A comparison of contact force and remote magnetic navigation on lesion formation for the ablation of atrial fibrillation.

RATIONALE: Pulmonary vein isolation (PVI) is the method of choice for the treatment of drug-resistant atrial fibrillation (AF). However, arrhythmia recurrences are frequent due to suboptimal lesions formation and pulmonary vein reconnection. Contact force (CF)- and remote magnetic navigation (RMN)-guided catheters are both capable of improving contact and energy transfer to the tissue, possibly improving PVI outcome. OBJECTIVE: The objective of our study was to compare CF- and RMN-guided PVI in patients with paroxysmal AF in terms of surrogate parameters of the dimension and quality of the lesions. METHODS AND RESULTS: Between March 2014 and March 2016, 44 patients affected by paroxysmal AF underwent a circumferential PVI procedure, 22 with a CF catheter and 22 with a RMN catheter. Signals were recorded before and after 30 seconds of radiofrequency point-by-point delivery. For each location, signal energy attenuation and impedance drop were evaluated as lesion dimension surrogates and signal fragmentation and shrinkage were estimated as lesion quality surrogates. Statistical analysis shows that CF catheter achieves higher attenuation and impedance drop than RMN-guided catheter, which instead performs better in terms of shrinkage and fragmentation. There were no differences in terms of PVI rate and sinus rhythm maintenance 1 year after the procedure (77.2% in both groups). CONCLUSIONS: CF-guided catheters produce lesions that are larger but less homogeneous than those produced by RMN-guided catheters in terms of surrogate parameters. These two features could possibly offset each other, resulting in identical acute and long-term outcomes.

Impact of targeting adenosine-induced transient venous reconnection in patients undergoing pulmonary vein isolation for atrial fibrillation: a meta-analysis of 3524 patients.

AIMS: Atrial fibrillation recurrences after pulmonary vein isolation (PVI) are not uncommon and are frequently related to pulmonary vein reconnection. Adenosine/ATP can reveal dormant pulmonary vein conduction after PVI. Previous studies revealed that adenosine-guided Additional ablation could improve arrhythmia-free survival. We performed a meta-analysis to assess the impact of additional ablation to eliminate adenosine-induced transient pulmonary vein reconnection in terms of atrial fibrillation recurrence at follow-up. METHODS: MEDLINE/PubMed, Cochrane Library and references reporting atrial fibrillation ablation and adenosine/ATP-following PVI were screened, and studies were included if they matched inclusion and exclusion criteria. RESULTS: A total of 3524 patients were enrolled with a median follow-up of 13 (6-20) months. Overall, 70% (60-85) of patients in ATP-guided ablation vs. 63% (48-79) in no ATP-guided ablation were free of atrial fibrillation at follow-up. Pooled results revealed that ATP-guided ablation reduced the risk of atrial fibrillation recurrence of 42% [odds ratio (OR) 0.58, 0.41-0.81], but this result was primary because of the contribution of retrospective over-randomized studies [OR 0.48 (0.35-0.65) vs. 0.76 (0.42-1.40), respectively]. 3.2% of patients experienced an adverse event. ATP-guided ablation is related to a nonsignificant increase in fluoroscopy time (OR 1.71, 0.98-2.96) and to a significant increase in procedure time (OR 2.84, 1.32-6.09). CONCLUSION: Additional ablation aiming to eliminate adenosine-induced transient pulmonary vein reconnection failed to reduce the risk of atrial fibrillation recurrence at follow-up. Moreover, although adenosine-guided PVI is not affected by an augmented risk of adverse events, it is associated with a NS increased fluoroscopy exposure and significantly longer procedure duration. Further studies are required to identify the actual role of adenosine in PVI.

Left Atrial Substrate Modification Targeting Low-Voltage Areas for Catheter Ablation of Atrial Fibrillation: A Systematic Review and Meta-Analysis.

