Coronary Artery Disease

Association of social containment on ST-segment elevation myocardial infarction presentations during the COVID-19 pandemic No abstract available

Vildagliptin vs. insulin treatment alone in diabetic acute coronary syndrome patients Background Vildagliptin, an oral antidiabetic of the dipeptidyl peptidase-4 (DPP-4) inhibitor drugs, exhibits an overall low risk of hypoglycemia with less frequent hypoglycemic events in type 2 diabetes mellitus (T2DM) patients than other antidiabetic drugs. We hypothesized that among hospitalized acute coronary syndrome (ACS) patients, the addition of vildagliptin to subcutaneous insulin therapy would reduce the risk of hypoglycemic events. Methods One hundred ACS T2DM adult patients naive to DPP-4 inhibitors were enrolled during admission to the ICCU. Patients were divided into two randomized controlled groups: a subcutaneous rapid-acting insulin-only therapy group and an oral vildagliptin plus subcutaneous insulin group. The trial was open label with no placebo arm. Mean glucose values, insulin values given for correction per hospitalization, and the number of hypoglycemic events (glucose < 70 mg/dL) were documented. Results Eight hypoglycemia events occurred in the insulin-only group and none in the insulin plus DPP-4 inhibitor group (P < 0.001). Patients with acute myocardial infarction experienced a higher number of hypoglycemic events compared with unstable angina diagnosed patients. No significant differences were found regarding glucose level (P = 0.462) and administered insulin units (P = 0.639). Conclusions In T2DM patients, the addition of DPP-4 inhibitors to routine subcutaneous insulin therapy may significantly reduce hypoglycemic events while maintaining acceptable recommended ranges of glucose. Further studies on a larger scale are required to verify these results and to support that DPP-4 inhibitors added to today's standard insulin-only treatment in hospitalized diabetic ACS patients may improve overall glycemic control and provide a potential treatment option in this challenging clinical setting.

Clinical features, sex differences and outcomes of myocardial infarction with nonobstructive coronary arteries: a registry analysis Introduction Clinical characteristics and outcomes of patients diagnosed with myocardial infarction (MI) with nonobstructive coronary arteries (MINOCA) remain largely unknown. Furthermore, we do not yet understand if women with MINOCA have worse outcomes similar to what has historically been observed with MI. The aims of the current study were to evaluate the (1) incidence of MINOCA in patients presenting with MI, (2) compare in-hospital outcomes of MINOCA and obstructive atherosclerotic coronary artery disease MI (OACD-MI), and (3) comparison of in-hospital clinical outcomes of patients with MINOCA stratified by sex. Methods and results In this observational study, we combined data from two large university hospitals from Canada and Australia. Clinical characteristics and in-hospital outcomes of MINOCA and OACD-MI were analyzed by matching these patients in a 1:1 ratio after selecting patients with OACD-MI by systematic random sampling. Clinical characteristics associated with MINOCA were identified through multivariate logistic regression. Primary outcome of interest was net adverse cardiovascular events (NACE) defined as death, heart failure, stroke, and major bleeding. The incidence rate of MINOCA was 9.5%. Women, absence of traditional cardiac risk factors, and absence of ST-deviations on ECG were associated with diagnosis of MINOCA on angiography. NACE (P = 0.0001), death (P = 0.019), stroke (P = 0.002), and heart failure (P = 0.001) were significantly lower in patients with MINOCA. Subgroup analysis of women and men diagnosed with MINOCA revealed similar in-hospital outcomes. Conclusion The incidence of MINOCA was 9.5%. Compared to OACD-MI, patients with MINOCA have less cardiac risk factors. In-hospital outcomes of patients diagnosed with MINOCA were better than OACD-MI.

