2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions

Evaluation of stenoses using AI video models applied to coronary angiography

The coronary angiogram is the gold standard for evaluating the severity of coronary artery disease stenoses. Presently, the assessment is conducted visually by cardiologists, a method that lacks standardization. This study introduces DeepCoro, a ground-breaking AI-driven pipeline that integrates advanced vessel tracking and a video-based Swin3D model that was trained and validated on a dataset comprised of 182,418 coronary angiography videos spanning 5 years. DeepCoro achieved a notable precision of 71.89% in identifying coronary artery segments and demonstrated a mean absolute error of 20.15% (95% CI: 19.88-20.40) and a classification AUROC of 0.8294 (95% CI: 0.8215-0.8373) in stenosis percentage prediction compared to traditional cardiologist assessments. When compared to two expert interventional cardiologists, DeepCoro achieved lower variability than the clinical reports (19.09%; 95% CI: 18.55-19.58 vs 21.00%; 95% CI: 20.20-21.76, respectively). In addition, DeepCoro can be fine-tuned to a different modality type. When fine-tuned on quantitative coronary angiography assessments, DeepCoro attained an even lower mean absolute error of 7.75% (95% CI: 7.37-8.07), underscoring the reduced variability inherent to this method. This study establishes DeepCoro as an innovative video-based, adaptable tool in coronary artery disease analysis, significantly enhancing the precision and reliability of stenosis assessment.

Sex differences in the impact of body mass index on outcomes of coronary artery disease in Koreans

BACKGROUND

Obesity is often considered a risk factor for cardiovascular disease, but recent studies have shown conflicting results regarding the effect of BMI on the prognosis of coronary artery disease (CAD). This study aimed to evaluate the relationship between BMI and clinical outcomes of CAD according to sex in a Korean population.

METHODS

A total of 3476 patients with a significant CAD who underwent percutaneous coronary intervention (PCI) were enrolled. Patients were classified as follows according to BMI using the Asia-Pacific cutoff points: underweight (<18.5 kg/m 2 ), normal weight (18.5-22.9 kg/m 2 ), overweight (23.0-24.9 kg/m 2 ) and obese (≥25 kg/m 2 ) patients. Underweight and normal weight patients were further categorized into the lower BMI group, whereas overweight and obese patients were categorized into the higher BMI group. The primary endpoint was all-cause mortality.

RESULTS

Among women, the higher BMI group showed poor clinical features in the prevalence of hypertension and chest pain presentation, and among men, the higher BMI group had a significantly lower rate of chronic renal failure. At the end of the follow-up period (median 53.5 months), the all-cause mortality rate was lower in the higher BMI group in men, and cardiovascular death and stroke rates were significantly lower in the higher BMI group in women.

CONCLUSION

In Korean CAD patients treated with PCI, inverse correlations were observed between the clinical outcomes and BMI, but there were differences between men and women.

Effect of hemoglobin A1c change on 24-month clinical outcomes in patients with diabetes after acute myocardial infarction

BACKGROUND

The average glycated hemoglobin (HbA1c) may not accurately reflect glycemic control status during the mid-term after acute myocardial infarction (AMI). We aimed to evaluate changes in HbA1c and their effect on mid-term clinical outcomes in patients with diabetes and AMI.

METHODS

We enrolled patients with diabetes (n = 967) who underwent HbA1c measurement in the Korean nationwide registry. These patients were categorized into three groups based on changes in HbA1c from index admission to the 1-year follow-up visit: a decrease in HbA1c > 1%, changes in HbA1c within 1%, and an increase in HbA1c > 1%. Clinical outcomes at 24 months were examined.

RESULTS

The baseline HbA1c levels were 8.55 ± 0.85, 7.00 ± 0.98 and 7.07 ± 1.05 (P = 0.001) and HbA1c levels after 1 year were 6.62 ± 0.73, 7.05 ± 0.98 and 9.26 ± 1.59 (P = 0.001) for patients with 3 groups, respectively. Patients with a 1% decrease in HbA1c had significantly lower incidence of major adverse cardiovascular events (MACE), cardiac death, and rehospitalization after 24 months than those with a 1% increase in HbA1c. However, in the Cox regression analysis, a >1% decrease in HbA1c change was not an independent factor for MACE, cardiac death, and rehospitalization.

CONCLUSIONS

Our analysis indicates that an HbA1c decrease of >1% within the first 12 months was not an independent prognostic factor until the 24-month mark. Therefore, standard diabetic control is recommended for patients with diabetes and AMI for up to 2 years.

Computed Tomography-Derived Physiology Assessment: State-of-the-Art Review

Coronary computed tomography angiography (CCTA) and CCTA-derived fractional flow reserve (FFRCT) are the best non-invasive techniques to assess coronary artery disease (CAD) and myocardial ischemia. Advances in these technologies allow a paradigm shift to the use of CCTA and FFRCT for advanced plaque characterization and planning myocardial revascularization.

In-hospital and 1-year outcomes of patients without modifiable risk factors presenting with acute coronary syndrome undergoing PCI: a Sex-stratified analysis

Aim

A considerable proportion of patients admitted with acute coronary syndrome (ACS) have no standard modifiable cardiovascular risk factors (SMuRFs: hypertension, diabetes mellitus, dyslipidemia, and cigarette smoking). The outcomes of this population following percutaneous coronary intervention (PCI) are debated. Further, sex differences within this population have yet to be established.

Methods

This retrospective cohort study included 7,847 patients with ACS who underwent PCI. The study outcomes were in-hospital mortality, all-cause mortality, and major adverse cardio-cerebrovascular events (MACCE). The association between the absence of SMuRFs (SMuRF-less status) and outcomes among all the patients and each sex was assessed using logistic and Cox proportional hazard regressions.

Results

Approximately 11% of the study population had none of the SMuRFs. During 12.13 [11.99-12.36] months of follow-up, in-hospital mortality (adjusted-odds ratio (OR):1.51, 95%confidence interval (CI): 0.91-2.65, P:0.108), all-cause mortality [adjusted-hazard ratio (HR): 1.01, 95%CI: 0.88-1.46, P: 0.731], and MACCE (adjusted-HR: 0.93, 95%CI:0.81-1.12, P: 0.412) did not differ between patients with and without SMuRFs. Sex-stratified analyses recapitulated similar outcomes between SMuRF+ and SMuRF-less men. In contrast, SMuRF-less women had significantly higher in-hospital (adjusted-OR: 3.28, 95%CI: 1.92-6.21, P < 0.001) and all-cause mortality (adjusted-HR:1.41, 95%CI: 1.02-3.21, P: 0.008) than SMuRF+ women.

Conclusions

Almost one in 10 patients with ACS who underwent PCI had no SMuRFs. The absence of SMuRFs did not confer any benefit in terms of in-hospital mortality, one-year mortality, and MACCE. Even worse, SMuRF-less women paradoxically had an excessive risk of in-hospital and one-year mortality.

The intellectual base and global trends in contrast-induced acute kidney injury: a bibliometric analysis

Contrast-induced acute kidney injury (CI-AKI) has become the third leading cause of hospital-acquired kidney injury. A comprehensive analysis of the current state of research in the field of CI-AKI will help to reveal trends and hot topics in the field. To date, there are no published bibliometric analyses related to CI-AKI studies. Here, we analyze the relevant literature since the emergence of the concept and provide valuable insights. The literature was collected from the Web of Science Core Collection. The data were analyzed visually using CiteSpace and VOSviewer software. We collected a total of 4775 papers, with the United States and Guangdong Acad Med Sci as the major publishing powers in terms of country/region and institution. J AM COLL CARDIOL was the journal with the most published and cocited articles. Cluster analysis showed that clinical trials are the current research hotspot. The areas of risk assessment, prevention strategies, risk factors, and vascular lesions have been popular in recent years. Research on the mechanism of injury in CI-AKI will be the focus of future research, which will be crucial to reduce the clinical incidence of CI-AKI. In summary, this study provides a comprehensive analysis of the development process in the field of CI-AKI and discusses future research directions based on the analysis of objective data from many studies on CI-AKI.

Distal Versus Proximal Radial Artery Access for Cardiac Catheterization: 30-Day Outcomes of the DIPRA Study

Background Proximal radial artery (pRA) access for cardiac catheterization is safe but can jeopardize subsequent use of the artery because of occlusion. Distal radial artery (dRA) access in the anatomical snuffbox preserves the radial artery, but safety and potential detrimental effects on hand function are unknown. Methods and Results In the DIPRA (Distal Versus Proximal Radial Artery Access for Cardiac Catheterization and Intervention) study, a single-center trial, 300 patients were randomized 1:1 to cardiac catheterization through dRA or pRA. The primary end point of change in hand function from baseline to 30 days was a composite of the QuickDASH (Quick Disabilities of the Arm, Shoulder and Hand) questionnaire, hand-grip test, and thumb forefinger pinch test. Secondary end points included access feasibility and complications; 254 of 300 patients completed follow-up at 30 days; of these, 128 were randomized to dRA and 126 to pRA with balanced demographic and procedural characteristics. Both groups had similar rates of access site bleeding (dRA 0% versus pRA 1.4%; P=0.25). Six patients with dRA failed access compared with 2 patients with pRA. Radial artery occlusion occurred in 2 pRA versus none in dRA. There were no significant differences in change in hand function, median hand-grip (dRA 0 [-3.2, 3.3] versus pRA 0.7 [-2.3, 3.3] kg; P=0.21), pinch-grip (dRA -0.3 [-1.2, 0.5] versus pRA 0 [-0.9, 0.9] kg; P=0.09), and QuickDASH (dRA 0 [-4.6, 2.3] versus pRA 0 [-4.6, 2.3] points, P=0.96). There was no significant difference in the composite of hand function between pRA and dRA. Conclusions dRA is a safe strategy for cardiac catheterization with a low complication rate. Compared with pRA, there is no increased risk of hand dysfunction at 30 days. Registration URL: https://www.ClinicalTrials.gov. Unique identifier: NCT04318990.

