the DES group. The primary endpoint occurred in 18.7% of patients in the BMS group versus 14.3% of patients in the DES group (p = 0.09). There was no difference in death (7.2% vs. 8.5%; p = 0.50), major hemorrhage (1.7% vs. 2.3%; p = 0.61), or cerebrovascular accident (1.2% vs. 1.5%; p = 0.77). Myocardial infarction (8.7% vs. 4.3%; p = 0.01) and target vessel revascularization (7.0% vs. 2.0%; p = 0.001) occurred more often in patients in the BMS group. Conclusions BMS and DES offer good clinical outcomes in this age group. DES were associated with a lower incidence of myocardial infarction and target vessel revascularization without increased incidence of major hemorrhage. (Xience or Vision Stent–Management of Angina in the Elderly [XIMA]; ISRCTN92243650 )

Assessment of intermediate coronary lesions can be done with fractional flow reserve (FFR) and intravascular ultrasound (IVUS). There are no randomised trials and only a small registry from one centre is available but this is subject to important bias. We sought to evaluate the clinical outcomes of an FFR strategy compared with an IVUS strategy for intermediate lesion assessment.We compared the outcome of patients assessed with FFR and IVUS in two centres with a differential approach. After propensity score matching 400 pairs of patients were included. Revascularisation was done when FFR was0.75 or minimum lumen area was4 mm2 in vessels3 mm, and3.5 mm2 in vessels 2.5-3 mm, along with plaque burden50%. After FFR and IVUS, 72% and 51.2% of lesions, respectively, were left untreated (p0.001). At one and two years no significant differences in MACE-free survival were observed in overall groups (97.7% at one year and 93.1% at two years in the FFR group and 97.7% at one year and 95.6% at two years in the IVUS group; p=0.35) and among those with deferred intervention (97.9% at one year and 94.2% at two years in the FFR group and 96.5% at one year and 93.6% at two years in the IVUS group; p=0.7).IVUS and FFR may be safely used to defer revascularisation of intermediate lesions. IVUS induces a higher degree of revascularisation but much lower than previously reported and does not affect the clinical outcome.

ResumenIntroduccion y objetivos La estimacion mediante ecografia intracoronaria de la repercusion funcional de lesiones angiograficas intermedias se ha basado principalmente en la medicion del area luminal minima. Estas estimaciones no han tenido en cuenta la longitud de la lesion y no han sido estudiadas suficientemente en lesiones coronarias largas. Metodos Se incluyen 61 lesiones con un 40-70% de estenosis angiografica visual y necesidad de stent ≥ 20 mm para su tratamiento, que se estudiaron con ecografia y reserva fraccional de flujo. Se realizo un analisis tridimensional offline del estudio de ecografia, ciego al valor de reserva fraccional. Se correlacionaron los parametros angiograficos y ecograficos con la reserva fraccional obtenida. Resultados Se obtuvieron por angiografia valores medios de diametro de referencia (2,87 ± 0,57 mm; longitud, 29,8 ± 10,01 mm) y grado de estenosis (50,3 ± 8,7%). El valor medio de reserva fraccional de flujo fue 0,78 ± 0,09. Se obtuvo una pobre correlacion lineal (R) entre la reserva fraccional y los parametros de ecografia que no incluian la longitud de la lesion: reserva fraccional-area luminal minima (R = 0,4; p = 0,003); y mejor cuando se la tenia en cuenta: reserva fraccional − volumen de la placa (R = –0,65; p

This article summarizes the main developments reported during the year 2012 concerning ischemic heart disease, together with the most relevant innovations in the management of acute cardiac patients. Full English text available from: www.revespcardiol.org/en.