Complete Revascularization with Multivessel PCI for Myocardial Infarction

A randomized comparison of the treatment sequence of percutaneous coronary intervention and transcatheter aortic valve implantation: Rationale and design of the TAVI PCI trial

BACKGROUND

About half of patients with severe aortic stenosis present with concomitant coronary artery disease. The optimal timing of percutaneous coronary intervention (PCI) and transcatheter aortic valve implantation (TAVI) in patients with severe aortic stenosis and concomitant coronary artery disease remains unknown.

STUDY DESIGN

The TAVI PCI trial is a prospective, international, multicenter, randomized, 2-arm, open-label study planning to enroll a total of 986 patients. It is designed to investigate whether the strategy "angiography-guided complete revascularization after (within 1-45 days) TAVI" is noninferior to the strategy "angiography-guided complete revascularization before (within 1-45 days) TAVI" using the Edwards SAPIEN 3 or 3 Ultra Transcatheter Heart Valve in patients with severe aortic stenosis and concomitant coronary artery disease. Patients are randomized in a 1:1 ratio to one of the 2 treatment strategies. The primary end point is a composite of all-cause death, nonfatal myocardial infarction, ischemia-driven revascularization, rehospitalization (valve- or procedure-related including heart failure), or life-threatening/disabling or major bleeding at 1 year.

CONCLUSIONS

The TAVI PCI trial tests the hypothesis that the strategy "PCI after TAVI" is noninferior to the strategy "PCI before TAVI" in patients with severe aortic stenosis and concomitant coronary artery disease.

The role of chronic total occlusions in non-infarct-related arteries in acute coronary syndrome patients: a systematic review

Aim: This systematic review evaluated the impact of a chronic total occlusion (CTO) in a non-infarct-related artery (non-IRA) on clinical outcomes in acute coronary syndrome (ACS) patients and assessed the benefits of staged revascularization.Methods: We performed a comprehensive systematic review to provide further insight into the impact of a CTO in a non-IRA on clinical outcomes after ACS. Moreover, we review the currently available evidence on the clinical significance of staged revascularization for a CTO in a non-IRA patients with ACS and propose whether prophylactic CTO percutaneous coronary intervention (PCI) could improve outcomes in patients who subsequently develop an ACS.Results: Our search identified 999 studies, from which 30 were selected and ten were included in the analysis. The results showed a trend of higher all-cause mortality and major adverse cardiac event rates in the culprit-only-PCI group compared with the multivessel (MV)-PC I group in ST elevation myocardial infarction patients, with varying statistical significance across different outcomes.Conclusion: This review highlights the significant impact of non-IRA CTOs in ACS. Successful CTO revascularization may provide benefits, particularly in ST elevation myocardial infarction, but the optimal management approach remains uncertain. The presence of a non-IRA CTO, especially in cardiogenic shock, predicts worse outcomes. Further research is warranted to determine the effective strategies to improve survival.

CVIT expert consensus document on primary percutaneous coronary intervention (PCI) for acute coronary syndromes (ACS) in 2024

Primary Percutaneous Coronary Intervention (PCI) has significantly contributed to reducing the mortality of patients with ST-segment elevation myocardial infarction (STEMI) even in cardiogenic shock and is now the standard of care in most of Japanese institutions. The Task Force on Primary PCI of the Japanese Association of Cardiovascular Intervention and Therapeutics (CVIT) proposed an expert consensus document for the management of acute myocardial infarction (AMI) focusing on procedural aspects of primary PCI in 2018 and updated in 2022. Recently, the European Society of Cardiology (ESC) published the guidelines for the management of acute coronary syndrome in 2023. Major new updates in the 2023 ESC guideline include: (1) intravascular imaging should be considered to guide PCI (Class IIa); (2) timing of complete revascularization; (3) antiplatelet therapy in patient with high-bleeding risk. Reflecting rapid advances in the field, the Task Force on Primary PCI of the CVIT group has now proposed an updated expert consensus document for the management of ACS focusing on procedural aspects of primary PCI in 2024 version.

Myocardial Revascularization in Heart Failure: A State-of-the-Art Review

Patients with heart failure (HF) and underlying coronary artery disease (CAD) have a substantially higher risk of mortality compared with those with HF from other causes. However, identifying individuals with HF for whom revascularization is likely to improve prognosis is a complex clinical decision. Revascularization is likely beneficial for patients with CAD-predominant symptoms, such as those with acute myocardial infarction or stable ischemic heart disease with refractory angina. However, for patients with HF-predominant symptoms, characterized by dyspnea without acute myocardial infarction or refractory angina, the benefits of revascularization are less clear. This state-of-the-art review summarizes the outcomes, clinical trials, and therapeutic approaches for patients with both CAD and HF, and proposes a therapeutic algorithm to guide the diagnosis and comprehensive workup of these complex patients.

Optical Coherence Tomography in Myocardial Infarction Management: Enhancing Precision in Percutaneous Coronary Intervention

In acute myocardial infarction (AMI), the urgency of coronary revascularization through percutaneous coronary intervention (PCI) is paramount, offering notable advantages over pharmacologic treatment. However, the persistent risk of adverse events, including recurrent AMI and heart failure post-revascularization, underscores the necessity for enhanced strategies in managing coronary artery disease. Traditional angiography, while widely employed, presents significant limitations by providing only two-dimensional representations of complex three-dimensional vascular structures, hampering the accurate assessment of plaque characteristics and stenosis severity. Intravascular imaging, specifically optical coherence tomography (OCT), significantly addresses these limitations with superior spatial resolution compared to intravascular ultrasound (IVUS). Within the context of AMI, OCT serves dual purposes: as a diagnostic tool to accurately identify culprit lesions in ambiguous cases and as a guide for optimizing PCI procedures. Its capacity to differentiate between various mechanisms of acute coronary syndrome, such as plaque rupture and spontaneous coronary dissection, enhances its diagnostic potential. Furthermore, OCT facilitates precise lesion preparation, optimal stent sizing, and confirms stent deployment efficacy. Recent meta-analyses indicate that OCT-guided PCI markedly improves safety and efficacy in revascularization, subsequently decreasing the risks of mortality and complications. This review emphasizes the critical role of OCT in refining patient-specific therapeutic approaches, aligning with the principles of precision medicine to enhance clinical outcomes for individuals experiencing AMI.

The impact of successful chronic total occlusion percutaneous coronary intervention on clinical outcomes: a tertiary single-center analysis

Background

The benefit of chronic total occlusion (CTO)-percutaneous coronary intervention (PCI) is controversial because of a lack of high-quality evidence. We aim to evaluate the impact of CTO-PCI on symptoms, quality of life and mortality.

Methods

We conducted a retrospective single center study of patients with CTO-PCI in a tertiary center in Austria. The study outcomes were Canadian Cardiovascular Society (CCS) angina score, quality of life measured by Seattle Angina Questionnaire (SAQ), and death at median follow up for patients with successful vs. failed CTO-PCI.

Results

A total of 300 patients underwent CTO-PCI for coronary artery disease, of which 252 (84%) were technically successful with median follow up of 3.4 years. There were no significant differences in in-hospital or all-cause mortality, major adverse cardiovascular event, or stent-related complications between the groups of failed and successful CTO-PCI. Among patients with successful CTO-PCI there was a significant improvement in CCS score, which was not found for the group with failed CTO-PCI. Successful reopening was associated with significant benefits of the SAQ domains of angina with stressful activity [3.7 ± 0.9 vs. 3.1 ± 0.5, p = 0.004, use of nitrates (4.7 ± 0.5 vs. 3.0 ± 1.0) p = 0.005] and satisfaction from angina relief (4.4 ± 1.1 vs. 3.6 ± 1.4 p < 0.001).

