Platelet function testing in atrial fibrillation patients undergoing percutaneous coronary intervention.

Platelet function testing (PFT) could be a useful clinical tool to guide individualized antithrombotic treatment in patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI). We aimed to investigate platelet reactivity (PR) in the context of a contemporary registry. "Real-world" data were retrieved from a nationwide, multicenter, observational study of AF patients on oral anticoagulants (OAC) undergoing PCI. Patients treated with a P2Y12 inhibitor, namely clopidogrel or ticagrelor, as part of double or triple antithrombotic therapy, were submitted to PFT before discharge and were followed up for 12 months. Out of 101 patients included in the study, 66 were submitted to PFT while on clopidogrel and 35 while on ticagrelor; PR was 162.9 ± 68 PRU and 46.02 ± 46 PRU, respectively (P < 0.001). High on-treatment PR (HTPR) was observed in 15 patients under clopidogrel (22.7%); 7 of them escalated to ticagrelor. Low on-treatment PR (LTPR) was found in 9 clopidogrel and 28 ticagrelor-treated patients (13.6% vs. 80%, P < 0.001), of whom only 1 de-escalated to clopidogrel. PR did not differ by OAC regimen. PFT results had no impact on aspirin prescription at discharge, while failed to predict significant bleeding events at follow up. Ticagrelor administration led to lower PR and lower incidence of HTPR in comparison with clopidogrel. Physicians' behavior in response to knowledge of a patient's PR was variable. Further studies are required to elucidate the role of PFT as a tool to guide individualized antithrombotic treatment in this clinical scenario.

Parallel Stenting for Treatment of an In-stent Chronic Total Occlusion after Successful Dissection Reentry Technique.

Percutaneous coronary interventions (PCI) for chronic total occlusions (CTO) are the most challenging type of procedure in interventional cardiology and are traditionally associated with increased complexity and reduced procedural success rates. New techniques, such as retrograde approach and dissection reentry technique, offer alternatives in case of traditional antegrade wiring failure. In this paper, we present a successful implantation of a stent parallel to other existing stent in an in-stent CTO (IS-CTO) using dissection reentry technique. The technical details involved and the clues to successful outcome in an individual with in-stent CTO are discussed.

Alternative access site choice after initial radial access site failure for coronary angiography and intervention.

BACKGROUND: Transradial access for coronary catheterization is more technically challenging compared to the traditional transfemoral approach and radial access failure is quite common. The aim of this study is to describe the additional steps after initial radial access site failure in a high specialized forearm approach center. METHODS: A retrospective evaluation of all coronary catheterizations performed in our Department between January 2016 and December 2016 was performed, with focus on arterial access. RESULTS: One thousand three hundred forty six procedures were evaluated. The initial access site used was right radial [1173 procedures (87.1%)], left radial [120 procedures (8.9%)], right ulnar [7 procedures (0.5%)], left ulnar [40 procedures (2.9%)] and femoral approach [6 procedures (0.4%)]. Radial artery cannulation failure was observed in 37 procedures (2.9% of 1293 procedures with initial radial approach). Failure of procedure completion after successful radial sheath insertion was observed in 46 procedures (3.6%). The alternative access site after initial radial approach failure was contralateral radial [43 procedures (51.8%)], ipsilateral ulnar [22 procedures (26.5%), contralateral ulnar [12 patients (14.5%)] and femoral approach [6 procedures (7.2%)]. CONCLUSION: Forearm arteries can be used as alternative access site after initial radial approach failure in order to reduce the use of femoral approach during cardiac catheterization.

Strategies to increase the use of forearm approach during coronary angiography and interventions.

The aim of this article is to focus on the utilization of forearm approach for cardiac catheterization in challenging groups of patients. Radial and ulnar approaches have gained significant popularity among the majority of interventional cardiologists. Multiple studies have demonstrated the feasibility, safety and efficacy of forearm route for cardiac catheterization and have highlighted the significant reduction in bleeding complications by avoiding the puncture of the groin. In this review we present the strategies need to be followed in order to apply the forearm approach in challenging group of patients.

