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Aim: To evaluate the impact of a clopidogrel therapy on the effectiveness of myocardial reperfusion in patients with ST-segment elevation acute myocardial infarction (AMI) undergoing routine infarct-related artery (IRA) stent implantation and receiving routine abciximab therapy. Background: Inflammatory processes after mechanical restoration of flow in AMI play a central role in decreasing the effectiveness of reperfusion at microcirculatory level. Several studies suggest that clopidogrel may exert a protective effect against adverse cardiovascular events by virtue of its anti-inflammatory properties. Methods: A total of 133 patients with a first ST-elevation AMI were randomized to clopidogrel (600-mg loading dose before IRA stenting followed by 75 mg daily, n = 66) or ticlopidine (500 mg before IRA stenting followed by 250 mg twice daily, n = 67). The primary end point was scintigraphic infarct size at 1 month. The secondary end points were ST-segment elevation resolution within 3 hours of procedure and 1-month clinical outcome, as a composite of death, reinfarction, target vessel revascularization, and stroke within 1 month of the index procedure. Results: The 1-month technetium 99m sestamibi scintigraphy revealed similar infarct size (16.2% +/- 14.6% vs 15.0% +/- 14.1%, P = .703) and severity (0.48 +/- 0.18 vs 0.49 +/- 0.15, P = .592) in the clopidogrel group as compared with the ticlopidine group. Three-hour ST-segment resolution rate was similar in the 2 study groups (86% vs 89%, P = .642). At 1 month, there was no difference in major cardiovascular adverse event rate (3% vs 3%, P = .988). Discontinuation of thienopiridine therapy within the first month occurred in no patient randomized to clopidogrel and in 3 (4.5%) patients randomized to ticlopidine (P = .082). Conclusion: Clopidogrel has no impact on the effectiveness of myocardial reperfusion in patients with AMI treated routinely with stenting and abciximab. However, clopidogrel, administered as a 600-mg loading dose followed by 75 mg daily, is safe and at least as effective as the standard ticlopidine therapy in this subgroup of patients. [ABSTRACT FROM AUTHOR]

Conflicting results have been reported about the prognostic impact of left bundle branch block (LBBB) after transcatheter aortic valve implantation (TAVI). The aim of this study was to evaluate the impact of LBBB after TAVI on left ventricular (LV) function and remodeling and on 1-year outcomes. Of 101 TAVI patients, 9 were excluded. All complications were evaluated according to the Valve Academic Research Consortium 2 definition. Of 92 patients, 34 developed LBBB without more advanced myocardial damage or inflammation biomarkers in comparison with patients without LBBB. The only predictor of new LBBB was larger baseline LV end-diastolic volume. LBBB plus advanced atrioventricular block was strongly correlated with permanent pacemaker implantation (p <0.0001). Patients with LBBB had a higher rate of permanent pacemaker implantation at 30 days (59% vs 19%, p <0.0001) and less recovery of LV systolic function and a trend toward a lower rate of LV reverse remodeling at 1 year. The development of acute kidney injury and the logistic European System for Cardiac Operative Risk Evaluation score were associated with poor outcomes (all-cause mortality and heart failure) (hazard ratio 6.86, 95% confidence interval 2.51 to 18.74, p <0.0001, and hazard ratio 1.04, 95% confidence interval 1.01 to 1.08, p = 0.021, respectively), but not LBBB. In conclusion, after TAVI, 37% of patients developed new LBBB without more advanced myocardial damage or inflammation biomarkers. LBBB was associated with a higher rate of permanent pacemaker implantation, which negatively affected the recovery of LV systolic function. The development of acute kidney injury, rather than LBBB, increases the 1-year risk for mortality and hospitalization for heart failure. [ABSTRACT FROM AUTHOR]

In the setting of patients with indication to receive dual antiplatelet therapy undergoing surgery or invasive procedures, the risk of perioperative cardiac ischemic events, particularly stent thrombosis, is high, because surgery has a prothrombotic effect and antiplatelet therapy is withdrawn in order to avoid bleeding complications. Cangrelor, an intravenous P2Y12 receptor antagonist, has been tested in a randomized trial as a "bridge" to cardiac surgery from discontinuation of oral P2Y12 receptor antagonists. Thus, a consensus document extended its off-label use in this setting and before non-cardiac surgery. Currently, despite the implementation of a standardized bridging protocol with cangrelor, a residual risk of adverse outcome mainly due to bleeding events, still persist during the perioperative phase. Accordingly, a personalized management driven by platelet reactivity serial measurements and careful assessment of ischemic and bleeding risks has potential to optimize outcomes and costs as compared to a standardized bridging protocol, based on average pharmacodynamic data of oral P2Y12 inhibitors. While specific indications for bridging have been extensively addressed in the aforementioned consensus statement, the aim of the present document is the proposal of a "tailored" clinical decision-making algorithm inspired to the principle of personalized medicine dealing with complex clinical scenarios. [ABSTRACT FROM AUTHOR]

No data exist about successful percutaneous coronary intervention (PCI) and clinical outcome in patients with multiple coronary chronic total occlusions (CTOs). The aim of this study was to determine the impact on cardiac mortality of PCI of multiple CTOs. The Florence CTO PCI registry includes patients treated with drug-eluting stent for at least 1 CTO. From this registry, we examined consecutive patients with ≽2 CTOs. Patients were stratified into successful PCI of all attempted CTOs and partially successful PCI (1 CTO PCI successful) or failed PCI (no CTO PCI success) groups. The primary end point of the study was cardiac mortality. Of 1,035 patients with CTO, 120 (11.6%) underwent PCI for ≽2 CTOs for a total of 249 CTOs. CTO PCI was successful in 195 CTOs (78.3%), and in 76 patients (63.3%), PCI was successful in all attempted lesions, whereas in 34 patients, CTO PCI was partially successful and in 10, completely unsuccessful. Cardiac mortality at 12 months was lower in the CTO PCI success group than CTO PCI failure or partial success group (1.3% vs 11.3%; p = 0.025). The 2-year survival rate was lower in patients with a complete coronary revascularization compared with those with incomplete revascularization (96 ± 3% vs 78 ± 7%; p = 0.002); completeness of revascularization was inversely related to the risk of death (hazard ratio 0.10; p = 0.029). In patients with multiple CTOs, a successful PCI of all CTOs was associated with increased survival and completeness of revascularization was a strong predictor of survival. [ABSTRACT FROM AUTHOR]

There is a lack of clarity concerning the clinical implications of myocardial injury occurring after transcatheter aortic valve implantation (TAVI) procedures. The aim of this study was to determine the incidence, degree, and timing of myocardial injury associated with TAVI procedures and to evaluate its 1-year prognostic value. Among 68 consecutive patients (mean age 80.9 - 6.4 years) treated with TAVI, 3 patients who died within 24 hours, precluding cardiac biomarker measurements, and 3 patients with major procedural complications were excluded. Cardiac troponin I, creatine kinase-MB, and creatinine levels were determined at baseline and 6, 12, 24, 48, and 72 hours after TAVI. All complications were defined according to the Valve Academic Research Consortium. Myocardial injury was observed in all patients (n [ 62), as determined by an increase in cardiac troponin I (median peak at 12 hours 3.8 mg/L, interquartile range 1.8 to 25.67), and a higher degree of myocardial injury was observed in patients (n [ 9) who developed acute kidney injury (AKI) (p [ 0.026). Periprocedural myocardial infarction was not found. At 1-year followup, 5 patients had died, and 7 patients had been hospitalized for heart failure. The development of AKI, not the degree of peak cardiac troponin I (p [ 0.348), was identified as the only strong independent predictor of 1-year mortality from any cause (including heart failure) after TAVI (hazard ratio 4.74, 95% confidence interval 1.12 to 20.03, p [ 0.034). In conclusion, TAVI was systematically associated with myocardial injury, occurring with a higher degree in patients who developed AKI. However, the simultaneous development of AKI occurring after TAVI is the strongest predictor of 1-year mortality. [ABSTRACT FROM AUTHOR]