Conclusion

While there was no significant difference in mortality, successful CTO-PCI was associated with greater reduction in angina and the use of nitrates compared to unsuccessful CTO-PCI.

Comparison of high-risk characteristics of non-culprit plaques in relation to plaque severity in acute coronary syndrome

INTRODUCTION

Patients with acute coronary syndrome (ACS) have high event rates related to non-culprit (NC) lesions, therefore plaque composition of these lesions is of great interest. Although marginal atherosclerotic lesions were studied extensively, more significant lesions might have more high-risk characteristics.

AIM

To compare differences in high-risk lesion characteristics between significant versus non-stenotic NC plaques in ACS and the discrepancies with chronic coronary syndrome (CCS) patients.

METHODS

Non-culprit vessels of 26 ACS patients with 26 angiographically significant lesions and 37 patients (17 ACS and 20 CCS) with 48 non-stenotic lesions were investigated with intravascular ultrasound (IVUS) and near-infrared spectroscopy (NIRS). Overall, 74 segments of 30 mm length were analyzed in 1 mm intervals. External elastic lamina (EEM), plaque burden (PB), minimal luminal area (MLA), percent atheroma volume (PAV) and lipid core burden index maximum 4 mm (maxLCBI4mm) were determined for each segment.

RESULTS

Cardiovascular risk factors were similar in all groups. PB was higher and MLA smaller in significant non-culprit ACS lesions vs non-stenotic lesions: PB 73.5% (IQR 68.7-78.5) vs 59.2 (IQR 49.6-71.5), p = 0.003, MLA 3.0 mm2 (IQR 2.3-3.9) vs 4.0 mm2 (IQR 2.8-4.7). MaxLCBI4mm was similar 308.1 (±155.4) vs 287.8 (±165.7), p = 0.67. Among non-stenotic plaques, MaxLCBI4mm was comparable between ACS and CCS patients, 275.7 (±151.5) in CCS patients vs 287.8 (±165.7) in ACS patients, p = 0.79.

CONCLUSION

Although visually significant non-culprit lesions had a higher plaque burden compared to non-stenotic lesions, a significant relation between MaxLCBI4mm and hemodynamic significance of the plaques couldn't be established.

Coronary bypass surgery for multivessel disease after percutaneous coronary intervention in acute coronary syndromes: why, for whom, how early?

Multivessel coronary artery disease is present in ∼50% of patients with acute coronary syndrome and, compared with single-vessel disease, entails a higher risk of new ischaemic events and a worse prognosis. Randomized controlled trials have shown the superiority of 'complete revascularization' over culprit lesion-only treatment. Trials, however, only included patients treated with percutaneous coronary intervention (PCI), and evidence regarding complete revascularization with coronary artery bypass graft (CABG) surgery after culprit lesion-only PCI ('hybrid revascularization') is lacking. The CABG after PCI is an open, non-negligible therapeutic option, for patients with non-culprit left main and/or left anterior descending coronary artery disease where evidence in chronic coronary syndrome patients points in several cases to a preference of CABG over PCI. This valuable but poorly studied 'PCI first-CABG later' option presents, however, relevant challenges, mostly in the need of interrupting post-stenting dual antiplatelet therapy (DAPT) for surgery to prevent excess bleeding. Depending on patients' clinical characteristics and coronary anatomical features, either deferring surgery after a safe interruption of DAPT or bridging DAPT interruption with intravenous short-acting antithrombotic agents appears to be a suitable option. Off-pump minimally invasive surgical revascularization, associated with less operative bleeding than open-chest surgery, may be an adjunctive strategy when revascularization cannot be safely deferred and DAPT is not interrupted. Here, the rationale, patient selection, optimal timing, and adjunctive strategies are reviewed for an ideal approach to hybrid revascularization in post-acute coronary syndrome patients to support physicians' choices in a case-by-case patient-tailored approach.

Impact of complete versus culprit-only revascularization on major adverse cardiovascular event in diverse subpopulations

Background: Myocardial infarction management relies on pharmaceuticals and interventions like percutaneous coronary intervention (PCI). While complete PCI has shown noninferiority to culprit-only PCI, its impact on major adverse cardiovascular events (MACE) outcomes in multiple subpopulations has been unknown.Methods: A systematic literature search (from January 2000 to May 2024) identified four relevant randomized controlled trials involving ST-segment elevation myocardial infarction patients. Data analysis employed a random-effects model with inverse variance weighting.Results: MACE risk was significantly lower in males than females undergoing complete PCI compared with culprit-only PCI (hazard ratio: 0.52; 95% CI: 0.39-0.68; p < 0.01; I2 = 53%). Furthermore, complete PCI significantly lowered the risk of MACE outcomes in patients without diabetes and in patients under the 65-year age limit in comparison to culprit-only PCI.Conclusion: Complete PCI reduces MACE risk in male, nondiabetic ST-segment elevation myocardial infarction patients under 65 with multivessel coronary artery disease, necessitating further investigation into outcome differences among different subpopulations.

Impact of Stenting Long Lesions on Clinical Outcomes in Patients Presenting With Acute Coronary Syndrome and Multivessel Disease: Data From the BIOVASC Trial

An increased total stent length (TSL) might be associated with a higher risk of clinical events; however, in patients with multivessel disease (MVD), a considerable TSL is often required. In patients presenting with acute coronary syndrome and MVD, immediate complete revascularization was associated with shorter TSL in the BIOVASC (Immediate versus staged complete revascularisation in patients presenting with acute coronary syndrome and multivessel coronary disease) Trial. This is a subanalysis of the BIOVASC trial comparing clinical outcomes in patients with either <60 or ≥60 mm TSL. The primary outcome was a composite of all-cause mortality, myocardial infarction, any unplanned ischemia driven revascularization, or cerebrovascular events at 2 years after the index procedure. A total of 1,525 patients were enrolled in the BIOVASC trial, of whom 855 had a TSL of ≥60 mm (long TSL). No significant difference was established when comparing patients treated with either long or short TSL in terms of the primary outcome at 2-year follow-up, which occurred in 117 patients (13.7%) in the ≥60 mm group and 69 patients (10.3%) in the <60 mm group (adjusted hazard ratio 1.25, 95% confidence interval 0.92 to 1.69, p = 0.16). Furthermore, no significant differences were observed in the secondary end points. In conclusion, in patients with acute coronary syndrome and MVD, long stenting did not show a significant difference in clinical event rate compared with short stenting.

Routine Stress Testing After PCI in Patients With and Without Acute Coronary Syndrome: A Secondary Analysis of the POST-PCI Randomized Clinical Trial

Importance

The appropriate follow-up surveillance strategy for patients with acute coronary syndrome (ACS) who have undergone percutaneous coronary intervention (PCI) remains unknown.

Objective

To assess clinical outcomes in patients with and without ACS who have undergone high-risk PCI according to a follow-up strategy of routine stress testing at 12 months after PCI vs standard care alone.

Design, Setting, and Participants

The POST-PCI (Pragmatic Trial Comparing Symptom-Oriented vs Routine Stress Testing in High-Risk Patients Undergoing Percutaneous Coronary Intervention) trial was a randomized clinical trial that compared follow-up strategies of routine functional testing vs standard care alone 12 months after high-risk PCI. Patients were categorized as presenting with or without ACS. Patients were enrolled in the trial from November 2017 through September 2019, and patients were randomized from 11 sites in South Korea; data analysis was performed in 2022.

Intervention

Patients categorized as presenting with or without ACS were randomized to either a routine functional testing or standard care alone follow-up strategy 12 months after high-risk PCI.

Main Outcomes and Measures

The primary outcome was a composite of death from any cause, myocardial infarction, or hospitalization for unstable angina at 2 years following randomization. Kaplan-Meier event rates through 2 years and Cox model hazard ratios (HRs) were generated, and interactions were tested.