Forearm Versus Femoral Approach for Cardiac Catheterization in End-Stage Renal Disease Patients.

BACKGROUND: End-stage renal disease (ESRD) is considered a relative contraindication for forearm (radial or ulnar) cardiac catheterization. However, in everyday practice, many ESRD patients are catheterized from the forearm. The aim of this study was to compare femoral and forearm approach for cardiac catheterization in ESRD patients. METHODS: All cardiac catheterization procedures performed in ESRD patients in three Greek hospitals in a 2-year period (2014-2015) were retrospectively evaluated. The primary endpoint of the study was major access-site complication, defined as any Blood Academic Research Consortium class ≥3 bleeding or limb ischemia requiring intervention or prolonging hospitalization. RESULTS: During the study period, a total of 124 procedures were performed in 109 ESRD patients: 44 procedures (35.5%) were performed transfemorally and 80 procedures (64.5%) were performed from the forearm approach (77 transradial [96.3%] and 3 transulnar [3.7%]). Forearm access was always performed from the contralateral arm of a functional hemodialysis access site. Sixty-one procedures (49.6%) were diagnostic coronary artery angiographies (CAAs) and 63 procedures (50.4%) were percutaneous coronary interventions with or without CAA. Two deaths and 1 procedure-related myocardial infarction were recorded during hospitalization. Five patients suffered major access-site complications, all from the femoral group (5/44 vs 0/80; P<.01). Three transradial patients had asymptomatic radial artery occlusion after a diagnostic procedure. Five patients (4.0%) had problems with their hemodialysis access site during long-term follow-up, and required a new access site. CONCLUSION: Forearm approach for cardiac catheterization is feasible and safe in ESRD patients. All measures to preserve radial patency should be taken in this high-risk patient group, where a possible forearm artery occlusion might have serious consequences.

Heart Rate and Blood Pressure: "Connecting the Dots" in Epidemiology and Pathophysiology.

There is robust evidence from epidemiological and clinical studies showing that elevated heart rate (HR) constitutes a powerful predictor of morbidity and mortality in patients with hypertension, underlining the significance of HR measurement in them. Autonomous nervous system dysfunction and atherosclerosis are important features in the pathogenesis of the untoward events. However, the relationship between HR and blood pressure (BP) is complex and differs depending on the type of BP measurement which is considered. This differentiation implicates complex physiological mechanisms and is of clinical importance regarding the divergent effect of the different types of antihypertensive agents on these parameters. The aim of this review is to summarize the current evidence on the relationship between HR and BP based on epidemiological, clinical, and experimental studies.

Needle versus cannula over needle for radial artery cannulation during transradial coronary angiography and interventions.

PURPOSE: To evaluate the efficacy of radial artery cannulation with needle versus cannula over needle during transradial coronary angiography and intervention. METHODS: Five hundred patients scheduled to undergo transradial catheterization were randomized between the two methods. Primary endpoint of the study was the combined endpoint of switching to another access site due to inability of successful sheath insertion or switching to another method of cannulation (from needle to cannula over needle and vice versa). RESULTS: The primary end point was met in 12 patients (4.8%) from the needle group and 14 patients (5.6%) from the cannula over needle group (p=0.695). There were no differences in switching of cannulation method [10 (4.0%)% versus 11 (4.4%), p=0.831], switching of access site [6 (2.8%) versus 9 (3.6%), p=0.441), time for artery cannulation [1.20 (0.80-2.20) min versus 1.26 (1.01-2.39) min, p=0.152], total procedure time [15.05 (9.47-29.03) min versus 19.14 (10.13-32.02) min, p=0.112] number of attempts [2 (1-4) versus 2 (1-5), p=0.244] and number of skin punctures [1 (1-2) versus 1 (1-2), p=0.399] before successful radial artery cannulation. There were no differences recorded in the safety endpoints of EASY grade III or more radial hematomas [2 (0.8%) versus 1 (0.4%), p=1.000] or the incidence of radial artery occlusion after the procedure [9 (3.6% versus 16 (6.8%), p=0.358]. CONCLUSION: Radial artery cannulation with needle and cannula over needle seems to be equal in terms of efficacy and safety.

