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Platelet function testing (PFT) could be a useful clinical tool to guide individualized antithrombotic treatment in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). We aimed to investigate platelet reactivity (PR) in the context of a contemporary registry. “Real-world” data were retrieved from a nationwide, multicenter, observational study of AF patients on oral anticoagulants (OAC) undergoing PCI. Patients treated with a P2Y12 inhibitor, namely clopidogrel or ticagrelor, as part of double or triple antithrombotic therapy, were submitted to PFT before discharge and were followed up for 12 months. Out of 101 patients included in the study, 66 were submitted to PFT while on clopidogrel and 35 while on ticagrelor; PR was 162.9 ± 68 PRU and 46.02 ± 46 PRU, respectively (P

GReek-AntiPlatElet Atrial Fibrillation (GRAPE-AF) registry is a multicenter, observational, non-interventional study of AF patients undergoing PCI. Primary endpoint included clinically significant bleeding rate at 12 months between different antithrombotic regimens prescribed at discharge; secondary endpoints included major adverse cardiovascular events (MACEs) as well as net adverse clinical events (NACEs).A total of 647 patients were analyzed. The majority (92.9%) were discharged on NOACs with only 7.1% receiving VKA. A little over half of patients (50.4%) received triple antithrombotic therapy (TAT) - mostly (62.9%) for ≤ 1 month - while the rest (49.6%) received dual antithrombotic therapy (DAT). Clinically significant bleeding risk was similar between TAT and DAT (HR = 1.08; 95% CI = 0.66 - 1.78), though among TAT-receiving patients, the risk was lower in those receiving TAT for ≤ 1 month (HR = 0.50; 95% CI = 0.25 - 0.99). Anticoagulant choice (NOAC vs VKA) did not significantly affect bleeding rates (P=0.258). Age, heart failure, leukemia/myelodysplasia and acute coronary syndrome were associated with increased bleeding rates. Risk of MACEs and NACEs was similar between ΤAT and DAT (HR = 1.73; 95% CI = 0.95 - 3.18, P = 0.075 and HR = 1.39; 95% CI = 0.93 - 2.08, P=0.106, respectively).In conclusion, clinically significant bleeding and ischemic rates were similar between DAT and TAT, although TAT1 month was associated with higher bleeding risk.

The unprecedented for modern medicine pandemic caused by the SARS-COV-2 virus ("coronavirus", Covid-19 disease) creates in turn new data on the management and survival of cardiac arrest victims, but mainly on the safety of CardioPulmonary Resuscitation (CPR) providers. The Covid-19 pandemic resulted in losses of thousands of lives, and many more people were hospitalized in simple or in intensive care unit beds, both globally and locally in Greece. More specifically, in victims of cardiac arrest, both in- and out- of hospital, the increased mortality and high contagiousness of the SARS-CoV-2 virus posed new questions, of both medical and moral nature/ to CPR providers. What we all know in resuscitation, that we cannot harm the victim and therefore do the most/best we can, is no longer the everyday reality. What we need to know and incorporate into decision-making in the resuscitation process is the distribution of limited human and material resources, the potentially very poor outcome of patients with Covid-19 and cardiac arrest, and especially that a potential infection of health professionals can lead in the lack of health professionals in the near future. This review tries to incorporate the added skills and precautions for CPR providers in terms of both in- and out- hospital CPR.

The pandemic of coronavirus disease 2019 (COVID-19) has become a public health emergency of international concern. During this time, the management of people with acute coronary syndromes (ACS) and COVID-19 has become a global issue, especially since preexisting cardiovascular disease is a risk factor for the presence and the severity of COVID-19. The number of people with ST- elevation myocardial infarction (STEMI) has decreased during the pandemic and delays in the time looking for medical care have been reported. In addition, the diagnosis of ACS may have been difficult due to possible underlying myocarditis or other clinical entities. Regarding management of people with STEMI, although the superiority of primary percutaneous coronary intervention (PCI) over thrombolysis is well established, the notable exposure risks due to absence of negative pressure in catheterization rooms and the increased difficulty in fine manipulation on guidewires under proper protection equipment may contribute to the relatively secondary role of PCI during the COVID-19 pandemic; thus, fibrinolytic therapy or robotic-assisted PCI in early presenting STEMI patients may have an alternative role during this period if prevention measures cannot be taken. Healthcare stuff should take the proper measures to avoid the spread of and their exposure to the virus.

Patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS) are at high residual risk for long-term cardiovascular (CV) mortality. Cathepsin S (CTSS) is a lysosomal cysteine protease with elastolytic and collagenolytic activity that has been involved in atherosclerotic plaque rupture.; The purpose of this study was to determine the following: 1) the prognostic value of circulating CTSS measured at patient admission for long-term mortality in NSTE-ACS; and 2) its additive value over the GRACE (Global Registry of Acute Coronary Events) risk score.; This was a single-center cohort study, consecutively recruiting patients with adjudicated NSTE-ACS (n = 1,112) from the emergency department of an academic hospital. CTSS was measured in serum using enzyme-linked immunosorbent assay. All-cause mortality at 8 years was the primary endpoint. CV death was the secondary endpoint.; In total, 367 (33.0%) deaths were recorded. CTSS was associated with increased risk of all-cause mortality (HR for highest vs lowest quarter of CTSS: 1.89; 95% CI: 1.34-2.66; P < 0.001) and CV death (HR: 2.58; 95% CI: 1.15-5.77; P = 0.021) after adjusting for traditional CV risk factors, high-sensitivity C-reactive protein, left ventricular ejection fraction, high-sensitivity troponin-T, revascularization and index diagnosis (unstable angina/ non-ST-segment elevation myocardial infarction). When CTSS was added to the GRACE score, it conferred significant discrimination and reclassification value for all-cause mortality (Delta Harrell's C: 0.03; 95% CI: 0.012-0.047; P = 0.001; and net reclassification improvement = 0.202; P = 0.003) and CV death (AUC: 0.056; 95% CI: 0.017-0.095; P = 0.005; and net reclassification improvement = 0.390; P = 0.001) even after additionally considering high-sensitivity troponin-T and left ventricular ejection fraction.; Circulating CTSS is a predictor of long-term mortality and improves risk stratification of patients with NSTE-ACS over the GRACE score.

BACKGROUND There were gaps between guidelines and practice when surgery was the only treatment for aortic stenosis (AS). OBJECTIVES This study analyzed the decision to intervene in patients with severe AS in the EORP VHD (EURObservational Research Programme Valvular Heart Disease) II survey. METHODS Among 2,152 patients with severe AS, 1,271 patients with high-gradient AS who were symptomatic fulfilled a Class I recommendation for intervention according to the 2012 European Society of Cardiology guidelines; the primary end point was the decision for intervention. RESULTS A decision not to intervene was taken in 262 patients (20.6%). In multivariate analysis, the decision not to intervene was associated with older age (odds ratio [OR]: 1.34 per 10-year increase; 95% CI: 1.11 to 1.61; P = 0.002), New York Heart Association functional classes I and II versus III (OR: 1.63; 95% CI: 1.16 to 2.30; P = 0.005), higher age adjusted Charlson comorbidity index (OR: 1.09 per 1-point increase; 95% CI: 1.01 to 1.17; P = 0.03), and a lower transaortic mean gradient (OR: 0.81 per 10-mm Hg decrease; 95% CI: 0.71 to 0.92; P < 0.001). During the study period, 346 patients (40.2%, median age 84 years, median EuroSCORE II [European System for Cardiac Operative Risk Evaluation II] 3.1%) underwent transcatheter intervention and 515 (59.8%, median age 69 years, median EuroSCORE II 1.5%) underwent surgery. A decision not to intervene versus intervention was associated with lower 6-month survival (87.4%; 95% CI: 82.0 to 91.3 vs 94.6%; 95% CI: 92.8 to 95.9; P < 0.001). CONCLUSIONS A decision not to intervene was taken in 1 in 5 patients with severe symptomatic AS despite a Class I recommendation for intervention and the decision was particularly associated with older age and combined comorbidities. Transcatheter intervention was extensively used in octogenarians. (J Am Coll Cardiol 2021;78:2131-2143) (c) 2021 by the American College of Cardiology Foundation.

