Ventricular Septal Rupture Complicating an Acute ST-Segment Elevation Myocardial Infarction during the COVID-19 Pandemic.

Ventricular septal rupture (VSR) is rare but a lethal complication of acute myocardial infarction (MI). Definite treatment requires the surgical closure of the VSR and coronary artery bypass grafting (CABG). However, the optimal timing for surgery is still controversial, particularly during the novel coronavirus disease 2019 (COVID-19) pandemic where medical procedures should be performed within the safest environment. Before surgery, a proper management in the intensive cardiovascular care unit is essential to maintain the stability of the hemodynamic profile related with VSR and determines the prognosis of the patient. We described a case of VSR complicating an anterior wall MI in a patient who admitted to our hospital during the COVID-19 pandemic that was treated successfully by surgical closure of the VSR and CABG.

Interhospital Transfer versus Direct Admission in Patients with Acute ST-Segment Elevation Myocardial Infarction.

There is concern whether patients with ST-segment elevation myocardial infarction (STEMI) who admitted to a percutaneous coronary intervention (PCI) center from interhospital transfer is associated with longer reperfusion time compared with direct admission. We evaluated the reperfusion delays in patients with STEMI who admitted to a primary PCI center through interhospital transfer or direct admission. We retrospectively analyzed 6,494 consecutive STEMI patients admitted between 2011 and 2019. Compared with direct admission ( n = 4,121; 63%), interhospital transferred patients ( n = 2,373) were younger (55 ± 10 vs. 56 ± 10 years, p < 0.001), had similar gender (85.6 vs. 86% male, p = 0.67), greater proportion of off-hour admission (65.2 vs. 48.3%, p < 0.001), less diabetes mellitus (28 vs. 30.8%, p = 0.019), and received more primary PCI (70.5 vs. 48.7%, p < 0.001). Interhospital transferred patients who received primary PCI ( n = 3,677) or fibrinolytic ( n = 238) had longer symptom-to-PCI center admission time (median, 360 vs. 300 minutes, p < 0.001), shorter door-to-device (DTD) time for primary PCI (median, 74 vs. 87 minutes, p < 0.001), and longer total ischemic time (median, 465 vs. 414 minutes, p < 0.001). Logistic regression in interhospital transferred patients showed that delay in door-in-to-door-out (DI-DO) time at the first hospital was strongly associated with prolonged total ischemic time (adjusted odds ratio = 3.92; 95% confidence interval: 3.06-5.04, p < 0.001). This study suggests that although interhospital transferred patients received more primary PCI with shorter DTD time, interhospital transfer creates longer total ischemic time that associates with the delay in DI-DO time at the first hospital that should be improved.

Relationship between Hemoglobin Concentration at Admission with the Incidence of No-Reflow Phenomenon and In-Hospital Mortality in Acute Myocardial Infarction with Elevation of ST Segments in Patients who underwent Primary Percutaneous Coronary Intervention.

Anemia in acute ST-segment elevation myocardial infarction (STEMI) is associated with a pro-coagulant state, contributing to the incidence of no-reflow phenomenon and increased mortality following primary percutaneous coronary intervention (PPCI). However, clinical data remain contradictory. The objective of our study was to evaluate the association of admission hemoglobin (Hb) concentration and in-hospital mortality of STEMI patients' post-PPCI, as well as final thrombolysis in myocardial infarction (TIMI) flow. A cross-sectional study was performed from the database of Jakarta Acute Coronary Syndrome Registry, consisting of 3,071 STEMI patients who underwent PPCI between January 2014 and December 2019. No-reflow phenomenon was defined as final TIMI flow <3 of the infarct-related artery. Outcome measures were the occurrence of no-reflow and in-hospital mortality. Anemia criteria were based on the World Health Organization. Anemia was found in 550 patients (17.9%). Patients with anemia were older (60 ± 10 years, p < 0.001), predominantly women (20.7 vs. 11.2%, p < 0.001), TIMI risk score >4 (45.8 vs. 30.4%, p < 0.00), and Killip classification >1 (25.8 vs. 20.8%, p < 0.009). Anemia at admission was not associated with no-reflow phenomenon (odds ratio [OR] = 0.889; 95% confidence interval [CI] = 0.654-1.209, p = 0.455). Multivariate regression models showed that anemia was not associated with in-hospital mortality (OR = 0.963; 95% CI = 0.635-1.459, p = 0.857) and with no-reflow phenomenon (OR = 0.939; 95% CI = 0.361-2.437, p = 0.896). Anemia upon admission was not related to the no-reflow phenomena or in-hospital mortality in STEMI patients undergoing PPCI.

