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Introduction. Chronic total occlusion (CTO) of the coronary artery still represents one of the most challenging lesion subsets in the field of interventional cardiology. Considering the complexity and increased risk posed by the retrograde approach, it is most often performed after a failed antegrade approach. Case report. We present a series of cases describing the retrograde approach as a special technique for treating CTO of the coronary artery. All cases had some special characteristics that are part of a dedicated portfolio in every catheterization lab today. In our series of cases, all three percutaneous coronary interventions (PCI) with a different strategies of the retrograde approach and supported with rotational atherectomy or intravascular ultrasound finished with successful recanalization of CTO. Conclusion. In cases where there is the presence of ?interventional? collaterals, as well as when the antegrade approach is very difficult, the retrograde approach can increase the success rate of procedures. The retrograde approach requires a long learning curve as well as very skilled and experienced operators who are able to per-form the procedure independently.

Aims Previous studies indicated that a chronic total occlusion (CTO) in a non-infarct-related artery is linked to higher mortality mainly in the acute setting in patients with ST-elevation myocardial infarction (STEMI). Our aim was to assess the temporal distribution of mortality risk associated with non-culprit CTO over years after STEMI. Methods and results The study included 8679 STEMI patients treated with primary percutaneous coronary intervention (PCI). Kaplan–Meier cumulative mortality curves for non-culprit CTO vs. no CTO were compared with log-rank test, with landmarks set at 30 days and 1 year. Adjusted Cox regression models were constructed to assess the impact of non-culprit CTO on mortality over different time intervals. Tests for interaction were pre-specified between non-culprit CTO and acute heart failure and left ventricular ejection fraction. The primary outcome variable was all-cause mortality, and the median follow-up was 5 years. Non-culprit CTO was present in 11.6% of patients (n = 1010). Presence of a CTO was associated with increased early [30-day adjusted hazard ratio (HR) 1.91, 95% confidence interval (CI) 1.54–2.36; P Conclusions Non-culprit CTO is independently associated with mortality over 5 years after primary PCI for STEMI, with a constant annual two-fold increase in the risk of death beyond the first year of follow-up.

To use Quality Indicators to study the management of ST segment elevation myocardial infarction (STEMI) in different regions.Prospective cohort study of STEMI within 24 hours of symptom onset (11,462 patients, 196 centres, 26 ESC member and 3 affiliated countries). The median delay between arrival at a PCI centre and primary PCI was 40 min (IQR 20 to 74) with 65.8% receiving PCI within guideline recommendation of 60 min. A third of patients (33.2%) required transfer from their initial hospital to one that could perform emergency PCI for whom only 27.2% were treated within the quality indicator recommendation of 120 mins. Radial access was used in 56.6% of all primary PCI, but with large geographic variation, from 76.4% to 9.1%. Statins were prescribed at discharge to 98.7% of patients, with little geographic variation. Of patients with a history of heart failure or a documented LVEF ≤40%, 84.0% were discharged on an ACEI/ARB and 88.7% were discharged on beta blockers.Care for STEMI shows wide geographic variation in the receipt of timely primary PCI, and is in contrast with the more uniform delivery of guideline-recommended pharmacotherapies at time of hospital discharge.

Background: Surgical aortic valve replacement (SAVR) represents a class I indication in symptomatic patients with severe aortic stenosis (AS). However, indications for early SAVR in asymptomatic patients with severe AS and normal left ventricular function remain debated. Methods: The AVATAR trial (Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis) is an investigator-initiated international prospective randomized controlled trial that evaluated the safety and efficacy of early SAVR in the treatment of asymptomatic patients with severe AS, according to common criteria (valve area ≤1 cm 2 with aortic jet velocity >4 m/s or a mean transaortic gradient ≥40 mm Hg), and with normal left ventricular function. Negative exercise testing was mandatory for inclusion. The primary hypothesis was that early SAVR would reduce the primary composite end point of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with a conservative strategy according to guidelines. The trial was designed as event-driven to reach a minimum of 35 prespecified events. The study was performed in 9 centers in 7 European countries. Results: Between June 2015 and September 2020, 157 patients (mean age, 67 years; 57% men) were randomly allocated to early surgery (n=78) or conservative treatment (n=79). Follow-up was completed in May 2021. Overall median follow-up was 32 months: 28 months in the early surgery group and 35 months in the conservative treatment group. There was a total of 39 events, 13 in early surgery and 26 in the conservative treatment group. In the early surgery group, 72 patients (92.3%) underwent SAVR with operative mortality of 1.4%. In an intention-to-treat analysis, patients randomized to early surgery had a significantly lower incidence of primary composite end point than those in the conservative arm (hazard ratio, 0.46 [95% CI, 0.23–0.90]; P =0.02). There was no statistical difference in secondary end points, including all-cause mortality, first heart failure hospitalizations, major bleeding, or thromboembolic complications, but trends were consistent with the primary outcome. Conclusions: In asymptomatic patients with severe AS, early surgery reduced a primary composite of all-cause death, acute myocardial infarction, stroke, or unplanned hospitalization for heart failure compared with conservative treatment. This randomized trial provides preliminary support for early SAVR once AS becomes severe, regardless of symptoms. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02436655.

BackgroundCoronary chronic total occlusion (CTO) is characterized by the presence of collateral blood vessels which can provide additional blood supply to CTO-artery dependent myocardium. Successful CTO recanalization is followed by significant decrease in collateral donor artery blood flow and collateral derecruitment, but data on coronary hemodynamic changes in relation to myocardial function are limited. We assessed changes in coronary flow velocity reserve (CFVR) by echocardiography in collateral donor and recanalized artery following successful opening of coronary CTO.MethodsOur study enrolled 31 patients (60 ± 9 years; 22 male) with CTO and viable myocardium by SPECT scheduled for percutaneous coronary intervention (PCI). Non-invasive CFVR was measured in collateral donor artery before PCI, 24 h and 6 months post-PCI, and 24 h and 6 months in recanalized artery following successful PCI of CTO.ResultsCollateral donor artery showed significant increase in CFVR 24 h after CTO recanalization compared to pre-PCI values (2.30 ± 0.49 vs. 2.71 ± 0.45,p = 0.005), which remained unchanged after 6-months (2.68 ± 0.24). Baseline blood flow velocity of the collateral donor artery significantly decreased 24 h post-PCI compared to pre-PCI (0.28 ± 0.06 vs. 0.24 ± 0.04 m/s), and remained similar after 6 months, with no significant difference in maximum hyperemic blood flow velocity pre-PCI, 24 h and 6 months post-PCI. CFVR of the recanalized coronary artery 24 h post-PCI was 2.55 ± 0.35, and remained similar 6 months later (2.62 ± 0.26, p = NS).ConclusionsIn patients with viable myocardium, prompt and significant CFVR increase in both recanalized and collateral donor artery, was observed within 24 h after successful recanalization of CTO artery, which maintained constant during the 6 months.Trial registrationClinicalTrials.gov (NumberNCT04060615).