Risk of hypertensive disorders in pregnancy following assisted reproductive technology: overview and meta-analysis.

The extent of the increased risk of pregnancy hypertensive disorders following assisted reproductive technology (ART) was investigated. PubMed and the Cochrane Collaboration Library were used as data sources to identify and select longitudinal cohorts comparing pregnancies following ART with spontaneously conceived pregnancies, between 1978 and June 2016. Risk ratios and 95% confidence intervals (CIs) of three outcomes, ie, gestational hypertension (GH), preeclampsia (PE), and their sum (PHD), were calculated. Stratification of results by gestation order (singletons and nonsingletons) was pursued, but a separate "all orders" mixed stratification was considered. Sixty-six longitudinal studies (7 038 029 pregnancies; 203 375 following any ART) were eligible. All outcomes independent of gestation order ("all orders") were increased following any invasive ART: GH (+79% [95% CI, 24%-157%]) and PE (+75% [95% CI, 50%-103%]) to a greater extent, with smaller increases in PHD (+54% [95% CI, 39%-70%]). The risk of PHD following ART steadily increased independent of gestation order.

Noninvasive assessment of haemodynamics in resistant hypertension: the role of the renal resistive index.

OBJECTIVE: The association of resistant hypertension (RHTN) with renal haemodynamics is unclear. Our aim was to evaluate differences in haemodynamic characteristics of patients with RHTN compared with patients with controlled hypertension (HTN) at the level of the heart, kidney and aorta. METHODS: We studied 50 patients with RHTN confirmed by ambulatory blood pressure monitoring and 50 controlled hypertensive patients matched for age and sex. All participants underwent renal Doppler ultrasound to determine the renal resistive index (RRI), a complete echocardiographic study including measurements of diastolic function and evaluation of augmentation index. RESULTS: Hypertensive patients with RHTN compared with those without RHTN had a significantly decreased E/A ratio (by 0.12, P = 0.043), an increased E/e' ratio (by 3.1, P < 0.001), increased albumin-to-creatinine ratio levels (by 49 mg/g, P = 0.023) and a significantly higher RRI (by 0.078, P < 0.001) but similar augmentation index values (P = 0.79). Logistic regression revealed that presence of RHTN was the strongest predictor of an RRI more than 0.7 after controlling for other haemodynamic variables including blood pressure levels. Receiver-operator characteristic analysis revealed an area under the curve for prediction of RHTN by the RRI alone of 80.3% (95% confidence interval: 0.72-0.89, P < 0.001). An RRI cut-point of 0.648 has a sensitivity of 78% and a specificity of 72% for prediction of RHTN. CONCLUSION: In a well treated hypertensive population, patients with RHTN show more pronounced renal and cardiac haemodynamic dysfunction compared with patients with controlled HTN. A greater RRI seems to be associated with RHTN and may help identify such patients.

Peri-procedural care of renal nerve ablation candidates.

Percutaneous catheter-based transluminal renal nerve ablation (RNA) by delivery of radiofrequency energy constitutes a novel therapeutic strategy for the treatment of resistant hypertension. The sympathetic nervous activation to the kidney and the sensory afferent signals to the central nervous system represent the targets of RNA. In this review we summarize current recommendations for appropriate patient selection for RNA and multimodal strategies in order to optimize pharmacological treatment for resistant hypertension. The safety and efficacy of the RNA based on published trials are also presented. Furthermore, a detailed description of the periprocedural management, the methodology of the RNA procedure and appropriate follow-up are provided. In conclusion, in order to improve the overall clinical outcome and achieve optimal management of resistant hypertensive patients before and after the RNA, experienced and certified centers are of major importance.