In recent years, the management of complex lesions in patients undergoing percutaneous coronary intervention (PCI) constitutes a field of high interest and concern for the interventional cardiology. As more and more studies demonstrate the increased hazard of ischemic events in this group of patients, it is of paramount importance for the physicians to choose the optimal periprocedural (pre-PCI, during-PCI and post-PCI) antithrombotic treatment strategies wisely. Evidence regarding the safety and efficacy of current anticoagulation recommendation, the possible beneficial role of the pretreatment with a potent P2Y12 inhibitor in the subgroup of patients with non-ST segment elevation myocardial infarction with complex lesions, and the impact of a more potent P2Y12 inhibitor in individuals with stable coronary artery disease undergoing complex PCI are needed. This will provide and serve as a guide to clinicians to deploy the maximum efficacy of the current choices of antithrombotic therapy, which will lead to an optimal balance between safety and efficacy in this demanding clinical scenario.

A 60-year-old patient presented with recalcitrant electrical storm (ES). Mild sedation and initial antiarrhythmic combination of esmolol and amiodarone did not affect the intensity of ES, which resulted in battery exhaustion. Oral propranolol in addition to intravenous amiodarone might be preferred in hemodynamically stable patients before interventional therapies. (Level of Difficulty: Intermediate.), Graphical abstract, A 60-year-old patient presented with recalcitrant electrical storm (ES). Mild sedation and initial anti-arrhythmic combination of esmolol and…

SARS-CoV-2 (Covid-19) infection has recently become a worldwide challenge with dramatic global economic and health consequences. As the pandemic is still spreading, new data concerning Covid-19 complications and related mechanisms become increasingly available. Accumulating data suggest that the incidence of cardiac arrest and its outcome are adversely affected during the Covid-19 period. This may be further exacerbated by drug-related cardiac toxicity of Covid-19 treatment regimens. Elucidating the underlying mechanisms that lead to Covid-19 associated cardiac arrest is imperative, not only in order to improve its effective management but also to maximize preventive measures. Herein we discuss available epidemiological data on cardiac arrest during the Covid-19 pandemic as well as possible associated causes and pathophysiological mechanisms and highlight gaps in evidence warranting further investigation. The risk of transmission during cardiopulmonary resuscitation (CPR) is also discussed in this review. Finally, we summarize currently recommended guidelines on CPR for Covid-19 patients including CPR in patients with cardiac arrest due to suspected drug-related cardiac toxicity in an effort to underscore the most important common points and discuss discrepancies proposed by established international societies., Highlights • Covid-19 pandemic is associated with increased incidence of cardiac arrest. • Cardiac, non-cardiac causes and drug-related toxicity may jointly contribute to cardiac arrest associated with Covid-19. • Recommendations for cardiac arrest management are modified during the pandemic. • Recommendations for prevention and management of drug-related toxicity related to Covid-19 are summarized.

Background The sporadic form of transthyretin amyloidosis cardiomyopathy (ATTR-CM) is underdiagnosed but its prevalence is increasing due to the aging population. Given the poor prognosis of ATTR-CM understanding the underlying pathophysiologic mechanisms of the disease is imperative in order to improve strategies for early diagnosis and risk stratification and to develop new effective therapeutic options. ATTR-CM is associated with hypotension and there is preliminary experimental evidence of vascular involvement but its presence and clinical significance remains unknown. Purpose To characterize peripheral arterial involvement and explore its clinical role in ATTR-CM. Methods We consecutively recruited 28 previously untreated patients with newly diagnosed ATTR-CM and 34 elderly controls >70 years old, without ATTR-CM or heart failure. In both groups, flow-mediated dilatation (FMD) and intima-media thickness (IMT) in the carotid arteries were measured by high-resolution ultrasonography as markers of peripheral vascular reactivity and of subclinical atherosclerosis, respectively. Carotid-femoral pulse wave velocity (PWV) was measured as a marker of arterial stiffness. Aortic blood pressure (BP) and augmentation index (AI) using applanation tonometry were measured as markers of arterial wave reflections, peripheral arterial resistance and central hemodynamics. Echocardiography was performed in all ATTR patients. All cardiovascular (CV) measurements were performed before administration of any ATTR-specific therapy. Results ATTR patients were older and had lower prevalence of hypertension and male gender (p Conclusion ATTR-CM is associated with lower aortic wave reflections, which correlate with more advanced structural cardiac disease, as assessed by IVwt. Further, ATTR-CM patients present accelerated subclinical carotid atherosclerosis as compared to elderly control subjects. These findings suggest that in ATTR-CM there is disease-specific peripheral vascular involvement in parallel to cardiac involvement. The clinical significance of these findings merits further investigation. Funding Acknowledgement Type of funding source: None