The aim of the present study was the comparison of the everolimus-eluting stent (EES) with the paclitaxel-eluting stent (PES) in patients treated for long chronic total occlusions (CTOs). Previous randomized trials have shown the superiority of EESs over PESs. No data exist about the efficacy and safety of EESs in patients treated for complex CTOs requiring multiple stent implantation. We identified 258 patients treated for CTOs who received multiple EESs (n = 112) or PESs (n = 146), with a total stent length of ≥40 mm. The primary end point was in-segment restenosis, defined as >50% luminal narrowing at the segment site, including the stent and 5 mm proximal and distal to the stent edges of the target vessel, on the follow-up angiogram. The secondary end point was the 9-month composite of major adverse cardiovascular events. The 2 patient groups were similar in all baseline characteristics. The median lesion length was 48 mm in the EES group and 46 mm in the PES group (p = 0.793). The incidence of the primary end point of the study was 11.8% in the EES group and 31.4% in the PES group (p = 0.001). The major adverse cardiovascular event rate was lower in the EES group than in the PES group (8.9% and 22.6%, respectively, p = 0.003). Definite or probable stent thrombosis occurred in 5 patients in the PES group (3.4%), with no stent thrombosis occurring in the EES group (p = 0.048). On multivariate analysis, EES was the only variable independently related to the risk of binary angiographic restenosis with an odds ratio of 0.29 (95% confidence interval 0.14 to 0.62; p = 0.002). In conclusion, in patients treated for long CTOs and requiring multiple stent implantation, EESs performed better than PESs, with a >50% reduction in the risk of restenosis and major adverse cardiovascular events. [Copyright &y& Elsevier]

ST-segment resolution is used to classify the response to reperfusion therapy in acute myocardial infarction, but the possibility to predict outcome in individual patients is unclear, particularly in the setting of primary percutaneous coronary intervention (PCI) and abciximab therapy. We studied 213 patients who underwent successful revascularization with PCI. Maximal ST-segment elevation was measured before and 30 minutes after PCI. Patient outcome was defined on the basis of infarct size and left ventricular ejection fraction (EF) as derived from gated single-photon emission computed tomography that was acquired 1 month after infarction. Patients who had ≥50% ST resolution showed a smaller infarct (15.1 ± 13.6% vs 19.9 ± 15.7%, p <0.05) but not a higher left ventricular EF (48.7 ± 12.3% vs 45.2 ± 11.8%) than did patients who had <50% resolution. According to cluster analysis of infarct size and left ventricular EF, 132 patients had favorable outcome (central values: infarct size 7.5%, left ventricular EF 55%) and 81 did not (central values: infarct size 30%, left ventricular EF 36%). Using receiver-operating characteristic curve analysis, the optimal ST-resolution cutoff was >60%, with 77% sensitivity and 51% specificity for predicting favorable outcome. ST-segment elevation ≤4.5 mV before PCI was 80% sensitive and 48% specific, and ST-segment elevation ≤1 mV after PCI was 74% sensitive and 60% specific for predicting favorable outcome. In conclusion, in the setting of primary PCI and abciximab therapy, ST-segment elevation resolution requires a high threshold (>60%) to effectively classify patients; the capability of ST-segment analysis to predict patient outcome is limited, with ST-segment elevation after PCI showing the best compromise between sensitivity and specificity. [Copyright &y& Elsevier]

Objectives: We sought to determine whether, in a real word context of patients with Acute Myocardial Infarction (AMI), multivessel disease (MVD) and cardiogenic shock (CS), the successful treatment with primary percutaneous coronary intervention (p-PCI) of only culprit lesions (OC-PCI) is associated with better long-term mortality rates than multivessel PCI (MV-PCI) of all significant lesions.Methods: From our registry of all consecutive patients admitted for AMI between January 1995 and December 2016 we selected those presenting with CS and MVD successfully treated with p-PCI, and compared those who underwent OC-PCI against MV-PCI, either during the p-PCI (MV-pPCI) or by staged revascularization (Staged-PCI) during hospitalization. The primary endpoint was 2-year all-cause death.Results: Among 4210 patients with AMI, 406 (9.6%) presented CS (Killip class IV). A total of 292 patients had MVD. Of them, 252 (86.3%) were successfully treated with p-PCI, 159 patients with OC-PCI and 93 with MV-PCI, either in the same (n = 29) or staged procedure (n = 64). At 2-year follow-up the overall mortality was 47.6%, lower in MV-PCI group (37.6% vs 53.5% in OC-PCI, p = 0.019). Diabetes (HR = 1.50, 1.01-2.22), three vessel disease (HR = 1.49, 1.02-2.17) and basal left ventricular ejection fraction <15% (HR = 3.39, 2.41-6.27) were independent predictors of mortality, while MV-PCI was the only variable associated with improved survival (HR = 0.54, 0.36-0.81).Conclusions: In this real world registry of AMI patients with MVD presenting CS, MV-PCI was associated with better long-term survival. [ABSTRACT FROM AUTHOR]

Background The CHA 2 DS 2 -VASc score predicts stroke risk in patients with atrial fibrillation, but recently has been reported to have a prognostic role even in patients with ACS. We sought to assess the ability of the CHA 2 DS 2 -VASc score to predict the severity of coronary artery disease, high residual platelet reactivity and long-term outcomes in patients with acute coronary syndrome (ACS). Methods Overall, 1729 consecutive patients with ACS undergoing invasive management were included in this prospective registry. We assessed platelet reactivity via light transmittance aggregometry after clopidogrel loading. Patients were divided according to the CHA 2 DS 2 -VASc score: group A = 0, B = 1, C = 2, D = 3, E = 4 and F ≥ 5. Results Patients with higher CHA 2 DS 2 -VASc score were more likely to have a higher rate of multivessel CAD (37%, 47%, 55%, 62%, 67 and 75% in Group A, B, C, D, E and F; p < 0.001); moreover, CHA 2 DS 2 -VASc score correlated linearly with residual platelet reactivity (R = 0.77; p < 0.001). At long-term follow-up, estimated adverse event rates (MACCE: cardiac death, MI, stroke or any urgent coronary revascularization) were 3%, 8%, 10%, 14%, 19% and 24% in group A, B, C, D, E and F; p < 0.001. Multivariable analysis demonstrated CHA 2 DS 2 -VASc to be an independent predictor of severity of coronary artery disease, of high residual platelet reactivity and of MACCE. Conclusions In a cohort of patients with ACS, CHA 2 DS 2 -VASc score correlated with coronary disease severity and residual platelet reactivity, and therefore it predicted the risk of long-term adverse events. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article on the association of prasugrel with increased inhibition of platelet aggregation, by Roger Jelliffe published in the February 26, 2014 issue.

Background In clinical practice there is a gap between guidelines recommendation and antiplatelet strategies used for acute coronary syndrome (ACS). We sought to evaluate appropriateness of antiplatelet strategies employed in a tertiary center. Methods and results From January to June 2014, 430 ACS were treated with percutaneous coronary intervention by 3 groups of interventional cardiologists. Aspirin and clopidogrel (52%) were the most commonly used antiplatelet therapies, being prasugrel associated with aspirin in 110 (25.5%) and ticagrelor in 97 (22.5%) ACS. Inappropriate use of prasugrel (Tia/Ictus) was found in 2 (1.8%) patients and not recommended use (> 75 years, without diabetes or previous myocardial infarction) in 11 (10%). Not recommended use of ticagrelor (plus warfarin) was found in 4 (4.4%). Switching from clopidogrel to prasugrel occurred in 29% [28 showing high residual platelet reactivity (HRPR: ADP 10 μmol > 70%), and 4 left main stenting], while from clopidogrel to ticagrelor occurred in 13.4% (all showing HRPR, but 1). The most powerful predictor for prescription of 3rd generation P2Y12 inhibitors was the HRPR (OR 5.473, 95%CI 2.41–12.43, p < 0.0001), whereas the behavior of attending cardiologist (HR 0.674, 95%CI 0.573–0.847, p = 0.001) and the older age reduced the probability of receiving it (OR0.963, 95%CI 0.943–0.984, p = 0.001). Conclusions Clopidogrel remained the most common P2Y12 inhibitor employed for ACS. Third generation P2Y12 inhibitor prescription was lower than the one expected by guidelines recommendations, and the switching was largely based on clopidogrel HRPR. These findings suggest the need for a greater effort to improve adherence of cardiology community to current guidelines. [ABSTRACT FROM AUTHOR]

