Reliability of Fractional Flow Reserve in Non-Infarct-Related Arteries in ST-Segment Elevation Myocardial Infarction Patients Undergoing a Pharmaco-Invasive Approach.

Objectives We investigated the reproducibility of fractional flow reserve (FFR) of significant stenoses (≥70% narrowing) in the non-infarct related artery (NIRA) during the pharmaco-invasive percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI) within 24 hours of thrombolysis and at a follow up of 2-3 weeks. Background STEMI with multivessel disease has worse outcomes. The benefits of FFR-directed PCI of NIRA at the time of primary PCI are yet controversial. Assessing the hemodynamic severity of the NIRA may help in deciding the management strategy of these lesions, save time, and avoid complications. Methods Thirty-one patients undergoing PCI for STEMI under a pharmaco-invasive approach were prospectively recruited. The FFR measurements in 34 stenoses (≥70% diameter stenosis) were obtained immediately after PCI of the culprit stenosis and were repeated at a mean follow-up of 17.6 ± 3.55 (14-21) days. In addition, time to thrombolysis, time from symptom onset to PCI, left ventricular ejection fraction (LVEF), quantitative coronary angiographic measurements of the non-culprit stenoses, and thrombolysis in myocardial infarction (TIMI) flow were recorded. Results There was a significant change in FFR values at follow-up as compared to baseline (0.78 ± 0.08 (0.68-0.93) to 0.77 ± 0.08 (0.67-0.93)) (p = 0.014). In four of the lesions, the FFR values differed by >0.05 at follow-up. The follow-up FFR values led to a change in the management strategy in 5 out of 31 patients (15%) of the lesions. The TIMI flow, percentage diameter stenosis, minimum lumen diameter, and LVEF did not change. There were no predictors of this change in FFR values. Conclusions During the acute phase of STEMI, the severity of non-culprit coronary artery stenoses can not be reliably assessed by FFR. The prolonged jeopardized state of myocardium in pharmaco-invasive PCI as compared to primary PCI seems to be responsible.

Optical Coherence Tomography Findings in Patients Presenting With In-Stent Restenosis: A Prospective Observational Study of Patterns of Neointimal Hyperplasia and Associated Risk Factors.

Introduction Morphological features of neointimal tissue play a pivotal role in the pathophysiology of in-stent restenosis (ISR) after percutaneous coronary intervention (PCI). This study was designed to qualitatively and quantitatively assess neointimal characteristics of lesions using optical coherence tomography (OCT) in patients presenting with ISR.  Methods This was a single-center, prospective, observational study performed at a tertiary-care center in India. Patients diagnosed with stable angina and acute coronary syndrome with post-procedural angiographically documented restenosis (>50%) were included. Results A total of 34 patients with ISR were studied. Neointimal hyperplasia was classified as (i) homogenous group (n = 18) and (ii) non-homogenous group (n = 16). Fourteen (77.8%) diabetics belonged to the homogenous group. Predominant plaque characteristics such as neoatherosclerosis, cholesterol crystals, and calcium were documented in 14 (77.8%), 12 (66.7%), and 11 (61.1%) patients in the homogenous group and 10 (62.5%), 10 (62.5%), and 9 (56.2%) patients in the non-homogenous group, respectively. Unexpanded stent struts were identified in 11 (61.1%) and 11 (68.8%) patients in the homogenous and non-homogenous groups, respectively. Mean strut thickness was 93.73 ± 31.03 µm and 83.54 ± 18.0 µm, ISR was 72.50 ± 15.93% and 65.37 ± 21.69%, the neointimal thickness was 588.06 ± 167.82 µm and 666.25 ± 218.05 µm, and neointimal hyperplasia was 54.54 ± 11.23% and 59.26 ± 8.86% in the homogenous and non-homogenous groups, respectively. Conclusion Neoatherosclerosis and stent underexpansion were predominantly observed in our study and only diabetes was found to be significantly associated with homogenous neointimal hyperplasia.

De novo sequencing, assembly, and characterization of Asparagus racemosus transcriptome and analysis of expression profile of genes involved in the flavonoid biosynthesis pathway.