Background/Aim. Chronic total coronary artery occlusions (CTOs) are still one of the most complex procedures in the treatment of coronary arteries. If there is a bifurcation lesion within the CTO, it is certainly one of the biggest challenges for interventional cardiologists. Methods. We present a retrospective analysis of patients from our center who underwent percutaneous coronary intervention (PCI) with a bifurcation lesion within the CTO and a side branch with a diameter of 2 mm or more, in the period from January 2017 to December 2020. Results. Out of a total of 216 patients in the four-year period, 38 (18%) of them had a bifurcation lesion within the CTO. The most common bifurcation lesions were on the left anterior descending (LAD) artery (50%), and the least frequent on the circumflex coronary artery (21%). CTO recanalization was successful in 35 patients (92%). One stent technique was used in 27 patients (77%), while the two stent technique was used in 8 patients (23%). Conclusion. Bifurcation lesions in the context of PCI CTO are a relatively common finding on coronary angiography and represent a special challenge for CTO operators. Provisional technique (one stent technique) is the most common strategy for the treatment of bifurcation lesions in patients with CTO.

Introduction. The left main stem coronary artery (MSCA) thrombosis is a rare, but potentially lethal manifestation of the acute coronary syndrome. The standard approach in treating such patients is the primary percutaneous coronary intervention or coronary artery bypass graft surgery. In some cases, depending on the morphological appearance of the thrombus, findings and flow rates assessed on coronary angiography, clinical conditions, and cardiologist?s experiences, another method of treatment may be a conservative approach using the antithrombotic therapy. Case report. A 37 year-old male was admitted to the emergency room with symptoms of an acute myocardial infarction with an ST-elevation in diaphragmal localization. Using emergency coronary angiography we have visualized a thrombus at the ostial and proximal part of the left MSCA, with no complete obstruction of the blood flow. Initially, dual antithrombotic therapy (ticagrelor and acetylsalycilic acid) was applied, and in the further procedure , it was decided to introduce glycoprotein (GP) IIb/IIIa platelet receptor inhibitor (tirofiban) as an intracoronary bolus (0.3 ?g/kg) and later as continuous infusion (0.1 ?g /kg/min). Four days later, a control angiography and intravascular echocardiography were performed, and it was decided to continue the treatment using conservative therapy, without a pPCI procedure. The patient was discharged in a good condition with no signs of illness on the eighth day after hospital admission for home recovery, with planned frequent follow-ups in the future. Conclusion. In the case of non-obstructive thrombotic masses without significant atherosclerotic stenotic lesions, conservative treatment modality with the use of aggressive antithrombotic therapy may be considered.

Background Microvascular dysfunction might be a major determinant of clinical deterioration and outcome in patients with hypertrophic cardiomyopathy (HCM). However, long‐term prognostic value of transthoracic Doppler echocardiography (TDE) coronary flow velocity reserve (CFVR) on clinical outcome is uncertain in HCM patients. Therefore, the aim of our study was to assess long‐term prognostic value of CFVR on clinical outcome in HCM population. Methods and Results We prospectively included 150 HCM patients (82 women; mean age 48±15 years). Patients’ clinical characteristics, echocardiographic and CFVR findings (both for left anterior descending [LAD] and posterior descending artery [PD]), were assessed in all patients. The primary outcome was a composite of: HCM related death, heart failure requiring hospitalization, sustained ventricular tachycardia and ischemic stroke. Patients were stratified into 2 subgroups depending on CFVR LAD value: Group 1 (CFVR LAD>2, [n=87]) and Group 2 (CFVR LAD≤2, [n=63]). During a median follow‐up of 88 months, 41/150 (27.3%) patients had adverse cardiac events. In Group 1, there were 8/87 (9.2%), whereas in Group 2 there were 33/63 (52.4%, P P P Conclusions In patients with HCM, impaired CFVR LAD (≤2) is a strong, independent predictor of adverse cardiac outcome. When the aim of testing is HCM risk stratification and CFVR LAD data are available, the evaluation of CFVR PD is redundant.

Background Recent studies showed that coronary flow velocity reserve (CFVR) measurement by transthoracic Doppler echocardiography (TTDE) during inotropic stimulation with dobutamine (DOB), in comparison to vasodilation with adenosine, provides more reliable functional evaluation of myocardial bridging (MB). However, the adequate cut-off value of CFVR during DOB for diagnosing functional significant MB has not been fully established. Purpose The purpose of the study was to evaluate the adequate cut-off value of TTDE- CFVR during DOB for diagnosis of functional significant MB. Methods This prospective study included 79 patients (54 males, mean age 55±10 years) with angiographic evidence of isolated MB on the left anterior descending artery (LAD) and systolic compression ≥50% diameter stenosis. Exercise stress-echocardiography test (ExSE) and TTDE-CFVR in the distal segment of LAD during DOB infusion (DOB: 10–40μg/kg/min) were performed in all patients. Percent diameter stenosis (DS) of MB at end-systole and end-diastole were analyzed using quantitative coronary angiography. Results Exercise-SE was positive for myocardial ischemia in 22/79 (28%). CFVR during peak DOB was significantly lower in SE-positive group in comparison to SE-negative group (1.94±0.16 vs. 2.78±0.53, p Conclusion A cut-off value Funding Acknowledgement Type of funding sources: None.