Association of gender with clinical outcomes of patients with acute ST-segment elevation myocardial infarction presenting with acute heart failure Background There is limited data evaluating the sex differences in outcomes of patients with ST-segment elevation myocardial infarction presenting with acute heart failure. We compared the outcomes between women and men with ST-segment elevation myocardial infarction presenting with acute heart failure (Killip classification ≥II). Method All ST-segment elevation myocardial infarction patients presenting to the emergency department of a cardiovascular center in Jakarta, Indonesia, from 1 February 2011 to 30 August 2019 were retrospectively analyzed. Results Of 6557 patients recorded, 929 were women, and 276 (4.2%) presented with acute heart failure. Compared with men with acute heart failure (N = 1540), women who presented with acute heart failure were older (63 ± 10 vs. 57 ± 10 years, P < 0.001), had a greater proportion of thrombolysis in myocardial infarction risk score >4 (85% vs. 73%, P < 0.001), received fewer primary angioplasty and in-hospital fibrinolytic therapy (40% vs. 48%, P = 0.004 and 1.1% versus 3.5%, P = 0.03, respectively), and had longer median door-to-device and total ischemia times (96 vs. 83 minutes, P = 0.001, and 516 versus 464 minutes, P = 0.02, respectively). Multivariate analysis showed that women and men with acute heart failure were each associated with increased risk of in-hospital mortality (odds ratio: 4.70; 95% confidence interval: 3.28–6.73 and odds ratio: 4.75; 95% confidence interval: 3.84–5.88, respectively), and this remained relatively unchanged even among patients with acute heart failure who had undergone reperfusion therapy (odds ratio: 5.35; 95% confidence interval: 3.01–9.47 and odds ratio: 5.19; 95% confidence interval: 3.80–7.08, respectively). Conclusion In our population, women with ST-segment elevation myocardial infarction presenting with acute heart failure had relatively similar risk of early mortality with their male counterpart (≈5-fold), thus should receive evidence-based treatment.

Safety and efficacy study of prourokinase injection during primary percutaneous coronary intervention in acute ST-segment elevation myocardial infarction Objectives To evaluate the efficacy and safety of intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions in patients with acute ST-segment elevation myocardial infarction. Methods Acute ST-segment elevation myocardial infarction patients underwent primary percutaneous coronary interventions were randomly divided into two groups: intracoronary prourokinase group (n = 125) and control group (n = 135). During primary percutaneous coronary interventions, prourokinase or saline was injected to the distal end of the culprit lesion via balloon catheter after balloon catheter dilatation. Demographic and clinical characteristics, infarct size, myocardial reperfusion, and cardiac functions were evaluated and compared between two groups. Hemorrhagic complications and major averse cardiovascular events (MACE) occurred in the 6-months follow-up were recorded. Results No significant differences were observed between two groups with respect to baseline demographic, clinical, and thrombolysis in myocardial infarction grade (P > 0.05). In the intracoronary prourokinase group, more patients had ST-segment resolution (>50%) compared with control group (P < 0.05). Patients in the intracoronary prourokinase group showed lower levels of serum CK, creatine kinase-MB fraction, and troponin I than those in control group (P < 0.05). No significant differences in bleeding complications were observed between the two groups (P > 0.05). At 6-months follow-up, there was no statistically different of MACE between the two groups (P > 0.05). Conclusions Intracoronary administration of prourokinase via balloon catheter during primary percutaneous coronary interventions effectively improved myocardial perfusion and no increased bleeding in ST-segment elevation myocardial infarction patients.

Antithrombotic therapy in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention; insights from a meta-analysis Background The optimal antithrombotic regimen for patients undergoing percutaneous coronary intervention in acute coronary syndrome with concomitant atrial fibrillation is largely under investigation. Method PUBMED and EMBASE were searched through October 2019 for randomized trials or subgroup analyses of randomized trials investigating different antithrombotic strategies in patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention. We compared dual antithrombotic therapy versus triple antithrombotic therapy. Dual antithrombotic therapy was defined as vitamin K antagonist or direct oral anticoagulant plus P2Y12 inhibitor. Triple antithrombotic therapy was defined as vitamin K antagonist or direct oral anticoagulant plus dual antiplatelet therapy (aspirin plus P2Y12 inhibitor). The primary safety outcome was trial outcome was trial defined major adverse cardiovascular events. Results Our search identified 5 eligible subgroup analyses of randomized controlled trials that enrolled a total of 4733 patients. Dual antithrombotic therapy significantly decreased the bleeding risk when compared with triple antithrombotic therapy (hazard ratio: 0.61; 95% confidential interval [0.51–0.71], P < 0.001, I2 = 31%). However, there were no significant differences in major adverse cardiovascular event between dual antithrombotic therapy versus triple antithrombotic therapy (hazard ratio: 1.08; 95% confidential interval: 0.89–1.31, P = 0.44, I2 = 0%). Conclusion In patients with atrial fibrillation and acute coronary syndrome undergoing percutaneous coronary intervention, dual antithrombotic therapy was associated with lower bleeding risk compared with triple antithrombotic therapy while conferring similar major adverse cardiovascular event risk. Our results should be interpreted cautiously because we did not analyze the risk of stent thrombosis.

