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Introduction : Atherosclerotic coronary artery disease, in particular acute myocardial infarction (AMI), is a leading cause of morbidity and mortality globally. Percutaneous coronary intervention (PCI) is the mainstay of treatment for obstructive coronary artery disease and AMI through the restoration of TIMI III flow. Despite good macrovascular flow, the myocardium can remain hypoperfusion due to poor microvascular perfusion, and this is referred to as 'no-reflow'. Various treatments have been studied with variable success in both prevention and treatment of no-reflow. Areas covered : This review outlines the cutting-edge diagnostic investigations which have been explored in no-reflow, allowing a deeper understanding of mechanism and microvascular pathological processes involved in its genesis. These include utility of novel MRI techniques and perfusion echo in conjunction with traditional approaches. Detailed review has been undertaken of both pharmacological and non-pharmacological techniques to prevent and manage microvascular dysfunction associated with no-reflow. Particular attention was paid to the evolution and successes of various mechanical protection devices. Expert opinion : Most promising innovations in the diagnosis and management of no-reflow are evaluated, and future outlook is explored. Emerging advances in acute coronary syndrome have their findings applied a role in modifying the pathophysiology of no-reflow.

Antiphospholipid syndrome (APS) is an autoimmune multisystem disorder characterised by high incidence of arterial and venous thrombosis. Cardiovascular manifestations also include valvular heart disease, ventricular thrombi and higher risk for coronary artery disease (CAD). In this case report, we describe a 61-year-old woman who had no significant risk factors for CAD, and presented with aggressive disease in native and graft vessels that required multiple coronary interventions. The extent of her aggressive CAD could not be explained by her risk factors profile. Therefore autoantibodies screening was carried out and showed a strongly positive anticardiolipin and β2 glycoprotein-I antibody, and hence a diagnosis of antiphospholipid syndrome was made.

Dual antiplatelet therapy is well recognized in the prevention of thrombotic complications of acute coronary syndrome and percutaneous coronary interventions. Despite clinical benefits of aspirin and clopidogrel therapy, a number of limitations curtail their efficacy: slow onset of action, variability in platelet inhibitory response and potential drug-drug interactions. Furthermore, the single platelet-activation pathway targeted by these agents allows continued platelet activation via other pathways, ensuring incomplete protection against ischemic events, thus, underscoring the need for alternate antiplatelet treatment strategies. A number of novel antiplatelet agents are currently in advance development and many have established superior effects on platelet inhibition, clinical outcomes and safety profile than clopidogrel in high-risk patients. The aim of this review is to provide an overview of the current status of P2Y12 receptor inhibition and PAR-1 antagonists in determining a future strategy for individualized antiplatelet therapy.

Background: Despite continued advances in creating lower-profile intracoronary balloons and stents, technical difficulties with stent deliverability are frequently encountered. Recent advances in catheter design have yielded soft ended atraumatic catheters for use within standard guide catheters - the so called double coaxial guiding catheter technique. We report our preliminary experience using the 5 Fr Terumo guide catheter (Heartrail II, Terumo) from a single center., Methods: We describe six percutaneous coronary intervention (PCI) procedures where stent deployment initially failed during the standard approach. Subsequent utilization of this 5 Fr catheter system within a standard 6 Fr guide facilitated successful procedural outcomes. This catheter system facilitated non-traumatic deep intubation and stent delivery beyond the site of obstruction encountered during PCI of the distal right coronary and left anterior descending arteries., Results: 3 males and 3 females with a mean age of 72.5 ± 5.4 years underwent PCI using the Heartrail II catheter. Patient and procedural characteristics are summarized in Table 1. The intracoronary catheter was inserted into 3 right coronary arteries, 2 left circumflex arteries and 1 left anterior descending artery. Classification of discrete lesions yielded 6 type C lesions. The mean number of stents deployed was 3.33 ± 0.80 with a mean procedure X-ray screening duration of 35.04 ± 7.79 minutes. No complications relating to ostial artery catheter-induced dissections were encountered.