Association of Admission Time and Mortality in STEMI Patients: A Systematic Review and Meta-analysis.

This systematic review and meta-analysis aimed to evaluate patients with acute ST-segment elevation myocardial infarction (STEMI) who were admitted during off-hours and treated with primary angioplasty associated with an increased risk of mortality compared with those admitted during regular working hours. We performed a systematic literature search using PubMed, SCOPUS, Europe PMC, and Cochrane CENTRAL databases that was finalized on March 15, 2021. The primary outcome was mortality comprising early (in-hospital), midterm (30 days to 1 year), and long-term mortality (>1 year). A total of 384,452 patients from 56 studies were included. The overall mortality of acute STEMI patients admitted during off-hours and regular hours were 6.1 and 6.7%, respectively. Patients admitted during off-hours had similar risk of early, midterm, and long-term mortality compared to those admitted during regular working hours ([relative risk or RR = 1.07, 95% confidence interval or CI, 1.00-1.14, p = 0.06; I 2 = 45%, p = 0.0009], [RR = 1.00, 95% CI, 0.95-1.05, p = 0.92; I 2 = 13%, p = 0.26], and [RR = 0.95, 95% CI, 0.86-1.04, p = 0.26; I 2 = 0%, p = 0.76], respectively). Subgroup analyses indicated that the results were consistent across all subgroups ([women vs. men], [age >65 years vs. ≤65 years], and [Killip classification II to IV vs. Killip I]). Funnel plot was asymmetrical. However, Egger's test suggests no significance of small-study effects ( p = 0.19). This meta-analysis showed that patients with acute STEMI who were admitted during off-hours and treated with primary angioplasty had similar risk of early, midterm, and long-term mortality compared with those admitted during regular working hours.

Performance of Primary Angioplasty for STEMI during the COVID-19 Outbreak.

There has been concern whether the declining cases of ST-segment elevation myocardial infarction (STEMI) during the coronavirus disease 2019 (COVID-19) outbreak associate with primary angioplasty performance. We assessed the performance of primary angioplasty in a tertiary care hospital in Jakarta, Indonesia, by comparing the door-to-device (DTD) time and thrombolysis in myocardial infarction (TIMI) flow after angioplasty between two periods of admission: during the outbreak of COVID-19 (March 1 to May 31, 2020) and before the outbreak (March 1, to May 31, 2019). Overall, there was a relative reduction of 44% for STEMI admission during the outbreak ( n = 116) compared with before the outbreak ( N = 208). Compared with before the outbreak period ( n = 141), STEMI patients who admitted during the outbreak and received primary angioplasty ( n = 70) had similar median symptom onset-to-angioplasty center admission (360 minutes for each group), similar to radial access uptake (90 vs. 89.4%, p = 0.88) and left anterior descending infarct-related artery (54.3 vs. 58.9%, p = 0.52). The median DTD time and total ischemia time were longer (104 vs. 81 minutes, p < 0.001, and 475.5 vs. 449 minutes, p = 0.43, respectively). However, the final achievement of TIMI 3 flow was similar (87.1 vs. 87.2%), and so was the in-hospital mortality (5.7 vs. 7.8%). During the COVID-19 outbreak, we found a longer DTD time for primary angioplasty, but the achievement of final TIMI 3 flow and in-hospital mortality were similar as compared with before the outbreak. Thus, primary angioplasty should remain the standard of care for STEMI during the COVID-19 outbreak.