Increased blood pressure (BP) variability is associated with the development of target organ damage. However, the optimal type and index of BP variability (BPV) regarding their prognostic significance is unclear. The aim of our study was to compare the association of ambulatory and home BPV with the left ventricular mass index (LVMI) in patients with chronic kidney disease (CKD). From a total of 1560 consecutive subjects, 137 hypertensive patients with CKD underwent home and ambulatory BP monitoring and echocardiographic measurements. The variability of home BP monitoring was quantified by using the standard deviation (SD), coefficient of variation (CV), and morning minus evening BP values. Ambulatory BPV was quantified using the SD, CV, and the time rate (TR) of BP variation. The univariate analysis demonstrated that day-to-day systolic SD and the 24-h TR of systolic BP (SBP) variation were significantly associated with the LVMI. The multivariate linear regression analysis showed a significant and independent association of the LVMI with the 24-h TR of SBP variation (B = 9.204, 95% CI: 1.735-16.672; p = 0.016). A 0.1-mmHg/min increase in the 24-h TR of SBP variation was associated with an increment of 9.204 g/m2 in the LVMI, even after adjustment for BP and other vascular risk factors. In conclusion, ambulatory BPV but not home BPV was associated with the LVMI in CKD patients. The 24-h TR of SBP variation was the only BPV index associated with the LVMI, independent of average BP values.

The novel coronavirus disease 2019 (COVID-19) pandemic has already caused more than 300,000 deaths worldwide. Several studies have elucidated the central role of cardiovascular complications in the disease course. Herein, we provide a concise review of current knowledge regarding the involvement of cardiovascular system in the pathogenesis and prognosis of COVID-19. We summarize data from 21 studies involving in total more than 21,000 patients from Asia, Europe, and the USA indicating that severe disease is associated with the presence of myocardial injury, heart failure, and arrhythmias. Additionally, we present the clinical and laboratory differences between recovered and deceased patients highlighting the importance of cardiac manifestations. For the infected patients, underlying cardiovascular comorbidities and particularly existing cardiovascular disease seem to predispose to the development of cardiovascular complications, which are in turn associated with higher mortality rates. We provide mechanistic insights into the underlying mechanisms including direct myocardial damage by the virus and the consequences of the hyperinflammatory syndrome developed later in the disease course. Finally, we summarize current knowledge on therapeutic modalities and recommendations by scientific societies and experts regarding the cardiovascular management of patients with COVID-19.