Background Functional assessment of myocardial bridging (MB) remains clinically challenging because of the dynamic nature of the extravascular coronary compression with a certain degree of intraluminal coronary reduction. The aim of our study was to assess performance and diagnostic value of diastolic‐fractional flow reserve (d‐FFR) during dobutamine provocation versus conventional‐FFR during adenosine provocation with exercise‐induced myocardial ischemia as reference. Methods and Results This prospective study includes 60 symptomatic patients (45 men, mean age 57±9 years) with MB on the left anterior descending artery and systolic compression ≥50% diameter stenosis. Patients were evaluated by exercise stress‐echocardiography test, and both conventional‐FFR and d‐FFR in the distal segment of left anterior descending artery during intravenous infusion of adenosine (140 μg/kg per minute) and dobutamine (10–50 μg/kg per minute), separately. Exercise–stress‐echocardiography test was positive for myocardial ischemia in 19/60 patients (32%). Conventional‐FFR during adenosine and peak dobutamine had similar values (0.84±0.04 versus 0.84±0.06, P =0.852), but d‐FFR during peak dobutamine was significantly lower than d‐FFR during adenosine (0.76±0.08 versus 0.79±0.08, P =0.018). Diastolic‐FFR during peak dobutamine was significantly lower in the exercise‐stress‐echocardiography test –positive group compared with the exercise‐ stress‐echocardiography test –negative group (0.70±0.07 versus 0.79±0.06, P P =0.613). Among physiological indices, d‐FFR during peak dobutamine was the only independent predictor of functionally significant MB (odds ratio, 0.870; 95% CI, 0.767–0.986, P =0.03). Receiver‐operating characteristics curve analysis identifies the optimal d‐FFR during peak dobutamine cut‐off ≤0.76 (area under curve, 0.927; 95% CI, 0.833–1.000; P Conclusions Diastolic‐FFR, but not conventional‐FFR, during inotropic stimulation with high‐dose dobutamine, in comparison to vasodilatation with adenosine, provides more reliable functional significance of MB in relation to stress‐induced myocardial ischemia.

Platelet activation and aggregation play a critical role in thrombosis, a fundamental pathophysiologic event responsible for the acute clinical manifestations of atherothrombotic events such as acute coronary syndrome, myocardial infarction, ischemic stroke/transient ischemic attack and peripheral artery disease. Dual antiplatelet therapy (low-dose aspirin plus ADP-P2Y12 receptor blockers) has become the cornerstone of therapy for the management of acute and chronic coronary artery disease and the prevention of ischemic complications associated with percutaneous coronary intervention. However, dual antiplatelet therapy in primary prevention of cardiovascular disease in patients without known cardiovascular disease did not significantly reduce the risk of cardiovascular events, such as myocardial infarction, stroke or death, but significantly increased the rate of bleeding. Furthermore, despite multiple randomized controlled trials evaluating the efficacy and safety of aspirin use in patients without known cardiovascular disease, its role in primary prevention is still unclear, especially in patients with a higher risk of cardiovascular disease (non-diabetic individuals with >2 risk factors for coronary artery disease, elderly >60 years with additional risk factors, and patients with diabetes). Currently, there are four ongoing randomized controlled trials aiming to fill the missing gap in the efficacy and safety of aspirin therapy for primary prevention in these patients. The current European and United States Guidelines agree that primary prevention of cardiovascular disease is essential, but there are some substantial differences in risk estimation and treatment strategies among patients without known cardiovascular disease. This short review is focused on these differences and practical treatment approach to these patients based on present European and United States recommendations.

The aim of this randomized prospective study was to evaluate the quality of life (QoL) using the “Seattle Angina Questionnaire” (SAQ) in patients with chronic total occlusion (CTO) in coronary arteries treated with either percutaneous coronary intervention (PCI) or optimal medical therapy (OMT), or only with OMT. The potential benefits of recanalization of CTO by PCI have been controversial because of the scarcity of randomized controlled trials. A total of 100 patients with CTO were randomized (1:1) prospectively into the PCI CTO or the OMT group (50 patients in each group). There were no baseline differences in the SAQ scores between the groups, except for physical limitation scores (P = 0.03). During the mean follow-up (FUP) of 275 ± 88 days, patients in the PCI group reported less physical activity limitations (72.7 ± 21.3 versus 60.5 ± 27, P = 0.014), less frequent angina episodes (89.8 ± 17.6 versus 76.8 ± 27.1, P = 0.006), better QoL (79.9 ± 22.7 versus 62.5 ± 25.5, P = 0.001), greater treatment satisfaction (91.2 ± 13.6 versus 81.4 ± 18.4, P = 0.003), and borderline differences in angina stability (61.2 ± 26.5 versus 51.0 ± 23.7, P = 0.046) compared to patients in the OMT group. There were no significant differences in SAQ scores in the OMT group at baseline and during the FUP. There was a statistically significant increase in all five domains in the PCI group. Symptoms and QoL measured by the SAQ were significantly improved after CTO PCI compared to OMT alone.

Background Coronary chronic total occlusion (CTO) is characterized by the presence of collateral blood vessels which can provide additional blood supply to CTO-artery dependent myocardium. Successful CTO recanalization is followed by significant decrease in collateral donor artery blood flow and collateral derecruitment. Purpose Study aim was to assess time-dependent changes in coronary flow reserve (CFR) in collateral donor artery after CTO recanalization and identify factors that influence these changes. Methods Our study enrolled 31 patients with CTO scheduled for percutaneous coronary intervention (PCI). Non-invasive CFR was measured before PCI in collateral donor artery, and 24h and 6 months post-PCI in CTO and collateral donor artery. Gated SPECT MIBI was performed before PCI, while quality of life was assessed by Seattle angina questionnaire (SAQ) pre-PCI, and 6 months after PCI. Results Collateral donor artery showed significant increase in CFR 24h after CTO recanalization compared to pre-PCI values (2.30±0.49 vs. 2.71±0.45, p=0.005), which remained unchanged after 6 months (2.68±0.24). Maximum baseline blood flow velocity of the collateral donor artery showed significant decrease measured 24h post-PCI compared to pre-PCI values (0.28±0.06 vs. 0.24±0.04m/s), and remained similar after 6-months. There was no significant difference in maximum hyperemic blood flow velocity pre-PCI, 24h and 6 months post-PCI. CFR change of the collateral donor artery 24h post-PCI compared to pre-PCI values showed inverse correlation with left ventricle ejection fraction (LVEF) measured on SPECT. CFR changes showed no correlation with the changes in quality of life assessed by SAQ post-PCI compared to pre-PCI. Conclusions Significant increase in CFR of the collateral donor artery was observed within 24h after successful recanalization of CTO artery, which maintained constant after the 6 months follow-up. This increase was largely driven by the significant reduction in the maximum baseline blood flow velocity within 24h after CTO recanalization compared to pre-PCI values. Our results suggest that possible benefit of CTO recanalization could be the improvement in physiology of the collateral donor artery. Funding Acknowledgement Type of funding source: None