Asparagus racemosus is known for its diverse content of secondary metabolites, i.e., saponins, alkaloids, and a wide range of flavonoids. Flavonoids, including phenols and polyphenols, have a significant role in plant physiology and are synthesized in several tissues. Despite the diverse role of flavonoids, genetic information is limited for flavonoid biosynthesis pathways in A. racemosus. The current study explores full-scale functional genomics information of A. racemosus by de novo transcriptome sequencing using Illumina paired-end sequencing technology to elucidate the genes involved in flavonoid biosynthesis pathways. The de novo assembly of high-quality paired-end reads resulted in ∼2.3 million high-quality reads with a pooled transcript of 45,647 comprising ∼76 Mb transcriptome with a mean length (bp) of 1,674 and N50 of 1,868bp. Furthermore, the coding sequence (CDS) prediction analysis from 45,647 pooled transcripts resulted in 45,444 CDS with a total length and mean length of 76,398,686 and 1,674, respectively. The Gene Ontology (GO) analysis resulted in a high number of CDSs assigned to 25,342 GO terms, which grouped the predicted CDS into three main domains, i.e., Biological Process (19,550), Molecular Function (19,873), and Cellular Component (14,577). The Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway database was used to categorize 6,353 CDS into 25 distinct biological pathway categories, in which the majority of mapped CDS were shown to be related to translation (645), followed by signal transduction (532), carbohydrate metabolism (524), folding, sorting, and degradation (522). Among these, only ∼64 and 14 CDSs were found to be involved in the phenylpropanoid and flavonoid biosynthesis pathways, respectively. Quantitative Real-time PCR was used to check the expression profile of fourteen potential flavonoid biosynthesis pathway genes. The qRT-PCR analysis result matches the transcriptome sequence data validating the Illumina sequence results. Moreover, a large number of genes associated with the flavonoids biosynthesis pathway were found to be upregulated under the induction of methyl jasmonate. The present-day study on transcriptome sequence data of A. racemosus can be utilized for characterizing genes involved in flavonoid biosynthesis pathways and for functional genomics analysis in A. racemosus using the reverse genetics approach (CRISPR/Cas9 technology).

Developing Standard Treatment Workflows-way to universal healthcare in India.

Primary healthcare caters to nearly 70% of the population in India and provides treatment for approximately 80-90% of common conditions. To achieve universal health coverage (UHC), the Indian healthcare system is gearing up by initiating several schemes such as National Health Protection Scheme, Ayushman Bharat, Nutrition Supplementation Schemes, and Inderdhanush Schemes. The healthcare delivery system is facing challenges such as irrational use of medicines, over- and under-diagnosis, high out-of-pocket expenditure, lack of targeted attention to preventive and promotive health services, and poor referral mechanisms. Healthcare providers are unable to keep pace with the volume of growing new scientific evidence and rising healthcare costs as the literature is not published at the same pace. In addition, there is a lack of common standard treatment guidelines, workflows, and reference manuals from the Government of India. Indian Council of Medical Research in collaboration with the National Health Authority, Govt. of India, and the WHO India country office has developed Standard Treatment Workflows (STWs) with the objective to be utilized at various levels of healthcare starting from primary to tertiary level care. A systematic approach was adopted to formulate the STWs. An advisory committee was constituted for planning and oversight of the process. Specialty experts' group for each specialty comprised of clinicians working at government and private medical colleges and hospitals. The expert groups prioritized the topics through extensive literature searches and meeting with different stakeholders. Then, the contents of each STW were finalized in the form of single-pager infographics. These STWs were further reviewed by an editorial committee before publication. Presently, 125 STWs pertaining to 23 specialties have been developed. It needs to be ensured that STWs are implemented effectively at all levels and ensure quality healthcare at an affordable cost as part of UHC.

Impact of Complete Revascularization in the ISCHEMIA Trial.