Corticosteroid Therapy in Management of Myocarditis Associated with COVID-19; a Systematic Review of Current Evidence.

INTRODUCTION: Myocarditis in patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seems to be associated with a higher mortality rate. This study aims to summarize the latest evidence on whether the use of corticosteroids in patients with myocarditis associated with COVID-19 is necessary. METHODS: We performed an extensive search using a combination of search terms in PubMed, Europe PMC, ProQuest, EBSCOhost, and Google Scholar up to January 2021. Full-text articles that met the predefined inclusion criteria were included in the present study. RESULTS: The full-texts of 18 articles have been reviewed. Thirteen out of the eighteen (72%) patients who got corticosteroid administration experienced major clinical improvements during follow-up while the other five (28%) were experiencing uneventful events. The mean age of the reported patients was 47.8±13.2 years. There was no gender predominance. Most of the reported cases were from USA (39%) followed by Spain, China, and UK (11% each), while Brazil, Colombia, France, Belgium, and Italy contributed one case each. Various corticosteroids were used but the most commonly applied were methylprednisolone (89%), hydrocortisone (5.5%), and prednisolone (5.5%). The most common route of administration among the studies was intravenous administration and the duration of treatment varied between one and fourteen days. CONCLUSION: A review of the currently available literature shows that with the use of corticosteroid agents in treating myocarditis associated with COVID-19, favorable outcomes are attainable. Well-established randomized clinical trials are needed to evaluate the efficacy and safety of using corticosteroids in this condition.

Association of gender with clinical outcomes of patients with acute ST-segment elevation myocardial infarction presenting with acute heart failure.

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

Comparison of Real-Life Systems of Care for ST-Segment Elevation Myocardial Infarction.

The success of ST-segment elevation myocardial infarction (STEMI) networks application in Europe and the United States in delivering rapid reperfusion therapy in the community have become an inspiration to other developing countries to develop regional STEMI network in order to improve the STEMI care. Although barriers are found in the beginning phase of constructing the network, recent analysis from national or regional registries worldwide have shown improvement of the STEMI care in many countries over the years. To improve the overall care of patients with STEMI particularly in developing countries, improvements should be focusing on how to minimize the total ischemia time, and this includes care improvement at each step of care after the patient shows signs and symptoms of chest pain. Innovation in health technology to develop the electrocardiogram transmission and communication system, along with routine performance measures of the STEMI network may help bridging the disparities of STEMI system of care between guideline recommended therapy and the real world clinical practice.

Association of microRNA-224-3p and microRNA-155-5p expressions with plasma long pentraxin 3 concentration and coronary microvascular obstruction following primary angioplasty for acute ST-segment elevation myocardial infarction.

OBJECTIVE: Pro-inflammatory stimuli induce a variety set of microRNAs (miRs) expression that regulate long pentraxin-3 (PTX3) protein, which associates with a procoagulant state in the endothelial cells. We evaluated, for the first time in human, the association of miR-224-3p and miR-155-5p expressions with plasma PTX3 concentration and coronary microvascular obstruction (MVO) in patients with acute ST-segment elevation myocardial infarction (STEMI) with symptom onset ≤ 12 h and treated by primary angioplasty. Blood samples for miRs and PTX3 measurement were drawn at emergency department presentation, and were measured by TaqMan real-time PCR and human ELISA kit, respectively. RESULTS: Of the 217 patients (median age: 54 years, male: 88%), 130 (60%) had angiographic MVO. Spearman analysis showed no correlation between miR-224-3p and miR-155-5p expressions with plasma PTX3 concentration. After adjustment with sex, age, diabetes mellitus, and plasma PTX3 concentration, miR-224-3p ≥ median group was associated with angiographic MVO (odds ratio, 2.60; 95% confidence interval, 1.24 to 5.44, p = 0.01). This study suggests that miR-224-3p and miR-155-5p expressions did not correlate with plasma PTX3 concentration. However, miR-224-3p expression associates with angiographic MVO following primary angioplasty for STEMI. Future studies are needed to identify the specific gene/protein related with miR-224-3p expression in MVO.