Background Chronic total coronary occlusion (CTO) is frequent finding in patients with ischaemic heart disease, but it is not clear yet how it affects myocardial function, especially electrical stability. Myocardial strain by echocardiography can objectively quantify extent and timing of myocardial deformation. Echocardiographically derived dyssynchrony, mechanical dispersion, is good predictive tool for patients at risk of ventricular arrhythmias. Purpose The purpose of this study was to evaluate the influence of chronic total occlusion percutaneous coronary intervention (CTO PCI) on myocardial contractility and arrhythmogenicity. Methods We analysed total of 35 CTO patients (age 56±9, 86% male). Convectional echocardiographic exam with two dimensional speckle tracking echocardiography (2D STE) was performed before CTO PCI and after 24 months of follow-up. Peak longitudinal strain was assessed in 17 left ventricular segments. 2D STE computed global longitudinal strain (GLS). Time intervals from start of Q/R on electrocardiogram to peak negative strain during the cardiac cycle were assessed. Mechanical dispersion was defined as the standard deviation of this time interval from 17 left ventricular segments, reflecting myocardial contraction heterogeneity. Results 24 months after CTO PCI patients showed no change in ejection fraction (EF) (55.75±7.56% vs. 56.03±6.29%, p=0.622). There was slight improvement in GLS (−14.89±2.81% vs. −15.93±2.64%, p Conclusion CTO recanalization improved GLS without changes in left ventricular EF after 24 months. Mechanical dispersion as a surrogate for arrhythmogenic substrate was reduced by CTO PCI. Funding Acknowledgement Type of funding source: None

Background Percutaneous coronary intervention of chronic total occlusion (PCI CTO) can reduce angina and the need for bypass surgery, however, it is still not clear how it effects the myocardial function. Conventional echocardiography is subjective and experience-dependent while tissue Doppler imaging together with strain imaging provides a more objective assessment of myocardial contractility. Purpose Our aim was to access the effectiveness of percutaneous coronary intervention (PCI) along with optimal medical therapy (OMT) on myocardial function. Methods We compared two groups of patients. The first group of patients underwent PCI CTO with OMT while the second group of patients only received OMT (control group). The echocardiographic exam was performed before randomization and after 24 months of follow-up. Doppler time intervals- isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT) and ejection time (ET) were measured from mitral inflow and left ventricular outflow Doppler tracings. Myocardial performance index (MPI) is equal to the sum of the IVRT and IVCT divided by the ET. Velocity of early mitral filling wave (E) was measured and divided by average peak early diastolic annular velocity (e'). Peak longitudinal strain was assessed in 17 left ventricular segments. Time intervals from start Q/R on electrocardiogram to peak negative strain during the cardiac cycle were assessed. Mechanical dispersion was defined as the standard deviation of this time interval from 17 left ventricular segments, reflecting myocardial contraction heterogeneity Results Comparing the groups at follow up, there was no significant change in ejection fraction (EF), diastolic function, and mechanical dispersion, however, there was improvement in GLS and MPI (Table 1). Conclusion Global longitudinal strain as a parameter of systolic function and Myocardial performance index as a parametar of global systolic and diastolic function are sensitive markers that can detect subtle improvement in myocardial function after recanalisation of CTO. Funding Acknowledgement Type of funding source: None

Supplemental Digital Content is available in the text., Objectives Recent improvements in coronary stent design have focussed on thinner struts, different alloys and architecture, more biocompatible polymers, and shorter drug absorption times. This study evaluates safety and efficacy of a newer generation thin-strut cobalt chromium sirolimus-eluting coronary stent (SES, Ultimaster) in comparison with a second-generation thicker strut stainless steel biolimus-eluting stent (BES, Nobori) in percutaneous coronary intervention (PCI) practice. Methods A propensity score analysis was performed to adjust for differences in baseline characteristics of 8137 SES patients and 2738 BES patients of two PCI registries (e-Ultimaster and NOBORI 2). An independent clinical event committee adjudicated all endpoint-related adverse events. Results The use of SES, as compared with BES was associated with a significantly lower rate of myocardial infarction (MI) (1.2% vs 2.2%; P = 0.0006) and target vessel-related MI (1.1% vs 1.8%; P = 0.002) at 1 year. One-year composite endpoints of all predefined endpoints were lower in patients undergoing SES implantation (target lesion failure: 3.2% vs 4.1%; P = 0.03, target vessel failure: 3.7% vs 5.0%; P = 0.003, patient-oriented composite endpoint 5.7% vs 6.8%; P = 0.03). No significant differences between SES and BES were observed in all-cause death (2.0% vs 1.6%; P = 0.19), cardiac death (1.2% vs 1.2%; P = 0.76) or stent thrombosis (0.6% vs 0.8%; P = 0.43). Conclusions These findings suggest an improved clinical safety and efficacy of a newer generation thin-strut SES as compared with a second-generation thicker strut BES.

Background Percutaneous coronary intervention of chronic total coronary occlusion (PCI of CTO) is proved to reduce symptoms of angina and long term survival. Purpose This study aimed to assess systolic and diastolic left ventricular function with standard echocardiographic indices. Methods We analyzed total of 46 CTO patients (age 58 ± 9, 73% male). Measures were obtained with the transducer in the apical four-chamber view. Doppler time intervals were measured from mitral inflow and left ventricular outflow Doppler tracings by pulsed wave Doppler. The isovolumetric relaxation time (IVRT) was measured from closure of the aortic valve to opening of the mitral valve. The isovolumetric contraction time (IVCT) was measured from closure of the mitral valve to opening of the aortic valve. Ejection time (ET) was measured from the opening to the closure of the aortic valve on the LV outflow velocity profile. Myocardial performance index (MPI) is simple method for evaluation of overall cardiac function and is independent of heart rate and blood pressure. MPI was equal to the sum of the IVRT and IVCT divided by the ET. Velocity of early mitral filling wave (E) was measured and divided by average peak early diastolic annular velocity (e") which was measured as average value between septal and lateral side of the mitral annulus using Doppler tissue imaging. The E/e’ ratio was calculated to estimate the LV filling pressures Results Six months after PCI of CTO patients showed no change in ejection fraction (EF) (55.69 ± 8.56% vs. 54.83 ± 8.44%, p = 0.10). MPI was significantly decreased (0.676 ± 0.99 vs. 0.632 ± 0.96 p Conclusion PCI of CTO improves overall cardiac function, particularly diastolic function in patients with reduced ejection fraction.