Hidden Fatal ECG Manifestations

This case report presents the electrocardiogram findings of a patient in their 50s with syncope and palpitation and amaurosis followed by loss of consciousness for several minutes without preceding position change, cough, chest pain, or shortness of breath.

The diagnostic accuracy of two-dimensional strain imaging echocardiography to detect the severity of coronary artery disease in non-ST segment elevation acute coronary syndrome

OBJECTIVE

Strain imaging by two-dimensional speckle tracking echocardiography can detect severe coronary artery disease (CAD). This study aims to assess the diagnostic accuracy of various strain parameters in patients with non-ST segment acute coronary syndrome to detect the angiographic severity of CAD and also to compare among them.

METHODS

This hospital-based observational study was conducted on 178 patients with NSTEACS and preserved left ventricular ejection fraction who presented in emergency or outdoor from July 2021 to December 2022. We excluded patients with prior coronary revascularization, heart failure, arrhythmia, more than trivial valvular heart disease, or poor acoustic window. Global longitudinal strain (GLS), peak systolic strain (SS), post systolic index (PSI), and systolic strain rate (SR) were calculated by speckle tracking with automated function imaging. Coronary angiography was done in all patients, and the syntax score was calculated.

RESULTS

The strain parameters showed a significant correlation with the syntax score. There was a statistically significant difference in strain parameters between patients with left main (LM) or triple vessel disease (TVD) and others. Receiver operating characteristic (ROC) curve analysis showed that GLS had a better diagnostic accuracy for detecting LM or TVD than other strain parameters. GLS with a cut-off value of -11.2% had a sensitivity of 85.7% and specificity of 53.5% for detecting LM or TVD.

CONCLUSION

Strain imaging can be a helpful bedside adjunct to conventional investigations for detecting severe CAD in patients with NSTEACS.

Diagnostic performance of a novel automated CT-derived FFR technology in detecting hemodynamically significant coronary artery stenoses: A multicenter trial in China

BACKGROUND AND AIMS

Computed tomography-derived fractional flow reserve (CT-derived FFR) algorithms have emerged as promising noninvasive methods for identifying hemodynamically significant coronary artery disease (CAD). However, its broad adaption is limited by the complex workflow, slow processing, and supercomputer requirement. Therefore, CT-derived FFR solutions capable of producing fast and accurate results could help deliver time-sensitive results rapidly and potentially alter patient management. The current study aimed to determine the diagnostic performance of a novel CT-derived FFR algorithm, esFFR, on patients with CAD was evaluated.

METHODS

329 patients from 6 medical centers in China were included in this prospective study. CT-derived FFR calculations were performed on 350 vessels using the esFFR algorithm using patients' presenting coronary computed tomography angiography (CCTA) images, and results and processing speed were recorded. Using invasive FFR measurements from direct coronary angiography as the reference standard, the diagnostic performance of esFFR and CCTA in detecting hemodynamically significant lesions were compared. Post-hoc analyses were performed for patients with calcified lesions or stenoses within the CT-derived FFR diagnostic "gray zone."

RESULTS

The esFFR values correlated well with invasive FFR. The sensitivity, specificity, accuracy, positive and negative predictive value for esFFR were all above 90%. The overall performance of esFFR was superior to CCTA. Coronary calcification had minimal effects on esFFR's diagnostic performance. It also maintained 85% of diagnostic accuracy for "gray zone" lesions, which historically was <50%. The average esFFR processing speed was 4.6 ± 1.3 minutes.

CONCLUSIONS

The current study demonstrated esFFR had high diagnostic efficacy and fast processing speed in identifying hemodynamically significant CAD.

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals

BACKGROUND

International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI).

METHODS

We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017-2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors.

RESULTS

Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45-0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients.

CONCLUSION

Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

Determination of Left Main Coronary Artery Stenosis Through Noninvasive Testing to Guide Revascularization in Ischemic Heart Disease

Anatomically severe left main coronary artery (LMCA) stenosis (>50%) remains one of the few groups to benefit from early revascularization in stable ischemic heart disease (SIHD). Identification of these patients through widely available noninvasive testing would decrease the need for additional upfront anatomic testing, lowering the overall cost of healthcare. Patients with SIHD who underwent either percutaneous or surgical revascularization over a 7-year period at our institution were retrospectively analyzed and categorized as having LMCA stenosis versus non-LM stenosis. All preceding noninvasive testing, including resting electrocardiogram, echocardiogram, and functional testing was evaluated and compared between groups using chi-square and t test. In total, 806 patients were evaluated. Of those, 121 were identified as having significant LMCA stenosis with 685 patients in the non-LM cohort. Between LMCA versus non-LM cohorts, there were similar rates of electrocardiogram abnormalities (68.9% vs 70.8%, p >0.05), abnormal echocardiograms (72.7% vs 69.7%, p >0.05), abnormal functional testing (83.3% vs 77.4%, p >0.05), and high-risk imaging findings (5.6% vs 4.8%, p >0.05). More importantly, of those with a complete workup, there were similar rates of normal results between the LMCA (3 of 18, 16.7%) and non-LM stenosis (9 of 189, 4.8%) groups. A comprehensive noninvasive profile of patients with IHD failed to identify or exclude patients with anatomically severe LMCA stenosis, necessitating anatomic assessment.

CathAI: fully automated coronary angiography interpretation and stenosis estimation

Coronary angiography is the primary procedure for diagnosis and management decisions in coronary artery disease (CAD), but ad-hoc visual assessment of angiograms has high variability. Here we report a fully automated approach to interpret angiographic coronary artery stenosis from standard coronary angiograms. Using 13,843 angiographic studies from 11,972 adult patients at University of California, San Francisco (UCSF), between April 1, 2008 and December 31, 2019, we train neural networks to accomplish four sequential necessary tasks for automatic coronary artery stenosis localization and estimation. Algorithms are internally validated against criterion-standard labels for each task in hold-out test datasets. Algorithms are then externally validated in real-world angiograms from the University of Ottawa Heart Institute (UOHI) and also retrained using quantitative coronary angiography (QCA) data from the Montreal Heart Institute (MHI) core lab. The CathAI system achieves state-of-the-art performance across all tasks on unselected, real-world angiograms. Positive predictive value, sensitivity and F1 score are all ≥90% to identify projection angle and ≥93% for left/right coronary artery angiogram detection. To predict obstructive CAD stenosis (≥70%), CathAI exhibits an AUC of 0.862 (95% CI: 0.843-0.880). In UOHI external validation, CathAI achieves AUC 0.869 (95% CI: 0.830-0.907) to predict obstructive CAD. In the MHI QCA dataset, CathAI achieves an AUC of 0.775 (95%. CI: 0.594-0.955) after retraining. In conclusion, multiple purpose-built neural networks can function in sequence to accomplish automated analysis of real-world angiograms, which could increase standardization and reproducibility in angiographic coronary stenosis assessment.

Association of Device Industry Payments, Physician Supply, and Regional Utilization of Orthopedic and Cardiac Procedures

BACKGROUND

Geographic variation in high-cost medical procedure utilization in the USA is not fully explained by patient factors but may be influenced by the supply of procedural physicians and marketing payments.

OBJECTIVE

To examine the association between physician supply, medical device-related marketing payments to physicians, and utilization of knee arthroplasty (KA) and percutaneous coronary interventions (PCI) within hospital referral regions (HRRs).

DESIGN

Cross-sectional analysis of data from the 2018 CMS Open Payments database and procedural utilization data from the CMS Provider Utilization and Payment database.

PARTICIPANTS

Medicare-participating procedural cardiologists and orthopedic surgeons.

MAIN MEASURES

Regional rates of PCIs and KAs per 100,000 Medicare fee-for-service (FFS) beneficiaries were estimated after adjustment for beneficiary demographics.

KEY RESULTS

Across 306 HRRs, there were 109,301 payments (value $17,554,728) to cardiologists for cardiac stents and 68,132 payments (value $40,492,126) to orthopedic surgeons for prosthetic knees. Among HRRs, one additional interventional cardiologist was associated with an increase of 12.9 (CI, 9.3-16.5) PCIs per 100,000 beneficiaries, and one additional orthopedic surgeon was associated with an increase of 20.6 (CI, 16.9-24.4) KAs per 100,000 beneficiaries. A $10,000 increase in gift payments from stent manufacturers was associated with an increase of 26.0 (CI, 5.1-46.9) PCIs per 100,000 beneficiaries, while total and service payments were not associated with greater regional PCI utilization. A $10,000 increase in total payments from knee prosthetic manufacturers was associated with an increase of 2.9 (CI, 1.4-4.5) KAs per 100,000 beneficiaries, while a similar increase in gift and service payments was associated with an increase of 14.5 (CI, 5.0-24.1) and 3.4 (CI, 1.6-5.2) KAs, respectively.