BACKGROUND: This meta-analysis aims to assess the impact of a voltage-guided substrate modification by targeting low-voltage area (LVA) in addition to pulmonary vein isolation (PVI) in patients undergoing catheter ablation for atrial fibrillation (AF). METHODS: MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and "voltage* OR substrate* OR fibrosis OR fibrotic area*" were screened and studies included if matching inclusion and exclusion criteria. RESULTS: Six studies were included. Patients enrolled were 885 (517 in the study group and 368 in the control group). Median age was 60 years; 92% had nonparoxysmal AF. At a mean follow-up of 17 months, 70% of patients in the study group vs. 43% in the control group were free from AF/atrial tachycardia (AT) recurrences (odds ratio [OR] = 3.41, 95% confidence interval [CI] 2.22-5.24). LVA ablation in addition to PVI was more effective than PVI alone and PVI + conventional wide empirical ablation (70% vs. 43%, OR = 3.41, 95% CI 2.22-5.24), without increasing the adverse event rate (2.5% vs. 6%, OR = 0.43, 95% CI 0.15-1.26). Compared to PVI + conventional wide empirical ablation, LVA ablation reduced the occurrence of postablation AT (14% vs. 46%, OR = 0.16, 95% CI 0.07-0.37), procedure time (176 min vs. 220 min, OR = 0.36, 95% CI 0.24-0.56), fluoroscopy time (25 min vs. 31 min, OR = 0.22, 95% CI 0.12-0.39), and radiofrequency time (55 min vs. 90 min, OR = 0.49, 95% CI 0.27-0.90). CONCLUSIONS: A voltage-guided substrate modification by targeting LVA in addition to PVI is more effective, safer, and holds a lower proarrhythmic potential than conventional ablation approaches. Further randomized studies are necessary to confirm these findings.

Targeted Cancer Therapies and QT Interval Prolongation: Unveiling the Mechanisms Underlying Arrhythmic Complications and the Need for Risk Stratification Strategies.

The care and treatment of cancer patients has significantly changed in the last decade with a remarkable shift towards novel targeted therapies. These promising new drugs may represent effective and potentially life-saving therapeutic options in cancer patients, but are also emerging in the cardiotoxicity scenario for their arrhythmogenic potential due to their QT-prolonging activity. In this article we review the mechanisms underlying drug-induced QT interval prolongation and the classes of anticancer-targeted therapies most frequently responsible for this adverse event, with a particular focus on tyrosine kinase-targeting molecules. Since up to 49 % of serious adverse drug reactions (ADRs) and 58 % of potentially fatal ADRs may not appear on initial drug safety labels, we also review and discuss data from the post-marketing VigiBase® safety reporting system, the World Health Organization's global database of ADRs. Finally, we discuss arrhythmic risk stratification and prevention strategies in the complex multiple-risk setting of cancer patients, paying particular attention to drug-drug interactions with common antimicrobial, psychotropic and antiemetic supportive care, and we also provide an electrocardiographic QT monitoring algorithm for patients who are candidates for targeted cancer therapies.

Apixaban for periprocedural anticoagulation during catheter ablation of atrial fibrillation: a systematic review and meta-analysis of 1691 patients.

PURPOSE: Apixaban, a direct factor Xa inhibitor recently approved for thromboembolic prophylaxis in patients with nonvalvular atrial fibrillation (AF), is increasingly used in patients undergoing catheter ablation of AF. However, large randomized studies supporting its use in the ablation context are still lacking. We undertook the present meta-analysis to assess the impact of apixaban in terms of thromboembolic and bleeding events in patients undergoing AF ablation as compared to warfarin. METHODS: MEDLINE/PubMed, Cochrane Library, and references reporting AF ablation and apixaban were screened and studies included if matching inclusion and exclusion criteria. RESULTS: One randomized and five nonrandomized studies were included in the analysis. Patients enrolled were 1691 patients (668 on apixaban and 1023 on warfarin). There was no heterogeneity in all the outcome comparisons. No deaths were reported. We did not observe any difference between apixaban and warfarin with respect to thromboembolic events (OR = 1.10, 95 % CI 0.24-5.16), major bleedings (OR = 1.56, 95 % CI 0.59-4.13), cardiac tamponade (OR 1.69, 95 % CI 0.52-5.54), minor bleedings (OR 0.96, 95 % CI 0.58-1.59), and the composite endpoint of death, thromboembolic events, and bleedings (OR 1.03, 95 % CI 0.65-1.64). CONCLUSIONS: The rates of death, thromboembolic events, major bleedings including cardiac tamponade, and minor bleedings in patients on apixaban undergoing AF ablation are very low and similar to that seen in patients treated with uninterrupted warfarin. Although primary driven by nonrandomized studies, these results support apixaban as periprocedural anticoagulation during AF ablation procedures.