Double Antithrombotic versus Triple Antithrombotic Therapy in Patients with Atrial Fibrillation and Acute Coronary Syndrome.

In atrial fibrillation (AF), oral anticoagulant (OAC) therapy with either vitamin K antagonist or non-vitamin K antagonist is used to prevent thromboembolic complications. In patients who presented with acute coronary syndrome (ACS) and were treated by percutaneous coronary intervention (PCI), dual antiplatelet therapy (DAPT) with aspirin and a P2Y 12 inhibitor reduces major adverse cardiac events (MACEs) and stent thrombosis. Consequently, in patients with AF who presented with ACS and were treated by PCI, the combination of OAC and DAPT, the so-called triple antithrombotic therapy (TAT) is needed to improve the outcome of the patients. However, the use of TAT increases the risk of bleeding. Several randomized clinical trials and a meta-analysis evaluated the use of TAT and double antithrombotic therapy (DAT) in this population, and DAT is defined as patients who receive combination of one antiplatelet and OAC. In general, the studies demonstrated a reduction in bleeding event in patients who received DAT as compared with TAT, with similar incidence of thromboembolic complications and MACE. To date, there is no established consensus or guideline for the most appropriate combination of antithrombotic agents in patients with AF and ACS who undergo PCI. Tailoring the treatment for each individual is likely the best approach to determine the balance of bleeding risk and ischemic events before starting antithrombotic therapy. Future trials with adequate sample size are needed to find the most appropriate combination of antiplatelet and OAC in patients with AF who presented with ACS and treated by PCI.

Association between Adherence to Guideline-Recommended Preventive Medications and In-Hospital Mortality among Non-Reperfused ST-Elevation Myocardial Infarction Patients Admitted to a Tertiary Care Academic Center in a Developing Country.

Background and aims: Acute ST-elevation myocardial infarction (STEMI) is a potentially fatal presentation of coronary artery disease (CAD). Evidence of the impact of acute pharmacological interventions in non-reperfused STEMI patients on subsequent events is limited. We aimed to assess the association between adherence to guideline-recommended preventive medications and in-hospital mortality among this high-risk patient population. Methods: We conducted a cohort study using data obtained from the Jakarta Acute Coronary Syndrome (JAC) Registry database from a tertiary care academic hospital in Indonesia. We included 1132 of 2694 patients with STEMI recorded between 1 January 2014 and 31 December 2016 who did not undergo acute reperfusion therapy. Adherence to guideline-recommended preventive medications was defined as the combined administration of aspirin, clopidogrel, anticoagulants and statins after hospital admission. The main outcome measure was in-hospital mortality. Results: Overall, 778 of 1132 patients (69%) received the combination of preventive medications. The guideline non-adherent group had significantly more patients with earlier onset of STEMI, higher Killip class and thrombolysis in myocardial infarction (TIMI) score. After adjustments for measured characteristics using logistic regression modeling, exposure to the combination of preventive therapies was associated with a statistically significant lower risk for in-hospital mortality (adjusted odds ratio: 0.46, 95% confidence interval: 0.30-0.70). Conclusions: Adherence to guideline-recommended preventive medications was associated with lower risk of in-hospital mortality in non-reperfused STEMI patients. The predictors of not receiving these medications need to be confirmed in future research.

"Door-In to Door-Out" Delay in Patients with Acute ST-Segment Elevation Myocardial Infarction Transferred for Primary Percutaneous Coronary Intervention in a Metropolitan STEMI Network of a Developing Country.