Background Percutaneous coronary intervention for chronic total occlusion (PCI CTO) is still high risk procedure and it is doubtful will it become standard of care. There is evidence that it can reduce angina but even silent ischemia represent ischemic burden that ultimately lead to left ventricle remodeling and electrical instability. Purpose Our aim was to access effectiveness of percutaneous coronary intervention (PCI) when added to optimal medical therapy (OMT) on myocardial function. Methods We compared two groups of pts. First patients with percutaneous coronary intervention of chronic total occlusion with optimal medical therapy and second group - patients with only optimal medical therapy (control group). Echocardiographic exam was performed before randomization and after 6 months of follow-up. Doppler intervals- isovolumetric relaxation time (IVRT), isovolumetric contraction time (IVCT) and ejection time (ET) were measured. MPI (Myocardial performance index) is equal to the sum of the IVRT and IVCT divided by the ET. Velocity of early mitral wave (E) was divided by average peak early diastolic annular velocity (e"). Peak longitudinal strain was assessed in 17 left ventricular segments. Time intervals from start Q/R on electrocardiogram to peak negative strain during the cardiac cycle were assessed. Mechanical dispersion was defined as the standard deviation of this time intervals from 17 segments, reflecting myocardial contraction heterogeneity. Results A total of 94 age matched CTO patients (48 in PCI + OMT group and 46 in OMT) were analyzed. Changes in ejection fraction (EF), diastolic function represented by E/e", global cardiac function represented by MPI, global longitudinal strain (GLS) and myocardial dispersion changes were compared between groups. At follow up between groups in there was no significant change in ejection fraction (EF), diastolic function, GLS and mechanical dispersion, but there was improvement in MPI. Conclusion Myocardial performance index is sensitive marker which can detect subtle improvement in global myocardial function after recanalization of chronic total occlusion.. Variable PCI + OMT (n = 46) OMT (n = 48) ΔOMT vs. ΔPCI + OMT p value baseline At 6month follow up P value baseline At 6month follow up P value EF (%) 55.69 ± 8.56 54.83 ± 8.44 0.10 50.22 ± 11.71 51.42 ± 10.45 0.06 0.71 MPI 0.676 ± 0.99 0.632 ± 0.96

Background Coronary collateral circulation exerts protective effects on myocardial ischaemia due to coronary artery disease and can be promoted by exercise with heparin co-administration. Whether this arteriogenetic effect is accompanied by functional improvement of left ventricle during stress and lessening of angina symptoms remains unknown. Aims To evaluate the anti-ischaemic efficacy of heparin plus exercise in coronary artery disease. Methods In a prospective, single-centre, randomized, double-blind study we recruited 32 ‘no-option’ patients (27 males; mean age 61 ± 8 years) with stable angina, exercise-induced ischaemia and coronary artery disease not suitable for revascularization. All underwent a two-week cycle of exercise (two exercise sessions per day, five days per week) and were randomized (n = 16 per group) to intravenous placebo (0.9% saline) versus unfractionated heparin (5.000 IU intravenously), 10 min prior to exercise. We assessed Canadian Cardiovascular Society angina class, stress electrocardiogram and echo parameters (wall motion score index) and computed tomography angiography for collaterals. Results After two-week cycle, Canadian Cardiovascular Society class statistically decreased in both groups (heparin plus exercise group: 2.6 ± 0.7 to 1.9 ± 0.7, p Conclusion A two-week, 10-test cycle of heparin plus exercise is better than exercise in improving angina class, myocardial ischaemia and collaterals by computed tomography angiography.

The objective of the study was to evaluate major adverse cardiovascular events (MACE) after successful versus failed percutaneous coronary intervention for chronic total occlusion (PCI-CTO).Limited data are available on long-term clinical follow-up in the treatment of chronic total occlusion (CTO).Between January 2009 and December 2010 PCI-CTO was attempted in 283 consecutive patients with 289 CTO lesions. Procedural success was 62.3% and clinical follow-up covered 83% (235/283) of the study population with a median follow-up of 66 months (range, 59-74).The total incidence of MACE was 57/235 (24.3%), and was significantly higher in the procedural failure group than in the procedural success group (33/87 (37.9%) versus 24/148 (16.2%), P < 0.001). All-cause mortality was significantly lower in patients with successful PCI-CTO compared to failed PCI-CTO (10.8% versus 20.7%, P < 0.05). Also, the rate of cardiovascular death in the procedural failure group (14.9%) was slightly higher than that in the procedural success group (7.4%, P = 0.066). The rate of TVR was statistically higher in the procedural failure group (P < 0.009). Propensity score-adjusted Cox regression showed that procedural success remained a significant predictor of MACE (adjusted HR 0.402; 95% CI 0.196-0.824; P = 0.013).Our study emphasizes the importance of CTO recanalization in improving long-term outcome including all-cause mortality with a borderline effect on cardiovascular mortality.

Aims The aim of this study was to establish the long-term safety and efficacy of a sirolimus-eluting stent with bioresorbable polymer (BP-SES; Ultimaster) by comparison with an everolimus-eluting stent with permanent polymer (PP-EES; XIENCE). Methods and results CENTURY II (Clinical Evaluation of New Terumo Drug-Eluting Coronary Stent System in the Treatment of Patients with Coronary Artery Disease) is a large-scale, prospective, multicentre, randomised single-blind, controlled, non-inferiority trial conducted at 58 study sites globally, including Europe, Japan and Korea, powered to prove non-inferiority for freedom from target lesion failure (TLF: cardiac death, target vessel-related myocardial infarction [MI] and target lesion revascularisation) at nine months. Patients requiring a percutaneous coronary intervention (PCI) were randomised (1:1) to BP-SES (n=551) or PP-EES (n=550). Freedom from TLF at five years was 90.0% in the BP-SES and 91.1% in the PP-EES group (p=0.54). The patient-oriented composite endpoint (all death, any MI, any revascularisation) was 24.1 and 25.6% (p=0.57) with BP-SES and PP-EES, respectively. The very late stent thrombosis rate from one to five years was especially low at 0.2% in both arms. Conclusions This randomised clinical trial showed that the BP-SES stent was non-inferior to the benchmark PP-EES stent for TLF. Safety and efficacy measures were comparable up to five-year follow-up after PCI.