Background There is increasingly recognized undetected residual cardiovascular (CV) risk in postmenopausal women, suggesting the need for new risk biomarkers in this population. We have previously shown that amyloid-beta (1–40) (Aβ1–40), a proinflammatory and pro-atherosclerotic peptide, is associated with concurrent subclinical cardiovascular disease (CVD) in the general population and with major adverse cardiac events in patients with established cardiac disease. However, the clinical value of Aβ1–40 in menopause or whether this peptide is linked with an increased rate of progression of atherosclerotic disease is unknown. Purpose To examine the association of Aβ1–40 levels with the rate of progression of carotid intima-media thickness (IMT) in postmenopausal women. Methods In the settings of a Menopause Clinic, postmenopausal women (n=140) without clinically overt CVD or diabetes were consecutively recruited and re-evaluated after a median follow-up period of 24 months. IMT in the carotid arteries was measured by ultrasonography. The average of maximal IMT (mean cIMT) measured at both left and right common carotid, carotid bulb (cb)and internal carotid (ic) artery were used as the main end-point of the analysis. Aβ1–40 was measured in plasma samples at baseline and follow up. Fasting insulin resistance was assessed using the homeostasis model assessment of insulin resistance (HOMA-IR). Results Women with increased plasma levels Aβ1–40 in the highest tertile presented the highest probability to have increased mean cIMT (adjusted OR=2.97, 95% CI 1.18–7.52, p=0.021) independently of age, smoke, hypertension, and hyperlipidemia. After adjustment for HOMA-IR, this association remained significant. Similarly, Aβ1–40 levels were associated with increased mean cb and icIMT (adjusted OR=3.34 for highest versus lower tertile, 95% CI 1.27–8.81, p=0.015). Mean cIMT significantly increased across the follow up period (0.73mm (0.065–0.08) to 0.77mm (0.07–0.089), median increase rate per year 0.024mm, p Conclusion Aβ1–40 is an independent predictor of the rate of progression of subclinical carotid atherosclerosis in menopausal women. This finding supports the clinical value of Aβ1–40 in menopause and warrants further investigation for its prognostic role in this population.

COVID-19 pandemic caused a major crisis, affecting and straining health care systems, including some very advanced ones. The pandemic may have also indirectly affected access to health care for patients with other conditions, not related to COVID-19, even in countries not overwhelmed by an outbreak.We analyzed and compared visits to the emergency room (ER) department during the same calendar period of 2019 and 2020 (from March 1 to March 31 of each year) in our hospital, a medium size, tertiary center, located in the center of Athens, which is not a referral center for COVID-19.Total ER visits were reduced by 42.3% and the number of those requiring hospitalization by 34.8%. This reduction was driven by lower numbers of visits for low risk, non-specific symptoms and causes. However, there was a significant decrease in admissions for cardiovascular symptoms and complications (chest pain of cardiac origin, acute coronary syndromes, and stroke) by 39.7% and for suspected or confirmed GI hemorrhage by 54.7%. Importantly, number of ER visits for infections remained unchanged, as well as the number of patients that required hospitalization for infection management; only few patients were diagnosed with COVID-19.During the initial period of the pandemic and lock-down in Greece, there was a major decrease in the patients visiting ER department, including decrease in the numbers of admissions for cardiovascular symptoms and complications. These observations may have implications for the management of non-COVID-19 diseases during the pandemic.

Essentials The comparative efficacy and safety of antiplatelet agents in ‘real life’ is not clear. We recruited acute coronary syndrome patients receiving percutaneous coronary intervention. At 1-year follow-up, prasugrel offers better anti-ischemic protection than clopidogrel. Prasugrel and ticagrelor are accompanied by more frequent bleeding events. SummaryBackground The comparative efficacy and safety of antiplatelet treatment outside randomized trials is not clear. Objectives To investigate long-term efficacy and safety in ‘real-life’ acute coronary syndrome (ACS) patients treated by percutaneous coronary intervention (PCI) with contemporary use of clopidogrel, prasugrel and ticagrelor. Methods In a prospective, observational, multicenter cohort study, 2047 patients were recruited into the GReek AntiPlatElet (GRAPE) Registry and were followed-up for 1 year for major adverse cardiovascular events (MACE, a composite of death, non-fatal myocardial infarction, urgent revascularization and stroke) and bleeding events (Bleeding Academic Research Consortium [BARC] classification). Results Exposure to clopidogrel, prasugrel and ticagrelor by PCI occurred in 959, 363 and 717 patients, respectively. After adjustment, the rate of MACE (primary outcome endpoint) was lower in prasugrel-treated patients (4.4%) than in clopidogrel-treated patients (10.1%) (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.30–0.91), although not significantly different between ticagrelor (6.8%) and clopidogrel groups (HR, 0.78; 95% CI, 0.54–1.12). Any type of BARC-classified bleeding (secondary outcome endpoint) was more frequent in prasugrel-treated patients (51.2%) than in clopidogrel-treated patients (37.6%) (HR, 1.61; 95% CI, 1.33–1.95) and more frequent in ticagrelor-treated patients (56.9%) than in clopidogrel-treated patients (HR, 1.81; 95% CI, 1.55–2.10). An adjusted comparison between prasugrel and ticagrelor-treated groups did not reveal differences in any outcome measure. After adjustment, the death rate was more reduced by novel agents in comparison with clopidogrel (2.9% vs. 6.2%). Conclusions In ACS/PCI patients, prasugrel offered better anti-ischemic protection than clopidogrel, whereas use of both novel agents is accompanied by more frequent bleeding events.