Results

Of 1706 included patients, 350 patients (20.5%) were female, and the mean (SD) patient age was 64.7 (10.3) years. In total, 526 patients (30.8%) presented with ACS. Compared with those without ACS, patients with ACS had a 55% greater risk of the primary outcome (HR, 1.55; 95% CI, 1.03-2.33; P = .03) due to higher event rates in the first year. The 2-year incidences of the primary outcome were similar between strategies of routine functional testing or standard care alone in patients with ACS (functional testing: 16 of 251 [6.6%]; standard care: 23 of 275 [8.5%]; HR, 0.76; 95% CI, 0.40-1.44; P = .39) and in patients without ACS (functional testing: 30 of 598 [5.1%]; standard care: 28 of 582 [4.9%]; HR, 1.04; 95% CI, 0.62-1.74; P = .88) (P for interaction for ACS = .45). Although a landmark analysis suggested that the rates of invasive angiography and repeat revascularization were higher after 1 year in the routine functional testing group, the formal interactions between ACS status and either invasive angiography or repeat revascularization were not significant.

Conclusion and Relevance

Despite being at higher risk for adverse clinical events in the first year after PCI than patients without ACS, patients with ACS who had undergone high-risk PCI did not derive incremental benefit from routine surveillance stress testing at 12 months compared with standard care alone during follow-up.

Trial Registration

ClinicalTrials.gov Identifier: NCT03217877.

Role of physiology in the management of multivessel disease among patients with acute coronary syndrome

Multivessel coronary artery disease (CAD), defined as ≥50% stenosis in 2 or more epicardial arteries, is associated with a high burden of morbidity and mortality in acute coronary syndrome (ACS) patients. A salient challenge for managing this cohort is selecting the optimal revascularisation strategy, for which the use of coronary physiology has been increasingly recognised. Fractional flow reserve (FFR) is an invasive, pressure wire-based, physiological index measuring the functional significance of coronary lesions. Understanding this can help practitioners evaluate which lesions could induce myocardial ischaemia and, thus, decide which vessels require urgent revascularisation. Non-hyperaemic physiology-based indices, such as instantaneous wave-free ratio (iFR), provide valid alternatives to FFR. While FFR and iFR are recommended by international guidelines in stable CAD, there is ongoing discussion regarding the role of physiology in patients with ACS and multivessel disease (MVD); growing evidence supports FFR use in the latter. Compelling findings show FFR-guided complete percutaneous coronary intervention (PCI) can reduce adverse cardiovascular events, mortality, and repeat revascularisations in ACS and MVD patients compared to angiography-based PCI. However, FFR is limited in identifying non-flow-limiting vulnerable plaques, which can disadvantage high-risk patients. Here, integrating coronary physiology assessment with intracoronary imaging in decision-making can improve outcomes and quality of life. Further research into novel physiology-based tools in ACS and MVD is needed. This review aims to highlight the key evidence surrounding the role of FFR and other functional indices in guiding PCI strategy in ACS and MVD patients.

Impact of Immediate Versus Staged Complete Revascularization on Short-Term and Long-Term Clinical Outcomes in Patients With Acute Coronary Syndrome and Multivessel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

In patients with acute coronary syndrome (ACS) and multivessel disease (MVD), complete revascularization (CR) improves prognosis. This meta-analysis, summarizing recent RCTs, contrasts short-term and long-term clinical outcomes between immediate complete revascularization (ICR) and staged complete revascularization (SCR).

METHODS

We systematically searched the online database and eight RCTs were involved. The primary outcomes included long-term unplanned ischemia-driven revascularization, re-infarction, combined cardiovascular (CV) death or myocardial infarction (MI), all-cause death, CV death, stroke, and hospitalization for heart failure (HHF). The secondary outcomes were 1-month unplanned ischemia-driven revascularization, re-infarction, all-cause death, and CV death. Safety endpoints included stent thrombosis and major bleeding.

RESULTS

Eight RCTs comprising 5198 patients were involved. ICR reduced long-term unplanned ischemia-driven revascularization (RR 0.64, 95% CI 0.51-0.81, p < 0.001), combined CV death or MI (HR 0.51, 95% CI 0.34-0.78, p = 0.002), and re-infarction (RR 0.66,95% CI 0.48 to 0.91, p = 0.012) compared with SCR. ICR also decreased 1-month unplanned ischemia-driven revascularization (RR 0.41, 95% CI: 0.21-0.77, p = 0.006) and re-infarction (RR 0.33, 95% CI:0.15-0.74, p = 0.007) but increased 1-month all-cause death (RR 2.22, 95% CI 1.06-4.65, p = 0.034).

CONCLUSION

In ACS patients with MVD, we first found that ICR significantly lowered the risk of both short-term and long-term unplanned ischemia-driven revascularization and re-infarction, as well as the long-term composite outcome of CV death or MI compared with SCR. However, there may be an increase in 1-month all-cause death in the ICR group.

Completeness of revascularization by FFRCT in stable angina: Association to adverse cardiovascular outcomes

BACKGROUND

The prognostic impact of complete coronary revascularization relative to non-invasive testing methods is unknown.

OBJECTIVES

To assess the association between completeness of revascularization defined by CTA-derived fractional flow reserve (FFRCT) and cardiovascular outcomes in patients with stable angina.

METHODS

Multicenter 3-year follow-up study of patients with new onset stable angina and ≥ 30% stenosis by CTA. The lesion-specific FFRCT value (two cm-distal-to-stenosis) was registered in all vessels with stenosis and considered abnormal when ≤ 0.80. Patients with FFRCT ≤ 0.80 were categorized as: Completely revascularized (CR-FFRCT), all vessels with FFRCT ≤ 0.80 revascularized; incompletely revascularized (IR-FFRCT), ≥ 1 vessels with FFRCT ≤ 0.80 non-revascularized. Early revascularization (< 90 days from index CTA) categorized vessels as revascularized. The primary endpoint comprised cardiovascular death and non-fatal myocardial infarction; the secondary endpoint vessel-specific late revascularization and non-fatal myocardial infarction.

RESULTS

Amongst 900 patients and 1759 vessels, FFRCT was ≤ 0.80 in 377 (42%) patients, 536 (30%) vessels; revascularization was performed in 244 (27%) patients, 340 (19%) vessels. Risk of the primary endpoint was higher for IR-FFRCT (15/210 [7.1%]) compared to CR-FFRCT (4/167 [2.4%]), RR: 2.98; 95% CI: 1.01-8.8, p ​= ​0.036, and to normal FFRCT (3/523 [0.6%]), RR: 12.45; 95% CI: 3.6-42.6, p ​< ​0.001. Incidence of the secondary endpoint was higher in non-revascularized vessels with FFRCT ≤ 0.80 (29/250 [12%]) compared to revascularized vessels with FFRCT ≤ 0.80 (5/286 [1.7%]), p ​= ​0.001, and to vessels with FFRCT > 0.80 (10/1223 [0.8%]), p ​< ​0.001.

CONCLUSION

Incomplete revascularization of patients with lesion-specific FFRCT ≤ 0.80 is associated to unfavorable cardiovascular outcomes compared to those with complete revascularization or FFRCT > 0.80.

Design and rationale of the CLEAR SYNERGY (OASIS 9) trial: A 2x2 factorial randomized controlled trial of colchicine versus placebo and spironolactone vs placebo in patients with myocardial infarction

BACKGROUND

Patients experiencing myocardial infarction (MI) remain at high risk of future major adverse cardiovascular events (MACE). While low-dose colchicine and spironolactone have been shown to decrease post-MI MACE, more data are required to confirm their safety and efficacy in an unselected post-MI population. Therefore, we initiated the CLEAR SYNERGY (OASIS 9) trial to address these uncertainties.