A series of interventional tools have emerged since the advent of percutaneous coronary angioplasty. Several are fundamental and used routinely, while others less favourable have fallen short of mainstream therapy and/or have settled as a niche device. We present an overview of the evolution of directional coronary atherectomy (DCA), a unique device that was originally conceived in 1984 to solve the limitations of balloon angioplasty. Unfortunately, we have witnessed its use fall significantly out of favour due to premature and controversial study results. In many interventional laboratories DCA is no longer available. However, we strongly feel that allowing DCA to join the list of extinct interventional tools would be very unfortunate. We, herein, present a series of complex percutaneous coronary procedures to illustrate the convenience of DCA use as a lesion-specific niche device. Finally, DCA offers a valuable distinct clinical research function as it allows for in vivo pathological coronary tissue examination. In conclusion, we plead for its continued production and use as an interventional niche device for the wellbeing of our patients.

Carotid duplex ultrasonography (DUS) is routinely performed prior to coronary artery bypass graft surgery (CABG) on all patients > 65 years old because of the reported associated risk of finding concomitant carotid artery stenosis. Identifying risk factors that correlate with severe carotid stenosis may result in more cost-effective screening for patients with asymptomatic carotid artery disease prior to CABG. We performed a retrospective study to identify risk factors for significant carotid artery disease in patients scheduled to undergo CABG between March 2005 and March 2008 at the Massachusetts General Hospital. Patients with carotid stenosis >or= 70% identified by DUS (n = 50) were matched by age and sex to control patients who had < 50% stenosis (n = 50). Data were analyzed using the chi-squared test or analysis of variance as appropriate. Logistic regression was used to examine multivariate correlates of carotid stenosis. A total of 643 patients were screened to arrive at the patient cohorts described below. This produced a prevalence of 7.7% for significant (> 70%) carotid disease. The patient cohorts were predominantly male with no significant difference in the incidence of diabetes, hypertension, extent of coronary artery disease (CAD) (i.e. left main coronary artery disease (LMCA) and one, two-, or three-vessel CAD) or lipid abnormalities in the two groups. Univariate analysis identified the presence of peripheral arterial disease (PAD, p = 0.001), a cervical bruit (p < 0.0001), a prior neurological event (p = 0.020), and the presence of an abdominal aortic aneurysm (AAA; p = 0.046) as significant predictors of >or= 70% internal carotid artery stenosis. Logistic regression analysis revealed that the presence of a carotid bruit (p = 0.0068) and PAD (p = 0.0194) were associated with an increased risk of significant carotid artery disease. In conclusion, the presence of a carotid bruit or PAD predicts an increased likelihood of significant carotid artery disease in patients undergoing CABG. Unlike previous studies, LMCA or extent of CAD did not correlate with significant carotid artery disease. Using these predictive models, a prospective outcomes trial is required to validate these criteria.

Aims: Therapeutic options for patients with recurrent cardiac ischemia after coronary artery bypass surgery may be limited and some patients may be considered nonrevascularizable. To further the understanding of this patient cohort, we performed a population-based study of post-coronary bypass patients who developed recurrent angina., Methods and Results: Patients who underwent coronary artery and bypass graft angiography at Mayo Clinic from 2001 to 2005 were identified. Medical records were reviewed to determine indication for angiography, and angiographic analysis was performed in all patients. Among 133 000 residents of Olmsted County, Minnesota, 347 post-bypass patients with angina underwent coronary angiography from 2001 to 2005. Of these, 177 patients received further revascularization (145 percutaneous coronary intervention and 32 redo coronary artery bypass grafting) and the remaining 170 patients were managed medically. Revascularization was not associated with improvement in all-cause or cardiac mortality. Multivariate analysis identified renal dysfunction, diabetes, and severe left ventricular dysfunction but not the lack of revascularization as predictors of mortality., Conclusion: In this population-based study, we identified a yearly incidence range of 17.9-33.2 patients with nonrevascularizable angina after coronary artery bypass grafting per 100 000 population. Further revascularization was not associated with improved mortality or morbidity. Attempts to develop therapeutics for this population must consider the incidence and outcomes of this cohort.