The management of ST-segment elevation myocardial infarction (STEMI) has evolved significantly over the last decades. STEMI treatment includes reperfusion therapy, ideally by primary percutaneous coronary intervention (pPCI), modern antithrombotic therapy and secondary prevention measures. Even though many areas in the management of STEMI are well studied and analyzed in the guidelines, there are still challenges and unanswered questions on how to improve outcomes. This review aims to offer an insight in areas that need to be explored. Keywords: Myocardial infarction, Primary PCI, Antithrombotic treatment

Aims Data on the clinical impact of gender in ‘real life’ acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI), receiving clopidogrel, prasugrel or ticagrelor are limited. We aimed to investigate sex-based differences in clinical outcome of those patients. Methods In a prospective, observational, multicenter, cohort study 2047 patients were recruited into the GReekAntiPlatElet (GRAPE) Registry and were followed-up until 1 year for major adverse cardiovascular events (MACE, composite of death, non fatal myocardial infarction,urgent revascularization and stroke) and bleeding events [Bleeding Academic Research Consortium (BARC) classification]. Results Women (n=360, 17.6%) were more frequently administered clopidogrel (rather than novel P2Y12 receptor antagonists) at PCI hospital and at discharge. MACE occurred in 9.2% and 8.1% of women and men, respectively and did not differ significantly by gender. Rate of observed bleeding BARC any type was 57.2% and 44.4% in women and men, respectively. Following adjustment, only differences in BARC any type and BARC type 1 events remained significant, with higher rates observed between women: hazard ratio (95% confidence interval)1.51(1.23-1.85) and 1.58(1.27-1.96), respectively, p

Objectives: To assess the clinical impact of impaired renal function (IRF), in “real-world” acute coronary syndrome (ACS) patients, receiving clopidogrel, prasugrel, or ticagrelor. Methods: This was a prospective, observational, multicenter, cohort study of ACS patients undergoing percutaneous coronary interventions (PCI) with IRF (creatinine clearance Results: Out of 2,047 registered patients, there were 344 (16.8%) with IRF. At the 1-year follow-up, MACE occurred in 18.6 and 6.2% of those patients with and without IRF, respectively: adjusted hazard ratio (HR) = 2.13 (95% confidence interval, CI 1.16-3.91), p = 0.02. IRF patients were also at higher risk of death and BARC type ≥2 and ≥3 bleeding: adjusted HR = 3.55 (95% CI 1.73-7.27), p = 0.001; HR = 2.75 (95% CI 1.13-6.68), p = 0.03; and HR = 6.02 (95% CI 2.30-15.77), p < 0.001, respectively. Combined MACE and BARC type ≥2 bleeding occurred in 34.0 and 14.0% of those with and without IRF, respectively: adjusted HR = 2.65 (95% CI 1.36-5.16), p = 0.004. At discharge, clopidogrel was more frequently prescribed in IRF patients (61.0 vs. 33.1%, p < 0.001). Conclusions: Real-world ACS patients with IRF subjected to PCI demonstrate higher thrombotic and bleeding risks than patients with normal renal function.