METHODS

The CLEAR SYNERGY trial is a 2 × 2 factorial randomized controlled trial of low-dose colchicine 0.5 mg daily versus placebo and spironolactone 25 mg daily versus placebo in 7,062 post-MI participants who were within 72 hours of the index percutaneous coronary intervention (PCI). We blinded participants, healthcare providers, research personnel, and outcome adjudicators to treatment allocation. The primary outcome for colchicine is the first occurrence of the composite of cardiovascular death, recurrent MI, stroke, or unplanned ischemia-driven revascularization. The coprimary outcomes for spironolactone are (1) the composite of the total numbers of cardiovascular death or new or worsening heart failure and (2) the first occurrence of the composite of cardiovascular death, new or worsening heart failure, recurrent MI or stroke. We finished recruitment with 7,062 participants from 104 centers in 14 countries on November 8, 2022, and plan to present the results in the fall of 2024.

CONCLUSIONS

CLEAR SYNERGY is a large international randomized controlled trial that will inform the effects of low-dose colchicine and spironolactone in largely unselected post-MI patients who undergo PCI. (ClinicalTrials.gov Identifier: NCT03048825).

Change in Pd/Pa: Clinical Implications for Predicting Future Cardiac Events at Deferred Coronary Lesions

BACKGROUND

Cardiovascular events still occur at intermediate stenosis with fractional flow reserve (FFR) ≥0.81, underscoring the additional measure to evaluate this residual risk. A reduction in distal coronary artery pressure/aortic pressure (Pd/Pa) from baseline to hyperemia (ie, change in Pd/Pa) reflects lipidic burden within vessel walls. We hypothesized that this physiological measure might stratify the risk of future cardiac events at deferrable lesions.

METHODS

Lesion- (899 intermediate lesions) and patient-based (899 deferred patients) analyses in those with FFR ≥0.81 were conducted to investigate the association between change in Pd/Pa and target lesion failure (TLF) and major adverse cardiac events at 7 years, respectively.

RESULTS

The occurrence of TLF and major adverse cardiac events was 6.7% and 13.4%, respectively. The incidence of target lesion-related nonfatal myocardial infarction was 0.6%. Lesions with TLF had a greater change in Pd/Pa (0.11±0.03 versus 0.09±0.04; P=0.002), larger diameter stenosis (51.0±9.2% versus 46.4±12.4%; P=0.048), and smaller FFR (0.84 [0.82-0.87] versus 0.86 [0.83-0.90]; P=0.02). Change in Pd/Pa (per 0.01 increase) predicted TLF (odds ratio, 1.16 [95% CI, 1.05-1.28]; P=0.002) and major adverse cardiac event (odds ratio, 1.08 [95% CI, 1.01-1.16]; P=0.03). Lesions with change in Pd/Pa ≥0.10 had 2.94- and 1.85-fold greater likelihood of TLF (95% CI, 1.30-6.69; P=0.01) and major adverse cardiac event (95% CI, 1.08-3.17; P=0.03), respectively. Lesions with FFR ≤0.85 had a substantially higher likelihood of TLF when there is a change in Pd/Pa ≥0.10 (12.4% versus 2.9%; hazard ratio, 3.60 [95% CI, 1.01-12.80]; P=0.04). However, change in Pd/Pa did not affect TLF risk in lesions with FFR ≥0.86 (3.8% versus 3.7%; hazard ratio, 0.56 [95% CI, 0.06-5.62]; P=0.62).

CONCLUSIONS

Despite deferrable FFR values, lesions and patients with a change in Pd/Pa ≥0.10 had higher cardiovascular risk. Change in Pd/Pa might help stratify lesion- and patient-level risks of future cardiac events in those with FFR ≥0.81.

Optimal Timing of Angiography-Guided Complete Revascularization of Non-Culprit Lesions in STEMI Patients with Multivessel Disease

Background: There are many questions regarding the optimal approach to treating non-culprit lesions in STEMI patients. Several questions still need to be answered, such as identifying the lesions to be revascularized and the optimal timing. Methods: We conducted a single-center analysis. The primary outcome was the incidence of major cardiovascular and cerebral adverse events (MACCE) at 12 months in patients with STEMI and multivessel disease (MVD) who achieved complete revascularization during the index procedure or with a staged procedure. The secondary outcomes were death from any cause, myocardial infarction, target lesion revascularization, stroke, major bleeding events, new angina episodes, new hospitalization, and in-hospital MACCE. Results: From January 2021 to December 2022, a total of 230 patients with STEMI underwent primary PCI in our department; 87 patients had MVD. Fifty-nine patients (67.8%) underwent a non-culprit revascularization strategy during the index procedure strategy, and 28 patients (32.2%) during a staged procedure. The incidence of MACCE at 12 months was 11.9% (seven patients) in the index PCI group, compared with 32.1% (nine patients) in the staged PCI group (odds ratio, 3.52; 95% CI, 1.15 to 10.77; p = 0.022). In-hospital MACCE occurred in five patients (8.5%) of the index PCI group, compared with seven patients (25%) in the staged PCI group (odds ratio, 3.60; 95% CI, 1.03 to 12.61; p = 0.036). A trend towards better outcomes favoring the index PCI group was observed with death from any cause, myocardial infarction, target lesion revascularization, and new angina episodes. Conclusions: Better outcomes were evident with an index PCI strategy than with a staged PCI strategy for complete revascularization in patients with STEMI and MVD.

Complete vs Culprit-Only Revascularization in Older Patients With Myocardial Infarction With or Without ST-Segment Elevation

BACKGROUND

The effectiveness of complete revascularization is well established in patients with ST-segment elevation myocardial infarction (STEMI), but it is less investigated in those with non-ST-segment elevation myocardial infarction (NSTEMI).

OBJECTIVES

This study aimed to assess whether complete revascularization, compared with culprit-only revascularization, was associated with consistent outcomes in older patients with STEMI and NSTEMI.

METHODS

In the FIRE (Functional Assessment in Elderly MI Patients with Multivessel Disease) trial, 1,445 older patients with myocardial infarction (MI) were randomized to culprit-only or physiology-guided complete revascularization, stratified by STEMI (n = 256 culprit-only vs n = 253 complete) and NSTEMI (n = 469 culprit-only vs n = 467 complete). The primary outcome comprised a composite of death, MI, stroke, or revascularization at 1 year. The key secondary outcome included a composite of cardiovascular death or MI at 1 year.

RESULTS

In the overall study population, physiology-guided complete revascularization reduced both primary and key secondary outcomes. The primary outcome occurred in 54 (21.1%) STEMI patients randomized to culprit-only vs 41 (16.2%) STEMI patients of the complete group (HR: 0.75; 95% CI: 0.50-1.13) and in 98 (20.9%) NSTEMI patients randomized to culprit-only vs 72 (15.4%) NSTEMI patients of the complete group (HR: 0.71; 95% CI: 0.53-0.97), with negative interaction testing (P for interaction, 0.846). Similarly, no signal of heterogeneity with respect to the initial clinical presentation was observed for the key secondary endpoint (P for interaction, 0.654).

CONCLUSIONS

Physiology-guided complete revascularization, compared with culprit-only revascularization, provided consistent benefit across the whole spectrum of patients with MI. (FIRE [Functional Assessment in Elderly MI Patients With Multivessel Disease]; NCT03772743).

An observational study of therapeutic procedures and in-hospital outcomes among patients admitted for acute myocardial infarction in Spain, 2016-2022: the role of diabetes mellitus

BACKGROUND

We used the Spanish national hospital discharge data from 2016 to 2022 to analyze procedures and hospital outcomes among patients aged ≥ 18 years admitted for ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) according to diabetes mellitus (DM) status (non-diabetic, type 1-DM or type 2-DM).

METHODS

We built logistic regression models for STEMI/NSTEMI stratified by DM status to identify variables associated with in-hospital mortality (IHM). We analyzed the effect of DM on IHM.