Characteristics of recurrent in-stent restenosis after second- and third-generation drug-eluting stent implantation Background In second- and third-generation drug-eluting stent (DES) era, in-stent restenosis (ISR) is not commonly seen. However, a few patients still need repeat revascularizations for recurrent ISR even after second- and third-generation DES implantation. Methods From January 2012 to March 2017, 2339 lesions underwent second- and third-generation DES (Nobori, Promus Element, Resolute Integrity, Xience, Ultimaster and Synergy) implantation, of which 95 lesions (4.1%) underwent revascularization for first ISR. All lesions were divided into two groups of recurrent ISR group and non-recurrent ISR group. After successful optical coherence tomography (OCT) guided revascularization for all lesions, we investigated characteristics of recurrent ISR, and 2 years follow-up were completed. Results The mean age was 70.8 ± 11.7 years, and 73.2% were males. Among 56 DES-ISR lesions which were assessed by OCT, recurrent ISR was seen in 33.9% (N = 19) at 2 years follow-up after revascularization for first ISR. Serum low-density lipoprotein-cholesterol (LDL-C) level was higher in recurrent ISR group compared with non-recurrent ISR group (114.1 ± 53.9 mg/dl vs. 90.9 ± 27.8 mg/dl, P = 0.04) and heterogeneous tissue pattern was more frequently found in recurrent ISR group compared with non-recurrent ISR group (63.2% vs. 27.0%, P = 0.03). Multivariate analysis identified a heterogeneous tissue pattern (odds ratio 3.71; 95% confidence interval 1.09–12.59; P = 0.03) as an independent predictor of recurrent restenosis. Conclusion Recurrent ISR of second- and third-generation DES was associated with heterogeneous tissue pattern of first ISR, and high LDL-C level was associated with recurrence.

Prevalence, predictors, prognostic significance, and effect of techniques on outcomes of coronary lesion calcification following implantation of drug-eluting stents: a patient-level pooled analysis of stent-specific, multicenter, prospective IRIS-DES registries Aims There is limited information on the clinical relevance and procedural impact of coronary artery calcification (CAC) in the contemporary percutaneous coronary intervention (PCI) setting. This study sought to determine the incidence and clinical significance of procedural techniques on the outcomes in 'real-world' patients with CAC undergoing PCI with drug-eluting stents (DESs). Methods and results Using patient-level data from seven stent-specific, prospective DES registries, we evaluated 17 084 patients who underwent PCI with various DES types between July 2007 and July 2015. The primary outcome was target-vessel failure (TVF), defined as a composite of cardiac death, target-vessel myocardial infarction, or target-vessel revascularization. Outcomes through 3 years (and between 0–1 and 1–3 years) were assessed according to CAC status (none/mild vs. moderate/severe) and stenting technique (predilation or post-dilation). Among 17 084 patients with 22 739 lesions included in the pooled dataset, moderate to severe CAC was observed in 11.3% of patients (10.1% of lesions). Older age, lower BMI, diabetes, hypertension, family history of coronary artery disease, and renal failure were independent predictors of moderate/severe CAC. The presence of moderate/severe CAC was significantly associated with an adjusted risk of TVF at 3 years [hazard ratio, 1.37; 95% confidence interval (CI), 1.19–1.58; P < 0.001]. For severe CAC, optimal lesion preparation with predilation was associated with a lower 3-year rate of TVF (no vs. yes, 22.3 vs. 12.8%), in which the effect of predilation was prominent at the late period of 1–3 years (hazard ratio, 0.28; 95% CI, 0.12–0.69; P = 0.003) than at the early period through 1 year (hazard ratio, 1.16; 95% CI, 0.37–3.71; P = 0.80). However, post-dilation (with a high-pressure noncompliant balloon) had no effect on the outcome. Conclusions In this study, moderate/severe CAC was common (~10%) and strongly associated with TVF during 3 years of follow-up. For severe CAC, optimal lesion preparation with pre-balloon dilation has a significant effect on long-term outcomes, especially during the late period beyond 1 year. Clinical Trial Registration – URL: http://www.clinicaltrials.gov. Unique identifier: NCT01186133.