Coronary artery disease encompasses a spectrum of clinical presentations caused by underlying coronary atherosclerosis. Acute manifestations of atherosclerotic disease occur when rupture/erosion of atherosclerotic plaque becomes substrate for platelet activation and aggregation, which have a central role in the formation and propagation of intracoronary thrombi. Therefore, antiplatelet therapy represents a standard of care in the primary and secondary prevention of CAD. Dual antiplatelet therapy (DAPT) typically refers to aspirin along with P2Y12 receptor inhibitor (clopi-dogrel, prasugrel or ticagrelor). Choice and duration of DAPT requires an individual approach and assessment of each patient, emphasizing the tailored antiplatelet treatment. This is largely driven by patient's clinical presentation (stable coronary artery disease or acute coronary syndrome), existing risk factors (ischemic vs. hemorrhagic risk), and following treatment plan (medical treatment, percu-taneous coronary intervention, or coronary artery bypass graft). In this review, we present the evidence supporting DAPT administration and therapy duration in different subpopulations of patients with CAD. Also, we will review these data in the context of current 2017 ESC focused update on dual antiplatelet therapy in coronary artery disease, emphasizing the novelties from the present guidelines.

Background/Aim. It is not know which factors influence no-reflow phenomenon after successful primary percutaneous intervention (pPCI) in patients with myocardial infarction with ST elevation (STEMI). The aim of this study was to estimate predictive value of some admission characteristics of patients with STEMI, who underwent pPCI, for the development of no-reflow phenomenon. Worse clinical outcome in patients with no-reflow points to importance of selection and aggressive treatment in a group at high risk. Methods. This was retrospective and partly prospective study which included 491 consecutive patients with STEMI, admitted to a single centre, during the period from 2000 to September 2015, who underwent pPCI. Descriptive characteristics of the patients, presence of classical risk factors for cardiovascular disease, total ischemic time and clinical features at admission were all estimated as predictors for the development of no-reflow phenomenon. No-reflow phenomenon is defined as the presence of thrombolysis in myocardial infarction (TIMI) < 3 coronary flow at the end of the pPCI procedure, or ST-segment resolution by less than 50% in the first hours after the procedure. The significance of the predictive value of some parameters was evaluated by univariate and multivariate regression analysis. In univariate analysis, we used the ?2 test and Mann Whitney and Student's t-tests. Results. No-reflow phenomenon was detected in 84 (17.1%) patients (criteria used: TIMI < 3 coronary flow) and in 144 (29.3%) patients (criteria used: STsement resolution < 50%). Patients older than 75 years [odds ratio (OR) = 2.53; 95% confidence interval (CI) 1.48? 4.33; p = 0.001] and those who had Killip class at admission higher than 1 had increased risk to achieve TIMI-3 flow after pPCI. Killip class higher than 1 (OR 1.59; 95% CI 1.23? 2.04; p < 0.001), left anterior descendent artery (LAD) as infarct related artery (IRA) and total ischemic time higher than 4 hour were associated with increased risk to failure of rapid ST segment resolution after pPCI. Conclusion. Older age and Killip class were main predictors of TIMI < 3 flow, and Killip class, LAD as IRA and longer total ischemic time were predictors for the failure of rapid ST segment resolution after pPCI.

Serbia's interventional community has been facing the multifaceted challenge of an ageing population with cardiovascular diseases as the primary cause of death nationwide, coronary artery disease (CAD) being the most prevalent subset. The following two fields of activity have marked the trajectory of progress in the field of interventional cardiology in Serbia: first, the expansion of the infrastructure, mainly through the opening of new catheterisation laboratories across all of the country's administrative regions, which has resulted in better accessibility to coronary interventions for the general population; second, the creation of national platforms for continuous education, training and the promotion of clinical research in interventional cardiology, with close programmatic links to European Association of Percutaneous Cardiovascular Interventions (EAPCI)-based educational initiatives, including the curriculum for interventional cardiology. As growth seems to be inherent to the concept of progress, we report here on the expanding numbers of coronary interventions in the period between January 2010 and December 2015, and the early experiences with structural heart interventions in Serbia.

Introduction. Atrial fibrillation (AF) is the major cause of stroke, particularly in older patients over 75 years of age. European Society of Cardiology guidelines recommend chronic anticoagulation therapy in patients with atrial fibrillation if CHA2DS2-VASc score is ≥ 1 [CHA2DS2-VASc score for estimating the risk of stroke in patients with nonrheumatic AF consisting of the first letters of patients condition: C - congestive heart failure; H - hypertension; A2 - age ≥ 75 years; D - diabetes mellitus; S2 - prior stroke, transitory ischaemic attack (TIA) or thrombolism; V - vascular disease; A - age 65-74 years; Sc - sex category]. However, a significant number of patients have a high bleeding risk, or are contraindicated for chronic oral anticoagulation, and present a group of patients in whom alternative treatment options for thromboembolic prevention are required. Transcatheter percutaneous left atrial appendage closure (LAAC) devices have been recommended in patients with contraindications for chronic anticoagulant therapy. Case report. We present our first three patients with nonvalvular AF and contraindications for chronic anticoagulant therapy who were successfully treated with implantation of LAAC Watchman device in Catheterization Laboratory of the Clinic for Cardiology, Clinical Center of Serbia in Belgrade Conclusion. Our initial results with Watchman LAAC device are promising and encouraging, providing real alternative in patients with non-valvular AF and contraindication for chronic anticoagulant therapy and high bleeding risk.

Aims The Acute Cardiac Care Association (ACCA)–European Association of Percutaneous Coronary Intervention (EAPCI) Registry on ST-elevation myocardial infarction (STEMI) of the EurObservational programme (EORP) of the European Society of Cardiology (ESC) registry aimed to determine the current state of the use of reperfusion therapy in ESC member and ESC affiliated countries and the adherence to ESC STEMI guidelines in patients with STEMI. Methods and results Between 1 January 2015 and 31 March 2018, a total of 11 462 patients admitted with an initial diagnosis of STEMI according to the 2012 ESC STEMI guidelines were enrolled. Individual patient data were collected across 196 centres and 29 countries. Among the centres, there were 136 percutaneous coronary intervention centres and 91 with cardiac surgery on-site. The majority of centres (129/196) were part of a STEMI network. The main objective of this study was to describe the demographic, clinical, and angiographic characteristics of patients with STEMI. Other objectives include to assess management patterns and in particular the current use of reperfusion therapies and to evaluate how recommendations of most recent STEMI European guidelines regarding reperfusion therapies and adjunctive pharmacological and non-pharmacological treatments are adopted in clinical practice and how their application can impact on patients’ outcomes. Patients will be followed for 1 year after admission. Conclusion The ESC ACCA-EAPCI EORP ACS STEMI registry is an international registry of care and outcomes of patients hospitalized with STEMI. It will provide insights into the contemporary patient profile, management patterns, and 1-year outcome of patients with STEMI.