BACKGROUND: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. OBJECTIVES: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. METHODS: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. RESULTS: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference -3.5; 95% CI: -7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was -2.4%. Results were similar but less pronounced with FCR. CONCLUSIONS: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Impact of complete revascularization in the IschemiaTrial

BACKGROUND: Anatomic complete revascularization (ACR) and functional complete revascularization (FCR) have been associated with reduced death and myocardial infarction (MI) in some prior studies. The impact of complete revascularization (CR) in patients undergoing an invasive (INV) compared with a conservative (CON) management strategy has not been reported. OBJECTIVES: Among patients with chronic coronary disease without prior coronary artery bypass grafting randomized to INV vs CON management in the ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches) trial, we examined the following: 1) the outcomes of ACR and FCR compared with incomplete revascularization; and 2) the potential impact of achieving CR in all INV patients compared with CON management. METHODS: ACR and FCR in the INV group were assessed at an independent core laboratory. Multivariable-adjusted outcomes of CR were examined in INV patients. Inverse probability weighted modeling was then performed to estimate the treatment effect had CR been achieved in all INV patients compared with CON management. RESULTS: ACR and FCR were achieved in 43.4% and 58.4% of 1,824 INV patients. ACR was associated with reduced 4-year rates of cardiovascular death or MI compared with incomplete revascularization. By inverse probability weighted modeling, ACR in all 2,296 INV patients compared with 2,498 CON patients was associated with a lower 4-year rate of cardiovascular death or MI (difference -3.5; 95% CI: -7.2% to 0.0%). In comparison, the event rate difference of cardiovascular death or MI for INV minus CON in the overall ISCHEMIA trial was -2.4%. Results were similar but less pronounced with FCR. CONCLUSIONS: The outcomes of an INV strategy may be improved if CR (especially ACR) is achieved. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Rotablation-Assisted Staged Culottes Bifurcation Stenting of Left Main Chronic Total Occlusion.

Left main coronary artery chronic total occlusion is an unusual finding discovered on coronary angiography. Historically, coronary artery bypass graft has been the preferred treatment. However, recent studies have revealed the role of left main percutaneous coronary intervention in selected patients. This is a case of staged left main coronary artery chronic total occlusion percutaneous coronary intervention. (Level of Difficulty: Advanced.).

Feasibility and efficacy of delayed pharmacoinvasive therapy for ST-elevation myocardial infarction.

BACKGROUND: ST-elevation myocardial infarction (STEMI) refers to a clinical syndrome that features symptoms of myocardial ischemia with consequent ST-elevation on electrocardiography and an associated rise in cardiac biomarkers. Rapid restoration of brisk flow in the coronary vasculature is critical in reducing mortality and morbidity. In patients with STEMI who could not receive primary percutaneous coronary intervention (PCI) on time, pharmacoinvasive strategy (thrombolysis followed by timely PCI within 3-24 h of its initiation) is an effective option. AIM: To analyze the role of delayed pharmacoinvasive strategy in the window period of 24-72 h after thrombolysis. METHODS: This was a physician-initiated, single-center prospective registry between January 2017 and July 2017 which enrolled 337 acute STEMI patients with partially occluded coronary arteries. Patients received routine pharmacoinvasive therapy (PCI within 3-24 h of thrombolysis) in one group and delayed pharmacoinvasive therapy (PCI within 24-72 h of thrombolysis) in another group. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE) within 30 d of the procedure. The secondary endpoints included major bleeding as defined by Bleeding Academic Research Consortium classification, angina, and dyspnea within 30 d. RESULTS: The mean age in the two groups was comparable (55.1 ± 10.1 years vs 54.2 ± 10.5 years, P = 0.426). Diabetes was present among 20.2% and 22.1% of patients in the routine and delayed groups, respectively. Smoking rate was 54.6% and 55.8% in the routine and delayed groups, respectively. Thrombolysis was initiated within 6 h of onset of symptoms in both groups (P = 0.125). The mean time from thrombolysis to PCI in the routine and delayed groups was 16.9 ± 5.3 h and 44.1 ± 14.7 h, respectively. No significant difference was found for the occurrence of measured clinical outcomes in the two groups within 30 d (8.7% vs 12.9%, P = 0.152). Univariate analysis of demographic characteristics and risk factors for patients who reported MACCE in the two groups did not demonstrate any significant correlation. Secondary endpoints such as angina, dyspnea, and major bleeding were non-significantly different between the two groups. CONCLUSION: Delayed PCI pharmacoinvasive strategy in a critical diseased but not completely occluded artery beyond 24 h in patients who have been timely thrombolyzed seems a reasonable strategy.