Aim Metalloproteinases inhibition by doxycycline reduces cardiac protein degradation at extracellular and intracellular level in the experimental model ischemia/reperfusion injury. Since both extracellular cardiac matrix and titin filaments inside the cardiomyocyte are responsible for the myocardial stiffness, we hypothesized that doxycycline could favorably act on left ventricular (LV) filling pressures in patients after reperfused acute ST-elevation myocardial infarction (STEMI). Methods and results Seventy-three of 110 patients of the TIPTOP trial underwent a 2D-Echo-Doppler on admission, and at pre-discharge and at 6-month after a primary PCI for STEMI and LV dysfunction. From admission to pre-discharge, LV filling changed from a high filling pressure (HFP) to a normal filling pressure (NFP) pattern in 91% of the doxycycline-group, and in 67% of the control-group. Conversely, 1% of the doxycycline-group, and 37% of the control-group changed the LV filling from NFP to HFP pattern. Overall, a pre-discharge HFP pattern was present in 4 patients (11%) of the doxycycline-group and in 13 patients (36%) of the control-group ( p = 0.025). The evaluation of metalloproteinases and their tissue inhibitors plasma concentrations provide possible favorable action of doxycycline. On the multivariate analyses, troponine I peak ( p = 0.026), doxycycline ( p = 0.033), and on admission to pre-discharge LVEF changes ( p = 0.044) were found to be associated with pre-discharge HFP pattern. Independently of their baseline LV filling behavior, the 6-month remodeling was less in patients with pre-discharge NFP pattern than in patients with HFP pattern. Conclusions In patients with STEMI and LV dysfunction doxycycline can favorably modulate the LV filling pattern early after primary PCI. [ABSTRACT FROM AUTHOR]

Background: Endovascular therapy for long femoropopliteal lesions using percutaneous transluminal balloon angioplasty or first-generation of peripheral stents has been associated with unacceptable one-year restenosis rates. However, with recent advances in equipment and techniques, a better primary patency rate is expected. This study was conducted to detect the long-term primary patency rate of nitinol self-expandable stents implanted in long, totally occluded femoropopliteal lesions TransAtlantic Inter-Society Census (TASC II type C & D), and determine the predictors of reocclusion or restenosis in the stented segments.Methods: The demographics, clinical, anatomical, and procedural data of 213 patients with 240 de novo totally occluded femoropopliteal (TASC II type C & D) lesions treated with nitinol self-expandable stents were retrospectively analysed. Of these limbs, 159 (66.2%) presented with intermittent claudication, while 81 (33.8%) presented with critical limb ischaemia. The mean-time of follow-up was 36±22.6 months, (range: 6.3-106.2 months). Outcomes evaluated were, primary patency rate and predictors of reocclusion or restenosis in the stented segments.Results: The mean age of the patients was 70.9±9.3 years, with male gender 66.2%. Mean pre-procedural ABI was 0.45±0.53. One-hundred-and-seventy-five (73%) lesions were TASC II type C, while 65 (27%) were type D lesions. The mean length of the lesions was 17.9±11.3mm. Procedure related complications occurred in 10 (4.1%) limbs. There was no periprocedural mortality. Reocclusion and restenosis were detected during follow-up in 45 and 30 limbs respectively, and all were re-treated by endovascular approach. None of the patients required major amputation. Primary patency rates were 81.4±1.1%, 77.7±1.9% and 74.4±2.8% at 12, 24, and 36 months respectively. Male gender, severe calcification, and TASC II D lesion were independent predictors for reocclusion, while predictors of restenosis were DM, smoking and TASC II D lesions.Conclusions: Treatment of long, totally occluded femoropopliteal (TASC II C & D) lesions with nitinol self-expandable stents is safe and is associated with highly acceptable long-term primary patency rates. [ABSTRACT FROM AUTHOR]

Background Morphine is frequently used in ST-segment elevation myocardial infarction (STEMI) patients, even if recently it has been associated with a delayed onset of action of the oral antiplatelet agents. There are no data regarding the impact of morphine on myocardial reperfusion after primary percutaneous coronary intervention (PPCI). Objective This study sought to assess myocardial reperfusion by early ST-segment resolution (≥ 50% at 30 minutes) according to morphine use in STEMI patients undergoing PPCI. Methods 182 STEMI patients undergoing PPCI and receiving either prasugrel (n = 51) or ticagrelor (n = 131), who were antiplatelet and anticoagulant therapies naïve, were included in the study. All patients had serial ST-segment elevation evaluations by ECG and residual platelet reactivity assessments by VerifyNow P2Y12 Reactivity Units (PRU). Results Overall, 74 (41%) patients received morphine according to the attending physician's preference and showed lower ST-segment resolution rate as compared with patients without morphine (76% vs 87%, p = 0.047). Higher baseline TIMI flow < 2 rate (79% vs 64%, p = 0.036) and peak CPK values (1821 [924–3283] U/L vs 1483 [718–2327] U/L, p = 0.034) were observed in morphine patients. Moreover, a delayed response to oral antiplatelet (PRU area under the curve [AOU0–8]: 1448 ± 448 vs 686 ± 292, p = 0.001) was documented in patients with morphine as compared with those without. The independent predictors of early ST-segment elevation resolution failure were PRU ≥ 208 after antiplatelet loading (OR 2.78, 95% CI 1.08–7.14; p = 0.034) and TIMI flow grade < 3 after PPCI (OR 5.89, 95% CI 1.64–21.12; p = 0.009), but not morphine use. Conclusions In STEMI patients undergoing PPCI, morphine use is associated with a higher residual platelet reactivity and a poorer myocardial reperfusion. Independent predictors of impaired myocardial reperfusion were high residual platelet reactivity and TIMI flow grade after PPCI but not morphine use, questioning the direct relationship between morphine and worse myocardial reperfusion. [ABSTRACT FROM AUTHOR]

Objective To evaluate the possible role of high on-aspirin platelet reactivity (HaPR) in a prospective cohort of acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI). Background Several studies documented that high on-clopidogrel platelet reactivity (HcPR) is associated with increased risk of ischemic events in ACS patients undergoing PCI. On the contrary, conflicting data are available on HaPR and clinical outcome. Methods Platelet reactivity was assessed by light transmittance aggregometry using arachidonic acid as an agonist in 1789 ACS patients undergoing PCI. Results HaPR was found in 20.3% of patients. These patients were significantly older, with a higher prevalence of hypertension, diabetes and reduced ejection fraction. Patients with non ST-segment elevation ACS, 3-vessel disease and multivessel PCI had a significantly higher prevalence of HaPR. In addition, stent number and length, and use of drug-eluting stents were significantly higher in HaPR patients. At 24-month follow-up the prevalence of cardiac death was 9.7% in HaPR and 3.8% in non-HaPR [HR2.63(1.72–4.02), p < 0.0001], that of stent thrombosis 6.1% in HaPR and 2.6% in non-HaPR [HR2.4(1.42–4.07), p < 0.001], with no significant differences in other clinical end-points. At multivariate analysis, HaPR was confirmed as an independent risk factor for cardiac death [HR1.88(1.21–2.93), p = 0.005] and stent thrombosis [HR1.91(1.12–3.28), p = 0.018]. The addition of HaPR to a model including clinical and procedural risk factors and HcPR led to a significant improvement in the prediction of cardiac death (NRI 39 ± 10%, p = 0.0003) and stent thrombosis (NRI 34.7 ± 13.2%, p = 0.009). Conclusion HaPR was found to be an independent risk factor for cardiac death and stent thrombosis in ACS patients undergoing PCI. [ABSTRACT FROM AUTHOR]