RESULTS

Spanish hospitals reported 201,950 STEMIs (72.7% non-diabetic, 0.5% type 1-DM, and 26.8% type 2-DM; 26.3% female) and 167,285 NSTEMIs (61.6% non-diabetic, 0.6% type 1-DM, and 37.8% type 2-DM; 30.9% female). In STEMI, the frequency of percutaneous coronary intervention (PCI) increased among non-diabetic people (60.4% vs. 68.6%; p < 0.001) and people with type 2-DM (53.6% vs. 66.1%; p < 0.001). In NSTEMI, the frequency of PCI increased among non-diabetic people (43.7% vs. 45.7%; p < 0.001) and people with type 2-DM (39.1% vs. 42.8%; p < 0.001). In NSTEMI, the frequency of coronary artery by-pass grafting (CABG) increased among non-diabetic people (2.8% vs. 3.5%; p < 0.001) and people with type 2-DM (3.7% vs. 5.0%; p < 0.001). In the entire population, lower IHM was associated with undergoing PCI (odds ratio [OR] [95% confidence interval] = 0.34 [0.32-0.35] in STEMI; 0.24 [0.23-0.26] in NSTEMI) or CABG (0.33 [0.27-0.40] in STEMI; 0.45 [0.38-0.53] in NSTEMI). IHM decreased over time in STEMI (OR = 0.86 [0.80-0.93]). Type 2-DM was associated with higher IHM in STEMI (OR = 1.06 [1.01-1.11]).

CONCLUSIONS

PCI and CABG were associated with lower IHM in people admitted for STEMI/NSTEMI. Type 2-DM was associated with IHM in STEMI.

Predictive utility of residual SYNTAX score for clinical outcomes after successful primary percutaneous coronary intervention

BACKGROUND

In patients presenting with ST-segment elevation myocardial infarction (STEMI), the prevalence of having concomitant severe non-culprit lesion(s) is ≥40%. While timely primary PCI (pPCI) for the culprit lesion is the standard practice, management of the non-culprit lesions remains unsettled.

RESULTS

This prospective multi-center observational study recruited 492 acute STEMI patients who underwent successful pPCI for the culprit lesion. Culprit-only versus complementary non-culprit lesion(s) PCI (either immediate or staged during the same hospital stay) was according to the operator's discretion. Clinical, echocardiographic, and angiographic data were collected and tabulated. The residual SYNTAX score (rSS) was completed by the time of discharge considering the residual lesions after all in-hospital revascularization procedures. Through a minimum follow-up of 12 months, older age, presentation with heart failure Killip class ≥ II, lower estimated glomerular filtration rate (eGFR) on admission, lower left ventricular ejection fraction (LVEF), and higher rSS by discharge were significantly associated with recurrent MACE. In multivariate regression analysis, Killip class ≥ II, LVEF, and rSS were found to be independent predictors for recurrent MACE. In the Receiver Operating Characteristics curve, an rSS of >8 had a sensitivity of 70.1%, and specificity of 75.3% to predict 1-year MACE.

CONCLUSIONS

Residual syntax score proved to be an independent predictor for recurrent MACE through the subsequent year post STEMI. Patients with rSS >8 seem to be at the highest risk for adverse events and are likely to be the most deserving for completing revascularization to reduce the disease burden.

Review of Advancements in Managing Cardiogenic Shock: From Emergency Care Protocols to Long-Term Therapeutic Strategies

Cardiogenic shock (CS) is a complex multifactorial clinical syndrome of end-organ hypoperfusion that could be associated with multisystem organ failure, presenting a diverse range of causes and symptoms. Despite improving survival in recent years due to new advancements, CS still carries a high risk of severe morbidity and mortality. Recent research has focused on improving early detection and understanding of CS through standardized team approaches, detailed hemodynamic assessment, and selective use of temporary mechanical circulatory support devices, leading to better patient outcomes. This review examines CS pathophysiology, emerging classifications, current drug and device therapies, standardized team management strategies, and regionalized care systems aimed at optimizing shock outcomes. Furthermore, we identify gaps in knowledge and outline future research needs.

Challenges and Advances in Interventional Cardiology for Coronary Artery Disease Management

The development of percutaneous coronary intervention (PCI) has been one of the greatest advances in cardiology and has changed clinical practice for patients with coronary artery disease (CAD). Despite continuous improvements in operators' experience, techniques, and the development of new-generation devices, significant challenges remain in improving the efficacy of PCI, including calcification, bifurcation, multivascular disease, stent restenosis, and stent thrombosis, among others. The present review aims to provide an overview of the current status of knowledge of endovascular revascularization in CAD, including relevant trials, therapeutic strategies, and new technologies addressing particular scenarios that can impact the prognosis of this vulnerable population.

Low Levels of Adropin Predict Adverse Clinical Outcomes in Outpatients with Newly Diagnosed Prediabetes after Acute Myocardial Infarction

Adropin-a multifunctional peptide with tissue-protective capacity that regulates energy homeostasis, sensitivity to insulin and inflammatory response-seems to show an inverse association with the presence of cardiovascular and renal diseases, obesity and diabetes mellitus in the general population. The purpose of the study is to elucidate whether adropin may be a plausible predictive biomarker for clinical outcomes in post-ST elevation of myocardial infarction (STEMI) patients with newly diagnosed prediabetes according to the American Diabetes Association criteria. A total of 1214 post-STEMI patients who received percutaneous coronary intervention were identified in a local database of the private hospital "Vita Center" (Zaporozhye, Ukraine). Between November 2020 and June 2024, we prospectively enrolled 498 patients with prediabetes in this open prospective cohort study and followed them for 3 years. The combined clinical endpoint at follow-up was defined as cardiovascular death due to acute myocardial infarction, heart failure, sudden death due to arrhythmia or cardiac surgery, and/or all-cause death. We identified 126 clinical events and found that serum levels of adropin < 2.15 ng/mL (area under the curve = 0.836; 95% confidence interval = 0.745-0.928; sensitivity = 84.9%; specificity = 72.7%; likelihood ratio = 3.11; p = 0.0001) predicted clinical outcomes. Multivariate logistic regression showed that a Gensini score ≥ 32 (Odds ratio [OR] = 1.07; p = 0.001), adropin ≤ 2.15 ng/mL (OR = 1.18; p = 0.001), use of SGLT2i (OR = 0.94; p = 0.010) and GLP-1 receptor agonist (OR = 0.95; p = 0.040) were independent predictors of clinical outcome. Kaplan-Meier plots showed that patients with lower adropin levels (≤2.15 ng/mL) had worse clinical outcomes compared to patients with higher adropin levels (>2.15 ng/mL). In conclusion, low levels of adropin (≤2.15 ng/mL) independently predicted clinical outcomes in post-STEMI patients with newly detected prediabetes and improved the discriminative ability of the Gensini score for 3-year follow-up events. Future clinical studies are needed to clarify whether adropin is a promising molecule to be incorporated into conventional risk scores for the prediction of MACCEs after STEMI.

Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review

Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.

Systematic review and meta-analysis comparing complete versus incomplete or culprit-only revascularization by percutaneous coronary intervention in elderly patients with acute coronary syndrome

BACKGROUND

Complete revascularization (CR) is favored over culprit-only or incomplete revascularization (IR) for patients with acute coronary syndrome (ACS) and multi-vessel disease (MVD) due to better long-term outcomes. However, the optimal revascularization strategy is currently uncertain in elderly patients, where frailty, polypharmacy, multi-morbidity, inherent bleeding risk and presumed cognitive decline can often burden the decision-making process.