Atrial Conduction Velocity Correlates with Frequency Content of Bipolar Signal.

BACKGROUND: Anisotropy in conduction velocity (CV) is a key substrate abnormality influencing atrial arrhythmias. In skeletal muscle fibers, CV and frequency content of the surface electromyogram signal are directly related. We hypothesized that in human atria the frequency content of the bipolar signal, recorded on the endocardial surface, is directly related to the local CV. METHODS: In 15 patients submitted to ablation of supraventricular arrhythmias, incremental pacing was performed through an octapolar catheter inserted into the coronary sinus (CS), alternatively from both extremities in two different sequences: CS bipole 1-2 as the pacing site and CS bipole 7-8 as the detection site in the first, and vice versa in the second. The pacing cycle length (PCL) was stepwise decreased from 600 ms to 500 ms, 400 ms, 300 ms, until 250 ms. Estimation of the CV was performed as the ratio between the distance traveled by the propagating pulse and the propagation time. The frequency distribution of the signal energy was estimated using the fast Fourier transform, and the characteristic frequency (CF) was estimated as the barycenter of the frequency spectrum. RESULTS: A total of 2,496 bipolar signals were analyzed; CV and CF were estimated and compared. The single patient and group data analysis showed a significant direct correlation between CV and CF of the local bipolar signal. CONCLUSIONS: Comparing the degree of spectral compression among signals registered in different points of the endocardial cardiac surface in response to decreasing PCL enables to map local differences in CV, a useful arrhythmogenic substrate index.

Scar Detection by Pulse-Cancellation Echocardiography: Validation by CMR in Patients With Recent STEMI.

OBJECTIVES: This study sought to assess an echocardiographic approach (scar imaging echocardiography with ultrasound multipulse scheme [eSCAR]), based on existing multipulse ultrasound scheme, as a marker of myocardial scar in humans, compared with cardiac magnetic resonance assessing late gadolinium enhancement (CMR-LGE). BACKGROUND: The detection of myocardial scar impacts patient prognosis and management in coronary artery disease and other types of cardiac disease. The clinical experience with echocardiography suggests that the reflected ultrasound signal is often significantly enhanced in infarcted myocardial segments. METHODS: Twenty patients with a recent ST-segment elevation myocardial infarction (STEMI) (cases) and 15 patients with absent CMR-LGE (negative controls) were imaged with both the eSCAR pulse-cancellation echocardiography and CMR-LGE to assess their potential association. RESULTS: Scar was detectable at CMR-LGE in 19 of 20 STEMI patients (91%), whereas all (100%) demonstrated eSCAR at echocardiography. In the 19 STEMI patients in whom CMR-LGE was detected, regional matching between eSCAR and CMR-LGE was total, although the segmental extent of detected scar was not always superimposable, particularly in the most apical segments, a region in which eSCAR demonstrated undersensitivity for the true extent of scar. CONCLUSIONS: A 2-dimensional multipulse echocardiography allows detection of myocardial scar, reliably matching the presence and site of CMR-LGE at 30 days after STEMI, or its absence in negative controls.

Temporal changes in the current practice of primary angioplasty: a real life experience of a single high-volume center.

BACKGROUND: In the last years, new techniques, drugs and devices have been introduced in the current practice of primary angioplasty (PPCI) and validated by pivotal studies The objective of our study was to evaluate if these studies have led to significant changes on the current practice of primary PCI in our center. METHODS: From March 2003 to December 2013 1980 patients with ST-segment elevation myocardial infarction underwent PPCI within 12-hours of onset of symptoms. We considered 2 periods of our activity: from 2003 to 2009 (P1) with 1078 patients and from 2010 to 2013 (P2) with 902 patients, and compared them in terms of pharmacological and arterial access strategies and of devices utilization. RESULTS: In P2 there was a significant increase of radial access (34.1% vs. 1.5, p<0.001), as well as of the use of bivalirudin (22.7% vs. 0.5%, p<0.001) and of new antiplatelet drugs (prasugrel or ticagrelor) (18.3% vs. 0%, p<0.001) whereas the use of GP IIb-IIIa and of intraaortic balloon pump significantly decreased (from 82.3% to 52%, p<0.001 and from 17% to 7.5%, p<0.001 respectively). In the P2 there was a significant increase of the procedural efficacy (97.2% vs. 95.1%, p=0.01) that persisted after the logistic regression adjustment (OR 2.09, CI 95%, 1.04-4.21). CONCLUSIONS: Our study shows that in the last years, in a high-PCI center, after the publication of pivotal randomized trial and nationwide registries, there were significant changes in the PPCI current practice that could have had an impact on procedural efficacy.