Ischemia With Nonobstructive Coronary Arteries: Insights From the ISCHEMIA Trial.

BACKGROUND: Ischemia with nonobstructive coronary arteries (INOCA) is common clinically, particularly among women, but its prevalence among patients with at least moderate ischemia and the relationship between ischemia severity and non-obstructive atherosclerosis severity are unknown. OBJECTIVES: The authors investigated predictors of INOCA in enrolled, nonrandomized participants in ISCHEMIA (International Study of Comparative Health Effectiveness with Medical and Invasive Approaches), sex differences, and the relationship between ischemia and atherosclerosis in patients with INOCA. METHODS: Core laboratories independently reviewed screening noninvasive stress test results (nuclear imaging, echocardiography, magnetic resonance imaging or nonimaging exercise tolerance testing), and coronary computed tomography angiography (CCTA), blinded to results of the screening test. INOCA was defined as all stenoses <50% on CCTA in a patient with moderate or severe ischemia on stress testing. INOCA patients, who were excluded from randomization, were compared with randomized participants with ≥50% stenosis in ≥1 vessel and moderate or severe ischemia. RESULTS: Among 3,612 participants with core laboratory-confirmed moderate or severe ischemia and interpretable CCTA, 476 (13%) had INOCA. Patients with INOCA were younger, were predominantly female, and had fewer atherosclerosis risk factors. For each stress testing modality, the extent of ischemia tended to be less among patients with INOCA, particularly with nuclear imaging. There was no significant relationship between severity of ischemia and extent or severity of nonobstructive atherosclerosis on CCTA. On multivariable analysis, female sex was independently associated with INOCA (odds ratio: 4.2 [95% CI: 3.4-5.2]). CONCLUSIONS: Among participants enrolled in ISCHEMIA with core laboratory-confirmed moderate or severe ischemia, the prevalence of INOCA was 13%. Severity of ischemia was not associated with severity of nonobstructive atherosclerosis. (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches [ISCHEMIA]; NCT01471522).

Clinical Outcomes of a Non-Compliant Balloon Dilatation Catheter: MOZEC™ NC Study.

The present study sought to assess the clinical outcomes of the Mozec™ Non-compliant (NC) Rx PTCA balloon dilatation catheter (BDC) (Meril Life Sciences Pvt. Ltd., Vapi, India) for dilatation of coronary lesions. This was a post-marketing, single-centre, single-arm, retrospective study. In total, 57 patients who had undergone post-dilatation with the Mozec™ NC Rx PTCA balloon dilatation catheter were evaluated. The primary endpoint was procedural success defined as (i) successful delivery of the investigational device to and across the target lesion; (ii) successful inflation, deflation, and withdrawal of the investigational device; (iii) absence of vessel perforation, flow-limiting vessel dissection, increase in thrombolysis in myocardial infarction (TIMI) flow from baseline, clinically significant arrhythmia requiring medical treatment; and (iv) achievement of final TIMI flow grade 3 after percutaneous coronary intervention of the target lesion after single or multiple attempts to cross the target lesion. Procedural success was achieved in 57 (100%) patients. There were no incidences of major adverse cardiac events (MACE)/target lesion failure (TLF). Mozec™ NC Rx PTCA balloon dilatation catheter has demonstrated favourable outcomes for the dilatation of routine and complex coronary lesions in a small cohort, as evidenced by its 100% procedural success rate and absence of MACE.

Correlation of lipoprotein (a) levels and plaque morphology in very young acute coronary syndrome patients using optical coherence tomography.