CONCLUSIONS

Among Medicare FFS beneficiaries, regional supply of physicians and receipt of industry payments were associated with greater use of PCIs and KAs. Relationships between payments and procedural utilization were more consistent for KAs, a largely elective procedure, compared to PCIs, which may be elective or emergent.

Readmission and adverse outcomes after percutaneous coronary intervention in patients with dementia

BACKGROUND

As the population ages, clinicians increasingly encounter ischemic heart disease in patients with underlying dementia. Therefore, we quantified differences in inhospital adverse events and 30-day readmission rates among patients with and without dementia undergoing percutaneous coronary intervention (PCI).

METHODS

Using the National Readmissions Database 2017-2018, we identified 755,406 index hospitalizations in which PCI was performed, of which 17,309 (2.3%) had a diagnosis of dementia. After propensity score matching patients with and without dementia, we assessed 30-day readmission and inhospital adverse events by Cox proportional hazards and logistic regression modeling and compared them with those of other common cardiac (pacemaker placement [PP]) and noncardiac (hip replacement surgery [HRS]) procedures.

RESULTS

Thirty-day readmission was significantly higher in patients with dementia than patients without dementia (hazard ratio [HR] 1.67, 95% confidence interval [CI] 1.60-1.74). Patients with dementia also experienced higher odds of delirium (odds ratio [OR] 4.37, CI 3.69-5.16), inhospital mortality (OR 1.15, CI 1.01-1.30), cardiac arrest (OR 1.19, CI 1.01-1.39), acute kidney injury (OR 1.30, CI 1.21-1.39), and fall (OR 2.51, CI 2.06-3.07). On multivariable Cox modeling, dementia independently predicted 30-day readmission (HR 1.14, CI 1.07-1.20). The higher readmission risk with PCI (11%) among those with dementia was similar to that of patients undergoing PP (10%), but lower than in those undergoing HRS (41%).

CONCLUSION

Patients with dementia who undergo PCI experience significantly increased rates of inhospital delirium, mortality, kidney injury, falls, and 30-day readmission. These adverse outcomes should be considered during shared decision-making with patients and their families.

Prevalence, risk factors, and clinical effect of coronary artery disease in patients with asymptomatic bilateral carotid stenosis

OBJECTIVE

In the present report, we have described the prevalence, risk factors, and clinical effects of coronary artery disease (CAD) for patients with asymptomatic bilateral carotid stenosis.

METHODS

We conducted a single-center, retrospective cohort study of consecutive patients referred for bilateral carotid stenosis >70% (2014-2021). All the patients had undergone systematic coronary angiography. Depending on the anatomic and clinical characteristics, the patients had undergone combined carotid endarterectomy (CEA) plus coronary artery bypass grafting, coronary percutaneous intervention followed by CEA or carotid artery stenting (CAS), or staged bilateral CEA with cardiac best medical therapy. The cumulative 30-day stroke/myocardial infarction (MI) rate after cardiac and bilateral carotid interventions and long-term survival and freedom from cardiovascular mortality were assessed.

RESULTS

A total of 167 patients with bilateral carotid stenosis >70% had undergone preoperative coronary angiography, identifying severe CAD in 108 patients (65.1%). Echocardiographic abnormalities (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.03-5.78; P = .04) and prior coronary intervention (OR, 11.94; 95% CI, 2.99-63.81; P = .001) were significantly associated with severe CAD. CAD was treatable in 91 patients (84%) and untreatable in 17 (16%). The cumulative MI rate was 4.8%; 5.6% for the patients with severe CAD and 1.7% for those without severe CAD (P = .262). The cumulative stroke rate was 1.8%; 1.8% for those with severe CAD and 1.7% for those without severe CAD (P = 1.00). The overall stroke/MI rate was 6.6%; 8.3% for those with severe CAD and 3.3% for patients without severe CAD (P = .33). Patients with severe CAD deemed untreatable for coronary bypass or percutaneous intervention had a higher risk of perioperative stroke/MI (OR, 1.24; 95% CI, 1.00-2.83; P = .04). At 10 years, overall survival was 67.1% (95% CI, 57%-79%), and freedom from cardiovascular mortality was 78.5% (95% CI, 69%-89%). Patients with untreatable CAD maintained a higher risk of 10-year mortality (hazard ratio, 5.5; 95% CI, 1.6-19.9; P < .01).

CONCLUSIONS

In the present study, the prevalence of CAD in patients with bilateral carotid stenosis was high, especially for those with abnormal echocardiographic findings. CAD was potentially treatable in 80% of patients, and staged or simultaneous CAD treatment was performed with an acceptable stroke/MI complication rate for these patients. The presence of untreatable CAD was associated with worsened early and long-term outcomes, questioning the benefit of carotid interventions for this subset of patients.

Evaluation of cases with early repolarization on electrocardiogram and normal population in terms of laboratory and clinical results

Aim: Early repolarization (ER) is a frequent indication, and it is important to correctly evaluate the effects of its benign and malignant forms in terms of prognosis. It was aimed to compare ER cases with the normal population in terms of multi-vessel disease, bypass and mortality. Material and Method: This study comprised 776 patients aged 18 and older who admitted the emergency department between January 2015 and December 2020. 377 of these patients had ER in the electrocardiogram (ECG), 409 patients had normal ECGs and were added to the study as the control group. Age, gender, multi-vessel disease, by-pass and mortality relations of the patients were evaluated with angiographic findings. Results: The mean age of 786 patients was 50.49±6.82 years, 372 (47.3%) were female, and the age range was 23-66 years (p

Best Practices for Cardiac Catheterization Laboratory Morbidity and Mortality Conferences

Cardiac catheterization laboratory (CCL) morbidity and mortality conferences (MMCs) are a critical component of CCL quality improvement programs and are important for the education of cardiology trainees and the lifelong learning of CCL physicians and team members. Despite their fundamental role in the functioning of the CCL, no consensus exists on how CCL MMCs should identify and select cases for review, how they should be conducted, and how results should be used to improve CCL quality. In addition, medicolegal ramifications of CCL MMCs are not well understood. This document from the American College of Cardiology's Interventional Section attempts to clarify current issues and options in the conduct of CCL MMCs and to recommend best practices for their conduct.

Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting for Revascularization of Left Main Coronary Artery Disease

Owing to a large-jeopardized myocardium, left main coronary artery disease (LMCAD) represents the substantial high-risk anatomical subset of obstructive coronary artery disease. For several decades, coronary artery bypass grafting (CABG) has been the "gold standard" treatment for LMCAD. Along with advances in CABG, percutaneous coronary intervention (PCI) has also dramatically evolved over time in conjunction with advances in the stent or device technology, adjunct pharmacotherapy, accumulated experiences, and practice changes, establishing its position as a safe, reasonable treatment option for such a complex disease. Until recently, several randomized clinical trials, meta-analyses, and observational registries comparing PCI and CABG for LMCAD have shown comparable long-term survival with tradeoffs between early and late risk-benefit of each treatment. Despite this, there are still several unmet issues for revascularization strategy and management for LMCAD. This review article summarized updated knowledge on evolution and clinical evidence on the treatment of LMCAD, with a focus on the comparison of state-of-the-art PCI with CABG.

Impact of ramus coronary artery on computed tomography derived fractional flow reserve (FFRCT ) in no apparent coronary artery disease

BACKGROUND

The ramus artery contributes to the development of turbulence, which may influence computed tomography (CT) derived fractional flow reserve (FFR_CT ) even without coronary artery disease (CAD). The relationship between ramus-induced turbulence and FFR_CT is unclear.

METHOD AND RESULTS

A total of 120 patients with <20% coronary stenosis assessed by both FFR_CT and invasive coronary angiography were evaluated. The patients were divided into three groups: absent-ramus (n = 72), small-ramus that could not be analyzed by FFR_CT (n = 18), and large-ramus that could be analyzed by FFR_CT (n = 30). FFR_CT measurements were performed at the proximal and distal segments of the left anterior descending (LAD), left circumflex (LCX), and ramus artery. With absent-ramus and small-absent ramus groups, FFR_CT was measured at the distal end of the left main trunk at the same level for the proximal segments of the LAD and LCX. In absent-ramus group, proximal FFR_CT showed no significant differences between three vessels (LAD = .96 ± .02; MID = .97 ± .02; LCX = .97 ± .02). However, in small and large-ramus groups, proximal FFR_CT was significantly higher in the ramus artery than LAD and LCX (small-ramus, LAD = .95 ± .03, Ramus = .97 ± .02, LCX = .95 ± .03; large-ramus: LAD = .95 ± .03, Ramus = .98 ± .01; LCX = .96 ± .03; p < .05). A large ramus was associated with a higher prevalence of a distal FFR_CT ≤.80 (odds ratio 7.0, 95% CI 1.2-40.1, p = .03). A proximal ramus diameter predicted distal FFR_CT ≤.80 (cut-off 2.1 mm, AUC .76, sensitivity 100%, specificity 52%, 95% CI .61-.90).

CONCLUSIONS

The presence of a large-ramus artery may cause an FFR_CT decline in no apparent CAD.

