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Background: According to current guidelines, hemodynamic status should guide the decision between immediate and delayed coronary angiography (CAG) in out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation. A delayed strategy is advised in hemodynamically stable patients, and an immediate approach is recommended in unstable patients. Objectives: This study sought to assess the frequency, predictors, and clinical impact of acute coronary occlusion in hemodynamically stable and unstable OHCA patients without ST-segment elevation. Methods: Consecutive unconscious OHCA patients without ST-segment elevation who were undergoing CAG at Bern University Hospital (Bern, Switzerland) between 2011 and 2019 were included. Frequency and predictors of acute coronary artery occlusions and their impact on all-cause and cardiovascular mortality at 1 year were assessed. Results: Among the 386 patients, 169 (43.8%) were hemodynamically stable. Acute coronary occlusions were found in 19.5% of stable and 24.0% of unstable OHCA patients (P=0.407), and the presence of these occlusions was predicted by initial chest pain and shockable rhythm, but not by hemodynamic status. Acute coronary occlusion was associated with an increased risk of cardiovascular death (adjusted HR: 2.74; 95%CI: 1.22-6.15) but not of all-cause death (adjusted HR:0.72; 95%CI: 0.44-1.18). Hemodynamic instability was not predictive of fatal outcomes. Conclusions: Acute coronary artery occlusions were found in 1 in 5 OHCA patients without ST-segment elevation.The frequency of these occlusions did not differ between stable and unstable patients, and the occlusions wereassociated with a higher risk of cardiovascular death. In OHCA patients without ST-segment elevation, chest painorshockable rhythm rather than hemodynamic status identifies patients with acute coronary occlusion.

Zusammenfassung. Die Koronarangiographie ist seit Jahrzehnten die Standardmethode für die Beurteilung der Koronaranatomie und Durchführung der perkutanen Koronarintervention. Die Angiographie ist aber limitiert auf die Darstellung des Lumens mit einer Auflösung von 200 – 300 Mikrometer, und sämtliche darüber hinausgehende Informationen sind nicht erkennbar. Intrakoronare Bildgebungsverfahren wie der intravaskuläre Ultraschall (IVUS) und insbesondere die optische Kohärenztomographie (englisch: optical coherence tomography, OCT) liefern essentielle Zusatzinformationen, die für die Koronardiagnostik oder Therapie entscheidend sein können. Die Plaquemenge und -zuammensetzung (Lipid, fibröses Gewebe, Kalzifikationen, Wandhämatome), kleine intraluminale Strukturen (Thromben) und implantierte Stents kommen nur mit diesen Methoden präzise zur Darstellung. Deren Verwendung führt also zu einer Präzisierung und Individualisierung der Koronardiagnostik und zu einer Optimierung der Stentimplantation, wie wir in der folgenden Übersicht erörtern werden.

Background Complete revascularization reduces cardiovascular events in patients with acute coronary syndromes (ACSs) and multivessel disease. The optimal time point of non–target‐vessel percutaneous coronary intervention (PCI) remains a matter of debate. The aim of this study was to investigate the impact of early ( Methods and Results All patients with ACS undergoing planned staged PCI from 2009 to 2017 at Bern University Hospital, Switzerland, were analyzed. Patients with cardiogenic shock, in‐hospital staged PCI, staged cardiac surgery, and multiple staged PCIs were excluded. The primary end point was all‐cause death, recurrent myocardial infarction and urgent premature non–target‐vessel PCI. Of 8657 patients with ACS, staged revascularization was planned in 1764 patients, of whom 1432 patients fulfilled the eligibility criteria. At 1 year, there were no significant differences in the crude or adjusted rates of the primary end point (7.8% early versus 10.8% late, hazard ratio [HR], 0.72 [95% CI, 0.47–1.10], P =0.129; adjusted HR, 0.80 [95% CI, 0.50–1.28], P =0.346) and its individual components (all‐cause death: 1.5% versus 2.9%, HR, 0.52 [95% CI, 0.20–1.33], P =0.170; adjusted HR, 0.62 [95% CI, 0.23–1.67], P =0.343; recurrent myocardial infarction: 4.2% versus 4.4%, HR, 0.97 [95% CI, 0.475–1.10], P =0.924; adjusted HR, 1.03 [95% CI, 0.53–2.01], P =0.935; non–target‐vessel PCI, 3.9% versus 5.7%, HR, 0.97 [95% CI, 0.53–1.80], P =0.928; adjusted HR, 1.19 [95% CI, 0.61–2.34], P =0.609). Conclusions In this single‐center cohort study of patients with ACS scheduled to undergo staged PCI after hospital discharge, early ( Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02241291.

