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Patients undergoing staged percutaneous coronary intervention (SPCI) are exposed to extended duration of antiplatelet therapy, and a novel aspirin-free antiplatelet regimen after SPCI should be specifically evaluated among these patients. This is a prespecified substudy of the GLOBAL LEADERS which is a randomized, open-label trial, comparing an experimental regimen of 1-month dual antiplatelet therapy (DAPT; ticagrelor and aspirin) followed by 23-month ticagrelor monotherapy to a reference regimen of 12-month DAPT followed by 12-month aspirin monotherapy. Patients were stratified according to whether or not SPCI was performed. The impact of the timing of SPCI on clinical outcomes was also investigated. Of 15,968 randomized patients, 1,651 patients underwent SPCI within 3 months. These patients with SPCI had a significantly higher risk of bleeding and ischemic endpoints than those without SPCI. In patients undergoing SPCI, the primary endpoint (composite of all-cause death or new Q-wave myocardial infarction at 2 years) and secondary safety endpoint (Bleeding Academic Research Consortium [BARC]-defined bleeding 3 or 5) were similar in the 2 regimens. However, in patients presenting with acute coronary syndrome (ACS), the experimental regimen reduced a risk of BARC 3 or 5 bleeding (1.8% vs 4.5%; HR 0.387; 95% CI 0.179 to 0.836; p = 0.016). In patients undergoing SPCI later than 10 days after index procedure, this risk reduction was still prominent (0.8% vs 2.3%; HR 0.321; 95% CI 0.116 to 0.891; p = 0.029). In conclusion, patients undergoing SPCI are at high risk and may need special attention from clinicians. In ACS patients undergoing SPCI, a novel aspirin-free antiplatelet regimen appears to be associated with a lower bleeding risk than with standard DAPT., Competing Interests: Conflict of Interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Inc. All rights reserved.)

In this article, we report on a 22-year-old patient with myocardial infarction, which was the initial manifestation of polycythaemia vera. The awareness of myeloproliferative disorders as possible underlying disease - especially in young patients presenting with myocardial infarction - is crucial for clinical management, as a missed diagnosis can worsen the patient's further prognosis., (© Royal College of Physicians 2017. All rights reserved.)

Aims: We sought to compare the outcomes of low/moderate complexity patients treated with the Absorb BVS from the ABSORB EXTEND trial with patients treated with the XIENCE everolimus-eluting stent (EES), using propensity score (PS) matching of pooled data from the SPIRIT trials (SPIRIT II, SPIRIT III, SPIRIT IV) and the XIENCE V USA trial., Methods and Results: ABSORB EXTEND was a prospective, single-arm, open-label clinical study in which 812 patients were enrolled at 56 sites. This study allowed the treatment of lesions ≤28 mm in length and with a reference vessel diameter of 2.0-3.8 mm (as assessed by online QCA). The propensity score was obtained by fitting a logistic regression model with the cohort indicator as the binary outcome and other variables as the predictor variables. At one-year clinical follow-up, there was no statistical difference between groups with regard to MACE (5.0% vs. 4.8%, p=0.83), target lesion failure (5.0% vs. 4.7%, p=0.74), ischaemia-driven target vessel revascularisation (2.3% vs. 3.0%, p=0.38) and device thrombosis (1.0% vs. 0.3%, p=0.11). Myocardial infarction was higher with Absorb (3.3% vs. 1.5%, p=0.02), at the expense of periprocedural CK-MB elevation. Independent predictors of MACE among patients receiving Absorb BVS were treatment of multivessel disease, insulin-dependent diabetes and performance of post-dilation., Conclusions: At one-year follow-up, propensity score-matched analysis demonstrated that the clinical safety and effectiveness of Absorb are comparable to those of XIENCE EES among non-complex patients treated with PCI.