Biolimus-Eluting StenT For de-novo coRonary artery dIsease in patiENts with Diabetes mellituS: the BESTFRIENDS multicentre registry.

AIMS: Coronary inflammation and healing influence outcomes of diabetic patients treated with Percutaneous coronary revascularization (PCI). Stents covered with biodegradable polymers (bp) may offer advantages over nonerodible polymer ones, because polymer reabsorption extinguish coronary inflammation and favours healing. Aim of our study was to assess the safety and efficacy of bp-biolimus-eluting stent (bp-BES) in a large series of consecutive diabetic patients. METHODS: From 2009 to 2013 we retrospectively enrolled consecutive diabetic patients treated with PCI and bp-BES implantation. Primary end points were target lesion revascularization (TLR) and stent thrombosis rates. RESULTS: Study cohort counted 747 patients. Multivessel disease was present in 48.2% with a mean stent/patient ratio of 1.860.78. During the hospital stay no stent thrombosis occurred. At 3-year follow-up we observed a 1.5% cumulative incidence of cardiac death, 1.1% of myocardial infarction and 6.3% of TLR. Stent thrombosis occurred in 1.1% of patients, all in the first 2 years of follow-up. Kaplan-Meier analysis showed a TLR-free survival at 1 and 3 years of 97.2 and 96.1%, respectively. CONCLUSION: PCI with bp-BES seems to be well tolerated and effective in a large unselected population of diabetic patients. The good results observed were maintained at 3 years of follow-up.

Electrocardiographic evolution in patients with hypertrophic cardiomyopathy who develop a left ventricular apical aneurysm.

INTRODUCTION: Hypertrophic cardiomyopathy (HCM) patients with apical aneurysm have a largely unfavourable clinical course, and are often unrecognised because echocardiography is limited in the assessment of the left ventricular (LV) apex. The aim of this study is the identification of electrocardiographic (ECG) abnormalities associated with the development of apical aneurysm in HCM patients. MATERIALS AND METHODS: Electrocardiographic features were assessed in 14 HCM patients who had a good-quality baseline ECG recorded before and after the diagnosis of apical aneurysm. RESULTS: During follow-up (8.8±7.5years), the following ECG changes were observed: increase in QRS-complex duration (87±12ms to 118±34ms, p=0.006), QRS-complex fragmentation, decrease in QRS-complex amplitude (SV1+RV5-6, from 41±18mm to 26±11mm, p=0.015), ST-segment elevation in V4-V6 (J-point in V5, from -0.9±1.3mm to +0.7±1.3, p=0.003), positivisation of negative T waves in V3-V6 (T-wave depth in V5, from -3.4±6.6 to +3.1±4.1, p=0.005). CONCLUSIONS: HCM patients who develop LV apical aneurysm exhibit distinctive ECG changes along with apical remodelling. Suggestive ECGs should lead the physician to study LV apex by nonstandard echocardiographic views, and perform MRI.

Risk of sudden death and outcome in patients with hypertrophic cardiomyopathy with benign presentation and without risk factors.

Patients with hypertrophic cardiomyopathy (HC) are reported to have a mortality rate of about 1.0% per year, and those patients without sudden death risk factors and with no or mild symptoms are generally considered to have a benign clinical presentation. However, the risk of sudden death and the outcome in this latter subgroup have not been investigated systematically and remain unresolved. We assessed the risk of sudden death and outcome in 653 consecutive patients with HC without risk factors and with no or mild symptoms. Over a median follow-up of 5.3 years, 35 patients (5.4%) died of HC-related causes. Mean age at death was 46 ± 20 years in patients who died suddenly and 66 ± 15 and 72 ± 9 years, respectively, in patients who died of heart failure or stroke. Event rate was 0.6% per year for sudden death, 0.2% per year for heart failure death, and 0.1% per year for stroke-related death. Sudden death risk was independently and inversely related to age, and risk of heart failure or stroke death was directly related to age (p = 0.020). At 10 years after the initial evaluation, sudden death risk was 5.9%, with sudden death rate being the lowest (0.3% per year) in patients with normal left atrial dimension (≤40 mm). In conclusion, in patients with HC without conventional risk factors and with no or mild symptoms, the risk of sudden death was not negligible, with an event rate of 0.6% per year. Heart failure and stroke-related death were less common and largely confined to older patients. These results underscore the need for a more accurate assessment of the sudden death risk in patients with HC.