Computed Tomography-Derived Physiology Assessment: State-of-the-Art Review

Coronary computed tomography angiography (CCTA) and CCTA-derived fractional flow reserve (FFRCT) are the best non-invasive techniques to assess coronary artery disease (CAD) and myocardial ischemia. Advances in these technologies allow a paradigm shift to the use of CCTA and FFRCT for advanced plaque characterization and planning myocardial revascularization.

Intra-Aortic Balloon Pump During Percutaneous Coronary Intervention in ST-Elevation Myocardial Infarction With High Thrombus Burden and Cardiogenic Shock

BACKGROUND

Percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) with high-grade thrombus is a high-risk intervention associated with poor clinical outcomes. Circulatory support with an intra-aortic balloon pump (IABP) during PCI may potentially improve coronary hemodynamics and clinical outcomes in such patients. As existing data on this situation are sparse, we did an observational study to determine short-term outcomes of PCI with IABP support in STEMI patients with high thrombus burden.

OBJECTIVES

To determine whether IABP has a potential role in improving outcomes in patients with STEMI with high thrombus burden who are undergoing PCI.

METHODS AND RESULTS

Thirty consecutive patients of STEMI with high thrombus burden undergoing PCI with IABP assistance were included. Ninety-three percent of patients had a cardiogenic shock. Clinical and angiographic outcomes assessed include a change in left ventricular ejection fraction (LVEF), 30-day mortality, and assessment of TIMI (thrombolysis in myocardial infarction) flow, TIMI frame count, and TIMI myocardial perfusion grade in the culprit vessel. IABP was initiated before coronary angiography in 36.6% (n=11), between angiography and PCI in 30% (n=9), and after PCI in 33.3% (n=10) of patients. During the 30-day follow-up period, 50% (n=15) of patients died. 86.6% (n=13) of survivors had pre-PCI IABP initiation compared to only 46.6% (n=7) among those who died (p=0.020). With pre-PCI IABP initiation (n=20), 30-day mortality was 35% (n=7) compared to 80% (n=8) with post-PCI IABP initiation (n=10) (p=0.020).

CONCLUSION

IABP initiation before PCI in STEMI complicated by cardiogenic shock and high angiographic thrombus burden can decrease mortality without any effect on angiographic parameters.

BioMatrix Versus Orsiro Stents for Coronary Artery Disease: A Multicenter, Randomized, Open-Label Study

BACKGROUND

Comparative studies of ultrathin-strut biodegradable polymer sirolimus-eluting stent (BP-SES) have reported promising results and validated its excellent outcomes in terms of safety and efficacy. However, there are limited studies comparing BP drug-eluting stents with struts of different thicknesses. We compared the long-term clinical outcomes of patients treated with an ultrathin-strut BP-SES or a thick-strut biodegradable polymer biolimus-eluting stent (BP-BES).

METHODS

The BIODEGRADE trial (Biomatrix and Orsiro Drug-Eluting Stents in Angiographic Result in Patients With Coronary Artery Disease) is a multicenter prospective randomized study comparing coronary revascularization in patients with ultrathin-strut BP-SES and thick-strut BP-BES with the primary end point of target lesion failure at 18 months posttreatment. We performed the prespecified analysis of 3-year clinical outcomes.

RESULTS

In total, 2341 patients were randomized to receive treatment with ultrathin-strut BP-SES (N=1175) or thick-strut BP-BES (N=1166). The 3-year incidence rate of target lesion failure was 3.2% for BP-SES and 5.1% for BP-BES (P=0.023). The difference was primarily due to differences in ischemia-driven target lesion revascularization (BP-SES, 1.5%; BP-BES, 2.8%; P=0.035) between groups. A landmark analysis of the late follow-up period showed significant differences in target lesion failure, with outcomes being better in BP-SES. Cardiac death and target lesion revascularization were significantly lower in the BP-SES group.

CONCLUSIONS

In a large, randomized trial, the long-term clinical outcome of target lesion failure at 3 years was significantly better among patients treated with the ultrathin-strut BP-SES. The results indicate the superiority of the ultrathin-strut BP-SES compared with the thick-strut BP-BES.

REGISTRATION

URL: https://clinicaltrials.gov; Unique identifier: NCT02299011.

Impact of coronary bifurcation angle on computed tomography derived fractional flow reserve in coronary vessels with no apparent coronary artery disease

OBJECTIVES

Computed tomography (CT) derived fractional flow reserve (FFR_CT) decreases from the proximal to the distal part due to a variety of factors. The energy loss due to the bifurcation angle may potentially contribute to a progressive decline in FFR_CT. However, the association of the bifurcation angle with FFR_CT is still not entirely understood. This study aimed to investigate the impact of various bifurcation angles on FFR_CT decline below the clinically crucial relevance of 0.80 in vessels with no apparent coronary artery disease (CAD).

METHODS

A total of 83 patients who underwent both CT angiography including FFR_CT and invasive coronary angiography, exhibiting no apparent CAD were evaluated. ΔFFR_CT was defined as the change in FFR_CT from the proximal to the distal in the left anterior descending artery (LAD) and left circumflex artery (LCX). The bifurcation angle was calculated from three-dimensional volume rendered images. Vessel morphology and plaque characteristics were also assessed.

RESULTS

ΔFFR_CT significantly correlated with the bifurcation angle (LAD angle, r = 0.35, p = 0.001; LCX angle, r = 0.26, p = 0.02) and vessel length (LAD angle, r = 0.30, p = 0.005; LCX angle, r = 0.49, p < 0.0001). In LAD, vessel length was the strongest predictor for distal FFR_CT of ≤ 0.80 (β-coefficient = 0.55, p = 0.0003), immediately followed by the bifurcation angle (β-coefficient = 0.24, p = 0.02). The bifurcation angle was a good predictor for a distal FFR_CT ≤ 0.80 (LAD angle, cut-off 31.0°, AUC 0.70, sensitivity 74%, specificity 68%; LCX angle, cut-off 52.6°, AUC 0.86, sensitivity 88%, specificity 85%).

CONCLUSIONS

In vessels with no apparent CAD, vessel length was the most influential factor on FFR_CT, directly followed by the bifurcation angle.

KEY POINTS

• Both LAD and LCX bifurcation angles are factors influencing FFR _CT. • Bifurcation angle is one of the predictors of a distal FFR_CT of ≤ 0.80 and an optimal cut-off value of 31.0° for the LAD and 52.6° for the LCX. • Bifurcation angle should be taken into consideration when interpreting numerical values of FFR_CT.

Association of hemoglobin levels with clinical outcomes in acute coronary syndromes in Koreans

Anemia is a well-known risk factor for cardiovascular disease. However, there are limited data on whether anemia on admission is a long-term prognostic factor in acute coronary syndrome (ACS) patients undergoing percutaneous coronary intervention. We sought to evaluate the prevalence and prognostic consequences of anemia in patients with ACS treated with percutaneous coronary intervention in Korea. We retrospectively enrolled 1930 consecutive patients. Among the anemic population (hemoglobin [Hb] < 13 g/dL in men, and < 12 g/dL in women), we classified patients with Hb ≥ 7 g/dL, <10 d/dL as moderate anemia, other cases classified as mild anemia. Among patients with normal hemoglobin levels, we classified those with Hb > 16.5 g/dL in men, and > 16.0 g/dL in women, as having high hemoglobin. We examined the relationship between anemia with all-cause mortality and secondary outcomes - including cardiovascular mortality, myocardial infarction, stroke, and repeat revascularization. We classified 3.3%, 21.5%, and 5.3% of patients as moderate anemia, mild anemia, and high hemoglobin, respectively. During a median follow-up of 67.2 (interquartile range; 46.8-88.5) months, 74 (3.8%) patients died. Compared with patients with normal hemoglobin, we detected a significantly increased risk for all-cause mortality in patients with anemia (adjusted hazard ratios for moderate and mild anemia, respectively: 8.26 [95% confidence interval: 3.98-17.15], P < .001 and 2.60 [1.54-4.40], P < .001). Among patients with ACS, anemia is prevalent and is strongly associated with increased mortality and cardiovascular events. Clinical trials will prospectively evaluate the efficacy of treatment for anemia on the outcomes of patients with ACS.

NR4A2 may be a potential diagnostic biomarker for myocardial infarction: A comprehensive bioinformatics analysis and experimental validation

Background

Myocardial infarction is a well-established severe consequence of coronary artery disease. However, the lack of effective early biomarkers accounts for the lag time before clinical diagnosis of myocardial infarction. The present study aimed to predict critical genes for the diagnosis of MI by immune infiltration analysis and establish a nomogram.

Methods

Gene microarray data were downloaded from Gene Expression Omnibus (GEO). Differential expression analysis, single-cell sequencing, and disease ontology (DO) enrichment analysis were performed to determine the distribution of Differentially Expressed Genes (DEGs) in cell subpopulations and their correlation with MI. Next, the level of infiltration of 16 immune cells and immune functions and their hub genes were analyzed using a Single-sample Gene Set Enrichment Analysis (ssGSEA). In addition, the accuracy of critical markers for the diagnosis of MI was subsequently assessed using receiver operating characteristic curves (ROC). One datasets were used to test the accuracy of the model. Finally, the genes with the most diagnostic value for MI were screened and experimentally validated.