METHODS

We searched Medline, PubMed, and Google Scholar from inception to April 2024. The search of databases identified relevant studies that reported the comparative effects of CR and IR in the elderly population undergoing percutaneous coronary intervention (PCI). Data was pooled for individual studies using random-effects models on Comprehensive Meta-Analysis software, with statistical significance set at p < 0.05.

RESULTS

The meta-analysis included 14 studies and 62577 patients. CR demonstrated a significant reduction in all-cause mortality [RR: 0.680; 95 % CI: 0.57-0.82; p=<0.001], cardiovascular-related mortality [RR: 0.620; 95 % CI: 0.478-0.805; p=<0.001], and myocardial infarction [RR: 0.675; 95 % CI: 0.553-0.823; p=<0.001] rates. There was no difference between the risk of stroke [RR: 1.044; 95 % CI: 0.733-1.486; p = 0.81], major bleeding [RR: 1.001; 95 % CI: 0.787-1.274; p = 0.991], stent thrombosis [RR: 1.015; 95 % CI: 0.538-1.916; p = 0.936], and contrast-induced acute kidney injury [RR: 1.187; 95 % CI: 0.963-1.464; p = 0.109].

CONCLUSION

The meta-analysis suggests that CR may be a favorable revascularization strategy for elderly patients undergoing PCI, displaying a significant decrease in mortality and repeat myocardial infarction risk.

Clinical Updates in Coronary Artery Disease: A Comprehensive Review

Despite significant goals achieved in diagnosis and treatment in recent decades, coronary artery disease (CAD) remains a high mortality entity and continues to pose substantial challenges to healthcare systems globally. After the latest guidelines, novel data have emerged and have not been yet considered for routine practice. The scope of this review is to go beyond the guidelines, providing insights into the most recent clinical updates in CAD, focusing on non-invasive diagnostic techniques, risk stratification, medical management and interventional therapies in the acute and stable scenarios. Highlighting and synthesizing the latest developments in these areas, this review aims to contribute to the understanding and management of CAD helping healthcare providers worldwide.

Survival benefit of IABP in pre- versus post-primary percutaneous coronary intervention in patients with cardiogenic shock

BACKGROUND

Cardiogenic shock (CS) remains a major cause of in-hospital mortality in the setting of acute myocardial infarction (AMI). However, little evidence is available regarding the optimal order of intra-aortic balloon counter-pulsation (IABP) insertion and primary percutaneous coronary intervention (PPCI). The aim of this study was to assess the hospital and short-term survival benefits of two different IABP insertion approaches, before versus after PPCI in patients with acute myocardial infarction and cardiogenic shock.

RESULTS

Total mortality was 80 patients representing 48.4% of the total 165 studied patients; 60 patients died during the hospital admission period, while the remaining 20 patients died post-discharge. In-hospital mortality was significantly higher in Post-PPCI-IABP group 40 (49.4%) versus Pre-PPCI-IABP group 20 (23.8%) (P = 0.001). Moreover, the mortality difference between the two groups was sustained over six-month follow-up period, where 15 patients (18.5%) died in the Post-PPCI-IABP group, while only 5 patients 6.0% died in the Pre-PPCI-IABP (P = 0.001).

CONCLUSIONS

Early IABP insertion before PPCI is associated with improved in-hospital and long-term survival when used for patients presenting with AMI complicated by hemodynamic instability.

Precision Medicine in Acute Coronary Syndromes

Nowadays, current guidelines on acute coronary syndrome (ACS) provide recommendations mainly based on the clinical presentation. However, greater attention is being directed to the specific pathophysiology underlying ACS, considering that plaque destabilization and rupture leading to luminal thrombotic obstruction is not the only pathway involved, albeit the most recognized. In this review, we discuss how intracoronary imaging and biomarkers allow the identification of specific ACS endotypes, leading to the recognition of different prognostic implications, tailored management strategies, and new potential therapeutic targets. Furthermore, different strategies can be applied on a personalized basis regarding antithrombotic therapy, non-culprit lesion revascularization, and microvascular obstruction (MVO). With respect to myocardial infarction with non-obstructive coronary arteries (MINOCA), we will present a precision medicine approach, suggested by current guidelines as the mainstay of the diagnostic process and with relevant therapeutic implications. Moreover, we aim at illustrating the clinical implications of targeted strategies for ACS secondary prevention, which may lower residual risk in selected patients.

Current Management of Non-ST-Segment Elevation Acute Coronary Syndrome

Cardiovascular disease constitutes the leading cause of morbimortality worldwide. Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) is a common cardiovascular condition, closely related to the ageing population and significantly affecting survival and quality of life. The management of NSTE-ACS requires specific diagnosis and therapeutic strategies, thus highlighting the importance of a personalized approach, including tailored antithrombotic therapies and regimens, combined with timely invasive management. Moreover, specific and frequent populations in clinical practice, such as the elderly and those with chronic kidney disease, pose unique challenges in the management of NSTE-ACS due to their increased risk of ischemic and hemorrhagic complications. In this scenario, comprehensive management strategies and multidisciplinary care are of great importance. Cardiac rehabilitation and optimal management of cardiovascular risk factors are essential elements of secondary prevention since they significantly improve prognosis. This review highlights the need for a personalized approach in the management of NSTE-ACS, especially in vulnerable populations, and emphasizes the importance of precise antithrombotic management together with tailored revascularization strategies, as well as the role of cardiac rehabilitation in NSTE-ACS patients.

Utility of coronary revascularization in patients with ischemic left ventricular dysfunction

BACKGROUND

Revascularization in patients with left ventricular (LV) dysfunction has been a subject of ongoing uncertainty and conflicting results. This is further complicated by factors including viability, severity of LV dysfunction, and method of revascularization using percutaneous coronary intervention (PCI) versus coronary-artery bypass grafting (CABG).

OBJECTIVES

The purpose of this meta-analysis is to evaluate the association of coronary revascularization with outcomes in patients with ischemic LV dysfunction.

METHODS

A literature search was conducted for studies reporting on cardiovascular outcomes after revascularization compared to optimal medical therapy (OMT) in patients with ischemic LV dysfunction.

RESULTS

A total of 23 studies with 10,110 participants met inclusion criteria. Revascularization was significantly associated with lower all-cause mortality and CV mortality compared to OMT. The association was statistically significant regardless of severity of LV dysfunction or method of revascularization. Subgroup analysis demonstrated that revascularization was significantly associated with lower all-cause and CV mortality compared to OMT for patients with viable myocardium and mixed cohorts with variable viability, but not patients without viable myocardium. Revascularization was not associated with a significant difference in risk of heart failure (HF) hospitalization or acute myocardial infarction (AMI) compared to OMT.

CONCLUSIONS

Revascularization in patients with ischemic LV dysfunction is associated with lower risk of all-cause and CV mortality independent of severity of LV dysfunction or method of revascularization. Revascularization is not associated with lower risk of mortality in patients without evidence of viable myocardium and is not associated with lower risk of AMI or HF hospitalization.

Association of Preprocedural SYNTAX Score With Outcomes in Impella-Assisted High-Risk Percutaneous Coronary Intervention

Background

Patients with complex coronary artery disease, as defined by high SYNTAX scores, undergoing percutaneous coronary intervention (PCI) have poorer outcomes when compared with patients with lower SYNTAX I scores. This study aimed to assess if mechanical circulatory support using Impella mitigates the effect of the SYNTAX I score on outcomes after high-risk percutaneous coronary intervention (HRPCI).

Methods

Using data from the PROTECT III study, patients undergoing Impella-assisted HRPCI between March 2017 and March 2020 were divided into 3 cohorts based on SYNTAX I score-low (≤22), intermediate (23-32), and high (≥33). Procedural and clinical outcomes out to 90 days were compared between groups. Multivariable regression analysis was used to assess the impact of SYNTAX I score on major adverse cardiovascular and cerebrovascular events (MACCE) at 90 days.