Coronary artery bypass graft versus percutaneous coronary intervention with drug-eluting stent implantation for diabetic patients with unprotected left main coronary artery disease: the D-DELTA registry.

AIMS: Data regarding the impact on clinical outcomes of PCI with DES implantation vs. CABG to treat unprotected left main coronary artery (ULMCA) disease in diabetic patients are still insufficient. The present study evaluated the short-term and long-term results of percutaneous and surgical revascularisation in diabetic patients with ULMCA disease in a large population. METHODS AND RESULTS: A total of 826 diabetic patients with ULMCA stenosis who received DES (n=520) or underwent CABG (n=306) were selected and analysed from the DELTA registry. In-hospital MACCE was significantly higher in the CABG group, mainly driven by a higher incidence of MI. At four-year follow-up, freedom from death and the composite endpoint of death, MI and cerebrovascular accident (CVA) was similar in the two treatment groups (CABG 87.4%, PCI 82.5%, p=0.124, and CABG 85.4%, PCI 78.9%, p=0.11, respectively). Conversely, freedom from TVR and MACCE was significantly higher in the CABG compared to the PCI group (CABG 95.4%, PCI 79.4%, p<0.001, and CABG 81.9%, PCI 64.7%, p<0.001). CONCLUSIONS: In diabetic patients with ULMCA disease with/without concomitant multivessel disease, PCI and CABG led to similar results in terms of death, MI and CVA. However, CABG was associated with less MACCE at long-term follow-up, primarily due to the higher repeat revascularisation rate with DES.

Clinical outcomes following percutaneous coronary intervention with drug-eluting stents versus bare metal stents in patients on chronic hemodialysis.

BACKGROUND: Patients on chronic hemodialysis (HD) are recognized as a high-risk group for adverse events after percutaneous coronary intervention, and whether drug-eluting stents (DES) are associated with improved outcomes over bare metal stents (BMS) is still uncertain. The purpose of this study was to assess the efficacy of DES compared with BMS at short- and long-term follow-up (FU) in an unselected sample of HD patients. METHODS AND RESULTS: In the time period 2005-2010, consecutive patients on chronic HD treated with percutaneous coronary intervention (PCI) and stent implantation were retrospectively selected and analyzed. A total of 169 patients were selected, 77 treated exclusively with BMS and 92 exclusively with DES. Baseline clinical characteristics were similar in the 2 groups as well as the number of treated vessels, treated lesions, and the stent per patient ratio. At longest available FU, no difference between the 2 study groups was found in terms of cardiac death (18.2% vs 16.3%, P=0.83), myocardial infarction (2.5% vs 8.6%, P=0.09), cerebrovascular accidents (0% vs 1.1%, P=0.98), and target vessel revascularization (TVR) (9.1% vs 16.3%, P=0.17). Major adverse cardiac and cerebrovascular events-free survival at 1,500 days in the BMS and DES groups was 57.6% and 50.9% (P=0.11), respectively. CONCLUSIONS: PCI in patients on chronic HD treatment is associated with a high incidence of adverse events at FU, mainly represented by death. In our study, the use of DES was not associated with a reduction of target lesion revascularization (TLR) and TVR.

Primary percutaneous coronary intervention without on-site cardiac surgery backup in unselected patients with ST-segment-elevation myocardial infarction: the Rivoli ST-segment elevation myocardial infarction (RISTEMI) registry.

