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Introduction and objectives There is little evidence on rates of stent thrombosis (ST) in patients receiving dual antiplatelet therapy (DAPT) with ticagrelor or prasugrel . The aim of this study was to analyze the incidence and predictors of ST after an acute coronary syndrome among patients receiving DAPT with ticagrelor vs prasugrel. Methods We used data from the RENAMI registry (REgistry of New Antiplatelet therapy in patients with acute Myocardial Infarction), analyzing a total of 4123 acute coronary syndrome patients discharged with DAPT with ticagrelor or prasugrel in 11 centers in 6 European countries. The endpoint was definite ST within the first year. A competitive risk analysis was carried out using a Fine and Gray regression model, with death being the competitive event. Results A total of 2604 patients received DAPT with ticagrelor and 1519 with prasugrel; ST occurred in 41 patients (1.10%), with a similar cumulative incidence between ticagrelor (1.21%) and prasugrel (0.90%). The independent predictors of ST were age (sHR, 1.03; 95% C I, 1.01-1.06), ST segment elevation (sHR, 2.24; 95%CI, 1.22-4.14), previous myocardial infarction (sHR, 2.56; 95%CI, 1.19-5.49), and serum creatinine (sHR, 1.29; 95%CI, 1.08-1.54). Conclusions Stent thrombosis is infrequent in patients receiving DAPT with ticagrelor or prasugrel. The variables associated with an increased risk of ST were advanced age, ST segment elevation, previous myocardial infarction, and serum creatinine.

Resumen Introduccion y objetivos Hay muy poca evidencia sobre las tasas de trombosis del stent (TS) en pacientes que reciben tratamiento antiagregante plaquetario doble (TAPD) con ticagrelor o prasugrel. El objetivo de este estudio es analizar la incidencia y predictores de la TS tras un sindrome coronario agudo en pacientes que reciben TAPD con ticagrelor frente a prasugrel. Metodos Se utilizaron datos del registro RENAMI (REgistry of New Antiplatelet therapy in patients with acute Myocardial Infarction), y se analizo en total a 4.123 pacientes con sindrome coronario agudo dados de alta con TAPD con ticagrelor o prasugrel en 11 centros de 6 paises europeos. Se considero como evento la TS confirmada en el primer ano. Se realizo un analisis de riesgos competitivos mediante un modelo de regresion de Fine y Gray, siendo la muerte el evento competitivo. Resultados Recibieron TAPD con ticagrelor 2.604 pacientes y con prasugrel, 1.519; 41 pacientes (1,10%) presentaron TS, con incidencias acumuladas similares entre ticagrelor (1,21%) y prasugrel (0,90%). Los predictores independientes de la TS fueron: la edad (sHR = 1,03; IC95%, 1,01-1,06), la elevacion del segmento ST (sHR = 2,24; IC95%, 1,22-4,14), el antecedente de infarto de miocardio (sHR = 2,56; IC95%, 1,19-5,49) y la creatinina serica (sHR = 1,29; IC95%, 1,08-1,54). Conclusiones La TS es infrecuente en pacientes que reciben TAPD con ticagrelor y prasugrel. La edad avanzada, la elevacion del segmento ST, el antecedente de infarto y la creatinina serica son las variables que se asocian con mayor riesgo de TS.

The goal of this study was to determine the association between the use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) and follow-up heart failure (HF) according to left ventricular ejection fraction (LVEF) in patients with acute myocardial infarction (AMI). This cohort study used a retrospective registry of 8169 consecutive patients discharged with a diagnosis of AMI from two university hospitals in Spain between 2010 and 2016. We used a multivariable competing risk analysis, survival-time inverse probability weighting (IPW) propensity score adjusting, and propensity score matching (PSM) to investigate the association between ACEI/ARB treatment and follow-up HF. During the follow-up (3.3 ± 2.2 years), 1296 patients were admitted for HF (5.2 per 100 person-years). ACEI/ARB use was not associated with fewer follow-up HF admissions in patients with LVEF > 40% (univariate analysis: sub-hazard ratio [sHR] 1.10; 95% confidence interval [CI] 0.95–1.27; p = 0.197; IPW adjusting analysis: sHR 1.11; 95% CI 0.95–1.29; p = 0.192; PSM analysis: sHR 1.12; 95% CI 0.92–1.36; p = 0.248). However, ACEI/ARB use was associated with a significant reduction in HF admission rates in patients with LVEF ≤ 40% (univariate analysis: HR 0.70; 95% CI 0.56–0.88; p = 0.003; IPW adjusting analysis: HR 0.64; 95% CI 0.50–0.83; p = 0.001; PSM analysis: HR 0.65; 95% CI 0.46–0.92; p = 0.014). Among hospitalized survivors of AMI, the use of ACEIs/ARBs was associated with a lower risk of follow-up HF in patients with LVEF ≤ 40% but not in those with LVEF > 40%. Further prospective studies are needed to confirm our results.