Results

335 DEGs were identified in GSE66360, including 280 upregulated and 55 downregulated genes. Single-cell sequencing results demonstrated that DEGs were mainly distributed in endothelial cells. DO enrichment analysis suggested that DEGs were highly correlated with MI. In the MI population, macrophages, neutrophils, CCR, and Parainflammation were significantly upregulated compared to the average population. NR4A2 was identified as the gene with the most significant diagnostic value in the immune scoring and diagnostic model. 191 possible drugs for the treatment of myocardial infarction were identified by drug prediction analysis. Finally, our results were validated by Real-time Quantitativepolymerase chain reaction and Western Blot of animal samples.

Conclusion

Our comprehensive in silico analysis revealed that NR4A2 has huge prospects for application in diagnosing patients with MI.

Efficacy of intravascular imaging-guided drug-eluting stent implantation: a systematic review and meta-analysis of randomized clinical trials

Background

Traditional angiography only displays two-dimensional images of the coronary arteries during stent implantation. However, intravascular imaging can show the structure of the vascular wall, plaque characteristics. This article aims to evaluate the efficacy of intravascular imaging-guided drug-eluting stent (DES) implantation.

Method

We conducted a systematic review and meta-analysis of randomized controlled trials of intravascular imaging-guided, including patients with DES implantation guided by intravascular ultrasound or optical coherence tomography and traditional angiography. The databases of PubMed, EMBASE, web of science, and Cochrane Library were searched. The primary outcome was target lesion revascularization (TLR). The secondary outcomes included the target vessel revascularization (TVR), myocardial infarction (MI), stent thrombosis (ST), cardiac death, all-cause death, and the major adverse cardiac events (MACE) during the 6–24 months follow-up. The fixed-effects model was used to calculate the relative risk (RR) and 95% confidence interval of the outcome event. Meanwhile, the trial sequence analysis was employed to evaluate the results.

Result

This meta-analysis included fourteen randomized controlled trials with 7307 patients. Compared with angiography-guided, intravascular imaging-guided DES implantation can significantly reduce the risk of TLR (RR 0.63, 0.49–0.82, P = 0.0004), TVR (RR 0.66, 0.52–0.85, P = 0.001), cardiac death (RR 0.58; 0.38–0.89; P = 0.01), MACE (RR 0.67, 0.57–0.79; P < 0.00001) and ST (RR 0.43, 0.24–0.78; P = 0.005). While there was no significant difference regarding MI (RR 0.77, 0.57–1.05, P = 0.10) and all-cause death (RR 0.87, 0.58–1.30, P = 0.50).

Conclusions

Compared with angiography, intravascular imaging-guided DES implantation is associated with better clinical outcomes in patients with coronary artery disease, especially complex lesions (Registered by PROSPERO, CRD 42021289205).

Outcomes of atherectomy in treating severely calcified coronary lesions in patients with reduced left ventricular ejection fraction: A systematic review and meta-analysis

Background

Severely calcified coronary lesions with reduced left ventricular (LV) function result in worse outcomes. Atherectomy is used in treating such lesions when technically feasible. However, there is limited data examining the safety and efficacy of atherectomy without hemodynamic support in treating severely calcified coronary lesions in patients with reduced left ventricular ejection fraction (LVEF).

Objective

To evaluate the clinical outcomes of atherectomy in patient with reduced LVEF.

Methods

We searched PubMed, Cochrane CENTRAL Register and ClinicalTrials.gov (inception through July 21, 2021) for studies evaluating the outcomes of atherectomy in patients with severe LV dysfunction. We used random-effect model to calculate risk ratio (RR) with 95% confidence interval (CI). The endpoints were in-hospital and long term all-cause mortality, cardiac death, myocardial infarction (MI), and target vessel revascularization (TVR).

Results

A total of 7 studies consisting of 2,238 unique patients were included in the analysis. The median follow-up duration was 22.4 months. The risk of in-hospital all-cause mortality using atherectomy in patients with severely reduced LVEF compared to the patients with moderate reduced or preserved LVEF was [2.4vs.0.5%; RR:5.28; 95%CI 1.65–16.84; P = 0.005], the risk of long term all-cause mortality was [21 vs. 8.8%; RR of 2.84; 95% CI 1.16–6.95; P = 0.02]. In-hospital TVR risk was 2.0 vs. 0.6% (RR: 4.15; 95% CI 4.15–15.67; P = 0.04) and long-term TVR was [6.0 vs. 9.9%; RR of 0.75; 95% CI 0.39–1.42; P = 0.37]. In-hospital MI was [7.1 vs. 5.4%; RR 1.63; 95% CI 0.91–2.93; P = 0.10], long-term MI was [7.5 vs. 5.7; RR 1.74; 95%CI 0.95–3.18; P = 0.07).

Conclusion

Our meta-analysis suggested that the patients with severely reduced LVEF when using atherectomy devices experienced higher risk of clinical outcomes in the terms of all-cause mortality and cardiac mortality. As we know that the patients with severely reduced LVEF are inherently at increased risk of adverse clinical outcomes, this information should be considered hypothesis generating and utilized while discussing the risks and benefits of atherectomy in such high risk patients. Future studies should focus on the comparison of outcomes of different atherectomy devices in such patients. Adjusting for the inherent mortality risk posed by left ventricular dysfunction may be a strategy while designing a study.

Staged revascularization vs. culprit-only percutaneous coronary intervention for multivessel disease in elderly patients with ST-segment elevation myocardial infarction

Backgroundand objective

Studies have highlighted the significant role of staged percutaneous coronary intervention (PCI) for a multivessel disease (MVD) among patients with ST-elevation myocardial infarction (STEMI). However, the relative benefit of staged vs. culprit-only PCI for MVD in elderly patients with STEMI remains undetermined. Thus, the present study compared the clinical outcomes of staged and culprit-only PCI in this cohort.

Methods

From January 2014 to September 2019, 617 patients aged ≥65 years with STEMI and MVD who underwent primary PCI of the culprit vessels within 12 h of symptom onset were enrolled. They were then categorized into the staged and culprit-only PCI groups according to intervention strategy. Propensity score matching (PSM) was conducted to adjust for confounding factors between groups. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of all-cause death, cardiac death, recurrent myocardial infarction (MI), stroke, and ischemia-driven revascularization.

Results

During a mean follow-up of 56 months, 209 patients experienced MACCE and 119 died. Staged revascularization was associated with a lower risk of MACCE, all-cause death, and cardiac death than culprit-only PCI in both overall patients and the PSM cohorts. In contrast, there was no significant difference in stroke or ischemia-driven revascularization. Moreover, on multivariate Cox regression analysis, staged PCI was a significant predictor of a lower incidence of MACCE and all-cause death.

Conclusion

In elderly patients with STEMI and MVD, staged PCI is superior to culprit-only PCI.

Prognostic value of plasma adipokine chemerin in patients with coronary artery disease

Background

Adipokine chemerin was proven to be associated with coronary artery disease (CAD), but its prognostic implications in CAD remain unclear.

Methods

This study consists of two parts, one is a basic study and the other is a clinical cohort study. First, we investigated the differential expression of six adipokines in the atherosclerotic mice model compared to mice with milder degrees of atherosclerosis and mice without atherosclerosis using microarray data. We then examined the potential of chemerin as a diagnostic and prognostic indicator in a CAD cohort. A total of 152 patients were enrolled in our study, including 77 patients with angiographically proven CAD and 75 control subjects without cardiovascular disease. Plasma adipokine chemerin levels were measured in all patients, and major adverse cardiovascular events (MACEs) were followed up, including ischemic stroke, non-fatal myocardial infarction, revascularization, and cardiovascular death.

Results

In the aortas of atherosclerotic mice, chemerin expression was up-regulated compared to control mice. The plasma chemerin levels of CAD patients were higher than those of non-CAD patients (128.93 ± 37.06 vs. 109.85 ± 27.47 mmol/L, respectively, P < 0.001). High chemerin levels were an independent predictor of CAD (β = 2.702, 95% CI, 1.344–5.431, P = 0.001). We followed up with patients for a median duration of 5.5 years (3.9–5.6). The Kaplan–Meier curves showed that patients in the high chemerin group had a significantly higher risk of MACEs than the low chemerin group in patients with CAD (log-rank P = 0.003), not with non-CAD (Log-rank P = 0.120). Furthermore, Cox multivariate analysis revealed that high chemerin levels were an independent predictor of MACEs (HR 2.267; 95% CI, 1.139–4.515; P = 0.020). Finally, the cellular study showed that chemerin is predominantly expressed in PBMC-derived macrophages.

Conclusion

Plasma chemerin levels were increased in the CAD patients, and a high chemerin level increased the risk of MACEs in CAD patients.

Prevalence and prognostic significance of malnutrition in patients with acute coronary syndrome treated with percutaneous coronary intervention

The incidence and impact of malnutrition on acute coronary syndrome (ACS) remain unclear. This study aimed to evaluate the prevalence, clinical relevance, and prognostic outcomes of malnutrition in patients with ACS treated with percutaneous coronary intervention. This retrospective study included 1930 consecutive patients with ACS undergoing percutaneous coronary intervention and assessed their nutritional status using 3 scoring systems: Controlling Nutritional Status score, nutritional risk index (NRI), and prognostic nutritional index (PNI). The primary endpoint was all-cause mortality. The Controlling Nutritional Status, NRI, and PNI scores showed that 5.2%, 17.5%, and 3.9% of patients were moderately or severely malnourished, respectively. During a median follow-up of 67.2 months (interquartile range: 46.8-88.5 months), 74 (3.8%) patients died. Malnutrition was associated with a significantly increased risk for all-cause mortality compared with good nutrition (adjusted hazard ratios for moderate and severe malnutrition, respectively: 5.65 [95% confidence interval: 3.27-9.78] and 15.26 [7.50-31.05] for the NRI score, 5.53 [2.10-14.49] and 11.08 [5.69-21.59] for the PNI; P < .001). The current findings demonstrated that malnutrition is prevalent among patients with ACS and is closely associated with increased mortality. Further study is needed to evaluate the effects of nutritional interventions on the outcomes of patients with ACS.