Prolonged dual-antiplatelet therapy with aspirin and clopidogrel is mandatory after drug-eluting stent implantation because of the potential increased risk of late stent thrombosis. The concern regarding prolonged antiplatelet therapy is the increased risk of bleeding. Gastrointestinal bleeding is the most common site of bleeding and presents a serious threat to patients due to the competing risks of gastrointestinal hemorrhage and stent thrombosis. Currently, there are no guidelines and little evidence on how best to manage these patients who are at high risk of morbidity and mortality from both the bleeding itself and the consequences of achieving optimum hemostasis by interruption of antiplatelet therapy. Managing gastrointestinal bleeding in a patient who has undergone recent percutaneous coronary intervention requires balancing the risk of stent thrombosis against further catastrophic bleeding. Close combined management between gastroenterologist and cardiologist is advocated to optimize patient outcomes.

The role of endovascular therapy for the treatment of coronary and peripheral vascular diseases (including carotid, renal and lower extremity arteries) is expanding. The steady growth in the volume of endovascular procedures is likely to result in an absolute increase in the incidence of procedural complications. Knowledge of common and specific procedural complications and their management are critical to successful outcomes. Complications can be classified as (i) access site-related and (ii) systemic.

Background: Endothelial dysfunction is an early manifestation of atherosclerotic disease. Circulating cells that express CD34, including endothelial and hematopoietic progenitor cells, might play a part in the development and progression of atherosclerosis. The aim of this study was to evaluate the association between coronary endothelial dysfunction and concentrations of circulating CD34+ cell subsets., Methods: Intracoronary acetylcholine challenge was used to test for coronary endothelial dysfunction in 57 consecutive patients scheduled to undergo diagnostic coronary angiography and with no signs of substantial obstructive lesions. Mononuclear cells were extracted from whole blood samples taken from all patients, analyzed by flow cytometry for CD14, CD34, CD133, CD45, and vascular endothelial growth factor receptor 2 (VEGFR2), and cultured for functional analysis., Results: Compared with patients with normal coronary endothelial function, in those with coronary endothelial dysfunction, the number of circulating CD34+/CD45(dim)/VEGFR2- cells, CD34+/CD45(dim)/CD133+/VEGFR2- cells and colony-forming units were reduced. Concentrations of CD34+/CD45-/VEGFR2+ cells did not differ between groups., Conclusions: Regulation of CD34+ cell subsets seems to differ between patients with coronary endothelial dysfunction and those with normal coronary endothelial function. Changes in specific circulating progenitor cell subsets might, therefore, be an early manifestation of atherosclerosis.

Angioplasty and stenting have become routine practice for the treatment of significant obstructive atherosclerotic vascular disease. This method of revascularization has a longer history concerning coronary artery disease but is becoming an increasingly used modality of revascularization in the peripheral circulation. Neointimal formation is the pathological basis for restenosis after revascularization procedures such as angioplasty, stenting, and bypass grafting. While restenosis is less of a problem in the coronary circulation with the advent of drug-eluting stents, it continues to be a problem however in the peripheral arterial system. Current treatments to prevent restenosis include pharmacologic, mechanical and cellular approaches which we will discuss in this manuscript.