INTRODUCTION: Levels of lipoprotein (LP) (a) are useful marker for risk stratification of cardiovascular disease. This genetic biomarker is suggestive of patient predisposition to acute coronary event. The present study was to study correlation of LP(a) levels and plaque morphology in very young patients (<35 years) with acute coronary syndrome (ACS). METHODS: A prospective, single-center, observational study consisting of very young patients with ACS and fit for optical coherence tomography (OCT) guided invasive coronary angiography was conducted at tertiary-care centre. LP(a) levels were compared between healthy controls and very young ACS patients. Correlation of LP(a) levels and plaque characteristics in very young ACS patients was done using OCT imaging. RESULTS: Out of enrolled 80 subjects, 40 were very young ACS and 40 were matched healthy controls. In very young patients, plaque rupture and erosion were mechanism of ACS in 67.5% and 32.5% patients, respectively. Mean levels of LP(a) were 28.10 ± 13.96 nmol/l in healthy controls and 47.19 ± 29.85 nmol/l in very young patients with ACS (p = 0.022). Among very young ACS patients, patients with LP(a) levels<75 nmol/l and ≥75 nmol/l had mean thin cap fibroatheroma thickness of 117.08 ± 52.542 µm and 95.00 ± 36.286 µm, respectively (p = 0.2355). CONCLUSION: Higher levels of LP(a) were seen in younger patients with ACS compared with matched healthy individuals. Plaque rupture was the commonest mechanism of ACS in very young ACS patients. Patients with high LP(a) levels had lesser thickness of fibrous cap in OCT imaging compared with low levels of LP(a).

Lipid Profile and Small Dense Low-Density Lipoprotein in Acute Coronary Syndrome Patients: Relationships to Demographic, Clinical, Angiographic, and Therapeutic Variables.

Background: Several lines of evidence have supported small dense low-density lipoproteins (sd-LDL) as a marker of cardiovascular disease. The present study assessed the relationship between lipid profile and sd-LDL levels with demographic, clinical, angiographic, and therapeutic variables in acute coronary syndrome (ACS) patients. Methods: This was a single-centre, prospective, cross-sectional study conducted from September 2014 to September 2015. Patients with a diagnosis of ACS were included in this study. High-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C) were determined by direct homogenous assay and sd-LDL levels were calculated using an earlier described equation by Srisawadi et al. Results: A total of 200 patients with a diagnosis of ACS were studied. Males constituted 78% of the population cohort and almost 45% of participants were aged <45 years. Patients aged ≤45 years displayed higher mean sd-LDL levels of 30.40 ± 14.18 mg/dL versus patients aged >45 years with mean sd-LDL levels of 28.01 ± 11.58 mg/dL, but the difference was not statistically significant (p = 0.19). Females also displayed higher mean sd-LDL levels, but the difference also failed to achieve statistical significance (30.95 ± 13.44 mg/dL and 28.54 ± 12.64, respectively; p = 0.185). Diabetics had higher mean sd-LDL levels (33.64 ± 13.01 mg/dL and 28.07 ± 12.60 mg/dL; p = 0.273) whilst smokers had lower mean levels (27.21 ± 12.12 mg/dL and 30.51 ± 13.21 mg/dL, respectively; p = 0.071). However, the ratio of sd-LDL/lb-LDL (large buoyant LDL) was significantly higher in diabetics (0.48 vs. 0.39; p = 0.023). In the angiography cohort (n = 88), single-vessel disease was the most predominant overall while among patients aged >45 years, triple-vessel disease was significantly higher (p = 0.005). Similarly, the sd-LDL levels were 33.12 ± 11.13 mg/dL, 27.68 ± 9.80 mg/dL, and 31.65 ± 15.26 mg/dL among patients with single, double, and triple-vessel disease and did not differ significantly (p = 0.262). Prior statin users had significantly lower mean sd-LDL levels of 24.79 ± 12.23 mg/dL compared to statin-naïve patients with a mean sd-LDL of 30.01 ± 12.79 mg/dL (p = 0.027). Non-HDL levels were also significantly lower in prior statin users (112.83 mg/dL vs. 128.9 mg/dL; p = 0.017). Conclusion: In this cohort of ACS patients, age, sex, diabetes, smoking, and the angiographic severity of coronary artery disease had no significant impact on sd-LDL levels, while prior statin usage led to significantly lower sd-LDL levels. Diabetic patients, however, did have significantly higher sd-LDL/lb-LDL ratios.