Background In ST‐segment–elevation myocardial infarction, angiography‐based complete revascularization is superior to culprit‐lesion‐only percutaneous coronary intervention. Quantitative flow ratio (QFR) is a novel, noninvasive, vasodilator‐free method used to assess the hemodynamic significance of coronary stenoses. We aimed to investigate the incremental value of QFR over angiography in nonculprit lesions in patients with ST‐segment–elevation myocardial infarction undergoing angiography‐guided complete revascularization. Methods and Results This was a retrospective post hoc QFR analysis of untreated nontarget vessels (any degree of diameter stenosis [DS]) from the randomized multicenter COMFORTABLE AMI (Comparison of Biolimus Eluted From an Erodible Stent Coating With Bare Metal Stents in Acute ST‐Elevation Myocardial Infarction) trial by assessors blinded for clinical outcomes. The primary end point was cardiac death, spontaneous nontarget vessel myocardial infarction, and clinically indicated nontarget vessel revascularization (ie, ≥70% DS by 2‐dimensional quantitative coronary angiography or ≥50% DS and ischemia) at 5 years. Of 1161 patients with ST‐segment–elevation myocardial infarction, 946 vessels in 617 patients were analyzable by QFR. At 5 years, the rate of the primary end point was significantly higher in patients with QFR ≤0.80 (n=35 patients, n=36 vessels) versus QFR >0.80 (n=582 patients, n=910 vessels) (62.9% versus 12.5%, respectively; hazard ratio [HR], 7.33 [95% CI, 4.54–11.83], P P =0.008) and nontarget vessel revascularization (58.6% versus 7.7%, respectively; HR, 10.99 [95% CI, 6.39–18.91], P 30% DS by 3‐dimensional quantitative coronary angiography. Conclusions Our study suggests incremental value of QFR over angiography‐guided percutaneous coronary intervention for nonculprit lesions among patients with ST‐segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES We aimed to assess the ischemic and bleeding risks of single antiplatelet therapy (SAPT) with prasugrel compared with standard dual antiplatelet therapy (DAPT) (aspirin plus clopidogrel for 1 year) in patients with chronic coronary syndrome (CCS) treated with new generation drug-eluting stents (DES). BACKGROUND To date, data on SAPT with potent P2Y12 inhibitors in the absence of aspirin immediately after PCI are limited. METHODS Between January 2009 and November 2019, all CCS patients undergoing percutaneous coronary intervention (PCI) enrolled to the Bern PCI registry were considered for analysis. We performed propensity score matching in a 1:4 fashion to compare patients who received SAPT with prasugrel versus standard DAPT. The primary ischemic endpoint was a composite of cardiovascular death, myocardial infarction, and stroke and the primary bleeding endpoint was BARC 3 or 5 bleeding, both assessed at 1 year. RESULTS After propensity score matching, the final study population consisted of 225 patients with SAPT and 889 with DAPT. There was no significant difference in rates of the primary ischemic (5.2% vs. 4.2%, p = .50) or the primary bleeding (1.5% vs. 2.0%, p = .60) endpoints between groups. SAPT was not associated with an increased risk of definite stent thrombosis (0.9% vs. 0.8%, p = .83). CONCLUSIONS Among selected CCS patients undergoing PCI with DES, SAPT with prasugrel was not associated with an excess of ischemic events compared with standard DAPT. No difference in bleeding was observed either. The results may serve as the basis for larger trials assessing the potential benefits and risks of SAPT.