Background Routine performance measures of primary percutaneous coronary intervention (PCI) within an ST-segment elevation myocardial infarction (STEMI) network are needed to improve care. Objective We evaluated the door-in to door-out (DI-DO) delays at the initial hospitals in STEMI patients as a routine performance measure of the metropolitan STEMI network. Patients and Methods We retrospectively analyzed the DI-DO time from 1,076 patients with acute STEMI who were transferred by ground ambulance to a primary PCI center for primary PCI between 4 October 2014 and 1 April 2019. Correlation analysis between DI-DO times and total ischemia time was performed using Spearman's test. Logistic regression analyses were used to find variables associated with a longer DI-DO time. Results Median DI-DO time was 180 minutes (25th percentile to 75th percentile: 120-252 minutes). DI-DO time showed a positive correlation with total ischemia time ( r = 0.4, p < 0.001). The median door-to-device time at the PCI center was 70 minutes (25th percentile to 75th percentile: 58-88 minutes). Multivariate analysis showed that women patients were independently associated with DI-DO time > 120 minutes (odds ratio 1.55, 95% confidence interval 1.03 to 2.33, p = 0.03). Conclusion The DI-DO time reported in this study has not reached the guideline recommendation. To improve the overall performance of primary PCI in the region, interventions aimed at improving the DI-DO time at the initial hospitals and specific threat for women patients with STEMI are possibly the best efforts in improving the total ischemia time.

Association of plasma pentraxin 3 concentration with angiographic and clinical outcomes in patients with acute ST-segment elevation myocardial infarction treated by primary angioplasty.

OBJECTIVE: To evaluate the association of plasma long pentraxin 3 (PTX3) concentration with angiographic and clinical outcomes in patients with acute ST-segment elevation myocardial infarction (STEMI) treated by primary angioplasty. BACKGROUND: Whether concentration of PTX3, a sensitive marker of inflammation, associates with angiographic and clinical outcomes in STEMI patients treated by primary angioplasty is unknown. METHODS: We prospectively enrolled 335 consecutive patients with acute STEMI undergoing primary angioplasty. Blood samples for plasma PTX3 measurement were drawn in all patients at the emergency department before primary angioplasty, and were measured by ELISA method. RESULTS: The median PTX3 concentrations were higher in patients with thrombus burden grade 4 and 5 versus grade <4 on initial coronary angiogram (0.29 ng/ml vs. 0.24 ng/ml, p = .02), thrombolysis in myocardial infarction (TIMI) grade <3 vs. TIMI grade-3 flow after primary angioplasty (0.31 ng/ml vs. 0.24 ng/ml, p < .001), incomplete versus complete ST-segment resolution within 12 hr after angioplasty (0.29 ng/ml vs. 0.22 ng/ml, p = .001) and in patients who did not survive versus those who survived at 30 days (0.44 ng/ml vs. 0.26 ng/ml, p = .001). A linear correlation was observed between PTX3 concentration and baseline leukocyte count (Spearman correlation = 0.21, p < .001). After adjustment for laboratory and selected clinical variables, patients in the highest quartile of PTX3 concentration (≥0.4 ng/ml) were associated with increased risk of 30-day mortality (hazard ratio = 11.83; 95% confidence interval = 1.52-92.27, p = .01). CONCLUSION: This study suggests that higher plasma PTX3 concentration associates with worse angiographic and clinical outcomes in STEMI patients treated by primary angioplasty.

Association of Hyperglycemia and Final TIMI Flow with One-Year Mortality of Patients with Acute ST-Segment Elevation Myocardial Infarction Undergoing Primary PCI.