Coronary artery calcification (CAC) is commonly encountered by interventional cardiologists. Severe CAC may impair stent delivery or result in stent underexpansion, stent thrombosis and/or in-stent restenosis (ISR). Multiple tools have been developed to help overcome the challenges associated with CAC and improve outcomes for these patients. Intravascular shockwave lithotripsy (IVL) is a novel therapy that uses acoustic pressure waves for the modification of CAC. This review discusses the growing body of evidence to support the safety and efficacy of IVL in the setting of de novo severely calcified coronary arteries prior to stenting. We also discuss international real-world experience with the coronary IVL system. This includes the use of IVL in the setting of acute coronary syndrome (ACS), ISR and in combination with other tools for calcium modification. IVL is a safe and effective therapy that results in the fracture of coronary calcium and facilitates optimal stent delivery and expansion. Longer term follow-up is essential to shed light on the durability and late outcomes of an IVL strategy. Randomized control trials are warranted to compare IVL to alternative methods of calcium modification and to explore further the use of IVL for ACS. [ABSTRACT FROM AUTHOR]

With an increasing prevalence of coronary heart disease, secondary prevention forms a major cornerstone of management. A dedicated nurse-led clinic for patients post percutaneous coronary intervention (PCI) offers a great opportunity to address risk factors in order to reduce cardiovascular events. To determine the impact of a nurse-led clinic follow up of patients post PCI in relation to the 30 day mortality rate and re-admission, and patient satisfaction. Risk factor assessment, compliance with dual antiplatelet therapy (DAPT), and interventions at the clinic visit were also assessed. A retrospective review of parameters recorded at clinic appointments from January 2015–December 2017. The data of patients were examined for baseline characteristics, risk factor assessment, and interventions at the clinic visit. Thirty day mortality and re-admission rates and patient satisfaction were major outcomes. 1325 individual patient records were retrospectively reviewed in our clinic. Mean age was 64 and 78% were males. The indications for PCI were STEMI (22.7%), NSTEMI (21.9%), and unstable and stable angina (43.1%). 5 patients (0.4%) died and 132 patients (10%) were re-admitted within 30 days after the follow-up visit. However, only 24 (1.8%) of the re-admissions were due to cardiac reasons. At the clinic appointment, 852 (64.3%) patients had non-pharmacological intervention and 473 (35.7%) patients had a pharmacological intervention. 712 (53.7%) patients had LDL-C above target and their statin therapy was amended accordingly. Nurse-led PCI clinics provide satisfactory assessment and management of risk factors achieving high patient satisfaction rates without increased risk of poor outcomes. • Secondary prevention constitutes a major cornerstone of management in patients treated with PCI. • Nurse-led clinics are widely utilised in several specialities providing care equivalent to non-nurse-managed clinics. • This study specifically assesses the outcomes of nurse-led clinics in patients post PCI. • Nurse-led PCI clinics provide comprehensive assessment and management of cardiovascular risk factors. • Nurse-led PCI clinics have high patient satisfaction rates without increased risk of mortality or cardiovascular readmission. [ABSTRACT FROM AUTHOR]

Introduction: Fractional flow reserve (FFR) is an objective physiological index utilized in coronary angiography. It expresses the blood flow in the presence of a coronary artery stenosis as a fraction of the normal blood flow and gives information regarding the functional significance of the lesion. FFR guided percutaneous coronary intervention (PCI) has been shown to be superior to angiography guided PCI in several trials and registries. In addition, it appears that the use of FFR may also be preferable from an economic perspective. Areas covered: This article will cover the physiological principles underpinning FFR, the landmark clinical trials that have established its diagnostic utility and the current recommendations for the use of the procedure in daily practice. We will also examine potential future directions for the technology and try to predict how its use will evolve in the next five years. Expert commentary: We see FFR as an essential diagnostic tool in the modern catheterization laboratory, enabling physicians to make optimal decisions regarding percutaneous coronary intervention for an individual patient. It must be stated however that FFR is an adjunctive invasive functional tool that must be used in conjunction with sensible clinical history and exam findings pertaining to the individual patient. We expect that the results of FAME3 will further establish the role of FFR in risk stratifying patients with 3 vessel disease by utilizing a functional SYNTAX score. [ABSTRACT FROM AUTHOR]