Background: Growing evidence suggests that poor coronary blood flow after primary percutaneous coronary intervention (PCI) is associated with unfavorable clinical out-come. We retrospectively evaluated data from our single center "real world patients" database of patients undergoing primary PCI to determine differences in clinical and angiographic patterns in patients with or without restoring thrombolysis in myocardial infarction (TIMI) flow 3., Methods and Results: Between 2001 and 2006, 500 patients underwent primary PCI for STEMI. In 430 patients, post-interventional TIMI flow 3 could be established. In this group, in-hospital mortality was significant lower (6.4% Vs. 32.9%; P < 0.0001), left ventricular ejection fraction was better (51.3 Vs. 44.2%; P < 0.0001), and prehospital fibrinolytic therapy (6.3% Vs. 14.3%; P = 0.015), cardiogenic shock (10.9% Vs. 24.3%; P = 0.002) and use of intra-aortic balloon pump were all more unlikely (5.8% Vs. 11.4%; P = 0.045) compared to patients with TIMI flow < or = 2. In patients with post-interventional TIMI flow < or = 2 the left anterior descending coronary artery (LAD) was significantly more often seen as the target vessel (54.3% Vs. 44.6%; P = 0.039). A regressions analysis showed that predictors leading to such flow patterns are diabetes (P = 0.013), pre-hospital fibrinolytic therapy (P = 0.017), cardiogenic shock (P = 0.002) and a 3-vessel disease (P = 0.003). After 6 months, patients without restored normal TIMI flow had worse New York Heart Association functional class (NYHA), and had to undergo repeat coronary angiography more often., Conclusion: Post-interventional TIMI flow < or = 2 is strongly associated with adverse out-come during hospitalization and after 6 months following hospitalization.

Background: Following stenting for acute myocardial infarction, transcoronary transplantation of granulocyte-colony stimulating factor (G-CSF) mobilized autologous stem cells (ASC) has been shown to result in an increased in-stent restenosis rate of bare metal stents (BMS)., Hypothesis: This study sought to compare the extent of neointimal growth in BMS and sirolimus-eluting stents (SES) after primary implantation, and subsequent transcoronary transplantation of G-CSF mobilized stem cells., Methods: Patients with stenting of the left anterior descending coronary artery for acute anterior myocardial infarction were randomly assigned to receive a BMS or SES. Intracoronary stem cell injection was performed after G-CSF application for at least 4 d and cell apheresis. The angiograms obtained after cell transplantation and after 6 mo were analyzed by quantitative coronary angiography., Results: We performed primary stenting and stem cell transplantion in 16 patients who received a BMS (n = 8) or an SES (n = 8). In 2 patients with a BMS, late stent thrombosis occurred after 58 d and 177 d, respectively. In the remaining patients, control angiography after 6 mo revealed in-stent restenosis of >50% in no patients with SES but in 4 patients with BMS (67%). Late lumen loss and in-stent plaque volume were significantly higher in patients with BMS compared with patients with SES., Conclusions: Compared with BMS, SES impair in-stent intima hyperplasia after stenting for acute myocardial infarction and transcoronary transplantation of G-CSF mobilized ASC.

Background: There is increasing evidence that transplantation of autologous stem cells improves cardiac function after acute myocardial infarction (AMI). For propagation of peripheral blood stem cells (PBSCs), application of granulocyte-colony stimulating factor (G-CSF) has been shown to be feasible, effective, and safe. We sought to evaluate a clinical and angiographic long-term safety profile of G-CSF application combined with transcoronary PBSC transplantation after recent stent implantation for AMI., Methods: In patients with AMI and successful primary stenting of the infarct-related coronary artery, pharmacological bone marrow stimulation with G-CSF was initiated on the second postinterventional day. At least after 4 days of G-CSF therapy, apheresis as well as transcoronary transplantation of PBSCs was performed. The PBSCs were infused via a balloon catheter which was inflated inside the stent. Ventriculography and quantitative coronary angiography were performed at baseline and after 6 months., Results: In the 20 patients who received PBSCs, mean left ventricular ejection fraction improved from 46.4% +/- 8.1% at baseline to 54.3% +/- 11% after 6 months (P < .001) because of an increase in systolic function in the infarct region. Control coronary angiography revealed a significant in-stent restenosis of the infarct-related coronary artery, defined as >50% stenosis, in 8 patients (40%), which was complicated by reinfarction in 2 patients (10%)., Conclusions: Transcoronary transplantation of G-CSF-mobilized PBSCs favorably influences cardiac function and can be performed without adverse periprocedural events. However, significant in-stent restenosis and reinfarction seem to occur frequently during the following 6 months.