Background The study sought to determine the impact of high residual platelet reactivity (HRPR) on long-term cardiac mortality in diabetic patients treated with PCI for CTO. No data exist about the impact of HRPR after 600 mg clopidogrel loading on long-term clinical outcome in patients with diabetes mellitus and treated with percutaneous coronary angioplasty (PCI) for chronic total occlusion (CTO). Methods From the Florence CTO-PCI registry, we identified consecutive diabetic patients with available in vitro platelet reactivity assessment by light transmittance aggregometry after a loading dose of 600 mg of clopidogrel. HRPR was defined as residual platelet aggregation by 10 μmol/L ADP test ≥ 70%. The primary end point of the study was long-term cardiac mortality. Results Two-hundred and three diabetic patients underwent CTO-PCI. The incidence of HRPR was 23%. The 3-year cardiac survival was lower in the HRPR group than the low residual platelet reactivity (LRPR) group (70 ± 7% and 92 ± 3%, respectively; p = 0.001). Within the oral antidiabetic patients there were no significant differences in long-term survival between HRPR and LRPR groups. Conversely, the association of insulin therapy and HRPR was related to a dramatic decrease in survival compared to the LRPR group (34 ± 14% vs. 89 ± 4%; p < 0.001). At multivariable analysis insulin therapy (HR 4.31; p = 0.001) and HRPR (HR 3.26; p = 0.004) were significantly related to long-term mortality, while completeness of revascularization was inversely related to cardiac mortality (HR 0.40; p = 0.029). Conclusion HRPR is a strong marker of increased risk of cardiac death in patients with DM who underwent PCI for CTO. [ABSTRACT FROM AUTHOR]

Coronary chronic total occlusion (CTO) carries a poor outcome in patients with acute myocardial infarction (AMI) treated with primary percutaneous coronary intervention (PCI). We sought to investigate the prognostic impact of a staged successful CTO-PCI in patients with AMI treated with primary PCI. Outcome analysis included consecutive patients treated by successful primary PCI with coexisting non-infarct-related artery CTO who survived after 1 week from AMI. A comparison between patients with successful CTO-PCI and patients with failed or nonattempted CTO-PCI was performed. The primary end points of the study were 1-year and 3-year cardiac survival. Of 1,911 patients who underwent successful primary PCI for AMI from 2003 to 2012, 169 (10%) had non-infarct-related artery CTO of a major branch. A staged CTO-PCI attempt was performed in 74 patients (44%) and was successful in 58 (success rate 78%). All patients with successful CTO-PCI received drug-eluting stents. In the successful CTO-PCI group, a complete coronary revascularization was achieved in 88% of the patients. The 1-year cardiac mortality rate was 1.7% in the successful CTO-PCI group and 12% in nonattempted or failed CTO-PCI group (p = 0.025). Successful CTO-PCI was an independent predictor of 3-year cardiac survival (hazard ratio 0.20, 95% confidence interval 0.05 to 0.92, p = 0.038). In conclusion, successful CTO-PCI in survivors after primary PCI is associated with improved long-term cardiac survival. [ABSTRACT FROM AUTHOR]

Background In acute coronary syndrome (ACS) patients older than 75 years old, prasugrel 10 mg maintenance therapy has shown less clinical efficacy and higher risk of bleeding. In patients older than 75 years, a prasugrel dose of 5 mg should be used if treatment is deemed necessary. Objective The aim of this study was to compare platelet reactivity and outcomes in elderly patients receiving prasugrel 5 mg therapy with non-elderly patients receiving prasugrel 10 mg therapy. Methods and results Consecutive ACS patients undergoing percutaneous coronary intervention (PCI) treated with prasugrel were included. Of 718 patients, 228 (32%) had ≥ 75 years and received prasugrel 5 mg/day. Residual platelet reactivity (RPR) was 47 ± 18% and 36 ± 16% in the elderly and non-elderly group, respectively (p = 0.001). High RPR (≥ 70%) was found in 9% and 2% (p = 0.0001) in elderly and non-elderly patients, respectively. In the 6-month follow-up, there was no difference in mortality, stent thrombosis, and reinfarction rates between the 2 groups but a higher rate of TIMI minor bleeding (7.9% vs 2.4%; p = 0.001) in elderly as compared with younger patients. Age ≥ 75 years was independently associated with bleeding events (HR 2.162 [1.105-4.229]; p = 0.024). Conclusions Elderly patients receiving prasugrel 5 mg are more likely to experience high RPR than younger patients treated by prasugrel 10 mg. Despite the use of a reduced prasugrel maintenance dose and a higher level of RPR, elderly patients show increased risk of bleeding during prasugrel therapy as compared to younger patients. [ABSTRACT FROM AUTHOR]

Doxycycline has been demonstrated to reduced left ventricular (LV) remodeling, but its effect in patients with ST-elevation myocardial infarction (STEMI) and a baseline occluded [thrombolysis in myocardial infarction (TIMI) flow grade ≤1] infarct-related artery (IRA) is unknown. According to the baseline TIMI flow grade, 110 patients with a first STEMI were divided into 2 groups. Group 1: 77 patients with TIMI flow ≤1 (40 patients treated with doxycycline and 37 with standard therapy, respectively), and a Group 2: 33 patients with TIMI flow 2-3 (15 patients treated with doxycycline and 18 with standard therapy, respectively). The two randomized groups were well matched in baseline characteristics. A 2D-Echo was performed at baseline and at 6 months, together with a coronary angiography, for the remodeling and IRA patency assessment, respectively. The LV end-diastolic volume index (LVEDVi) decreased in Group 2 [−3 mL/m (IQR: −12 to 4 mL/m)], and increased in Group 1 [6 mL/m (IQR: −2 to 14 mL/m)], ( p = 0.001). In Group 2, LVEDVi reduction was similar regardless of drug therapy, while in Group 1 the LVEDVi was smaller in patients treated with doxycycline as compared to control [3 mL/m (IQR: −3 to 8 mL/m) vs. 10 mL/m (IQR: 1-27 mL/m), p = 0.006]. A similar pattern was observed also for LV end-systolic volume and ejection fraction. In STEMI patients at higher risk, as those with a baseline TIMI flow grade ≤1, doxycycline reduces LV remodeling. [ABSTRACT FROM AUTHOR]

Abstract: Background: Although primary angioplasty achieves Thrombolysis In Myocardial Infarction (TIMI) 3 flow in most patients with ST-elevation myocardial infarction, epicardial recanalization does not guarantee optimal perfusion in a large proportion of patients. Multivessel disease has been demonstrated to be associated with impaired survival, however its impact on infarct size has not been largely investigated, that therefore is the aim of the current study. Methods: Our population is represented by 827 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Results: Multivessel disease was observed in 343 patients (41.5%). It was associated with older age (65 [57–74] vs 63 [53–71], p < 0.001), higher rate of previous MI (6.4% vs 2.5%, p = 0.005), longer ischemia time evaluated as continuous variable (210 [155–280] min vs 196 [145–270] min, p = 0.065) or percentage of patients with ischemia time >3 h (63.7% vs 56.4%, p = 0.038), and a trend in more cardiogenic shock (5.5% vs 2.9%, p = 0.055). Patients with multivessel disease received more often Abciximab (92.1% vs 88.4%, p < 0.001), Intra-aortic balloon pump (6.4% vs 1.9%, p < 0.001). No differences were observed in other clinical or angiographic characteristics. In particular, multivessel disease did not affect the rate of postprocedural TIMI 3 flow (90.9% vs 93.4%, p = 0.18) and ST-segment resolution (52.4% vs 54.9%, p = 0.48). Multivessel disease did not affect infarct size (12.7% [4.5%–24.9%] vs 12.3% [4%–24.1%], p = 0.58). Similar results were observed in subanalyses without any significant interaction for each variable (anterior infarct location (p int = 0.23), gender (p int = 0.9), age (p int = 0.7), diabetes (p int = 0.15)). The absence of any impact of multivessel disease on infarct size was confirmed when the analysis was conducted according to the percentage of patients with infarct size above the median, even after correction for baseline characteristics, such as age, previous MI, ischemia time, use of Gp IIb–IIIa inhibitors, cardiogenic shock, ischemia time (OR [95% CI] = 1.09 [0.82–1.45], p = 0.58). Conclusions: This study shows that among STEMI patients undergoing primary PCI multivessel disease does not affect infarct size. [Copyright &y& Elsevier]