Intracoronary imaging - an essential tool on the way to an individualized therapy of coronary artery disease?

Background Coronary embolism is an important non-atherosclerotic cause of acute myocardial infarction (AMI) that requires an individualized diagnostic and therapeutic approach. Although certain angiographic criteria exist that render an embolic origin likely, uncertainty remains. Optical coherence tomography (OCT) is a high-resolution intracoronary imaging technology that enables visualization of thrombus and the underlying coronary vessel wall, which may be helpful to distinguish between an atherosclerotic and non-atherosclerotic origin of AMI. Case summary A 50-year-old male was admitted with ongoing chest pain. Eleven years ago, he underwent implantation of a mechanical aortic valve prosthesis due to degenerated bicuspid valve with normal coronaries on preoperative angiography. The electrocardiogram showed anterior ST-segment elevation. Emergent angiography revealed total occlusion of the proximal left anterior descending artery (LAD). Thrombus was aspirated along with administration of intravenous glycoprotein IIbIIIa inhibitor. Except the apical part of the LAD showing distal embolization, coronary flow was completely re-established with no evidence of significant atherosclerosis. Stents were not implanted on the basis of the OCT finding, which demonstrated at the site of occlusion a normal vessel wall without atherosclerosis that could explain an erosion or plaque rupture event. Transoesophageal echocardiography confirmed a floating structure in the left ventricular outflow tract, suggesting that an embolus originating from the prosthetic aortic valve obstructed the LAD. The international normalized ratio 2 days prior to presentation measured 1.9. Discussion This case illustrates the utility of OCT to rule out the atherosclerotic aetiology of myocardial infarction and to avoid unnecessary stenting.

Background In patients with ST-segment-elevation myocardial infarction (STEMI), angiography-based complete revascularization is associated with superior outcomes compared with culprit-lesion-only percutaneous coronary intervention (PCI). Quantitative Flow Ratio (QFR) is a novel, non-invasive, vasodilator-free method to assess the hemodynamic significance of coronary stenoses. Purpose To investigate the incremental value of QFR over angiography alone in the assessment of non-culprit lesions (NCL) in STEMI patients undergoing primary PCI. Methods In the randomized, multicenter COMFORTABLE AMI trial, STEMI patients underwent angiography-guided complete revascularization. QFR was determined in untreated non-target vessels by assessors blinded for clinical outcomes. Results Out of 1161 STEMI patients, 946 vessels in 617 patients could be analyzed by QFR. At 5-year follow-up, the rate of the primary endpoint cardiac death, non-target vessel myocardial infarction (non-TV-MI) and clinically indicated, non-target vessel revascularization (non-TVR) was significantly higher in patients with QFR ≤0.80 compared with QFR >0.80 (62.9% vs. 12.7%, HR 7.20, 95% CI 4.46–11.62, p Conclusions Our study results suggest incremental value of QFR over angiography-guided PCI for NCL among STEMI patients undergoing primary PCI. Kaplan-Meier curves of primary endpoint Funding Acknowledgement Type of funding source: None

A 54-year-old man developed ST-segment elevation myocardial infarction 1 week after percutaneous coronary intervention of the left anterior descending artery. Optical coherence tomography at the emergent percutaneous coronary intervention revealed an intramural hematoma extending from the in-stent dissection. We highlight that in-stent dissection, although generally considered a benign finding, can extend and cause intramural hematoma, resulting in coronary artery occlusion. (Level of Difficulty: Intermediate.), Graphical abstract, A 54-year-old man developed ST-segment elevation myocardial infarction 1 week after percutaneous coronary intervention of the left anterior descending…