Patient, a man, age of 66 years, was admitted to the Internal Department,Interventional Cardiology Department for chest pains by type of stable anginapectoris. CCS II. In ambulatory conditions he was made non-invasive diagnostics,and after a positive ergometric test, a decision was made that the patient beadmitted to the catheterization hall for invasive diagnosis and possible percutaneouscoronary intervention.

Percutaneous coronary intervention (PCI) of Chronic total occlusion (CTO) is one of the major challenges in interventional cardiology. Symptomatic patients have significant improvement in quality of life after successful revascularization of CTO. Also, it has been shown to improve left ventricular (LV) systolic function, reduces the need for late bypass surgery as well as the reduction of the long term mortality. In this editorial, we review the current definition and indication for the revascularization of CTO.

Introduction. Left main coronary artery dissection is a rare and potentially life-threatening complication of coronary angiography and angioplasty which requests urgent revascularization. Case report. During the period between 2010 and November 2014 at single healthcare center we did totally 8,884 coronary procedures, out of which 2,333 were percutaneous coronary interventions (PCI). In this period we had a total of 3 (0,03%) left main coronary artery dissections, and all of them were successfully treated by PCI. We presented three cases with iatrogenic dissection of the left main coronary artery, occurred during elective diagnostic procedures, successfully treated with PCI with different techniques. Conclusion. PCI could be fast and life-saving approach in iatrogenic dissections of the left main coronary artery.

This prospective, first-in-man, open-label multicenter study sought to assess the pharmacokinetics of sirolimus after Ultimaster drug-eluting stent implantation (coated with sirolimus and bioabsorbable co-polymer) in patients with de novo coronary artery disease (the TCD-10023 PK study). The primary endpoint was sirolimus concentration in peripheral whole blood at 28 days after stent implantation. In addition, safety, tolerability, therapeutic outcome and vasomotor response after stent implantation were studied. Twenty patients were enrolled in the study. Blood samples for the measurements of sirolimus concentration were collected at eight time points during first 48 h, at 7 days and 28 days after stent implantation. Patients underwent 6-month angiographic and up to 12 months clinical follow-up. At 28 days, only two of 20 patients had sirolimus concentrations above lower limit of quantification (20.0 pg/mL). The highest sirolimus blood concentration was 105 pg/mL. The median maximum concentration was 36.8 pg/mL (range 22.9-41.5 pg/mL) for stent 3.0 × 15 mm and 87.2 pg/mL (range 60.0-105.0 pg/mL) for 3 × 28 mm stent. The median systemic exposure, as measured by the area under the time-concentration curve, was 8.3 ng h/mL (range 6.47-28.0 ng h/mL). At 6 months, endothelial function was well preserved, and up to 12 months, there were no signs of sirolimus toxicity nor any other safety concerns. Our results demonstrate that implantation of Ultimaster stent resulted in almost nondetectable sirolimus in blood after 28 days. These findings were translated into exceptional safety profile, without any sign of systemic toxicity.

The role of oral immunosuppressive therapy (OIT) to prevent restenosis after percutaneous coronary intervention (PCI) and stenting is still controversial. This study evaluates the impact of oral administration of prednisone or sirolimus to prevent restenosis.We conducted a meta-analysis of trials in which PCI-patients were randomized to bare metal stents (BMS) plus OIT (BMS + OIT group) versus BMS or drug-eluting stents alone (BMS/DES group). Primary endpoints were target lesion revascularization and death/myocardial infarction (MI). Secondary endpoints were death, MI, stent thrombosis and in-stent late lumen loss. Hazard ratio and weighted geometric mean difference [95% confidence intervals] served as summary statistics.Individual data of seven trials (1246 patients [BMS + OIT, n = 608 versus BMS/DES, n = 638] with 1456 coronary lesions) were merged. At a median follow-up of 360 days, BMS + OIT versus BMS/DES significantly reduced the risk of revascularization (0.49 [0.24-0.98], P = 0.04). In particular, BMS + OIT reduced the risk of revascularization (0.38 [0.21-0.67], P0.001) and late lumen loss (-0.39 mm [-0.67, -0.11], P0.001) as compared with BMS alone. BMS + OIT versus BMS/DES showed a similar risk of death/MI (0.67 [0.29-1.53], P = 0.34), death (0.82 [0.25-2.69], P = 0.71), MI (0.58 [0.24-1.39], P = 0.22) and stent thrombosis (0.43 [0.10-1.87], P = 0.26).In patients undergoing PCI the use of BMS and oral immunosuppressive therapy reduces the risk of revascularization as compared with BMS alone but not as compared with DES alone, while these therapies display a similar risk of death/MI. The advantage of adding oral immunosuppressive therapy to BMS is due to a lower risk of restenosis as compared with BMS alone.

Treatment of nonculprit coronary stenosis during primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction may be beneficial, but the mode and timing of the intervention are still controversial. The aim of this study was to examine the significance and prognostic value of preserved coronary flow velocity reserve (CFVR) in patients with nonculprit intermediate stenosis early after primary percutaneous coronary intervention.Two hundred thirty patients with remaining intermediate (50%-70%) stenosis of non-infarct-related arteries, in whom CFVR was performed within 7 days after primary percutaneous coronary intervention, were prospectively enrolled. Twenty patients with reduced CFVR and positive results on stress echocardiography or impaired fractional flow reserve underwent revascularization and were not included in further analysis. The final study population of 210 patients (mean age, 58 ± 10 years; 162 men) was divided into two groups on the basis of CFVR: group 1, CFVR 2 (n = 174), and group 2, CFVR ≤ 2 (n = 36). Cardiac death, nonfatal myocardial infarction, and revascularization of the evaluated vessel were considered adverse events.Mean follow-up duration was 47 ± 16 months. Mean CFVR for the whole group was 2.36 ± 0.40. There were six adverse events (3.4%) related to the nonculprit coronary artery in group 1, including one cardiac death, one ST-segment elevation myocardial infarction, and four revascularizations. In group 2, there were 30 adverse events (83.3%, P .001 vs group 1), including two cardiac deaths, two ST-segment elevation myocardial infarctions, and 26 revascularizations.In patients with CFVR 2 of the intermediate nonculprit coronary lesion, deferral of revascularization is safe and associated with excellent long-term clinical outcomes.