Abstract: Background: Prior studies have found that smokers with STEMI have lower mortality rates and a more favorable response to fibrinolytic therapy than nonsmokers, phenomenon defined as “the smoker's paradox”. Still poorly explored is the impact of cigarette smoking in patients undergoing primary percutaneous coronary intervention. Aim of the current study was to evaluate the impact of cigarette smoking on scintigraphic infarct size in STEMI patients undergoing primary PCI. Methods: Our population is represented by 830 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Results: Smoking was associated with younger age (p < 0.001), a lower prevalence of female gender (p < 0.001), hypertension (p < 0.001), diabetes (p = 0.003), shorter ischemia time (p = 0.037), but higher rates of previous PCI (p = 0.016). No differences were observed in other clinical or angiographic characteristics. In particular, smoking did not affect the rate of postprocedural TIMI 3 flow. As shown in Fig. 1, smoking did not affect infarct size (12.5% [3.3%–23.7%] vs 12.7% [4.9%–25.9%], p = 0.12). Similar results were observed in subanalyses according to infarct location (anterior STEMI, p int = 0.33), gender (p int = 0.95) age, (p Int = 0.96), diabetes (p int = 0.85). The absence of any impact of smoking on infarct size was confirmed after correction for baseline characteristics, such as age, gender, hypertension, diabetes, previous PCI, ischemia time (OR [95% CI] = 0.80 [0.59–1.09], p = 0.15). Conclusions: This study shows that among STEMI patients undergoing primary PCI smoking status does not affect infarct size. [Copyright &y& Elsevier]

Abstract: Background: Several reports have shown that in patient with ST-segment elevation acute myocardial infarction (STEMI) longer ischemia time is associated with impaired reperfusion and higher mortality. However, there is still some doubts with regards time to reperfusion role in patients treated with primary percutaneous coronary intervention (PCI). Therefore, the aim of the current study was to evaluate the impact of time-to-treatment on infarct size as evaluated by myocardial scintigraphy in a large cohort of STEMI patients undergoing primary PCI. Methods: Our population is represented by 830 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30days by technetium-99m-sestamibi. Results: Time-to-treatment was significantly associated with age and dyslipidemia. Time-to-treatment linearly affected the rate of postprocedural TIMI 3 flow (p<0.0001) and scintigraphic infarct size (p<0.001). The impact of time-to-treatment on infarct size persisted in the analysis restricted to patients with postpocedural TIMI 3 flow, and after correction for confounding factors such as age, dyslipidemia, postprocedural TIMI 3 flow (OR [95% CI]=1.26 [1.14–1.39], p<0.001). Conclusions: This study shows in a large population of STEMI patients undergoing primary PCI that time-to-treatment is linearly associated with infarct size. [Copyright &y& Elsevier]

Previous reports have shown that female gender is associated with impaired outcomes among patients with ST-segment elevation myocardial infarction (STEMI) treated by thrombolysis, mainly owing to a worst risk profile (more diabetes, more advanced age, and higher Killip class at presentation) compared to men. Still contrasting are data on the effect of gender on the outcome in patients with STEMI undergoing primary angioplasty. In particular, it is still unclear whether a larger infarct size might contribute to the explanation of the worse outcome in women. Therefore, the aim of the present study was to investigate gender-related differences in infarct size as evaluated by myocardial scintigraphy in a large cohort of patients with STEMI undergoing primary percutaneous coronary intervention. We included 830 patients with STEMI undergoing primary percutaneous coronary intervention. The infarct size was evaluated at 30 days using technetium-99m-sestamibi. A logistic regression analysis was performed to determine the relation between gender and infarct size (as percentage of patients above the median) after correction for baseline confounding factors. We also evaluated the presence of a potential age-gender interaction. A total of 183 patients (20.8%) were women. Female gender was associated with more advanced age and a greater prevalence of hypertension; previous infarction and smoking were more frequently observed in men. Female gender was associated with a smaller infarct size (p <0.001) that was confirmed after correction for baseline confounding factors (adjusted odds ratio 0.48, 95% confidence interval 0.33-0.7, p <0.001). No age-gender interaction was observed (p = 0.13). In conclusion, the results of the present study have shown that despite the presence of high-risk features at presentation, female gender was associated with a smaller infarct size than that in men, without any interaction between age and gender. [ABSTRACT FROM AUTHOR]

Purpose: In acute myocardial infarction (AMI) treated by primary percutaneous coronary intervention (PCI), there is a direct relationship between myocardial damage and consequent left ventricular (LV) functional impairment. It is however unclear whether there is a safety threshold below which infarct size does not significantly affect LV ejection fraction (EF). The aim of this study was to evaluate the relationship between infarct size and LVEF in AMI patients treated by successful PCI using a specific statistical approach to identify a possible safety threshold. Methods: Among patients with recent AMI submitted to perfusion gated single photon emission computed tomography (SPECT) to define the infarct size, the data of 427 subjects with sizable infarct size were considered. The relationship between infarct size and LVEF was analysed using a simple segmented regression (SSR) model and an iterative algorithm based on robust least squares (RLS) for parameter estimation. Results: The RLS algorithm detected two break points in the SSR model, set at infarct size values of 11.0 and 51.5 %. Because the slope coefficients of the two extreme segments of the regression line were not significant, by constraining such segments to zero slope in the SSR model, the lower break point was identified at infarct size = 8 % and the upper one at 45 %. Conclusion: Using a rigorous statistical approach, it is possible to demonstrate that below a threshold of 8 % the infarct size apparently does not affect the LVEF and therefore a safety threshold could be set at this value. Furthermore, the same analysis suggests that the relationship between infarct size and LVEF impairment is lost for an infarct size > 45 %. [ABSTRACT FROM AUTHOR]

Abstract: Background: Several clinical studies have demonstrated that anginal attacks shortly before the onset of STEMI limit infarct size and improve short- and long-term outcomes. However, the clinical significance of preinfarction angina in STEMI patients treated by primary PCI is still controversial. Therefore, the aim of the current study was to evaluate the impact of preinfarction angina on scintigraphic infarct size in STEMI patients undergoing primary PCI. Methods: Our population is represented by 430 STEMI patients undergoing primary PCI. Infarct size was evaluated at 30 days by technetium-99m-sestamibi. Results: Preinfarction angina was associated with more advanced age, a larger prevalence of family history for CAD, smoking, and longer ischemia time. No difference was observed in other clinical or angiographic characteristics. Preinfarction angina did not affect either the rate of postprocedural TIMI 3 flow or infarct size (19 ± 15.5 vs 16 ± 13.9, p = 0.18). Similar results were observed in subanalyses according to infarct location (anterior STEMI: 22.7 ± 14.8 vs 19.2 ± 16.1, p = 0.36; non-anterior STEMI: 16.1 ± 15.7 vs 13.8 ± 11.6, p = 0.36), gender (female gender: 15.6 ± 14.5 vs 11.5 ± 13.2, p = 0.30; male gender 20.4 ± 16 vs 17.2 ± 13.8, p = 0.3) or ischemia time (≤ or > 4 h) (17.6 ± 15.6 vs 15.8 ± 14.1, p = 0.52; 21.6 ± 15.5 vs 16.7 ± 13.3, p = 0.18). The absence of any impact of preinfarction angina on infarct size was confirmed after correction for baseline characteristics, such as age, smoking, family history for CAD and ischemia time (OR [95% CI] = 1.26 [0.66-2.41], p = 0.48). Conclusions: This study shows that among STEMI patients undergoing primary PCI preinfarction angina does not affect infarct size. [Copyright &y& Elsevier]