Study of coronary sinus anatomy during levophase of coronary angiography.

BACKGROUND: Coronary sinus (CS) imaging has recently gained importance due to increasing need for mapping and ablation of electrophysiological arrhythmias and left ventricular (LV) pacing during cardiac resynchronization therapy (CRT). Retrograde venogram is the current standard for imaging CS and its tributaries. AIM: To evaluate CS anatomy during levophase of routine coronary angiography to aid LV lead implantation during CRT. METHODS: In this prospective observational study, 164 patients undergoing routine coronary angiography for various indications (Chronic stable angina-44.5%, acute coronary syndrome- 39.5%, Dilated cardiomyopathy-11%, atypical chest pain-5%) were included. Venous phase (levophase) of left coronary injection was recorded in left anterior oblique - cranial and right anterior oblique -cranial views. Visibility of coronary veins, width and shape of CS ostium, angulations of proximal CS with body of CS were noted. Presence, size, take-off angle and tortuosity of posterolateral vein (PLV), anterior interventricular veins (AIV) and middle cardiac vein (MCV) were also noted. RESULTS: During levophase, visibility grade (Muhlenbruch grade) for coronary veins was 3 in 74% and 2 in 26% of cases. Visibility of CS did not correlate with body mass index. The diameter of CS ostium was < 10 mm, 10-15 mm and > 15 mm in 48%, 42% and 10% of patients respectively. Proximal CS was tubular in 136 (83%) patients and funnel-shaped in 28 (17%) patients. Sharp take-off angulation between ostium and body of CS was seen in 16 (10%) patients. Two or more PLV were present in 8 patients while PLV was absent in 52 (32%) patients. Angle of take-off of PLV with body of CS was favourable (0°-45°) in 65 (40%) patients. The angle was 45°-90° in 36 patients and difficult take-off angle (> 90°) was seen in 8 patients. Length of PLV reached distal third of myocardium in 84 cases and middle third in 11 cases. There was no tortuosity in 79 cases, a single bend in 29 cases and more than 2 bends in 4 cases. Thirty nine (24%) patients had other veins supplying posterior/Lateral wall of LV. There was a single vein supplying lateral/posterior wall in 31 (19%) patients. Diameter of MCV and AIV was significantly larger in patients with absent PLV as compared to patients with a PLV. CONCLUSION: Levophase study of left coronary injection is effective in visualization of the CS in almost all patients undergoing coronary angiography and may be an effective alternative to retrograde venogram in patients with LV dysfunction or LBBB.

Evaluation of only heparin-based rota-flush solution against alternative rota-flush solution in patients with severe coronary artery calcification undergoing rotational atherectomy.

OBJECTIVE: There is limited evidence on feasibility and safety of only heparin rota-flush(OHRF)solution in rotational atherectomy (RA). We compared the safety and efficacy of OHRF solution with alternative rota-flush (ARF) solution in patients who underwent RA. METHODS: A total of 48 patients who underwent RA were enrolled in the study. In 25 patients OHRF solution and in 23 patients ARF solution was utilized. The study end points were procedural success rateandrota-related adverse cardiovascular event (RRAE) including slow flow, no reflow, bradycardia, and hemodynamic instability. RESULTS: Procedural success was achieved in all patients in both the OHRF and ARF groups. There was no statistically significant difference in RRAE between the two groups(32.0% vs. 34.7%, p = 0.83). CONCLUSION: OHRF solution appears a more simplistic solution while performing rotablation as compared to ARF solution. Side effects such as hypotension and bradycardia can be circumvented with OHRF solution during rotablation.

Screening for Prevalence of Abdominal Aortic Aneurysm During Transthoracic Echocardiography in Patient With Significant Coronary Artery Disease.