Introduction Routine thrombus aspiration is proposed to be superior to conventional primary percutaneous coronary intervention (PCI) in terms of improved myocardial perfusion, in patients with ST-segment elevation acute myocardial infarction (STEMI). However, myocardial perfusion after thrombus aspiration has not been evaluated by a quantitative, invasive method. We intend to determine whether manual thrombus aspiration in the infarct-related coronary artery increases myocardial perfusion assessed by index of microcirculatory resistance (IMR) compared with conventional primary PCI. Study Design PATA STEMI is a single-center, prospective, randomized trial with a planned inclusion of 128 patients with the first STEMI. Prior to coronary angiography, patients are randomly assigned to thrombus aspiration using the Eliminate aspiration catheter (Terumo Medical Supply, Japan) or to conventional primary PCI. After completion of primary PCI, IMR is determined both in infarct-related artery and in noninfarct-related arteries without critical stenoses. The primary end-point is a group mean value of IMR after thrombus aspiration compared with conventional primary PCI. Secondary end-points are myocardial perfusion grade, resolution of ST-segment elevation, enzymatic estimation of infarct size, left ventricular remodeling assessed by echocardiographic indices, and major adverse cardiac events rate at 1, 6, and 12 months. Conclusion If manual thrombus aspiration significantly reduces microcirculatory resistance, thereby improving myocardial perfusion, it may become the routine strategy in primary PCI. (J Interven Cardiol 2014;27:341–347)

Although chronic total occlusions (CTOs) are a common coronary angiographic finding, with an incidence reaching >25%, a disproportionately smaller portion of patients are treated with percutaneous coronary intervention (PCI), comprising 8% of the overall PCI volume.1 There appear to be at least two important issues that are associated with the existing discrepancy between the occurrence of CTO and the rate of CTO PCI in contemporary clinical practice. First, percutaneous CTO recanalisation is often considered to be technically difficult, resource-demanding and time-demanding, with a complication rate exceeding that of a non-CTO PCI. However, recent advances in the interventional technique, both antegrade and retrograde, including the hybrid algorithm, have resulted in >90% procedural success rates, while being associated with a low occurrence of major complications, such as cardiac tamponade, myocardial infarction and death (all well below 1%).1 Second, the evidence base regarding clinical benefits of CTO PCI over medical therapy has largely been confined to observational data, stemming mainly from retrospective comparisons of clinical outcomes in patients with successful versus failed CTO PCI,1 whereas randomised studies evaluating the effects of PCI versus medical therapy for CTO have been scarce. Notwithstanding the currently insufficient randomised evidence base, the clinical appeal of CTO PCI seems to, at least in part, rest on the notion of achieving percutaneous complete revascularisation in patients with significant coronary artery disease as incomplete revascularisation has been linked to impaired prognosis.2 In their Heart manuscript, Elias et al 3 present long-term data of the hitherto only randomised controlled trial evaluating the effects of CTO PCI versus conservative management, published in a peer-review journal. Moreover, this was the first study to randomly investigate the value of PCI for a non-culprit CTO, …

Recanalisation of chronic total occlusions has remained suboptimal in the field of percutaneous coronary intervention (PCI). Hopes for a better outcome have been raised since its introduction and evolvement of new techniques, including retrograde approach. Along with conventional antegrade approaches this technique led to a success rate of more than 90% in experienced and chronic total occlusion-dedicated centres. This article focuses on contemporary retrograde approach strategy and the importance of experience and proctorship in PCI of coronary chronic total occlusions (CTO).

Background/Aim. Aortic stenosis (AS) is the most common valvular heart disease in elderly people, with rather poor prognosis in symptomatic patients. Surgical valve replacement is the therapy of choice, but a significant number of patients cannot undergo surgical procedure. We presented initial experience of transcatheter aortic valve implantation (TAVI) performed in Catheterization Laboratory of the Clinic for Cardiology, Clinical Center of Serbia. Methods. The procedures were performed in 5 patients (mean age 76 ± 6 years, 2 males, 3 female) with severe and symptomatic AS with contraindication to surgery or high surgical risk. The decision to perform TAVI was made by the heart team. Pre-procedure screening included detailed clinical and echocardiographic evaluation, coronary angiography and computed tomography scan. In all the patients we implanted a self-expandable aortic valve (Core Valve, Medtronic, USA). Six months follow-up was available for all the patients. Results. All interventions were successfully performed without significant periprocedural complications. Immediate hemodynamic improvement was obtained in all the patients (peak gradient 94.2 ± 27.6 to 17.6 ± 5.2 mmHg, p < 0.001, mean pressure gradient 52.8 ± 14.5 to 8.0 ± 2.1 mmHg, p < 0.001). None of the patients developed heart block, stroke, vascular complication or significant aortic regurgitation. After 6 months, the survival was 100% with New York Heart Association (NYHA) functional improvement in all the patients. Conclusion. This successful initial experience provides a solid basis to treat larger number of patients with symptomatic AS and high surgical risk who are left untreated. [Projekat Ministarstva nauke Republike Srbije, br. ON 175 020]

OBJECTIVE The aims of this study were to investigate the incidence and parameters associated with myocardial ischemia during mental stress (MS) as measured by echocardiography and to evaluate the relation between MS-induced and exercise-induced myocardial ischemia. METHODS Study participants were 79 patients (63 men; mean [M] [standard deviation {SD}] age = 52 [8] years) with angiographically confirmed coronary artery disease and previous positive exercise test result. The MS protocol consisted of mental arithmetic and anger recall task. The patients performed a treadmill exercise test 15 to 20 minutes after the MS task. Data of post-MS exercise were compared with previous exercise stress test results. RESULTS The frequency of echocardiographic abnormalities was 35% in response to the mental arithmetic task, compared with 61% with anger recall and 96% with exercise (p < .001, exercise versus MS). Electrocardiogram abnormalities and chest pain were substantially less common during MS than were echocardiographic abnormalities. Independent predictors of MS-induced myocardial ischemia were: wall motion score index at rest (p = .02), peak systolic blood pressure (p = .005), and increase in rate-pressure product (p = .004) during MS. The duration of exercise stress test was significantly shorter (p < .001) when MS preceded the exercise and in the case of earlier exercise (M [SD] = 4.4 [1.9] versus 6.7 [2.2] minutes for patients positive on MS and 5.7 [1.9] versus 8.0 [2.3] minutes for patients negative on MS). CONCLUSIONS Echocardiography can be successfully used to document myocardial ischemia induced by MS. MS-induced ischemia was associated with an increase in hemodynamic parameters during MS and worse function of the left ventricle. MS may shorten the duration of subsequent exercise stress testing and can potentiate exercise-induced ischemia in susceptible patients with coronary artery disease.