Abstract: Aims: Thus far, the prognostic value of reverse left ventricular (LV) remodeling after ST-elevation acute myocardial infarction (STEMI) has not been fully evaluated. We sought to investigate the incidence, major determinants, and long-term clinical significance of reverse LV remodeling in a large series of STEMI patients successfully treated with primary percutaneous coronary intervention (P-PCI). Methods and results: Serial complete 2D-echocardiograms were obtained within 24h after P-PCI, and at 1 and 6 months in 512 consecutive reperfused STEMI patients. Reverse remodeling was defined as a reduction >10% in LV end-systolic volume (LVESV) at 6 month follow-up. Reverse LV remodeling occurred in 49% of study population. At follow-up (41.6±23 months), late heart failure (HF) rate was significantly higher among patients without reverse LV remodeling as compared with those with it (32% vs. 11%, P <0.0001). At multivariate analysis, independent predictors of reverse LV remodeling were a small infarct size measured as peak creatine kinase value (P <0.0001), a small functional myocardial damage measured as wall motion score index within the infarct zone (P =0.018) and baseline LVESV (P <0.0001). After adjustment for several clinical, echographic and angiographic variables, Cox analysis identified reverse LV remodeling as the only beneficial independent predictor of long-term heart failure-free survival (HR: 0.44, 95% CI: 0.275–0.722). Conclusions: Reverse LV remodeling occurred in half of successfully reperfused STEMI patients. Small structural and functional myocardial damages within the infarct zone are the major determinants of reverse LV remodeling. As expression of effective myocardial salvage by P-PCI, the reverse remodeling is an important predictor of favorable long-term outcome. [Copyright &y& Elsevier]

Recent guidelines have recommended the use of aspirin and prasugrel in patients with acute coronary syndromes undergoing percutaneous coronary intervention. However, prasugrel use has been evaluated only in randomized trials. This study sought to evaluate bleeding rates and adherence to treatment in “real-world” patients treated with prasugrel. In total 298 consecutive patients 68 ± 10 years old (31% >75 years old) underwent stent implantation and received prasugrel therapy. Indications to prasugrel therapy were (1) ST-elevation acute myocardial infarction (41%), (2) drug-eluting stent implantation in diabetics (24%), (3) stent thrombosis (3%), (4) left main coronary artery drug-eluting stent implantation (6%), and (5) percutaneous coronary intervention in patients with high residual platelet reactivity on clopidogrel therapy (26%). All patients received a loading of prasugrel 60 mg. Patients ≥75 years old and with body weight ≤60 kg received a maintenance dose of 5 mg/day (10 mg/day for all the other patients). Follow-up data including adherence to prasugrel therapy were collected by telephone interviews or outpatient visits. Minimal follow-up length was 6 months (mean 9 ± 3). Major, minor, and minimal bleedings (Thrombolysis In Myocardial Infarction criteria) occurred in 2.7%, 4.7%, and 15.1% of enrolled patients. Low residual platelet reactivity (p = 0.001) and female gender (p = 0.29) were independent predictors of bleeding events. The most frequent minimal bleeding event was epistaxis. Only 8 patients (2.7%) permanently discontinued prasugrel therapy because of bleeding events (n = 4), possible side effects (n = 2), or medical decisions not associated with bleeding or side effects (n = 2). Fourteen patients (4.7%) temporarily discontinued prasugrel (average 6.5 days) mainly because of surgical procedures. No definite or probable stent thrombosis occurred, although 3 patients develop de novo myocardial infarction and 1 an ischemic stroke. There were 11 deaths because of heart failure or refractory cardiogenic shock in 9, pulmonary embolism in 1, and cancer in 1. In conclusion, in clinical practice, major and minor bleeding event rates associated with prasugrel therapy are comparable to those reported in controlled randomized trials. The minimal bleeding event rate is higher than reported but does not seem to affect adherence to treatment. [ABSTRACT FROM AUTHOR]

The article discusses a study of the role of high residual platelet reactivity (HRPR) after clopidogrel loading as a prognostic marker of long-term thrombotic events risk in acute coronary syndromes (ACS) patients undergoing an invasive procedure and receiving long-term anti-thrombotic treatment. The study involved 1,789 patients at the Careggi Hospital Division of Cardiology in Florence, Italy from April 2005 to April 2009. There was a 14% incidence of high residual platelet reactivity after clopidogrel loading. Results show a link between high residual platelet reactivity and cardiac mortality. One of the study limitations was the use of data from a prospective nonrandomized registry.

The optimal reperfusion strategy in very elderly patients with ST-segment elevation myocardial infarction is still a subject of debate. The aim of this multicenter study was to determine the medium-term outcomes of nonagenarians after primary percutaneous intervention for ST-segment elevation myocardial infarction. A systematic review of the databases of 7 Italian centers showed that these had performed 5,023 primary angioplasties over the previous 5 years, 100 of which (2%) involved patients ≥90 years old. Thirty-five subjects were in Killip class III or IV at time of presentation, 78 had multivessel coronary artery disease, and mean ejection fraction was 0.40 ± 0.12%. In-hospital mortality was 19% and was significantly higher in patients with shock (58% vs 10%, p <0.001). Survival rate after 6 months was 68%: 16% in those with Killip class IV at admission and 81% in the remaining patients (p <0.001). Cox regression analysis identified 3 independent predictors of 6-month mortality: cardiogenic shock at presentation (hazard ratio [HR] 10.82, 95% confidence interval [CI] 4.51 to 25.93, p <0.001), Thrombolysis In Myocardial Infarction myocardial flow after percutaneous coronary intervention (HR 0.19, 95% CI 0.07 to 0.50, p = 0.001), and abciximab administration (HR 0.32, 95% CI 0.13 to 0.78, p = 0.01). In conclusion, the results of this multicenter study suggest that selected nonagenarians with acute myocardial infarction benefit from successful primary angioplasty. The treatment does not affect the poor prognosis of patients presenting with cardiogenic shock, but the administration of abciximab seems to have a positive effect on 6-month mortality. [ABSTRACT FROM AUTHOR]

Abstract: Background: It has been shown that elevated heart rate identified patients with coronary artery disease and left ventricular dysfunction at increased risk of cardiovascular outcomes. Objective: We sought to assess the prognostic impact of heart rate at presentation in patients with ST-elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods and results: We collected 6-month follow-up data in 2477 consecutive patients with STEMI treated by primary PCI. Patients with atrio-ventricular block (n =64) and atrial fibrillation (n =34) were excluded from the analysis. The association of baseline heart rate with cardiovascular outcomes was analysed using Cox proportional hazard models for groups with a heart rate of 80 beats per min (bpm) or greater (n =799) versus those with a heart rate between 60 and 79bpm (n =1192) and those with a heart rate less than 60bpm (n =388). The variables related to mortality were: age (hazard ratio (HR) 1.072, 95% confidence interval (CI) 1.052–1.092, p <0.0001), cardiogenic shock (HR 4.622, 95% CI 2.892–7.387, p <0.0001), previous myocardial infarction (HR 1.724, 95% CI 1.036–2.869, p =0.036), peak creatine-kinase value (HR 1.227, 95% CI 1.142–1.318, p <0.0001), heart rate 80bpm or greater (HR 2.170, 95% CI 1.414–3.332, p =0.0001), and optimal PCI result (HR 0.126, 95% CI 0.065–0.244, p =0.0001). For every increase of 5bpm, there were increases in mortality (HR 1.321, 95% CI 1.232–1.415, p =0.0001), but not in reinfarction or in coronary revascularization rates. Conclusion: In patients with acute myocardial infarction undergoing primary PCI, elevated heart rate (80bpm or greater) identifies those at increased risk of death. It is unknown whether heart rate reduction will result in improved outcome in this setting of patients. [Copyright &y& Elsevier]

Experimental studies have demonstrated the adverse effects of senescence on cardiac function and remodeling after acute myocardial infarction (AMI). We sought to assess the impact of age on left ventricular (LV) remodeling and heart failure (HF) after successful primary angioplasty for AMI. A series of 512 consecutive patients underwent 2-dimensional echocardiography at admission and at 1 month and 6 months after index AMI. LV volumes, ejection fraction, and wall motion score index (WMSI) were measured. Patients were divided in group 1 (<70 years old, n = 361) and group 2 (> or =70 years old, n = 151). Group 2 patients showed a lower peak creatine kinase (p = 0.029) compared to group 1. In group 2 patients the 6-month prevalence of LV remodeling (increase >20% in end-diastolic volume) was higher (34% vs 25%, p = 0.041), recoveries of ejection fraction and WMSI were lower (p = 0.00002 for the 2 comparisons), and incidence of late HF was higher (35% vs 17%, p <0.0001) compared to group 1 patients. Independent predictors of LV remodeling were WMSI (p <0.0001), infarct size (p <0.0001), and LV end-diastolic volume (p <0.0001). Independent predictors of late HF were WMSI (hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.624 to 4.514), 6-month LV dilation (HR 2.13, 95% CI 1.404 to 3.233), diabetes (HR 1.6, 95% CI 1.008 to 2.595), infarct size (HR 1.12, 95% CI 1.037 to 1.215), and age as continuous variables (HR 1.064, 95% CI 1.044 to 1.085). In conclusion, besides infarct size, extensive regional systolic dysfunction may play a significant role in the development of LV remodeling and HF in patients > or =70 years old after successful primary angioplasty. [ABSTRACT FROM AUTHOR]