BACKGROUND: Prevalence of abdominal aortic aneurysm (AAA) has ethnic differences, and coronary artery disease (CAD) shares several risk factors with AAA. Sparse Indian data are available on this. We evaluated the prevalence of AAA during transthoracic echocardiography (TTE) and risk factors of AAA in patients with CAD. METHODS: This was a prospective observational study carried out in the cardiology department at a tertiary care center from January 1, 2017 to November 30, 2017. All patients with CAD/acute coronary syndrome (ACS) were included in the study, and patients with AAA due to other etiology were excluded. Screening for an AAA was performed directly using an echocardiographic 3.5-MHz cardiac probe. RESULTS: A total of 526 patients were screened; and AAA was present in 25 (4.8%) of CAD patients. Smoking, hypertension and hyperlipidemia were predominant risk factors for AAA in our study, but were not statistically significant because same risk factors were also prevalent in the comparison group. Diabetes, peripheral vascular disease and family history were statistically significant risk factors for AAA in our study. The mean size of AAA was 34 mm. CONCLUSIONS: Presence of AAA is significantly higher among CAD patients. CAD shares several risk factors with AAA. Therefore, opportunistic examination of the abdominal aorta during routine TTE could be an effective way of screening. Diabetes mellitus, peripheral artery disease and family history were the significant associated risk factors of AAA in CAD patients.

Culprit lesion characteristics in very young patients with acute coronary syndrome: An optical coherence tomography study.

OBJECTIVE: The concept of managing patients on the basis of culprit lesion characteristics is emerging. Atherosclerotic plaques are reported to be rare in young patients presenting with acute coronary syndrome (ACS). We aimed to assess culprit lesion characteristics in very young patients presenting with ACS by optical coherence tomography (OCT). METHODS: This was a prospective, single-center, open-label, observational study. Patients aged 35 years or less with ACS who underwent invasive coronary angiography and OCT were studied. RESULTS: Of the 43 patients, 22 (51.2%) had plaque rupture, 16 (37.2%) had plaque erosion, and five (11.6%) had no specific lesion character. Plaque was fibroatheromatous in 34 (79.1%) patients and fibrous in seven (16.3%). Plaque was not found in two (4.7%) patients; of these, one (2.3%) had left anterior descending coronary artery bridging, and one (2.3%) had intimal dissection without any plaque. Plaque rupture was more commonly associated with fibroatheromatous plaques, whereas plaque erosion was more commonly associated with fibrous plaque (p=0.010). CONCLUSION: Although plaque rupture and plaque erosion occurred at the same rate as seen in patients of all ages, calcified nodule as a culprit lesion was not found in young patients. Majority of the patients had plaque rupture and plaque erosion with fibroatheromatous plaque, signifying the occurrence of established coronary artery disease in very young patients of Southeast Asia.

Forearm hematoma as a complication of transradial coronary intervention: an Indian single-center experience.

BACKGROUND: Forearm hematomas are not uncommon after transradial coronary interventions. The present study describes the incidence and predictors of forearm hematoma formation after transradial coronary interventions. METHODS: This was a prospective study in 1754 patients undergoing angiography/angioplasty through transradial access. Each procedure was performed using optimum levels of anticoagulation, hydrophilic sheaths, and post-procedural patent hemostasis protocols. Patients were evaluated for forearm hematoma immediately after the procedure, after radial band removal, and on the next day of the procedure. Severity of hematomas was graded according to the Early Discharge after Transradial Stenting of Coronary Arteries Study scale. Univariate and multivariate logistic regression analyses were done to determine the predictors of hematoma formation. RESULTS: Mean age of the patients was 56.31 years and 82.2% were males. A total of 1374 (78.3%) patients underwent angioplasty while 380 (21.7%) underwent angiography. Forearm hematoma developed in 187 (10.7%) patients. Grade I hematoma was most common (3.53%) followed by Grade II (3.08%), Grade III (2.83%) and Grade IV (1.25%) hematoma. None of the patients required vascular or surgical interventions for this complication. Female gender, multiple puncture attempts, intensive antiplatelet therapy, complex procedure and longer hemostasis time were significant predictors of forearm hematoma formation post transradial coronary interventions. CONCLUSIONS: Forearm hematoma developed in substantial proportion of patients undergoing transradial coronary interventions and interventional variables were predominantly associated with hematoma formation. Pre-emptive knowledge of modifiable interventional risk factors can help in reducing the burden of this complication.