Background: The goal of the study was to validate the clinical benefit of adjunctive thrombus aspiration prior to balloon or stent angioplasty in patients with acute myocardial infarction., Hypothesis: Adjunctive thrombus aspiration reduces no-reflow by eliminating peripheral thromboembolism., Methods: In all, 143 consecutive patients underwent primary angioplasty for acute myocardial infarction in our institution. We excluded patients with subacute stent thrombosis or bundle-branch pattern of the electrocardiogram (ECG) and divided the remaining 131 into two groups: 62 patients who underwent intervention without a thrombus aspiration device (Group 1) and 69 patients who were treated as soon as a specifically designed thrombus aspiration catheter became available at our institution (Group 2). The intention was to use thrombus aspiration in every suitable case with proximal occlusion of a major vessel. The reduction of the sum of ST-segment elevation following angioplasty as a marker of rescued myocardial tissue was compared between the two groups., Results: Thrombus aspiration was technically feasible in 23 of 25 attempted cases. The reduction of the sum of ST-segment elevation following intervention was 0.41 +/- 0.39 mV in Group 1 and 0.37 +/- 0.42 mV in Group 2 (p > 0.05)., Conclusions: Thrombus aspiration may be helpful during primary angioplasty in selected cases but does not improve the general outcome. Other reasons for "no-reflow," apart from peripheral thromboembolism, seem to be responsible for the lack of clinical benefit.

Aims: This study aims to investigate the prevalence of Takotsubo syndrome (TTS) as a percentage of the total number of acute coronary syndrome (ACS), including non‐STE‐elevation myocardial infarction and ST‐elevation myocardial infarction, as well as the short‐term outcome of TTS patients before and during the COVID‐19 pandemic. Methods and results: We compared patients from two different periods: (i) Period 1 (before the COVID‐19 pandemic): 1 March to 30 December 2019, and (ii) Period 2 (during the COVID‐19 pandemic): 1 March to 30 December 2020. The retrospective database was created from the archives of the participating hospitals or electronic hospital systems by trained medical personnel. The subjects' medical history, cardiovascular risk factors, laboratory values, echocardiography findings, and an in‐hospital outcome were variables of interest. Furthermore, propensity score matching analysis was performed to evaluate the short‐term prognosis in TTS and ACS patients. Altogether six Austrian centres—(i) 3rd Medical Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, Vienna, Austria; (ii) 5th Medical Department of Cardiology, Clinic Favoriten, Vienna, Austria; (iii) 2nd Medical Department, Hanusch Hospital, Vienna, Austria; (iv) University Clinic of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Austria; (v) Department of Cardiology, University Hospital Graz, Graz, Austria; (vi) Department of Cardiology and Intensive Medicine, Kepler University Clinic, Linz, Austria—participated in the study. During period 1, 87 (3.5%) patients out of 2482 ACS patients had TTS in all participating centres. During period 2, 71 (2.7%) patients out of 2572 ACS patients had TTS in all participating centres. Accordingly, the prevalence of TTS remained stable irrespective of potential psychologic stress during the COVID pandemic. Furthermore, the baseline characteristics of TTS patients did not change during the COVID‐19 pandemic. The prevalence of in‐hospital complications [cardiogenic shock (4.6% vs. 4.3%, P = 0.925), ventricle thrombus (1.1% vs. 1.4%, P = 0.885) and in‐hospital bleeding (3.4% vs. 1.4%, P = 0.417)] remained stable. The all‐cause in‐hospital mortality of TTS patients did not change during the COVID‐19 pandemic [χ2(2) = 0.058, P = 0.810]. Moreover, a propensity score matching analysis of all‐cause in‐hospital mortality between matched TTS and ACS patients showed higher in‐hospital mortality in ACS patients during COVID‐19 pandemic (P = 0.043). Conclusions: Despite the well‐known increased psychologic stress during the COVID‐19 pandemic, the prevalence of TTS during the COVID‐19 pandemic and the short‐term clinical outcome in Austria remained unimpacted. [ABSTRACT FROM AUTHOR]