The association of hyperglycemia at admission and final thrombolysis in myocardial infarction (TIMI) flow with 1-year mortality of patient with acute ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not much been explored. We evaluated the association of hyperglycemia and final TIMI flow with 1-year mortality in patients with acute STEMI who underwent primary PCI. We retrospectively analyzed 856 patients with STEMI who underwent primary PCI in a tertiary care academic center between January 2014 and July 2016. Based on the receiver operating characteristics curve, the cutoff used for hyperglycemia in this study was greater than or equal to 169 mg/dL. Cox proportional hazard model was used to determine the association of hyperglycemia and TIMI flow with 1-year mortality. Compared with patients with lower blood glucose level (<169 mg/dL; n = 549), a greater proportion of patients who presented with hyperglycemia (≥169 mg/dL; n = 307) had final TIMI flow 0 to 1 (3.3 vs. 0.5%; adjusted odds ratio = 5.58, 95% confidence interval [CI] 1.30-23.9, p = 0.02). Hyperglycemia was associated with an increased risk for 1-year mortality (adjusted hazard ratio [HR]= 2.0, 95% CI: 1.13-3.53, p = 0.017). Multivariable Cox regression showed that the interaction of hyperglycemia and final TIMI flow 0 to 1 was associated with an elevated risk for 1-year mortality (adjusted HR= 9.4, 95% CI: 2.34-37.81, p = 0.002). A higher proportion of patients with acute STEMI who presented with hyperglycemia had final TIMI flow 0 to 1 after primary PCI. The interaction of hyperglycemia and final TIMI flow 0 to 1 was associated with an increased risk for 1-year mortality. This study suggests that aggressive control of hyperglycemia prior to primary PCI may facilitate better angiographic and clinical outcomes after primary PCI. Clinical Trial Registration Clinicaltrials.gov Identifier number: NCT02319473.

The Predictors of Post-Procedural Arm Pain after Transradial Approach in 1706 Patients Underwent Transradial Catheterization.

BACKGROUND: Although patients prefer radial over femoral approach, some develop post-procedural arm pain after transradial procedures. This complication has been poorly defined in prior studies. We evaluated the extent of non-ischemic arm pain after transradial arterial access and identify variables that may be associated with this complication. METHODS: We performed a retrospective analysis of a 1706 patient database on patients who underwent transradial catheterization at three experienced radial centers. Arm pain was assessed by adult visual analogue scale (score > 4) defined as moderate to severe pain at the accessed forearm not related to hand ischemia and was evaluated at one day after the procedure. Logistic regression was used to identify the predictors of post-procedural arm pain. RESULTS: The overall incidence of post-procedural arm pain one day after a transradial procedure was 4.5%. Covariate associated with post-procedural arm pain were hemostasis compression >4 h (odds ratio (OR) = 29.47, p < 0.001), radial artery occlusion by Doppler evaluation (OR = 3.35, p < 0.001), radial artery diameter < 2.8 mm (OR = 2.66, p = 0.01), and multiple puncture attempts (OR = 2.31, p = 0.03). CONCLUSION: Approximately 1 in 20 patients undergoing transradial procedure have post-procedural arm pain one day after the procedure. Predictors of this complication relate to radial hemostasis, radial artery occlusion, radial artery diameter, and number of access attempts.

Different Spasmolytic Regimens (Nitroglycerin vs Verapamil) and the Incidence of Radial Artery Occlusion After Transradial Catheterization.

OBJECTIVE: This study evaluated whether use of different spasmolytic regimens (nitroglycerin or verapamil) administered soon after sheath insertion affects postprocedure radial artery occlusion (RAO) in patients who underwent transradial catheterization. METHODS AND RESULTS: We performed a post hoc analysis of a randomized trial evaluating the use of 500 µg intra-arterial nitroglycerin just before sheath removal in 1706 patients undergoing transradial catheterization. Patients who received 200 µg or 300 µg nitroglycerin after sheath placement (group A; n = 688) were compared with patients who received 5 mg verapamil after sheath placement (group B; n = 1018). The primary endpoint was RAO diagnosed by Doppler ultrasound examination at 1 calendar day after the procedure. Logistic regression was used to determine predictors of RAO. RAO occurred in 16.0% of group A and 5.4% of group B. After adjustment for potential confounders, neither the use of verapamil nor nitroglycerin was associated with RAO (odds ratio [OR], 1.24; 95% confidence interval [CI], 0.51-3.02; P=.62). Radial artery compression >4 hours was the strongest predictor of RAO (OR, 5.41; 95% CI, 2.31-12.65; P<.001). CONCLUSIONS: In this study, the use of verapamil or nitroglycerin as a spasmolytic regimen was not associated with RAO. Given the strong association between duration of radial compression and RAO, further studies are needed to determine the interaction between vasodilator agents and compression protocols on RAO.