Coronary bifurcations treated with thin-strut drug-eluting stents: a prespecified analysis of the randomized BIO-RESORT trial Background Treatment of a coronary bifurcation lesion is often required in routine clinical practice, but data on the performance of very thin-strut biodegradable polymer drug-eluting stents are scarce. Methods Comparison of biodegradable polymer and durable polymer drug-eluting stents in an all comers population (BIO-RESORT) is a prospective, multicenter randomized clinical trial that included 3514 all-comer patients, who were randomized to very thin-strut biodegradable polymer-coated sirolimus- or everolimus-eluting stents, versus thin-strut durable polymer-coated zotarolimus-eluting stents. The approach of bifurcation stenting was left at the operator's discretion, and provisional stenting was generally preferred. This prespecified analysis assessed 3-year clinical outcome of all patients in whom treatment involved at least one bifurcation with a side-branch diameter ≥1.5 mm. Results Of all BIO-RESORT trial participants, 1236 patients were treated in bifurcation lesions and analyzed. Single- and two-stent techniques were used in 85.8% and 14.2%, respectively. 'True' bifurcation lesions (main vessel and side-branch obstructed) were treated in 31.1%. Three-year follow-up was available in 1200/1236 (97.1%) patients. The main endpoint target vessel failure (composite of cardiac death, target vessel-related myocardial infarction, or target vessel revascularization) occurred in sirolimus-eluting stents in 42/412 (10.3%) and in zotarolimus-eluting stents in 49/409 (12.1%) patients (P-logrank = 0.40). In everolimus-eluting stents, target vessel failure occurred in 40/415 (9.8%) patients (vs. zotarolimus-eluting stents: P-logrank = 0.26). There was no between-stent difference in individual components of target vessel failure. Findings were consistent in patients with single-vessel treatment and patients treated with a single-stent technique. Conclusions Three years after stenting all-comers with bifurcation lesions, clinical outcome was similar with the sirolimus-eluting and everolimus-eluting stents versus the zotarolimus-eluting stent.

Fragmented QRS complexes are associated with postoperative atrial fibrillation development after coronary artery bypass grafting surgery Objective Postoperative atrial fibrillation (PoAF) is one of the most frequent complications and a major risk factor of morbidity and mortality after coronary artery bypass grafting (CABG). Fragmented QRS complex (fQRS) on a 12-lead surface ECG is recently gained increasing attention as a simplified noninvasive ECG marker with diagnostic and prognostic value in various cardiac conditions. The aim of the present study was to evaluate the association between development of PoAF and presence of fQRS on admission ECG in patients undergoing CABG surgery. Methods A total of 242 patients who underwent CABG between February 2016 and June 2018 were included in this study. The patients were divided into two groups as developing and nondeveloping PoAF groups in the postoperative period. fQRS was defined as the presence of various RSR′ patterns including an additional R wave, notching of the R or S waves, or the presence of more than one fragmentation in two contiguous leads. Results In-hospital mortality was higher in PoAF (+) group compared to PoAF (–) group (20.5 vs. 6.4%, P = 0.004). PoAF rate was higher in fQRS (+) group than fQRS (–) group (25.3 vs. 9.8%, P = 0.001). In multivariate analysis, the presence of fQRS complexes on admission ECG [odds ratio (OR) 2.801, 95% confidence interval (CI) 1.262–6.211, P = 0.011) and hemoglobin (OR 0.794; 95% CI, 0.641–0.985; P = 0.036) were identified as independent predictors of PoAF after CABG surgery. Conclusion The presence of fQRS on admission ECG was found to be an independent predictor of PoAF in patients undergoing isolated CABG.

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Medicine by Alexandros G. Sfakianakis,Anapafseos 5 Agios Nikolaos 72100 Crete Greece,00302841026182,00306932607174,alsfakia@gmail.com,

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