Background: After acute myocardial infarction (AMI), patients are at risk of sudden cardiac death. The VEST trial failed to show a reduction in arrhythmic mortality in AMI patients with an LVEF ≤ 35% prescribed with a WCD, having a lower-than-expected WCD wearing compliance. Objectives: The aim was to investigate on outcomes of patients in a real-world Austrian cohort with good compliance. Methods: A retrospective analysis of all eligible Austrian WCD patients according to the VEST trial inclusion and exclusion criteria between 2010 and 2020 was performed. Results: In total, 105 Austrian patients (64 ± 11 years, 12% female; LVEF 28 ± 6%) received a WCD for a median of 69 (1; 277) days after AMI (wearing duration 23.5 (0; 24) hours/day). Within the first 90 days, 4/105 (3.8%) patients received 9 appropriate shocks (2 (1; 5) shocks). No inappropriate shocks were delivered, and 3/105 (2.9%) patients died during follow-up. Arrhythmic mortality (1.9% Austria vs. 1.6% VEST, p = 0.52), as well as all-cause mortality (2.9% vs. 3.1%, p = 0.42) was comparable in both cohorts. Conclusions: The WCD is a safe treatment option in a highly selected cohort of patients with LVEF ≤ 35% after AMI. However, despite excellent WCD wearing duration in our cohort, the arrhythmic mortality rate was not significantly different. [ABSTRACT FROM AUTHOR]

Models of the human body representing digital twins of patients have attracted increasing interest in clinical research for the delivery of personalized diagnoses and treatments to patients. For example, noninvasive cardiac imaging models are used to localize the origin of cardiac arrhythmias and myocardial infarctions. The precise knowledge of a few hundred electrocardiogram (ECG) electrode positions is essential for their diagnostic value. Smaller positional errors are obtained when extracting the sensor positions, along with the anatomical information, for example, from X-ray Computed Tomography (CT) slices. Alternatively, the amount of ionizing radiation the patient is exposed to can be reduced by manually pointing a magnetic digitizer probe one by one to each sensor. An experienced user requires at least 15 min. to perform a precise measurement. Therefore, a 3D depth-sensing camera system was developed that can be operated under adverse lighting conditions and limited space, as encountered in clinical settings. The camera was used to record the positions of 67 electrodes attached to a patient's chest. These deviate, on average, by 2.0 mm ± 1.5 mm from manually placed markers on the individual 3D views. This demonstrates that the system provides reasonable positional precision even when operated within clinical environments. [ABSTRACT FROM AUTHOR]

Simple Summary: Takotsubo syndrome, also known as "stress-induced cardiomyopathy" is a disease of the heart that occurs after physical or emotional stress and can mimic a heart attack. Patients with this disease may become critically ill with the need for treatment at the intensive care unit or may even die. For medical professionals it is very important to identify patients that worsen. Therefore, we performed an analysis of a large registry of patients with Takotsubo syndrome in Austria that includes 338 patients. As already known, patients with reduced cardiac function (measured by "left ventricular ejection fraction") have worse outcomes. Additionally, we present the "neutrophile lymphocyte ratio" (NLR), which is a new parameter deriving from standard blood count parameters. NLR identifies patients at high risk of complications, early mortality and death at long-term follow up. Background: Takotsubo syndrome (TTS) is an important type of acute heart failure with significant risk of acute complications and death. In this analysis we sought to identify predictors for in-hospital clinical outcome in TTS patients and present long-term outcomes. Methods: In this analysis from the Austrian national TTS registry, univariable and multivariable analyses were performed to identify significant predictors for severe in-hospital complications requiring immediate invasive treatment or leading to irreversible damage, such as cardiogenic shock, intubation, stroke, arrhythmias and death. Furthermore, the influence of independent predictors on long-term survival was evaluated. Results: A total of 338 patients (median age 72 years, 86.9% female) from six centers were included. Severe in-hospital complications occurred in 14.5% of patients. In multivariable analysis, high neutrophile-lymphocyte-ratio (NLR; OR 1.04 [95% CI 1.02–1.07], p = 0.009) and low LVEF (OR 0.92 [0.90–0.95] per %, p < 0.001) were significant predictors of severe in-hospital complications. Both the highest NLR tercile and the lowest LVEF tercile were significantly associated with reduced 5-year survival. Conclusions: Low LVEF and high NLR at admission were independently associated with increased in-hospital complications and reduced long-term survival in TTS patients. NLR is a new easy-to-measure tool to predict worse short- and long-term outcome after TTS. [ABSTRACT FROM AUTHOR]