BACKGROUND: Primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy for patients with ST-segment-elevation myocardial infarction (STEMI), but some concerns remain about its safety and efficacy in centers without on-site cardiac surgery (OCS). METHODS: The Infermi Hospital in Rivoli, Italy, is a community hospital without OCS with a high volume catheterization laboratory (>800 PCI and >150 primary PCI per year), which provides a 24-hour primary PCI service to a population of 583.000 and is only 14 km far from the nearest OCS hospital. We analyzed clinical and procedural data, as well as 30-day outcome, of all STEMI patients treated by primary PCI within 12 hours from symptom onset. RESULTS: From September 2001 to June 2010, 1302 patients with a suspect of STEMI underwent urgent coronary angiography. Of these, 1251 (96.1%), underwent primary PCI. A successful myocardial revascularization was achieved in 1172 patients (93.7%). Thirty-day mortality occurred in 7.1%. Multivariate predictors of 30-day mortality were: age ≥75 years (OR 3.96, p=0.0003), left ventricular ejection fraction ≤40% (OR 35.0, p=0.02), cardiogenic shock at presentation (OR 33.4, p<0.0001), anterior STEMI (OR 1.82, p=0.036) and total ischemic time ≤3 hours (OR 0.55, p=0.05). CONCLUSIONS: Primary PCI is a reperfusion strategy feasible and effective in unselected high-risk STEMI patients even in hospitals without OCS with a high volume of routine and emergency interventional procedures.

Relationship of ECG findings to phenotypic expression in patients with hypertrophic cardiomyopathy: a cardiac magnetic resonance study.

BACKGROUND: The 12-lead electrocardiogram (ECG) is considered an essential screening tool for hypertrophic cardiomyopathy (HCM). A vast array of ECG abnormalities has been described in HCM, although their relationship to left ventricle (LV) morphology and degree of hypertrophy appears elusive. Aim of this study was to assess the relationship of ECG patterns with the HCM phenotype assessed according to the novel opportunities offered by cardiac magnetic imaging (CMR). METHODS: CMR and 12-lead ECG were performed in 257 HCM patients. Severity of ECG abnormalities was defined by the sum of 9 criteria: abnormal cardiac rhythm, QRS duration ≥ 100 ms, Romhilt-Estes score ≥ 5, fascicular block (LAHB) and/or bundle-branch block (LBBB or RBBB), ST-T abnormalities, ST-T segment elevation ≥ 0.2 mV, prolonged QTc interval, pathological Q waves, absence of normal Q wave. Four ECG groups were identified: normal (0 criteria); mildly abnormal (1-3 criteria); moderately abnormal (4-6 criteria); markedly abnormal (7-9 criteria). RESULTS: There was a direct relationship between severity of ECG abnormalities and HCM phenotype. LV mass index was normal in most patients with normal ECG and progressively increased with each class of ECG score, from 70.9 ± 18.6g/m(2) in patients with normal ECG to 107.1 ± 55.1g/m(2) among those with markedly abnormal ECG (p=<0.0001). Likewise, the prevalence and extent of late gadolinium enhancement (LGE) increased significantly with the ECG score, from 37% in patients with normal ECG to 93% in patients with markedly abnormal ECG (overall p=0.0012). A normal ECG had a negative predictive accuracy of 96% for markedly increased LV mass (>91 g/m(2) for men and >69 g/m(2) for women), and of 100% for maximum LV thickness ≥ 30 mm. CONCLUSIONS: In a large HCM cohort, the number and severity of ECG abnormalities were directly related to phenotypic expression as revealed by CMR. Although false negative ECG findings remain a challenge in population screenings for HCM, a normal ECG proved effective in ruling out severe LV hypertrophy, suggesting potential implications for long-term follow-up of HCM patients and family members. A simple score for quantification of ECG abnormalities in HCM patients is proposed.

[Heart failure in Italian intensive cardiac care units: data from the BLITZ-3 survey]. / I pazienti con scompenso cardiaco nelle unità di terapia intensiva cardiologica italiane: i dati dello studio BLITZ-3.

BACKGROUND: Only limited information about clinical characteristics, diagnostic procedures and therapeutic options is available in patients admitted to an intensive cardiac care unit (ICCU) for heart failure. The aim of this study was to evaluate causes of admission, clinical characteristics, diagnostic and therapeutic options, and outcome of patients admitted for heart failure in the ICCU network. METHODS: The BLITZ-3 Registry prospectively included patients admitted by 332 Italian ICCUs. Data of the patients admitted with a principal diagnosis of heart failure are analyzed. RESULTS: From April 7 to 20, 2008, 6986 consecutive patients with acute cardiac conditions were admitted to ICCUs; 966 (14%) out of 6986 patients were admitted for acute heart failure. Heart failure was the second cause of admission after acute coronary syndromes (52%). Mean age of patients admitted for heart failure was 73 years, 42% were female, and diabetes accounted for 32% of heart failure patients. Most patients were admitted to the emergency department (62%), and were discharged by the cardiology ward (65%). Median length of stay in the ICCU was 4 days, and during the stay in ICCU 5% of the patients with heart failure died. Advanced age and elevated creatinine values were associated with a higher risk of death. Echocardiography was performed in 79% of heart failure patients, coronary angiography in 10%, assisted ventilation in 15%, ultrafiltration in 3%, and right catheterization in 1%. Diuretics were administered in 93% of patients admitted for acute heart failure, intravenous nitrates in 41%, inotropes in 22%, beta-blockers in 42%, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers in 66%. CONCLUSIONS: In a nationwide survey, acute heart failure accounted for 14% of hospital admissions in ICCUs. Patients admitted for heart failure are usually old, with frequent comorbidities. Diagnostic and therapeutic procedures are rarely used, with the exception of echocardiography.