In ‘real life’ acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention (PCI) and receiving contemporary antiplatelet treatment, data on dyspnea occurrence and impact on persistence with treatment are scarce. In a prospective, multicenter, cohort study, ACS patients undergoing PCI were recruited into the GReekAntiPlatElet (GRAPE) registry. During 1-year follow up, overall, 249/1989 (12.5%) patients reported dyspnea, more frequently at 1-month and decreasing thereafter. Multivariate analysis showed that ticagrelor administration (n = 738) at discharge was associated with the occurrence of dyspnea: Odds ratio 2.46 (95% confidence interval, CI, 1.87–3.25), p < 0.001. Older age, lower hematocrit, and prior bleeding event were also associated with dyspnea reports. Persistence, switching, and cessation rates were 68.3%, 20.9%, and 10.8% vs 76.7%, 12.5%, and 10.9% among patients reporting dyspnea compared with those who did not, p for trend = 0.002. In conclusion, in ACS patients undergoing PCI and treated with a P2Y12 receptor antagonist, dyspnea occurs commonly, particularly when ticagrelor is administered. Non-persistence with antiplatelet agents at discharge is more frequently observed among dyspnea-reporters.

Summary Aims Little is known about the use of bivalirudin in “real life”. In the context of contemporary antiplatelet treatment, we aimed to assess bivalirudin treatment patterns and short-term (one-month) outcome. Methods Greek Antiplatelet Registry (GRAPE) is a prospective, observational, multicenter cohort study of consecutive, moderate-to-high-risk acute coronary syndrome patients undergoing percutaneous coronary intervention (PCI). We assessed bivalirudin treatment patterns and predictive factors for its use. Combined in-hospital and one-month major adverse cardiovascular events (MACE, including death, myocardial infarction, urgent revascularization, and stroke), and bleeding events according to Bleeding Academic Research Consortium (BARC) criteria were analyzed after propensity matching. Results Of 2047 registered patients, 480 (23.4%) were treated with bivalirudin. Multivariate analysis (C statistic 0.77, 0.75–0.80 95% CIs, P

In ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI) peri-procedural P2Y12 antagonism - although of great importance - is often suboptimal, even with the novel oral antiplatelet agents prasugrel and ticagrelor. The concept of pre-hospital ticagrelor loading, investigated in the recently published Administration of Ticagrelor in the Cath Lab or in the Ambulance for New ST Elevation Myocardial Infarction to Open the Coronary Artery (ATLANTIC) trial, appears quite a promising strategy to optimize peri-procedural platelet inhibition and potentially clinical outcome. Implementation of such an approach when treating low risk STEMI patients in 'real life' practice might prove even more beneficial than expected from the ATLANTIC results, given the reported delays from first medical contact to primary PCI performance.

Background Few data exist about the implementation of contemporary oral antiplatelet treatment guidelines in patients with acute coronary syndrome (ACS) undergoing percutaneous coronary intervention (PCI). Methods GReek AntiPlatelet rEgistry (GRAPE), initiated on January 2012, is a prospective, observational, multicenter cohort study focusing on contemporary use of P2Y12 inhibitors. In 1434 patients we evaluated appropriateness of P2Y12 selection initially and at discharge by applying an eligibility-assessing algorithm based on P2Y12 inhibitors' contraindications/specific warnings and precautions. Results Appropriate, less preferable and inappropriate P2Y12 inhibitor selections were made initially in 45.8%, 47.2% and 6.6% and at discharge in 64.1%, 29.2% and 6.6% of patients, respectively. The selection of clopidogrel was most commonly less preferable, both initially (69.7%) and at discharge (75.6%). Appropriate selection of newer agents was high initially (79.2%–82.8%), with further increase as selection at discharge (89.4%–89.8%). Inappropriate selection of the newer agents was 17.2%–20.8% initially, decreasing to 10.2%–10.6% at discharge. Conditions and co-medications related to increased bleeding risk, presentation with ST elevation myocardial infarction and the absence of reperfusion within the first 24h were the most powerful predictors of appropriate P2Y12 selection initially, whereas age ≥75years, conditions and co-medications related to increased bleeding risk and regional trends mostly affected appropriate P2Y12 selection at discharge. Conclusions In GRAPE, adherence with the recently released guidelines on oral antiplatelet therapy was satisfactory. Clopidogrel was most commonly used as a less preferable selection, while prasugrel or ticagrelor selection was mostly appropriate. Certain factors may predict initial and at discharge guideline implementation. Clinical Trial Registration -clinicaltrials.gov Identifier: NCT01774955 http://clinicaltrials.gov/.