Summary: Background: An early diagnosis of acute coronary syndrome (ACS) is crucial for treatment and prognosis. The aim of this study was to evaluate the Manchester triage system (MTS) for patients with ACS, e.g. ST-segment elevation myocardial infarction (STEMI), non-ST elevation myocardial infarction (N-STEMI) and unstable angina pectoris (UAP). Methods: Retrospective analysis of patients diagnosed with ACS (STEMI, N‑STEMI and UAP) who were triaged in the emergency department (ED) with the MTS. Results: In this study 282 patients with ACS (STEMI: 34.0%, N‑STEMI: 61.7%, UAP: 4.3%) were triaged as MTS level 1 (immediate assessment): 0.4%, MTS level 2 (very urgent): 51.4%, MTS level 3 (urgent): 41.5%, MTS level 4 (standard): 6.7%, MTS level 5 (non-urgent): 0%. We observed significantly lower mean MTS levels in males (male: 2.48 ± 0.59, female: 2.68 ± 0.68, p = 0.02) and in patients younger than 80 years (age <80 years: 2.50 ± 0.61, age ≥80 years: 2.70 ± 0.67, p = 0.03). We did not find a significant difference of mean MTS levels in different types of ACS (STEMI: 2.46 ± 0.6, N‑STEMI: 2.59 ± 0.64, STEMI vs N‑STEMI: p = 0.11, UAP: 2.67 ± 0.65, STEMI vs UAP: p = 0.26) and with respect to diabetes (diabetic: 2.47 ± 0.57, non-diabetic: 2.58 ± 0.65, p = 0.13). The in-hospital mortality was 2.5% (MTS level 2: n = 3, MTS level 3: n = 3, MTS level 4: n = 1). Conclusion: The majority of patients with ACS were classified as MTS levels 2 and 3. There was no significant difference of mean MTS levels in patients with STEMI, NSTEMI and UAP. In order to assure an early diagnosis of STEMI, an electrocardiogram (ECG) should be carried out immediately or at least within 10 min after first medical contact in the ED in all patients suspected for ACS, irrespective of the assigned MTS level. [ABSTRACT FROM AUTHOR]

Background: The wearable cardioverter-defibrillator is a treatment option for patients at temporarily high risk of sudden cardiac death or in whom implantation of a cardioverter-defibrillator is temporarily not possible. Objectives: The aim of this study was to provide real-world data on patients receiving this therapy in a nurse-based wearable cardioverter-defibrillator training programme. Methods: A registry including all patients prescribed with a wearable cardioverter-defibrillator in Austria between 2010 and 2016. Overall, 448 patients received a wearable cardioverter-defibrillator in 48 centres. Patients received structured nurse-based wearable cardioverter-defibrillator educational initial training followed by remote monitoring. Results: Main indications were: severe non-ischaemic cardiomyopathy (21%); recent myocardial infarction and percutaneous coronary intervention (20%); and stable coronary artery disease with percutaneous coronary intervention/coronary artery bypass grafting (14%). Eleven patients (2.5%) received 22 appropriate wearable cardioverter-defibrillator shocks. Two patients (0.4%) received three inappropriate shocks. The risk of sudden cardiac death varied between different aetiologies. Eight out of 11 (73%) patients received their first wearable cardioverter-defibrillator shock within 30 days. The main reasons for termination of the wearable cardioverter-defibrillator therapy were implantable cardioverter-defibrillator implantation (55.5%) and improvement of left ventricular ejection fraction to more than 35% (33%). Conclusion: The wearable cardioverter-defibrillator is an effective and safe treatment option in patients at either transiently elevated risk of ventricular tachycardia/ventricular fibrillation or mandated postponed implantable cardioverter-defibrillator implantation, with a 2.5% shock rate over a median 54 days wearable cardioverter-defibrillator treatment period. However, both the wearable cardioverter-defibrillator shock rate and implantable cardioverter-defibrillator implantation rate vary widely depending on the wearable cardioverter-defibrillator indication. Nurse-based wearable cardioverter-defibrillator training is associated with high patient adherence, with a median wearing duration per day of 23.5 (1–24) hours. [ABSTRACT FROM AUTHOR]