Outcomes of Genetic Testing-Based Cardiac Rehabilitation Program in Patients with Acute Myocardial Infarction after Percutaneous Coronary Intervention

Objective

There can be extreme variability between individual responses to exercise training, and the identification of genetic variants associated with individual variabilities in exercise-related traits could guide individualized exercise programs. We aimed to screen the exercise-related gene sensitivity of patients with acute myocardial infarction after PCI by establishing the gene spectrum of aerobic exercise and cardiopulmonary function sensitivity, test the effect of individualized precision exercise therapy, and provide evidence for the establishment of a precision medicine program for clinical research.

Methods

Aerobic exercise- and cardiopulmonary function-related genes and single-nucleotide polymorphisms (SNPs) were obtained by data mining utilizing a major publicly available biomedical repository, the NCBI PubMed database. Biological samples from all participants underwent DNA testing. We performed SNP detection using Samtools. A total of 122 patients who underwent PCI were enrolled in the study. We screened the first 24 cases with a high mutation frequency for aerobic exercise- and cardiopulmonary function-related genes and the last 24 cases with a low mutation frequency and separated them into two groups for the exercise intervention experiment.

Results

In both the low mutation frequency group and the high mutation frequency group, after 8 weeks of exercise intervention, 6 MWT distance, 6 MWT%, VO₂/kg at peak, and VO₂/kg at AT were significantly improved, and the effect in the high mutation frequency group was significantly higher than that in the low mutation frequency group (6 MWT distance: 468 vs. 439, P=0.003; 6 MWT%: 85 vs. 77, P=0.002, VO₂/kg at peak: 14.7 vs. 13.3, P=0.002; VO₂/kg at AT: 11.9 vs. 13.3, P=0.003).

Conclusions

There is extreme variability between individual responses to exercise training. The identification of genetic variants associated with individual variabilities in exercise-related traits could guide individualized exercise programs. We found that the subjects with a high mutation frequency in aerobic exercise and cardiopulmonary function-related genes achieved more cardiorespiratory fitness benefits in the aerobic exercise rehabilitation program and provided evidence for the establishment of a precision medicine program for clinical research.

The Optimal Strategy of Dual Antiplatelet Therapy after Percutaneous Coronary Intervention with Drug-Eluting Stent

Objective: To test the optimal strategy of dual antiplatelet therapy (DAPT) after implantation of drug-eluting stents (DESs) according to specific DAPT time and subsequent monotherapy. Methods: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, and Web of Science to identify randomized controlled trials (RCTs). Six DAPT strategies were compared: 1-month DAPT followed by P2Y12 inhibitor monotherapy, 3-month DAPT followed by P2Y12 inhibitor monotherapy, 3-month DAPT followed by aspirin monotherapy, 6-month DAPT followed by aspirin monotherapy, 12-month DAPT, and >12-month DAPT. Pooled odd ratios (ORs) with 95% credible intervals (CrIs) were calculated to summarize the effect of each strategy tested. Results: We identified 24 RCTs containing 81,405 patients. In comparison with 12-month DAPT, 3-month DAPT followed by P2Y12 inhibitor monotherapy reduced net clinical events (OR: 0.72; CrI: 0.55−0.94). Major bleeding (OR: 0.57; CrI: 0.34−1.00) was marginally decreased without impact on ischemic events (OR: 0.93; CrI: 0.68−1.29). Moreover, the benefits of 3-month DAPT (P2Y12 inhibitor) were consistent for male patients with acute coronary disease, young age, complex lesion, single-vessel disease, low body mass index, and without diabetes. Although >12-month DAPT was associated with a lower risk of myocardial infarction (OR: 0.67; CrI: 0.51−0.93), the risk of major bleeding (OR: 1.70; CrI: 1.10−2.70) was increased. Conclusion: Among patients treated with DESs, 3-month DAPT followed by P2Y12 inhibitor monotherapy may be the optimal antiplatelet strategy, while DAPT beyond 1 year reduces myocardial infarction at the expense of increased major bleeding.

Peer evaluation and feedback for invasive medical procedures: a systematic review

BACKGROUND

There is significant variability in the performance and outcomes of invasive medical procedures such as percutaneous coronary intervention, endoscopy, and bronchoscopy. Peer evaluation is a common mechanism for assessment of clinician performance and care quality, and may be ideally suited for the evaluation of medical procedures. We therefore sought to perform a systematic review to identify and characterize peer evaluation tools for practicing clinicians, assess evidence supporting the validity of peer evaluation, and describe best practices of peer evaluation programs across multiple invasive medical procedures.

METHODS

A systematic search of Medline and Embase (through September 7, 2021) was conducted to identify studies of peer evaluation and feedback relating to procedures in the field of internal medicine and related subspecialties. The methodological quality of the studies was assessed. Data were extracted on peer evaluation methods, feedback structures, and the validity and reproducibility of peer evaluations, including inter-observer agreement and associations with other quality measures when available.

RESULTS

Of 2,135 retrieved references, 32 studies met inclusion criteria. Of these, 21 were from the field of gastroenterology, 5 from cardiology, 3 from pulmonology, and 3 from interventional radiology. Overall, 22 studies described the development or testing of peer scoring systems and 18 reported inter-observer agreement, which was good or excellent in all but 2 studies. Only 4 studies, all from gastroenterology, tested the association of scoring systems with other quality measures, and no studies tested the impact of peer evaluation on patient outcomes. Best practices included standardized scoring systems, prospective criteria for case selection, and collaborative and non-judgmental review.

CONCLUSIONS

Peer evaluation of invasive medical procedures is feasible and generally demonstrates good or excellent inter-observer agreement when performed with structured tools. Our review identifies common elements of successful interventions across specialties. However, there is limited evidence that peer-evaluated performance is linked to other quality measures or that feedback to clinicians improves patient care or outcomes. Additional research is needed to develop and test peer evaluation and feedback interventions.

Prognostic Value of Myocardial Blush Grade in ST-elevation MI: A Systematic Review and Meta-analysis

Background: Ineffective myocardial perfusion despite angiographic success after angioplasty occurs frequently and is associated with an increased risk of mortality. Hence, this study determined whether myocardial perfusion measured by myocardial blush grade (MBG) identifies ST-elevation MI (STEMI) patients at high risk for poor outcomes after successful angioplasty. Methods: The search employed strategies designed for research databases. An article was eligible if it included adults who underwent coronary angioplasty for STEMI, post-angioplasty MBG was assessed, and mortality or major adverse cardiovascular events (MACE) were determined. Risk for bias was assessed using the Quality In Prognosis Studies tool and forest plots in a Mantel-Haenszel fixed effects model were created using RevMan5.4. Results/discussion: Eight observational studies with an overall low risk of bias were included, involving 8,044 patients. MBG 0/1 with no to poor myocardial perfusion had a negative prognostic value for mortality (OR 2.68; 95% CI [2.22–3.23]) and MACE (OR 1.20; 95% CI [1.01–1.41]). Furthermore, MBG 2 with moderate myocardial perfusion and MBG 3 with normal myocardial perfusion were associated with increased survival with a logHR of 0.47 (95% CI [0.43–0.52]) and 0.20 percutaneous coronary intervention (95% CI [0.18–0.23]). These results imply MBG is a useful prognostic marker for STEMI patients. Conclusion: MBG 0/1 after primary angioplasty is a strong negative prognostic marker for long-term all-cause mortality and MACE among STEMI patients, and a post-primary angioplasty MBG of 2 or 3 is a robust prognostic marker for long-term survival.

Three-Dimensional Angiographic Characteristics versus Functional Stenosis Severity in Fractional and Coronary Flow Reserve Discordance: A DEFINE FLOW Sub Study

Background: Coronary angiography alone is insufficient to identify lesions associated with myocardial ischemia that may benefit from revascularization. Coronary physiology parameters may improve clinical decision making in addition to coronary angiography, but the association between 2D and 3D qualitative coronary angiography (QCA) and invasive pressure and flow measurements is yet to be elucidated. Methods: We associated invasive fractional flow reserve (FFR), coronary flow reserve (CFR) and coronary flow capacity (CFC) with 2D- and 3D-QCA in 430 intermediate lesions of 366 patients. Results: Overall, 2D-QCA analysis resulted in less severe stenosis severity compared with 3D-QCA analysis. FFR+/CFR− lesions had similar 3D-QCA characteristics as FFR+/CFR+ lesions. In contrast, vessels with FFR−/CFR+ discordance had 3D-QCA characteristics similar to those of vessels with concordant FFR−/CFR−. Contrarily, FFR+/CFR− lesions had CFC similar to that of as FFR-/CFR- lesions. Conclusions: Non-flow-limiting lesions (FFR+/CFR−) have 3D-QCA characteristics similar to those of FFR+/CFR+, but the majority are not associated with inducible myocardial ischemia as determined by invasive CFC. FFR−/CFR+ lesions have 3D-QCA characteristics similar to those of FFR−/CFR− lesions but are more frequently associated with a moderately to severely reduced CFC, illustrating the angiographic–functional mismatch in discordant lesions.