Results

A total of 850 subjects with core laboratory-adjudicated SYNTAX I scores were identified (low: n = 310; intermediate: n = 256; high: n = 284). Patients with high SYNTAX I scores were older than those with low or intermediate SYNTAX I scores (72.7 vs 69.7 vs 70.1 years, respectively; P < .01). After adjustment for covariates, high SYNTAX I score remained a significant predictor of 90-day MACCE (hazard ratio [HR], 2.14; 95% CI, 1.42-3.69; P < .01 vs low), whereas intermediate SYNTAX I score was not (HR, 0.92; 95% CI, 0.47-1.77; P = .80 vs low). These findings persisted after adjustment for post-PCI SYNTAX I score.

Conclusions

A high SYNTAX I score was associated with higher rates of 90-day MACCE in patients who underwent Impella-assisted HRPCI. Further research is needed to understand the patient and procedural factors driving this finding.

Complete percutaneous coronary revascularization: An elegant solution to left ventricular dysfunction caused by severe coronary artery disease

With increased complexity in both medical comorbidities and coronary anatomy, the proportion of surgically turndown patients and high-risk PCI will continue to rise. Impella-assisted complex PCI can be performed with high technical success and can improve quality of life, angina score, and potentially left ventricular ejection fraction.

Clinical significance of residual ischaemia in acute myocardial infarction complicated by cardiogenic shock undergoing venoarterial-extracorporeal membrane oxygenation

AIMS

Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction in residual ischaemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischaemia in patients undergoing mechanical circulatory supports. This study aimed to evaluate the effects of residual ischaemia on clinical outcomes in patients with AMI undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO).

METHODS AND RESULTS

Patients with AMI with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischaemia evaluated using the residual Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) score (rSS): rSS = 0, 0 < rSS ≤ 8, and rSS > 8. The primary outcome was 1-year all-cause death. A total of 408 patients were classified into the rSS = 0 (n = 100, 24.5%), 0 < rSS ≤ 8 (n = 136, 33.3%), and rSS > 8 (n = 172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9 vs. 55.4 vs. 66.1% for rSS = 0, 0 < rSS ≤ 8, and rSS > 8, respectively, overall P < 0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (adjusted hazard ratio 1.03, 95% confidence interval 1.01-1.05, P = 0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups.

CONCLUSION

In patients with AMI with refractory CS who underwent VA-ECMO, residual ischaemia was associated with an increased risk of 1-year mortality. Future studies are needed to evaluate the efficacy and safety of revascularization strategies to minimize residual ischaemia in patients with CS supported with VA-ECMO.

CLINICAL TRIAL REGISTRATION

REtrospective and Prospective Observational Study to Investigate Clinical oUtcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock (RESCUE), NCT02985008.

Impact of Anatomical and Viability-Guided Completeness of Revascularization on Clinical Outcomes in Ischemic Cardiomyopathy

BACKGROUND

Complete revascularization of coronary artery disease has been linked to improved outcomes in patients with preserved left ventricular (LV) function.

OBJECTIVES

This study sought to identify the impact of complete revascularization in patients with severe LV dysfunction.

METHODS

Patients enrolled in the REVIVED-BCIS2 (Revascularization for Ischemic Ventricular Dysfunction) trial were eligible if baseline/procedural angiograms and viability studies were available for analysis by independent core laboratories. Anatomical and viability-guided completeness of revascularization were measured by the coronary and myocardial revascularization indices (RIcoro and RImyo), respectively, where RIcoro = (change in British Cardiovascular Intervention Society Jeopardy score [BCIS-JS]) / (baseline BCIS-JS) and RImyo= (number of revascularized viable segments) / (number of viable segments supplied by diseased vessels). The percutaneous coronary intervention (PCI) group was classified as having complete or incomplete revascularization by median RIcoro and RImyo. The primary outcome was death or hospitalization for heart failure.

RESULTS

Of 700 randomized patients, 670 were included. The baseline BCIS-JS and SYNTAX (Synergy Between PCI With Taxus and Cardiac Surgery) scores were 8 (Q1-Q3: 6-10) and 22 (Q1-Q3: 15-29), respectively. In those patients assigned to PCI, median RIcoro and RImyo values were 67% and 85%, respectively. Compared with the group assigned to optimal medical therapy alone, there was no difference in the likelihood of the primary outcome in those patients receiving complete anatomical or viability-guided revascularization (HR: 0.90; 95% CI: 0.62-1.32; and HR: 0.95; 95% CI: 0.66-1.35, respectively). A sensitivity analysis by residual SYNTAX score showed no association with outcome.

CONCLUSIONS

In patients with severe LV dysfunction, neither complete anatomical nor viability-guided revascularization was associated with improved event-free survival compared with incomplete revascularization or treatment with medical therapy alone. (Revascularization for Ischemic Ventricular Dysfunction) [REVIVED-BCIS2]; NCT01920048).

Ventricular septal defect complicating acute myocardial infarction: diagnosis and management. A Clinical Consensus Statement of the Association for Acute CardioVascular Care (ACVC) of the ESC, the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC and the ESC Working Group on Cardiovascular Surgery

Ventricular septal defects are a rare complication after acute myocardial infarction with a mortality close to 100% if left untreated. However, even surgical or interventional closure is associated with a very high mortality and currently no randomized controlled trials are available addressing the optimal treatment strategy of this disease. This state-of-the-art review and clinical consensus statement will outline the diagnosis, hemodynamic consequences and treatment strategies of ventricular septal defects complicating acute myocardial infarction with a focus on current available evidence and a focus on major research questions to fill the gap in evidence.

Percutaneous Coronary Revascularization Strategies After Myocardial Infarction: A Systematic Review and Network Meta-Analysis

BACKGROUND

Complete revascularization with percutaneous coronary intervention improves outcomes compared with culprit revascularization following myocardial infarction (MI) with multivessel coronary artery disease. An all-cause mortality reduction has never been demonstrated. Debate also remains regarding the optimal timing of complete revascularization (immediate or staged), and method of evaluation of nonculprit lesions (physiology or angiography).

OBJECTIVES

This study aims to perform an updated systematic review with frequentist and Bayesian network meta-analyses including the totality of randomized data investigating revascularization strategies in patients presenting with MI and multivessel coronary artery disease.

METHODS

The primary comparison tested complete vs culprit revascularization. Timing and methods of achieving complete revascularization were assessed. The prespecified primary outcome was all-cause mortality. Outcomes were expressed as relative risk (RR) (95% CI).

RESULTS

Twenty-four eligible trials randomized 16,371 patients (weighted mean follow-up: 26.4 months). Compared with culprit revascularization, complete revascularization reduced all-cause mortality in patients with any MI (RR: 0.85; 95% CI: 0.74-0.99; P = 0.04). Cardiovascular mortality, MI, major adverse cardiac events and repeat revascularization were also significantly reduced. In patients presenting with ST-segment elevation myocardial infarction, the point estimate for all-cause mortality with complete revascularization was RR: 0.91 (95% CI: 0.78-1.05; P = 0.18). Rates of stent thrombosis, major bleeding, and acute kidney injury were similar. Immediate complete revascularization ranked higher than staged complete revascularization for all endpoints.

CONCLUSIONS

Complete revascularization following MI reduces all-cause mortality, cardiovascular mortality, MI, major adverse cardiac events, and repeat revascularization. There may be benefits to immediate complete revascularization, but additional head-to-head trials are needed.

Immediate versus staged complete revascularisation in patients presenting with STEMI and multivessel disease

BACKGROUND

Complete revascularisation is supported by recent trials in patients with ST-elevation myocardial infarction (STEMI) and multivessel disease (MVD) without cardiogenic shock. However, the optimal timing of non-culprit lesion revascularisation is currently debated.