There are very few (and conflicting) data about the effectiveness of primary percutaneous coronary interventions (PCIs) for stent thrombosis (ST) treatment. We sought to evaluate the prevalence, efficacy, and outcomes of primary PCI in patients with ST-elevation acute myocardial infarction (STEMI) due to ST in 2,464 consecutive patients treated by primary PCI. ST was the cause of STEMI in 67 patients (3%). Patients with ST showed a lower rate of significant collateral circulation (0% vs 6%, p = 0.034) and a higher peak creatine kinase value (2,678 ± 3,221 vs 2,375 ± 2,189 U/L, p = 0.003) compared with the other 2,397 patients with STEMI. PCI was successful in 64 patients (96%) in the ST group and consisted of additional stenting (78%) or only balloon angioplasty (22%). Abciximab and rheolytic thrombectomy were used in 75% and 31% of patients, respectively. Procedure (39 ± 26 vs 32 ± 19 minutes, p = 0.0001) and fluoroscopy (13 ± 10 vs 10 ± 8 minutes, p = 0.0001) times were longer, and contrast medium amount (221 ± 89 vs 194 ± 103 ml, p = 0.034) larger in patients with ST compared with patients with de novo STEMI. Six-month death (12% vs 8%, p = 0.216) and nonfatal reinfarction (10% vs 1%, p = 0.0001) rates were higher in patients with ST compared with those without. At 6-month angiographic follow-up (n = 1,843 of 2,269), the restenosis/reocclusion rate was 54% versus 17% (p = 0.0001) in patients with and without ST. In conclusion, the prevalence of primary PCI for ST is low. Additional stenting with or without thrombectomy is effective in restoring vessel patency in patients with ST, but restenosis and reocclusion are frequent. ST treated with successful PCI is associated with a large infarct and poor outcome. [Copyright &y& Elsevier]

The aim of this study was to evaluate the accuracy of a new-generation spiral multidetector computed tomographic scanner (the Brilliance 64) in the diagnosis of coronary in-stent restenosis (ISR). Forty-one patients with 87 coronary stents (70 drug-eluting stents) implanted were examined. Patients underwent multidetector computed tomography (MDCT) 6.7 ± 6.9 days before scheduled invasive coronary angiography, using intravenous contrast enhancement. Images were reconstructed in multiple formats using retrospective electrocardiographic gating. Stents were viewed in their long and short axes and were visually classified for the presence or absence of binary ISR (diameter reduction >50%), including the 5-mm borders proximal and distal to the stent. ISR was found by invasive coronary angiography in 13 of the stented segments (15%) and in 8 patients (19%). Of these, 11 cases of ISR were correctly detected by MDCT; additionally, 1 severely calcified stented segment was considered as occluded by MDCT (sensitivity 84%, 95% confidence interval [CI] 54% to 98%). Seventy-three of 74 stented segments without ISR were correctly classified by MDCT (specificity 97%, 95% CI 93% to 100%), whereas 2 stented segments were classified as false-negative ISR. The positive predictive value was 92% (95% CI 84% to 97%), the negative predictive value was 97% (95% CI 90% to 99%), and predictive accuracy was 96% (95% CI 90% to 99%). After the exclusion of the calcified stented segment, the sensitivity, specificity, positive predictive value, negative predictive value, and predictive accuracy were 84% (95% CI 74% to 91%), 100% (95% CI 96% to 100%), 100% (95% CI 96% to 100%), 97% (CI 90% to 99%), and 98% (95% CI 92% to 99%), respectively. In conclusion, even with improved scanner technology, the sensitivity for the detection of ISR was moderate (84%). Thus, further studies are needed to determine whether MDCT will be a clinically useful and cost-effective tool for the evaluation of ISR in the clinical arena. [Copyright &y& Elsevier]

This study prospectively evaluated the prevalence, predictors, time course, and prognostic impact of left ventricular (LV) functional recovery after successful primary percutaneous coronary intervention in 228 consecutive patients with acute myocardial infarctions (AMIs) and LV dysfunction. Serial echocardiographic exams were performed within 24 hours (time 1) and at 1 month (time 2) and 6 months (time 3) after AMI. Overall, 133 patients (58%) showed significant LV functional recovery (≥10% ejection fraction increase compared with time 1 or ejection fraction ≥50%) at time 3. Early (from time 1 to time 2) and late (from time 2 to time 3) functional recovery patterns were detected in 102 patients (45%) and 31 patients (14%), respectively. Independent predictors of LV functional recovery were enzymatic infarct size (p = 0.0001), time from symptom onset to reperfusion (p = 0.022), extent and severity of baseline LV wall motion abnormalities (p = 0.007), and female gender (p = 0.031). Six-month LV remodeling rates were 36% and 64% in patients with and without LV functional recovery (p = 0.0001). The five-year cardiac death rate was significantly lower in patients with LV functional recovery than in those without (8% vs 18%, respectively, p = 0.024). The time course of LV functional recovery during 6 months did not significantly affect long-term survival. In conclusion, after successful mechanical reperfusion of AMIs, nearly half of patients showed poor LV functional recovery. The presence of significant LV functional recovery 6 months after reperfused AMI, but not the specific time course of recovery, is clearly associated with a better long-term clinical outcome. Simple baseline variables can predict the improvement of cardiac function after reperfused AMI. [Copyright &y& Elsevier]

The correlation between Doppler deceleration time (DT) and brain natriuretic peptide (BNP) and their predictive value for detecting left ventricular (LV) remodeling in patients who are treated with primary percutaneous intervention for infarction and LV dysfunction are unknown. Fifty-six patients (64 +/- 12 years of age; 11 women) who had a first ST-segment elevation myocardial infarction and systolic dysfunction that was successfully treated with direct primary coronary intervention underwent 2-dimensional Doppler echocardiographic and plasma BNP evaluation at days 1 and 3 and 1 and 6 months after the index infarction. Repeat coronary angiograms were obtained at 1 and 6 months. Because of previous consistent evidence, 3 days after the index infarction was the time point of comparison between BNP and DT values. Echocardiographic LV remodeling was defined as an increase in end-diastolic volume index above baseline values of 2 x SD. Ventricular remodeling occurred in 20 patients (36%). Multivariate analyses that included BNP level, Doppler DT, echocardiographic measurements of systolic function, peak creatine kinase, and anterior infarct location showed Doppler DT to be the only predictor of LV remodeling (odds ratio 0.963, 95% confidence interval 0.936 to 0.990, p = 0.008). The optimal cutoff for DT in the prediction of 6-month LV remodeling was <136 ms (sensitivity 75%, specificity 97%, accuracy 81%, area under receiver-operating characteristic curve 0.90). Thus, in patients who have a first ST-segment elevation myocardial infarction and LV systolic dysfunction that is successfully treated with primary percutaneous coronary intervention, Doppler-derived DT 3 days after index infarction is more effective than BNP level in detecting patients who are at higher risk for 6-month LV remodeling. [ABSTRACT FROM AUTHOR]

Kounis syndrome (KS) is a rare condition characterized by acute myocardial infarction during an allergic reaction. It is classified into three subtypes based on pathophysiology. SonoVue, an ultrasound contrast agent that allows the evaluation of myocardial perfusion, is generally safe with a low incidence of severe adverse reactions. A 44-year-old man with a recent acute coronary syndrome treated with one stent implantation in the left circumflex artery underwent a contrast-enhanced stress perfusion echocardiography. Shortly after SonoVue administration, he developed diffuse rash, hypotension, tachycardia, and ultimately chest pain with an inferolateral ST-segment elevation myocardial infarction (STEMI) with 2:1 atrioventricular block. Coronary angiography revealed mild diffused coronary spasm and stent thrombosis at the proximal edge of the recently placed stent. After mechanical thrombectomy Optical Coherence Tomography was performed and revealed significant stent underexpansion and malapposition. The patient was treated with additional stent implantation in proximal overlap with the previously placed stent and he was discharged on the 7th post-operative day with a fully recovered left ventricular function. The case illustrates a rare combination of KS and an anaphylactic reaction to a contrast agent. The allergic reaction triggered type 3 KS with stent thrombosis and diffuse coronary vasospasm. Stent malapposition and underexpansion further facilitated thrombosis. Management included aggressive fluid resuscitation and norepinephrine, while epinephrine was avoided due to the risk of worsening coronary vasospasm. Serum tryptase levels were normal, possibly due to timing of sampling. Drug-coated balloon angioplasty was considered but it wasn't feasible due to stent undersizing., Competing Interests: The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (© 2024 The Authors.)