Acute effects of singing on cardiovascular biomarkers

Background

Singing is a physical activity involving components of the vagal nerves manifested as changes in cardiac autonomic regulation.

Aims

The aim of this pilot study is to investigate the acute effects of singing on biomarkers of cardiovascular health.

Methods

Adult subjects were recruited from cardiology clinics to participate in a single 90-min study visit. Vascular function was measured at the fingertips with peripheral arterial tonometry (PAT) before and after singing to a 14-min video led by a voice expert. Heart rate variability (HRV) was measured with a chest strap sensor at baseline, during, and after singing. PAT measurements were expressed as reactive hyperemia index (RHI) and Framingham reactive hyperemia index (fRHI). Measures of HRV included root mean square of successive RR interval differences (RMSSD) and standard deviation of NN (or RR) intervals (SDNN).

Results

Sixty subjects completed the study (68% female, mean age 61 ±13 years, mean BMI 32 ± 8). There was a significant increase in fRHI (1.88 ± 0.14 to 2.10 ± 0.14, p = 0.02) after singing with no significant change in the RHI (1.99 ± 0.10 to 2.12 ± 0.09, p = 0.22). There was a reduction in HRV during singing (compared to baseline) (RMSSD: 42.0 ± 5 to 32.6 ± 4, p = 0.004 and SDNN: 54 ± 4 to 33.5 ± 3, p = 0.009). HRV measures trended back toward baseline after singing.

Conclusions

A short duration of singing improved vascular function acutely. Improvements were more substantial in subjects with abnormal baseline endothelial function. HRV patterns were similar to that of light-intensity exercise. Future studies should confirm favorable vascular adaptation to more sustained singing interventions.

Clinical trial registration

ClinicalTrials.gov, identifer: NCT03805529.

Fallacy of Median Door‐to‐ECG Time: Hidden Opportunities for STEMI Screening Improvement

Background

ST‐segment elevation myocardial infarction (STEMI) guidelines recommend screening arriving emergency department (ED) patients for an early ECG in those with symptoms concerning for myocardial ischemia. Process measures target median door‐to‐ECG (D2E) time of 10 minutes.

Methods and Results

This 3‐year descriptive retrospective cohort study, including 676 ED‐diagnosed patients with STEMI from 10 geographically diverse facilities across the United States, examines an alternative approach to quantifying performance: proportion of patients meeting the goal of D2E≤10 minutes. We also identified characteristics associated with D2E>10 minutes and estimated the proportion of patients with screening ECG occurring during intake, triage, and main ED care periods. We found overall median D2E was 7 minutes (IQR:4–16; range: 0–1407 minutes; range of ED medians: 5–11 minutes). Proportion of patients with D2E>10 minutes was 37.9% (ED range: 21.5%–57.1%). Patients with D2E>10 minutes, compared to those with D2E≤10 minutes, were more likely female (32.8% versus 22.6%, P=0.005), Black (23.4% versus 12.4%, P=0.005), non‐English speaking (24.6% versus 19.5%, P=0.032), diabetic (40.2% versus 30.2%, P=0.010), and less frequently reported chest pain (63.3% versus 87.4%, P<0.001). ECGs were performed during ED intake in 62.1% of visits, ED triage in 25.3%, and main ED care in 12.6%.

Conclusions

Examining D2E>10 minutes can identify opportunities to improve care for more ED patients with STEMI. Our findings suggest sex, race, language, and diabetes are associated with STEMI diagnostic delays. Moving the acquisition of ECGs completed during triage to intake could achieve the D2E≤10 minutes goal for 87.4% of ED patients with STEMI. Sophisticated screening, accounting for differential risk and diversity in STEMI presentations, may further improve timely detection.

Trends in Arterial Access Site Selection and Bleeding Outcomes Following Coronary Procedures, 2011-2018

BACKGROUND

Prior studies of radial access for cardiac catheterization have focused on early adopters of the technique, and some have described a risk/treatment paradox of low radial access use among high bleeding risk patients. This study aimed to determine (1) trends in radial access use over time, (2) if increasing use of radial access is driven by new invasive and interventional cardiologists (operators) or existing operators changing their practice, and (3) if increasing radial rates are associated with lower bleeding rates and elimination of the risk/treatment paradox.

METHODS

In this cross-sectional study using data from the Clinical Assessment, Reporting, and Tracking Program, we calculated radial access rates and risk-adjusted postprocedural bleeding rates of patients undergoing diagnostic angiography or percutaneous coronary intervention (PCI) between 2011 and 2018 in Veterans Affairs hospitals. We used separate bleeding risk models for diagnostic angiography and PCI and assessed temporal trends with the Kendall Tau-b test.

RESULTS

Among 253 179 diagnostic angiograms and 93 614 PCIs, radial access rates increased over time for both diagnostic (17.5%-60.4%; P<0.01)) and PCI procedures (14.0%-51.8%; P<0.01). Existing operators and new operators increased their use at similar rates, but new operators entered practice with higher baseline rates. Nearly all operators used radial access at least once in 2018. Overall adjusted rates of bleeding declined, a trend that was significant for diagnostic angiography (2.4%-1.4%, P=0.02) but not PCI (3.4%-2.5%, P=0.20). Femoral access patients had a higher predicted risk for bleeding.

CONCLUSIONS

A steady rise in radial access for diagnostic angiography and PCI was driven by increasing use among existing operators and high use by new operators. While this was associated with decreasing bleeding rates, a risk/treatment paradox for access site selection persists; patients at higher bleeding risk were still more likely to receive femoral access.

Comparison of Coronary Artery Bypass Grafting and Drug-Eluting Stent Implantation in Patients With Chronic Kidney Disease: A Propensity Score Matching Study

Objectives

To compare the long-term outcomes of coronary artery bypass grafting (CABG) vs. percutaneous coronary intervention (PCI) with drug-eluting stents (DESs) for coronary artery disease (CAD) patients with chronic kidney disease (CKD).

Methods

Coronary artery disease patients with decreased kidney function (estimated glomerular filtration rate &lt;60 ml/min/1.73 m2) who underwent CABG (n = 533) or PCI with DES (n = 952) from 2013 to 2020 were enrolled at a single center. The baseline characteristics and clinical outcomes were compared between the CABG and PCI groups for each matched pair of patients with CKD. The primary endpoint was the occurrence of all-cause death. The secondary endpoints were major adverse cardiovascular events (MACCEs) such as death, myocardial infarction (MI), stroke, and repeat revascularization.

Results

A total of 1,485 patients underwent revascularization, such as 533 CABG and 952 patients with PCI. The median follow-up duration was 55.6 months (interquartile range 34.3–74.7 months). Multivariable Cox regression models were used for risk adjustment, and after propensity score matching (PSM), 399 patients were well matched in each group. The in-hospital mortality rate in the CABG group was higher than that in the PCI group, but the difference was not statistically significant (5.0 vs. 2.5%, p = 0.063). At the 1-year follow-up, CABG was associated with a lower survival rate than PCI (94.2 vs. 98.0%, hazard ratio [HR] of 3.72, 95% CI = 1.63–8.49, p &lt; 0.01). At the end of the 5-year follow-up, the freedom from MI and the freedom from repeated revascularization were both better in the CABG group compared to the PCI group (89.1 vs. 81.7%, HR of 0.59, 95% CI = 0.38–0.92, p = 0.019; 86.9 vs. 73.8%, HR of 0.54, 95% CI = 0.36–0.81, p = 0.003, respectively). Furthermore, the freedom from MACCEs was also better in the patients of CABG compared with the patients of PCI (58.5 vs. 51.3%, HR of 0.71, 95% CI = 0.55–0.91, p = 0.030). CABG had a higher cumulative survival rate (68.4 vs. 66.0%) but without a statistically significant difference (HR of 0.92, 95% CI = 0.67–1.27, p = 0.602) compared with that of PCI.

Conclusions

Compared to the use of PCI with a drug-eluting stent among patients with CKD, the use of CABG was associated with a lower MI rate, repeat revascularization rate, and lower number of MACCEs during the long-term follow-up. At a follow-up of 1 year, the number of MACCEs and other adverse events were comparable between the two cohorts, but CABG showed a lower survival rate than PCI.

Proton Pump Inhibitors and In-Hospital Gastrointestinal Bleeding in Patients With Acute Coronary Syndrome Receiving Dual Antiplatelet Therapy

OBJECTIVE

To evaluate the association between proton pump inhibitor (PPI) use and in-hospital gastrointestinal (GI) bleeding in patients with acute coronary syndrome (ACS) taking dual antiplatelet therapy (DAPT).

PATIENTS AND METHODS

This study is based on the Improving Care for Cardiovascular Disease in China-ACS project, an ongoing collaborative registry and quality improvement project of the American Heart Association and the Chinese Society of Cardiology. A total of 25,567 patients with ACS taking DAPT from 172 hospitals from July 1, 2017, through December 31, 2018, were included. Multivariable Cox regression and propensity score-matched analyses were used to evaluate the association between PPI use and in-hospital GI bleeding.