Long-term outcomes of percutaneous coronary interventions with stent implantation in patients ≤40 years old.

Data on the long-term prognosis of percutaneous coronary intervention (PCI) in young patients are limited. The aim of the present study was to report the immediate and long-term clinical outcomes in a consecutive series of young patients with premature coronary artery disease who underwent PCI with stent implantation. During the study period (2005 to 2010), 214 consecutive patients aged ≤40 years who had undergone PCI with a bare metal stent or drug-eluting stent implantation were retrospectively selected and analyzed. Primary end point of this study was the incidence of major adverse cardiac and cerebrovascular events at short- and long-term follow-up. Mean age was 36.3 ± 3.5 years and 88.3% of patients were men. Three-quarters were active smokers and all patients had ≥1 conventional cardiovascular risk factor. The total number of implanted stents was 272 (154 bare metal stent and 118 drug-eluting stent). During the hospital stay, no patient died, and the incidence of major adverse cardiac and cerebrovascular events was 2.3%. No additional events had occurred at 30 days of follow-up. At a median follow-up of 757 days (interquartile range 365 to 1,818), the overall death rate was 0.9%, and a new revascularization procedure was needed in 12.6% of patients. The major adverse cardiac and cerebrovascular event-free survival rate at the median follow-up point and 1,818 days was 89.6% and 84.2%, respectively. Active smoking and left ventricular ejection fraction <50% were independent predictors of major adverse cardiac and cerebrovascular events. In conclusion, PCI in young patients lead to excellent results in short- and long-term follow-up and should be considered as the treatment of choice. Traditional risk factors are important prognostic determinants of adverse events and might help identify higher risk patients within this cohort.

Early angio-guided complete revascularization versus culprit vessel PCI followed by ischemia-guided staged PCI in STEMI patients with multivessel disease.

BACKGROUND: Optimal management of multivessel disease (MVD) in ST-segment elevation myocardial infarction (STEMI) patients treated by primary percutaneous coronary intervention (PCI) is still unclear. OBJECTIVES: To compare short- and long-term clinical outcomes of early-staged, angio-guided approach and delayed, ischemia-guided treatment of non-infarct-related arteries (IRAs). METHODS: Consecutive patients with STEMI and MVD treated with primary PCI in 6 tertiary care centers were retrospectively selected and analyzed. Major adverse cardiac events (MACE) were defined as the composite end-point of death, MI, and repeat revascularization. All the events were adjudicated according to the Academic Research Consortium (ARC) definitions. RESULTS: In the time period 2004-2008, 800 primary PCIs in STEMI patients with MVD were performed. Four hundred and seventeen were addressed to early-staged, angio-guided PCI of non-IRAs (CR group) and 383 to an incomplete revascularization (IncR group). During the hospital stay, no difference in terms of death and repeat revascularization was found between groups but the incidence of periprocedural MI/reinfarction and MACE was significantly higher in the CR group (13.9% vs. 3.1%, P = 0.01 and 14.1% vs. 9.1%, P = 0.017, respectively). At a mean follow-up of 642 ± 545 days, no difference in terms of death and MI was found between the CR and IncR group. The MACE-free survival was significantly higher in the IncR group (73.8% vs. 57%, log rank 0.05), mainly driven by the lower incidence of re-PCI. CONCLUSIONS: Early complete revascularization based only on angiographic findings in patients with STEMI and MVD is associated with an excess of periprocedural/re-MI and with a significantly higher incidence of MACE at follow-up.