Combination Therapy With Nicardipine and Isosorbide Dinitrate to Prevent Spasm in Transradial Percutaneous Coronary Intervention (from the NISTRA Multicenter Double-Blind Randomized Controlled Trial).

Verapamil and nitroglycerin are widely used to prevent radial artery spasm (RAS) during percutaneous cardiovascular procedures. However, these agents are not typically available in most African countries and consequently, isosorbide dinitrate is often the only spasmolytic treatment. Our aim was to compare the efficacy of isosorbide dinitrate alone versus isosorbide dinitrate used together with nicardipine to prevent RAS during transradial coronary procedures. This was a randomized controlled double-blind multicenter trial. Patients (n = 1,523) were randomized to receive either a sole therapy of isosorbide dinitrate (n = 760) or the combination of isosorbide dinitrate and nicardipine (n = 763). Our primary end point was the occurrence of RAS; defined as considerable perceived hindrance of catheter advancement. Our secondary end points were severe RAS; defined as (1) severe arm pain, (2) the need for either morphine or midazolam treatment, and (3) necessity for crossover to the contralateral radial or femoral artery. RAS incidence was reduced with the combination therapy versus isosorbide dinitrate alone (15% vs 25%, p <0.001), with a number needed to treat of 10 patients. There was also a significant reduction in the incidence of the secondary end points with combination therapy (3.6% vs 8.2%, p <0.001), with a number needed to treat of 22 patients. This result was driven by reductions in both femoral crossover (0.5% vs 2.4%, p = 0.003) and the use of morphine or midazolam injections (1.6% vs 3.5%, p = 0.02) with combination therapy. In conclusion, we demonstrated the superiority of the combination therapy of isosorbide dinitrate and nicardipine over isosorbide dinitrate alone in reducing the incidence of RAS.

Relationship between stent expansion and fractional flow reserve after percutaneous coronary intervention: a post hoc analysis of the DOCTORS trial.

BACKGROUND: The best criteria for adequate stent expansion assessment by intracoronary imaging remain debated and their correlation with post-PCI FFR values is unknown. AIMS: This study aimed to analyse the relationship between stent expansion criteria using optical coherence tomography (OCT) analysis and the final PCI functional result. METHODS: This post hoc analysis of the DOCTORS study included non-ST-elevation segment ACS patients undergoing OCT-guided PCI. The procedure functional result was assessed by the measurement of fractional flow reserve (FFR). Stent expansion was assessed on OCT runs according to the DOCTORS criteria and ILUMIEN III criteria. RESULTS: The study included N=116 patients (age: 60.8±11.5 years; male gender: 71%). The final expansion was considered optimal in 10%, acceptable in 9% and unacceptable in 81% of the stents according to ILUMIEN III criteria, although being successful in 70% of the patients according to the DOCTORS criteria. Hypertension and larger proximal reference segment dimension were independent predictors of inadequate device ILUMIEN III expansion. FFR values were, respectively, 0.93 (0.91-0.95) versus 0.95 (0.92-0.97) in patients with optimal+acceptable versus unacceptable ILUMIEN III expansion (p=0.22), 0.94 (0.91-0.97) versus 0.95 (0.93-0.97) in patients with optimal versus non-optimal DOCTORS expansion (p=0.23), and 0.95 (0.92-0.97) versus 0.92 (0.90-0.95) in patients with minimal stent area ≥4.5 mm2 versus <4.5 mm2 (p=0.03). CONCLUSIONS: In this selected population, no relationship was observed between optimal stent expansion according to ILUMIEN III or DOCTORS OCT criteria and final post-PCI FFR values.

Optical coherence tomography to guide percutaneous coronary intervention of the left main coronary artery: the LEMON study.

BACKGROUND: Intravascular ultrasound (IVUS)-guided PCI improves the prognosis of left main stem (LMS) PCI and is currently recommended by international guidelines. Although OCT resolution is greater than that of IVUS, this tool is not yet recommended in LMS angioplasty due to the absence of data. AIMS: This pilot study aimed to analyse the feasibility, safety and impact of OCT-guided LMS PCI. METHODS: This prospective, multicentre trial investigated whether patients might benefit from OCT-guided PCI for mid/distal LMS according to a pre-specified protocol. The primary endpoint was procedural success defined as follows: residual angiographic stenosis <50% + TIMI 3 flow in all branches + adequate OCT stent expansion (LEMON criteria). RESULTS: Seventy patients were included in the final analysis (median age: 72 [64-81] years, 73% male). The OCT pre-specified protocol was applied in all patients. The primary endpoint was achieved in 86% of subjects. Adequate stent expansion was observed in 86%, significant edge dissection in 30% and residual significant strut malapposition in 24% of the cases. OCT guidance modified the operators' strategy in 26% of the patients. The rate of one-year survival free from major adverse clinical events was 98.6% (97.2-100). CONCLUSIONS: This pilot study is the first to report the feasibility and performance of OCT-guided LMS PCI according to a pre-specified protocol.

Spontaneous Coronary Artery Dissection: Less Is More!

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction (ACS). We report a case of acute coronary syndrome due to SCAD of the right coronary artery. Diagnosis was based on clinical presentation and coronary angiography, and confirmed by optical coherence tomography which guided our treatment strategy. (Level of Difficulty: Beginner.).

Case Report: Concomitant coronary stent and femoral artery thrombosis in the setting of heparin-induced thrombocytopenia.

Heparin induced thrombocytopenia (HIT) is a rare but potentially life threatening  adverse drug reaction. We report an unusual case of concomitant subacute coronary stent and femoral artery thrombosis secondary to HIT. In the current era of extensive growth of heparin use and percutaneous coronary interventions, it's important for clinicians to remember that such complication might occur and should be prevented.