RESULTS

Of these patients with ACS, 63.9% (n=16,332) were prescribed PPIs within 24 hours of admission. Patients using PPIs had a higher rate of GI bleeding compared with those not using PPIs (1.0% vs 0.5%; P<.001). In the multivariable Cox regression analysis, early PPI use was associated with a 58% higher risk of GI bleeding (hazard ratio, 1.58; 95% CI, 1.15 to 2.18; P=.005). Further propensity score matching attenuated the association but still showed that patients using PPIs had a higher rate of GI bleeding (0.8% vs 0.6%; P=.04).

CONCLUSION

In China, PPIs are widely used within 24 hours of admission in patients with ACS taking DAPT. An increased risk of GI bleeding is observed in inpatients with early PPI use. Randomized trials on early use of PPIs in patients with ACS receiving DAPT are warranted.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02306616.

Survivals of Angiography-Guided Percutaneous Coronary Intervention and Proportion of Intracoronary Imaging at Population Level: The Imaging Paradox

Background

There is a significant disparity between randomized controlled trials and observational studies with respect to any mortality benefit with intracoronary imaging during the percutaneous coronary intervention (PCI). This raises a suspicion that the imaging paradox, in which some operators may become over reliant on imaging and less proficient with angiography-guided PCI, might exist.

Method

This was a retrospective cohort study from 14 hospitals under the Hospital Authority of Hong Kong between January 1, 2010 and December 31, 2017. Participants were patients who underwent first-ever PCI. The association between mortality risks of patients undergoing angiography-guided PCI and three tertiles (low, medium, and high) of the proportion of PCI done under intracoronary imaging guidance at a population level (background imaging rate), were evaluated after confounder adjustment by multivariable logistic regression.

Results

In an adjusted analysis of 11,816 patients undergoing angiography-guided PCI, the risks of all-cause mortality for those were higher in the high-tertile group compared with the low-tertile group (OR, 1.45, 95% CI, 1.10–1.92, P = 0.008), the risks of cardiovascular mortality were higher in the high-tertile group compared with the low-tertile group (OR, 1.51, 95% CI, 1.08–2.13, P = 0.017). The results were consistent with multiple sensitivity analyses. Threshold analysis suggested that the mortality risks of angiography-guided PCI were increased when the proportion of imaging-guided PCI exceeded approximately 50%.

Conclusions

The risks of the all-cause mortality and cardiovascular mortality were higher for patients undergoing angiography-guided PCI in practices with a higher background imaging rate.

A Systematic Review and Meta-Analysis on the Efficacy of Puerarin Injection as Adjunctive Therapy for Unstable Angina Pectoris

Background

As adjunctive therapy, puerarin injection has been widely applied for the treatment of unstable angina pectoris (UAP) in China during the past decades. However, the efficacy of puerarin injection as adjunctive therapy for UAP has not been well confirmed. The purpose of this meta-analysis was to summarize the available evidence to estimate the efficacy of puerarin injection in treating UAP.

Objective

A systematic review and meta-analysis with subgroup analysis and sensitivity analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principle were carried out to evaluate the efficacy of puerarin injection as adjunctive therapy in treating UAP.

Methods

To obtain the published randomized controlled trials (RCTs) on puerarin injection, databases, namely, China National Knowledge Infrastructure (CNKI), Wanfang Database, Chinese Biomedical Literature Database, Sino-Med, PubMed, China Science and Technology Journal Database (VIP), Medline, Google Scholar, Cochrane Library, Chinese Science Citation Database, and Embase were systematically searched until June 2021. In this meta-analysis, Review Manager version 5.3 software and Stata version 12.0 software were employed to analyze the collected data. Based on the methodological quality, years of publications, sample size and dosages, sensitivity analysis, and subgroup analysis were performed. The GRADE assessment was conducted by the software GRADEpro version 3.6 software.

Results

A total of 17 RCTs involving 1,459 patients were included in this meta-analysis. Results indicated that puerarin injection as adjunctive therapy was more superior than conventional Western medicine alone in reducing angina symptoms [risk ratio (RR) = 1.22, 95% CI 1.16 to 1.28, Z = 8.11, p < 0.00001] and improving ECG (RR = 1.32, 95% CI 1.20 to 1.44, Z = 6.00, p < 0.00001), meanwhile reducing the frequency of angina attack [mean difference (MD) = −2.22, 95% CI −2.53 to −1.90, Z = 13.97, p < 0.00001] and the duration of angina attack (MD = −2.00, 95% CI −2.39 to −1.61, Z = 9.99, p < 0.00001) for the treatment of UAP. Results from the GRADE assessment suggested that the comprehensive quality of this evidence was low.

Conclusion

This meta-analysis indicated that puerarin injection was more effective than using conventional Western medicine alone in the treatment of UAP. However, because of the low methodological quality of the included RCTs, more evidence was still needed to verify the efficacy of puerarin injection.

High-speed rotational atherectomy in coronary artery calcification: The randomized ROTAXUS and PREPARE-CALC trials

BACKGROUND

The clinical outcomes of high-speed rotational atherectomy (RA) to optimize target lesion preparation in coronary artery calcification (CAC) have been examined in several trials.

AIMS

This study was conducted to evaluate the safety and efficacy of RA for CAC.

METHODS

Patient data were pooled from ROTAXUS and PREPARE-CALC. The primary endpoint was the in-stent late lumen loss and major adverse cardiac events (MACE) at 9 months. Secondary endpoints included in-segment late lumen loss, binary restenosis, strategy success, procedural duration, and contrast amount.

RESULTS

Four hundred and forty patients were enrolled from Germany in this study, 220 patients were randomized to the RA group and 220 patients were randomized to the Control group. Despite similar baseline characteristics, significantly more patients in the Control group were crossover (14.1% vs. 2.3%, p < 0.0001), resulting in higher strategy success in the RA group (95.0% vs. 82.3%, p < 0.0001). At 9 months, in-stent late lumen loss was higher in the RA group (0.34 ± 0.52 mm vs. 0.24 ± 0.47 mm, p = 0.03) and procedural duration was longer in the RA group (76.3 ± 41.8 min vs. 67.0 ± 38.8 min, p = 0.02). MACE (17.8% vs. 25.2%, p = 0.06), in-segment late lumen loss (0.28 ± 0.66 mm vs. 0.17 ± 0.55 mm, p = 0.05), binary restenosis (7.3% vs. 8.2%, p = 0.71 in-stent; 7.7% vs. 9.0%, p = 0.62 in-segment), and contrast amount (215.5 ± 112.5 ml vs. 203.7 ± 96.5 ml, p = 0.24) were similar in both groups.

CONCLUSION

Lesion preparation with upfront RA before drug-eluting stent implantation is feasible in CAC, is more strategy successful, and is associated with excessive in-stent late lumen loss and excellent clinical outcomes at 9 months although longer procedural duration.

Outcomes of mechanical circulatory support for acute myocardial infarction complicated by cardiogenic shock

BACKGROUND

Mechanical circulatory support (MCS) with the Impella device (Abiomed, Danvers, MA) has been associated with higher in-hospital mortality than intra-aortic balloon pump (IABP) in the Premier Healthcare Database and National Cardiovascular Data Registry.

METHODS

The objective of this retrospective cohort study was to describe trends and outcomes of Impella usage in acute myocardial infarction complicated by cardiogenic shock (AMICS) treated with MCS (Impella or IABP) using real-world observational data from the National Inpatient Sample (NIS) including hospitalizations for AMICS managed with MCS between January 2012 to December 2017. The primary outcomes included in-hospital mortality, transfusion, acute kidney injury, stroke, total costs, and length of stay. Propensity score matching was performed with hierarchical models using risk factor and Elixhauser comorbidity variables.

RESULTS AND CONCLUSION

We identified 54,480 hospitalizations for AMICS managed with MCS including 5750 (10.5%) utilizing Impella. Throughout the study period, Impella usage increased yearly to 19.9% of AMICS cases in 2017. After propensity score matching, Impella was associated with higher in-hospital mortality (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.41-2.13) and transfusions (OR 1.97, 95% CI 1.40-2.78) than IABP, without association with acute kidney injury or stroke. Impella use was associated with higher hospital costs (mean difference $22,416.80 [95% CI $17,029-27,804]). Impella usage for AMICS increased significantly from 2012 to 2017 and was associated with increased in-hospital mortality and costs. Randomized controlled trials are urgently needed to assess the safety and efficacy of Impella.

Antiplatelet Therapy for Atherothrombotic Disease in 2022—From Population to Patient-Centered Approaches

Antiplatelet agents, with aspirin and P2Y₁₂ receptor antagonists as major key molecules, are currently the cornerstone of pharmacological treatment of atherothrombotic events including a variety of cardio- and cerebro-vascular as well as peripheral artery diseases. Over the last decades, significant changes have been made to antiplatelet therapeutic and prophylactic strategies. The shift from a population-based approach to patient-centered precision medicine requires greater awareness of individual risks and benefits associated with the different antiplatelet strategies, so that the right patient gets the right therapy at the right time. In this review, we present the currently available antiplatelet agents, outline different management strategies, particularly in case of bleeding or in perioperative setting, and develop the concept of high on-treatment platelet reactivity and the steps toward person-centered precision medicine aiming to optimize patient care.