AIMS

This prespecified analysis of the BioVasc trial aims to determine the effect of immediate complete revascularisation (ICR) compared to staged complete revascularisation (SCR) on clinical outcomes in patients with STEMI.

METHODS

Patients presenting with STEMI and MVD were randomly assigned to ICR or SCR. The primary endpoint was the composite of all-cause mortality, myocardial infarction, any unplanned ischaemia-driven revascularisation, or cerebrovascular events at 1-year post-index procedure.

RESULTS

Between June 2018 and October 2021, 608 (ICR: 305, SCR: 303) STEMI patients were enrolled. No significant differences between ICR and SCR were observed at 1-year follow-up in terms of the primary endpoint (7.0% vs 8.3%, hazard ratio [HR] 0.84, 95% confidence interval [CI]: 0.47-1.50; p=0.55): all-cause mortality (2.3% vs 1.3%, HR 1.77, 95% CI: 0.52-6.04; p=0.36), myocardial infarction (1.7% vs 3.3%, HR 0.50, 95% CI: 0.17-1.47; p=0.21), unplanned ischaemia-driven revascularisation (4.1% vs 5.0%, HR 0.80, 95% CI: 0.38-1.71; p=0.57) and cerebrovascular events (1.4% vs 1.3%, HR 1.01, 95% CI: 0.25-4.03; p=0.99). At 30-day follow-up, a trend towards a reduction of the primary endpoint in the ICR group was observed (ICR: 3.0% vs SCR: 6.0%, HR 0.50, 95% CI: 0.22-1.11; p=0.09). ICR was associated with a reduction in overall hospital stay (ICR: median 3 [interquartile range {IQR} 2-5] days vs SCR: median 4 [IQR 3-6] days; p<0.001).

CONCLUSIONS

Clinical outcomes at 1 year were similar for STEMI patients who had undergone ICR and those who had undergone SCR.

Premature Acute Myocardial Infarction Treated With Invasive Revascularization: Comparing STEMI With NSTEMI in a Population-Based Study of Young Patients

BACKGROUND

Acute myocardial infarction (AMI) usually presents in older populations, in which there are established demographic and outcome differences for ST-elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI). No similar comparisons for AMI in the young population exist.

METHODS

We compared all index NSTEMI and STEMI hospitalizations in young (18-45 years) patients who required revascularization in Alberta, Canada. Outcomes were survival to discharge, and a composite of heart failure hospitalization, cardiac arrest hospitalization, and all-cause mortality at 1 and 5 years.

RESULTS

There were 1679 patients included with an index AMI who required revascularization: 655 (39.0%) NSTEMI and 1024 (61.0%) STEMI. The population was disproportionately male (86%), particularly in STEMI patients (87.3%). Marked dyslipidemia (35%) and active smoking (42%) were common, with similar rates among groups. Percutaneous coronary intervention was used in 98.7% of STEMI and 91.5% of NSTEMI patients (P < 0.001), with the remainder who underwent surgical revascularization. The in-hospital mortality rate during index AMI was higher in STEMI compared with NSTEMI patients (1.7% vs 0%; P < 0.001). The rates of the composite outcome were similar for both groups at 1 and 5 years of follow-up in patients who survived to index hospital discharge. After adjusting for sex, age, heart failure and/or cardiac arrest at index AMI, outcomes remained similar among groups at 1 and 5 years.

CONCLUSIONS

In young patients with AMI, STEMI was a disproportionately male phenomenon and associated with higher mortality at index hospitalization. One-year and 5-year outcomes were similar among STEMI and NSTEMI patients in those discharged alive at index AMI. Smoking and dyslipidemia appear to be major risk factors in the young.

Managing the Intricacies of Coronary Revascularization: A Close Look at the Complete Versus Culprit-Only Approach and its Implications in Elderly Patients

Coronary heart disease is the leading cause of mortality in the United States, and data indicates that 805,000 Americans will face a new or recurrent myocardial infarction (MI) attack every year. Frailty, a conceptual syndrome categorized by a functional decline that occurs with aging, has been linked to adverse health outcomes in cardiovascular disease and all cardiac-related procedures in general. It is therefore reasonable to deliberate that more conservative medical therapy or medical management should be considered in the frail population when managing acute coronary syndrome. This course of action has, in fact, been documented in clinical practice. However, the recent Functional Assessment in Elderly MI Patients with Multivessel Disease trial, in which all subjects were 75 years of age or above, indicated that the more invasive complete revascularization approach may be favorable over incomplete or culprit-only revascularization in patients with acute MI. In this review, we will discuss coronary heart disease and review guidelines and procedures for culprit lesion identification, including electrocardiogram procedures, coronary angiography, intravascular ultrasound, fractional flow reserve, and instantaneous fractional flow reserve. We then discuss the concept of complete vs culprit-only/incomplete coronary revascularization and staging. Following this, we will delve into recent trials discussing complete vs culprit-only revascularization, emphasizing the insights gleaned from this latest trial within this special frailty cohort which warrants special consideration.

From Atherosclerotic Plaque to Myocardial Infarction-The Leading Cause of Coronary Artery Occlusion

Cardiovascular disease (CVD) constitutes the most common cause of death worldwide. In Europe alone, approximately 4 million people die annually due to CVD. The leading component of CVD leading to mortality is myocardial infarction (MI). MI is classified into several types. Type 1 is associated with atherosclerosis, type 2 results from inadequate oxygen supply to cardiomyocytes, type 3 is defined as sudden cardiac death, while types 4 and 5 are associated with procedures such as percutaneous coronary intervention and coronary artery bypass grafting, respectively. Of particular note is type 1, which is also the most frequently occurring form of MI. Factors predisposing to its occurrence include, among others, high levels of low-density lipoprotein cholesterol (LDL-C) in the blood, cigarette smoking, chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and familial hypercholesterolaemia (FH). The primary objective of this review is to elucidate the issues with regard to type 1 MI. Our paper delves into, amidst other aspects, its pathogenesis, risk assessment, diagnosis, pharmacotherapy, and interventional treatment options in both acute and long-term conditions.

Use of coronary physiology to guide revascularization in clinical practice: results of the F(FR)2 registry

BACKGROUND

Despite the recommendation of coronary physiology to guide revascularization in angiographically intermediate stenoses without established correlation to ischemia, its uptake in clinical practice is slow.

AIMS

This study aimed to analyze the use of coronary physiology in clinical practice.

METHODS

Based on a multicenter registry (Fractional Flow Reserve Fax Registry, F(FR)2, ClinicalTrials.gov identifier NCT03055910), clinical use, consequences, and complications of coronary physiology were systematically analyzed.

RESULTS

F(FR)2 enrolled 2,000 patients with 3,378 intracoronary pressure measurements. Most measurements (96.8%) were performed in angiographically intermediate stenoses. Out of 3,238 lesions in which coronary physiology was used to guide revascularization, revascularization was deferred in 2,643 (78.2%) cases. Fractional flow reserve (FFR) was the most common pressure index used (87.6%), with hyperemia induced by an intracoronary bolus of adenosine in 2,556 lesions (86.4%) and intravenous adenosine used for 384 measurements (13.0%). The route of adenosine administration did not influence FFR results (change-in-estimate -3.1% for regression model predicting FFR from diameter stenosis). Agreement with the subsequent revascularization decision was 93.4% for intravenous and 95.0% for intracoronary adenosine (p = 0.261). Coronary artery occlusion caused by the pressure wire was reported in two cases (0.1%) and dissection in three cases (0.2%), which was fatal once (0.1%).

CONCLUSIONS

In clinical practice, intracoronary pressure measurements are mostly used to guide revascularization decisions in angiographically intermediate stenoses. Intracoronary and intravenous administration of adenosine seem equally suited. While the rate of serious complications of wire-based intracoronary pressure measurements in clinical practice seems to be low, it is not negligible.