Outcomes in the ISCHEMIA Trial Based on Coronary Artery Disease and Ischemia Severity.

BACKGROUND: The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) postulated that patients with stable coronary artery disease (CAD) and moderate or severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and ischemia and trial outcomes, overall and by management strategy. METHODS: In total, 5179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core laboratory-interpreted coronary computed tomographic angiography was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified with the modified Duke Prognostic Index (n=2475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary end point for this analysis was all-cause mortality. Secondary end points were myocardial infarction (MI), cardiovascular death or MI, and the trial primary end point (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest). RESULTS: Relative to mild/no ischemia, neither moderate ischemia nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio [HR], 0.89 [95% CI, 0.61-1.30]; severe ischemia HR, 0.83 [95% CI, 0.57-1.21]; P=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia, 1.20 [95% CI, 0.86-1.69] versus mild/no ischemia; HR for severe ischemia, 1.37 [95% CI, 0.98-1.91]; P=0.04 for trend, P=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR, 2.72 [95% CI, 1.06-6.98]) and MI (HR, 3.78 [95% CI, 1.63-8.78]) for the most versus least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary end point, or cardiovascular death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of cardiovascular death or MI was lower in the invasive strategy group (difference, 6.3% [95% CI, 0.2%-12.4%]), but 4-year all-cause mortality was similar. CONCLUSIONS: Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01471522.

Outcomes in the ISCHEMIA Trial Based on Coronary Artery Disease and Ischemia Severity

BACKGROUND: The ISCHEMIA trial (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches) postulated that patients with stable coronary artery disease (CAD) and moderate or severe ischemia would benefit from revascularization. We investigated the relationship between severity of CAD and ischemia and trial outcomes, overall and by management strategy. METHODS: In total, 5179 patients with moderate or severe ischemia were randomized to an initial invasive or conservative management strategy. Blinded, core laboratory­interpreted coronary computed tomographic angiography was used to assess anatomic eligibility for randomization. Extent and severity of CAD were classified with the modified Duke Prognostic Index (n=2475, 48%). Ischemia severity was interpreted by independent core laboratories (nuclear, echocardiography, magnetic resonance imaging, exercise tolerance testing, n=5105, 99%). We compared 4-year event rates across subgroups defined by severity of ischemia and CAD. The primary end point for this analysis was all-cause mortality. Secondary end points were myocardial infarction (MI), cardiovascular death or MI, and the trial primary end point (cardiovascular death, MI, or hospitalization for unstable angina, heart failure, or resuscitated cardiac arrest). RESULTS: Relative to mild/no ischemia, neither moderate ischemia nor severe ischemia was associated with increased mortality (moderate ischemia hazard ratio [HR], 0.89 [95% CI, 0.61­1.30]; severe ischemia HR, 0.83 [95% CI, 0.57­1.21]; P=0.33). Nonfatal MI rates increased with worsening ischemia severity (HR for moderate ischemia, 1.20 [95% CI, 0.86­1.69] versus mild/no ischemia; HR for severe ischemia, 1.37 [95% CI, 0.98­1.91]; P=0.04 for trend, P=NS after adjustment for CAD). Increasing CAD severity was associated with death (HR, 2.72 [95% CI, 1.06­6.98]) and MI (HR, 3.78 [95% CI, 1.63­8.78]) for the most versus least severe CAD subgroup. Ischemia severity did not identify a subgroup with treatment benefit on mortality, MI, the trial primary end point, or cardiovascular death or MI. In the most severe CAD subgroup (n=659), the 4-year rate of cardiovascular death or MI was lower in the invasive strategy group (difference, 6.3% [95% CI, 0.2%­12.4%]), but 4-year all-cause mortality was similar. CONCLUSIONS: Ischemia severity was not associated with increased risk after adjustment for CAD severity. More severe CAD was associated with increased risk. Invasive management did not lower all-cause mortality at 4 years in any ischemia or CAD subgroup.