The article presents the study which examined whether β-blockers are linked to lower rates of mortality and morbidity following cardiac or noncardiac surgery. Based on the results, β-blockers are linked with lower incidence of supraventricular tachycardias (SVT) and ventricular arrhythmias, while they are associated to lower incidence of acute myocardial infarctions (AMI) and SVTs in noncardiac surgery.

Abstract: We report on a case of non-ST-segment myocardial infarction in the absence of coronary artery disease, caused by coronary embolism from the left atrial appendage. Due to the fact that the angiographically confirmed embolus did not resolve within 4 days of treatment with aspirin, clopidogrel and low molecular weight heparin (LMWH), we intravenously administered bivalirudin instead of LMWH for another 2 days and could demonstrate complete resolution of the embolus following this protocol. No bleeding complications or recurrence of myocardial ischemia occurred. Our observations may draw attention to bivalirudin therapy for coronary emboli, when LMWH is not effective. [Copyright &y& Elsevier]

Background: Oral activated factor XI (FXIa) inhibitors may modulate coagulation to prevent thromboembolic events without substantially increasing bleeding. We explored the pharmacodynamics, safety, and efficacy of the oral FXIa inhibitor asundexian for secondary prevention after acute myocardial infarction (MI).Methods: We randomized 1601 patients with recent acute MI to oral asundexian 10, 20, or 50 mg or placebo once daily for 6 to 12 months in a double-blind, placebo-controlled, phase 2, dose-ranging trial. Patients were randomized within 5 days of their qualifying MI and received dual antiplatelet therapy with aspirin plus a P2Y12 inhibitor. The effect of asundexian on FXIa inhibition was assessed at 4 weeks. The prespecified main safety outcome was Bleeding Academic Research Consortium type 2, 3, or 5 bleeding comparing all pooled asundexian doses with placebo. The prespecified efficacy outcome was a composite of cardiovascular death, MI, stroke, or stent thrombosis comparing pooled asundexian 20 and 50 mg doses with placebo.Results: The median age was 68 years, 23% of participants were women, 51% had ST-segment-elevation MI, 80% were treated with aspirin plus ticagrelor or prasugrel, and 99% underwent percutaneous coronary intervention before randomization. Asundexian caused dose-related inhibition of FXIa activity, with 50 mg resulting in >90% inhibition. Over a median follow-up of 368 days, the main safety outcome occurred in 30 (7.6%), 32 (8.1%), 42 (10.5%), and 36 (9.0%) patients receiving asundexian 10 mg, 20 mg, or 50 mg, or placebo, respectively (pooled asundexian versus placebo: hazard ratio, 0.98 [90% CI, 0.71-1.35]). The efficacy outcome occurred in 27 (6.8%), 24 (6.0%), 22 (5.5%), and 22 (5.5%) patients assigned asundexian 10 mg, 20 mg, or 50 mg, or placebo, respectively (pooled asundexian 20 and 50 mg versus placebo: hazard ratio, 1.05 [90% CI, 0.69-1.61]).Conclusions: In patients with recent acute MI, 3 doses of asundexian, when added to aspirin plus a P2Y12 inhibitor, resulted in dose-dependent, near-complete inhibition of FXIa activity without a significant increase in bleeding and a low rate of ischemic events. These data support the investigation of asundexian at a dose of 50 mg daily in an adequately powered clinical trial of patients who experienced acute MI.Registration: URL: https://www.Clinicaltrials: gov; Unique identifier: NCT04304534; URL: https://www.clinicaltrialsregister.eu/ctr-search/search; Unique identifier: 2019-003244-79. [ABSTRACT FROM AUTHOR]