AIM: Estrogen action is exerted on the vasculature through estrogen receptors ER alpha and ER beta. We have previously reported significant association of ER alpha gene (ESR1) variants with more severe coronary artery disease (CAD) in postmenopausal women. The influence of ER beta gene (ESR2) variants on the cardiovascular system is not well established. We investigated the association of common ESR2 variants with risk factors for cardiovascular disease and with the severity of CAD in postmenopausal women. METHODS: ESR2 polymorphisms Alu I (1730 G > A) and Rsa I (1082 G > A) were studied in 174 postmenopausal women undergoing coronary angiography (age 45 - 88 yrs). The severity of CAD (0 - 3 vessels with > 50 % stenosis), indices of obesity and other predisposing risk factors for cardiovascular disease, biochemical and hormonal parameters were recorded. RESULTS: 75 women had 0, 39 had one, 37 had two and 23 had three vessels with severe stenosis in the coronary angiography. There was no association between Alu I (allele frequency = 40.2 %) and Rsa I (allele frequency = 2.6 %) variants and CAD severity. Carriers of Alu I had lower BMI (p = 0.044), lower waist perimeter (p = 0.029) and lower total cholesterol (p = 0.033) and LDL levels (p = 0.029). There was no association between Rsa I polymorphism and any metabolic risk factors. CONCLUSIONS: ESR2 Alu I polymorphism may have a favorable influence on risk factors for cardiovascular disease such as obesity indices and cholesterol levels. It does not appear to be associated with the severity of CAD in women. Exp Clin Endocrinol Diabetes

Pulse pressure has been recognized as a marker of cardiovascular disease in normotensives. Moreover, internal carotid artery intima-media thickness (IMT) has been proposed to reflect coronary artery lesions. The aim of the present study was to evaluate the predictive value of other parameters derived from ambulatory blood pressure monitoring (ABPM), myocardial ultrasound, and carotid ultrasound to predict the location and the severity of coronary artery disease in normotensives. One hundred and thirteen patients with suspected coronary artery disease underwent coronary angiography, 24-h ABPM and myocardial/carotid ultrasound. Multivariate analysis was applied and equations were extrapolated based on independent variables derived from ABPM and ultrasound. The Gensini score was independently correlated with male gender, pulse pressure, average heart rate for both 24-h (p=0.001) and night (p=0.006) values, as well as percentage of high systolic blood pressure (BP), average diastolic BP, average mean BP, and heart rate concerning daily mesurements (p=0.001). Moreover, the Gensini score was independently correlated with end-systolic volume, posterior wall thickness during systole and intraventricular septum thickness during diastole, along with male gender and age (p=0.001), as well as mean internal and right common carotid artery IMT (p=0.002). Similar mathematical formulas have been calculated separately for the coronary arteries and their main branches. In conclusion, the location and the severity of coronary disease can be effectively evaluated by ABPM and myocardial/carotid ultrasound in normotensives. This approach could be useful for determining atypical patients at risk and/or for treating patients with suspected coronary disease who refuse coronary angiography.

TNF-like cytokine 1A (TL1A)-mediated interactions are involved in atheromatic plaque formation. In stable coronary artery disease (CAD) we examined whether circulating TL1A levels correlate with coronary and/or peripheral atherosclerosis extent and predict future cardiovascular events.In this cross-sectional study, peripheral vascular studies and TL1A serum measurements were performed in 122 consecutive patients with angiographically confirmed CAD who were followed for a median of 41.9 months. TL1A levels were compared against controls (n = 63) and 20 patients with acute coronary syndrome (ACS).TL1A was higher in ACS than the 2 other groups (p0.001). In stable CAD, after adjustment for traditional risk factors independent positive correlations between TL1A serum levels and reflected waves (p = 0.049), and carotid atheromatic plaque score (p = 0.049) were evident. In stable patients with a history of ACS, TL1A levels correlated with worse endothelial function (p = 0.006), extent of CAD assessed by Gensini score (p = 0.042), and cardiac mortality (p = 0.051).This pilot study suggests that serum TL1A measurements are of clinical value in CAD. Studies on the pathogenetic role of TL1A in atherosclerosis and its sequelae are warranted.