OBJECTIVES: The REAC-TAVI (Assessment of platelet REACtivity after Transcatheter Aortic Valve Implantation) trial enrolled patients with aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) pre-treated with aspirin + clopidogrel, aimed to compare the efficacy of clopidogrel and ticagrelor in suppressing high platelet reactivity (HPR) after TAVI. BACKGROUND: Current recommendations support short-term use of aspirin + clopidogrel for patients with severe AS undergoing TAVR despite the lack of compelling evidence. METHODS: This was a prospective, randomized, multicenter investigation. Platelet reactivity was measured at 6 different time points with the VerifyNow assay (Accriva Diagnostics, San Diego, California). HPR was defined as (P2Y12 reaction units (PRU) ≥208. Patients with HPR before TAVR were randomized to either aspirin + ticagrelor or aspirin + clopidogrel for 3 months. Patients without HPR continued with aspirin + clopidogrel (registry cohort). The primary endpoint was non-HPR status (PRU

The aim of our study is to assess the impact of anemia, chronic kidney disease, and diabetes mellitus on platelet reactivity (PR) in patients with severe aortic stenosis, both at baseline and after transcatheter aortic valve implantation (TAVI). This study is a prespecified subanalysis of the REAC-TAVI prospective, multicenter trial that included patients pretreated with aspirin + clopidogrel before TAVI. PR was measured at baseline and at 5 different time points after TAVI with the VerifyNow assay (Accriva Diagnostics, San Diego, CA), over a 3-month follow-up period. Patients with high PR (HPR) at baseline, before TAVI (n = 48) were randomized to aspirin + clopidogrel or aspirin + ticagrelor for 3 months, whereas those with normal PR (NPR) (n = 20) were continued on aspirin + clopidogrel. A "raiser response" in PR was defined as an increase in PR units >20% of baseline after TAVI. Patients with HPR before TAVI presented concomitant anemia and chronic kidney disease more frequently than their counterparts with NPR. Anemia and higher body mass index were independently associated with HPR to clopidogrel at baseline. Moreover, anemic patients with baseline HPR who were continued on clopidogrel presented higher PR after TAVI than patients with HPR switched to ticagrelor. All patients with baseline NPR presented a "raiser response" after TAVI, which was nonexistent among patients with HPR managed with ticagrelor. In summary, anemia seems as a relevant factor associated with baseline HPR and higher PR after TAVI in patients with baseline HPR randomized to clopidogrel, whereas ticagrelor proved more effective than clopidogrel at attaining sustained reductions in PR during follow-up, regardless of baseline comorbidities.

Ticagrelor has proven more effective than clopidogrel at attaining a maintained suppression of high platelet reactivity (HPR) in aortic stenosis patients undergoing transcatheter aortic valve implantation (TAVI). This study aims to assess the influence of implanted valve type on the degree of platelet reactivity (PR) after TAVI.This study is a prespecified analysis of REAC-TAVI, a prospective, multicenter study that included patients on dual-antiplatelet therapy with aspirin and clopidogrel before TAVI. Patients with HPR (n = 48) were randomized to aspirin and clopidogrel or aspirin and ticagrelor for 3 months, while those without HPR (n = 20) were continued on aspirin and clopidogrel. PR was measured 6 hours, 24 hours, 5 days, 30 days, and 90 days after TAVI with VerifyNow assay. Bioprosthetic valves were classified as balloon-expandable valve (BEV), self-expandable valve (SEV), or other.Sixty-eight patients comprising 32 BEVs, 28 SEVs, and 8 other valves were included. Devices were larger and postdilation was more frequent in the SEV group. Follow-up PR was lower in patients treated with ticagrelor vs those treated with clopidogrel at all time points after TAVI, including patients without baseline HPR (P.001). PR after TAVI was similar in the three groups. Major cardiovascular adverse events, stroke, and hemorrhagic complications were comparable across the different bioprosthesis groups at 4-month follow-up.The effect of valve type on PR after TAVI is similar across the spectrum of most transcatheter valves. In our sample, ticagrelor achieved a faster and more effective reduction in PR than clopidogrel in patients with HPR undergoing TAVI, irrespective of valve type.

Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin II receptor blockers (ARB) showed comparable survival results in patients with heart failure (HF) and reduced left ventricular ejection fraction (LVEF). However, there is lack of evidence of the comparative effectiveness in preserved LVEF patients after an acute coronary syndrome (ACS). The aim of this study was to evaluate whether the selection between ACEi and ARB in preserved LVEF after an ACS confers a prognostic benefit, based on real life results. We analyzed a cohort of 3006 contemporary patients with LVEF ≥40% after an ACS. A propensity score matching and Cox regression analysis were performed to assess the association between treatment and events (death, acute myocardial infarction [AMI], HF, and combined event) for a mean follow-up of 3.6 ± 2.1 years. We found no significant differences between ACEi/ARB for all-cause mortality (hazard ratio [HR] for ARB: 0.95, 95% CI: 0.70-1.29), AMI (HR for ARB: 1.34, 95% CI: 0.95-1.89), HF (HR for ARB: 1.11, 95% CI: 0.85-1.45), or combined end point (death, AMI and HF: HR for ARB: 1.14, 95% CI: 0.92-1.40). In conclusion, there are no prognostic differences between the use of ACEi and ARB in patients with LVEF ≥40% after ACS. Further prospective studies are needed to confirm our results.

A 73-year-old man was admitted for non-ST segment elevation acute myocardial infarction. Coronary angiography suggested intrastent thrombosis as the etiology, but optical coherence tomography revealed a non-expanded stent, which was successfuly crushed and covered with a new stent.

An 81-year-old woman was referred for primary angioplasty due to a myocardial infarction. Upon her arrival, the patient was in cardiogenic shock. Coronarography revealed a large filling defect within the left main coronary artery. Thromboaspiration was performed, obtaining thrombotic material and tissue of different consistencies. Balloon angioplasty in the left anterior descending and left main arteries was performed, resulting in incomplete reperfusion, leading to irreversible electromechanical dissociation. Analysis of the aspirated material was consistent with thrombus, atheroma, and calcified tissue. Autopsy revealed a heavily calcified mitral valve, and distal embolization of amorphous material in the microvasculature identical to that found in the mitral valve subapparatus. .

Nowadays, more centers worlwide preferred the radial access as first choice to perform left cardiac catheterization. However, the radial approach might challenge operators with several anatomical problems and complications such as accessory radial artery, tortuosity, loop, spasm, dissection