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Background: It is uncertain whether a diagnostic strategy supplemented by early coronary computed tomography angiography (CCTA) is superior to contemporary standard optimal care (SOC) encompassing high-sensitivity troponin assays (hs-troponins) for patients suspected of acute coronary syndrome (ACS) in the emergency department (ED).Objectives: This study assessed whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC.Methods: In a prospective, open-label, multicenter, randomized trial, we enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Exclusion criteria included the need for urgent cardiac catheterization and history of ACS or coronary revascularization. The primary endpoint was the number of patients identified with significant coronary artery disease requiring revascularization within 30 days.Results: The study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS.Conclusions: CCTA, applied early in the work-up of suspected ACS, is safe and associated with less outpatient testing and lower costs. However, in the era of hs-troponins, CCTA does not identify more patients with significant CAD requiring coronary revascularization, shorten hospital stay, or allow for more direct discharge from the ED. (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography [BEACON]; NCT01413282). [ABSTRACT FROM AUTHOR]

Objectives: This study sought to comprehensively identify predictors of stent thrombosis (ST). Background: Given the devastating consequences of ST, efforts should be directed toward risk stratification to identify patients at highest risk for ST. Methods: Consecutive patients with angiographic ST were enrolled. Patients who did not suffer from a ST were randomly selected in a 2:1 ratio and were matched for: 1) percutaneous coronary intervention (PCI) indication; 2) same date of index PCI; and 3) same interventional center. Results: Of 21,009 patients treated with either a bare-metal or drug-eluting stent, 437 patients (2.1%) presented with a definite ST. A total of 140 STs were acute, 180 were subacute, 58 were late, and 59 were very late. Undersizing of the coronary stent, Thrombolysis In Myocardial Infarction flow grade <3, present malignancy, presence of intermediate coronary artery disease proximal and distal to the culprit lesion, dissection, lack of aspirin, bifurcation lesions, ejection fraction <30%, and younger age were associated with ST. The lack of clopidogrel therapy at the time of ST in the first 30 days after the index PCI (hazard ratio [HR]: 36.5, 95% confidence interval [CI]: 8.0 to 167.8), between 30 days and 6 months after the index PCI (HR: 4.6, 95% CI: 1.4 to 15.3), and beyond 6 months (HR: 5.9, 95% CI: 1.7 to 19.8) after the index PCI was strongly associated with ST. Conclusions: Important correlates of ST were identified. Discontinuation of clopidogrel, undersizing of the coronary stent, present malignancy, and intermediate (≥50% to <70% stenosis) coronary artery disease proximal to the culprit lesion were the strongest predictors of ST. [Copyright &y& Elsevier]

Background: Survival outcome after MitraClip treatment, compared with surgical or conservative treatment, is not well defined. We examined survival after MitraClip treatment in a large multicenter real-life setting., Methods and Results: We retrospectively formed matched high-risk surgically and conservatively treated control cohorts to compare to a high-risk MitraClip cohort. One thousand thirty-six patients were included in 4 Dutch centers, of which 568 were treated with the MitraClip. The observed survival at 5-year follow-up in our MitraClip cohort was low (39.8%) but was comparable to our conservative cohort (40.5%). Observed 5-year survival for our surgical cohort was 76.3%. However, there were significant differences between the baseline characteristics of the 3 studied cohorts, with the MitraClip cohort having the highest comorbidity burden. After adjusting for baseline differences by using Cox regression, the MitraClip and surgical cohorts showed similar survival ratios (hazard ratio, 0.92; 95% confidence interval, 0.67-1.26; P =0.609), whereas both showed a lower mortality hazard when compared with conservative treatment (hazard ratio, 0.61; 95% confidence interval, 0.49-0.77; P <0.001 and hazard ratio, 0.56; 95% confidence interval, 0.42-0.76; P <0.001, respectively)., Conclusions: This matched analysis suggests a lower mortality hazard for MitraClip intervention in a high-risk population with symptomatic mitral regurgitation when compared with conservative management alone., (© 2018 American Heart Association, Inc.)

Background: This study sought to determine the incidence, risk factors, and characteristics of Staphylococcus (S.) aureus infections complicating percutaneous coronary interventions (PCI)., Methods: Between January 1999 and December 2002, 7640 PCI's were evaluated from 1 to 16 days post-PCI for the occurrence of a documented S. aureus infection. A case-control study was used to identify risk factors for the development of S. aureus infection in patients undergoing PCI., Results: In total 21 S. aureus infections (0.27%) were documented at 1 to 16 days after the index PCI. The overall incidence of PCI-related infection was 0.14% (11 cases), 0.13% (10 cases) were intravascular line related. All 21 cases with S. aureus infections were matched with 63 controls randomly selected among patients who underwent a PCI but did not have S. aureus infections. Among the patients with S. aureus infections, the duration of hospital stay was significantly increased (24 vs 5 days). The overall mortality rate in the 21 patients with S. aureus infections was 4/21 [19%] (controls 2/42 [3%]). Congestive heart failure, alcohol abuse, emergency PCI, more than 1 PCI in three months and the presence of a sheath in the femoral artery and/or vein for the duration of more than 1 day after the procedure were independent risk factors for S. aureus infection after PCI., Conclusions: S. aureus infection is a rare but potentially serious complication of PCI. Additional precautions should be considered in patients with these risk factors.