Background: Myocardial reperfusion is the main target of treatment in patients with ST-segment elevation myocardial infarction (STEMI). The intracoronary administration of cangrelor bolus could favor a higher local drug concentration, favoring an earlier thrombotic resolution and a reduced distal micro-embolization., Methods: Seventy-one patients undergoing primary percutaneous coronary intervention (PCI) for STEMI: 37 treated with intracoronary and 34 with intravenous bolus administration of cangrelor. The primary endpoint was ST-segment elevation resolution (STR) ≥ 50% after 30 min from the end of the PCI. Other explorative reperfusion indices investigated were: STR ≥ 50% at 24 hours, STR ≥ 70% at 30 min, Thrombolysis In Myocardial Infarction frame count and the QT dispersion. Moreover, acute and subacute stent thrombosis, bleeding events and 30-day mortality have been evaluated., Results: More frequent STR ≥ 50% was observed in the intravenous cangrelor bolus group as compared to the intracoronary administration at 30 min (71.9% vs. 45.5%; p = 0.033), the difference was maintained 24 hours after PCI (87.1% vs. 63.6%; p = 0.030). STR ≥ 70% at 30 min was statistically more frequent in the intravenous bolus administration cohort (66.7% vs. 28.6% p = 0.02). At multivariable analysis, intravenous cangrelor administration was significantly related to STR ≥ 50% (odds ratio: 3.586; 95% confidence interval: 1.134-11.335; p = 0.030). The incidence of Bleeding Academic Research Consortium 3-5 bleedings was 15.5% and mortality was 4.2% without any significant difference between the two groups., Conclusions: In conclusion the results of the study do not show any advantages in the administration of intracoronary bolus of cangrelor in patients affected by STEMI and treated with primary PCI.

Objective: The role of left ventricular (LV) volumes and ejection fraction (EF) in the selection of patients for the MitraClip procedure remains matter of debate. The goal of this study is to assess the pattern of LV remodeling and its clinical implications after MitraClip procedures, and to evaluate the role of LV ejection fraction (EF) in patient selection., Methods: Complete echocardiography was performed before, at discharge, 1,6, and 12-months in 45 patients treated with MitraClip for severe mitral regurgitation (MR) [age 78.2 ± 8.3 yrs, NYHA 3.74 ± 0.44, EF 36.5 ± 12.8%]. From baseline to 6-month, reverse and adverse LV-R were defined as a ≥15% decrease in LV end-systolic volume and a ≥10% increase in LV end-systolic volume, respectively., Results: At 6-month, sustained reduction of MR ≤ 2 was observed in all patients, but two; reverse, adverse, and no LV-R occurred in 51% (N = 23), 18% (N = 8), and 31% (N = 14) of patients, respectively. Baseline LV end-diastolic volume was an independent predictor of reverse LV-R [P = 0.004], whereas EF was not. During follow-up (17.5 ± 9.3 months) period, 50% of adverse/no LV-R patients were free of the composite endpoint (mortality and hospitalization for heart failure) compared to 95.7% of reverse LV-R patients (P = 0.006). In Cox analysis, adverse LV-R and adverse/no LV-R were associated with composite endpoint with adjusted hazard ratios of 5.6 (95% CI 1.65-19.00) and 10.08 (95% CI 1.29-78.6), respectively., Conclusion: After MitraClip implantation, sustained adverse or no LV-R occurred in one-in-two patients and was associated with poor prognosis. Large LV volumes may help us to avoid the futility of the procedure., (Copyright © 2021 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Treatment of coronary chronic total occlusion (CTO) with percutaneous coronary intervention (PCI) has rapidly increased during the past decades. Different strategies and approach were developed in the recent past years leading to an increase in CTO-PCI procedural success. The goal to achieve an extended revascularization with a high rate of completeness is now supported by strong scientific evidences and consequently, has led to an exponential increase in the number of CTO-PCI procedures, even if are still underutilized. It has been widely demonstrated that complete coronary revascularization, achieved by either coronary artery bypass graft or PCI, is associated with prognostic improvement, in terms of increased survival and reduction of major adverse cardiovascular events. The application of "contemporary" strategies aimed to obtain a state-of-the-art revascularization by PCI allows to achieve long-term clinical benefit, even in high-risk patients or complex coronary anatomy with CTO. The increasing success of CTO-PCI, allowing a complete or reasonable incomplete coronary revascularization, is enabling to overcome the last great challenge of interventional cardiology, adding a "complex" piece to "complete" the puzzle., Competing Interests: Conflict-of-interest statement: Authors declare no conflict of interests for this article., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

The number of aortic stenosis patients in Western countries is increasing, along with better life conditions and expectancies. Presently, the volume of percutaneous transcatheter aortic valve implantations (TAVIs) is incessantly increasing, and has already overcome the surgical replacement procedure volume. According to the literature, TAVI is a feasible procedure even among low surgical risk patients, and American guidelines have extended the indications for TAVI, including shifting patient evaluations from high/low STS scores to old/young patients, a "paradigm shift" of aortic stenosis evaluation. As a result, low-risk young (<75 years-old) population management could be the next challenge in cardiology. To manage the life conditions of a 65 year old patient affected by aortic stenosis who is undergoing TAVI, one of the most crucial issue will be bioprosthesis durability and the appropriate intervention to make in cases of valve dysfunction or failure.

As transcatheter aortic valve Implantation (TAVI) moves to younger and lower risk patients with longer life expectancy, the long-term durability of TAVI is becoming an increasingly relevant issue. We sought to evaluate the long-term clinical outcome and prosthesis performance of the CoreValve self-expandable valve. Clinical registry of 182 patients consecutively treated with TAVI in a tertiary center from January 2009 to July 2017. Of these, 111 died during an average follow-up (FU) of 1,026 ± 812 days (median IQR: 745, 477 to 1,400 days; longest survival 11 years; 61% mortality at Kaplan-Meier analysis). At 1 month, functional profile improved in all survivors, with 93.9% of them achieving NYHA class I or II. At Cox analysis, the Society of Thoracic Surgeons score (HR: 1.55; p = 0.001), left ventricular ejection fraction <40% (HR: 1.65; p = 0.017) and incident acute kidney injury (HR: 1.96; p = 0.001) were independently associated with all-cause mortality. During FU, echocardiographically assessed mean transprosthetic aortic gradient remained substantially unchanged (from 9.0 ± 2.7 after TAVI to 9.0 ± 5.0 mm Hg at FU; p >0.05). Most patients had none and/or trivial (34%), or mild (58%), fewer had moderate (8%) and none had severe perivalvular leak, without significant change during FU. At 11 years, cumulative incidence of bioprosthetic valve failure and moderate structural valve deterioration (SVD) were 2.9% (95% CI 0.8% to 10%) and 9.3% (95% CI 3.3% to 26.7%), respectively. In conclusion, our registry confirmed that TAVI with the self-expandable CoreValve system was associated with favorable long-term clinical outcomes, with a reassuring low rate of significant bioprosthetic valve failure and moderate SVD., (Copyright © 2020 Elsevier Inc. All rights reserved.)