Intravascular Imaging in the Diagnosis and Management of Patients With Suspected Intracoronary Pathologies: A CJC White Paper.

Intravascular imaging has become an integral part of the diagnostic and management strategies for intracoronary pathologies. In this White Paper we summarize current evidence and its implications on the use of intravascular imaging in interventional cardiology practice. The areas addressed are planning and optimization of percutaneous coronary intervention, management of stent failure, and evaluation of ambiguous coronary lesions and myocardial infarction with nonobstructive coronary disease. The findings presented followed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system in an expert consensus process that involved a diverse writing group vetted by a review group. Expert consensus was achieved around 9 statements. Use of intravascular imaging in guiding percutaneous revascularization is supported by high-quality evidence, particularly for lesions with increased risk of recurrent events or stent failure. Specific considerations for intravascular imaging guidance of intervention in left main lesions, chronic occlusion lesions, and in patients at high risk of contrast nephropathy are explored. Use of intravascular imaging to identify pathologies associated with stent failure and guide repeat intervention, resolve ambiguities in lesion assessment, and establish diagnoses in patients who present with myocardial infarction with nonobstructive coronary disease is supported by moderate- to low-quality evidence. Each topic is accompanied by clinical pointers to aid the practicing interventional cardiologist in implementation of the White Paper findings. The findings presented in this White Paper will help to guide the use of intravascular imaging toward situations in which the balance of efficacy, safety, and cost are most optimal.

Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology 2023 Focused Update of the Guidelines for the Use of Antiplatelet Therapy.

Antiplatelet therapy (APT) is the foundation of treatment and prevention of atherothrombotic events in patients with atherosclerotic cardiovascular disease. Selecting the optimal APT strategies to reduce major adverse cardiovascular events, while balancing bleeding risk, requires ongoing review of clinical trials. Appended, the focused update of the Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology guidelines for the use of APT provides recommendations on the following topics: (1) use of acetylsalicylic acid in primary prevention of atherosclerotic cardiovascular disease; (2) dual APT (DAPT) duration after percutaneous coronary intervention (PCI) in patients at high bleeding risk; (3) potent DAPT (P2Y12 inhibitor) choice in patients who present with an acute coronary syndrome (ACS) and possible DAPT de-escalation strategies after PCI; (4) choice and duration of DAPT in ACS patients who are medically treated without revascularization; (5) pretreatment with DAPT (P2Y12 inhibitor) before elective or nonelective coronary angiography; (6) perioperative and longer-term APT management in patients who require coronary artery bypass grafting surgery; and (7) use of APT in patients with atrial fibrillation who require oral anticoagulation after PCI or medically managed ACS. These recommendations are all on the basis of systematic reviews and meta-analyses conducted as part of the development of these guidelines, provided in the Supplementary Material.

Catheter-Induced Postextrasystolic Potentiation in the Assessment of Severity of Low-Gradient Aortic Valve Stenosis.

BACKGROUND: Deciphering which patients with low-gradient aortic valve disease have severe stenosis can be difficult. We aimed to correlate the postextrasystolic potentiation (PESP) with dobutamine stress echocardiography and multidetector computed tomography in patients with low-gradient aortic valve stenosis. METHODS: Patients with an aortic valve area ≤1 cm2 and a mean gradient <40 mm Hg were included. Aortic valve stenosis severity was assessed by a core lab with dobutamine stress echocardiography, followed by a multidetector computed tomography aortic valve score if indeterminate. A premature ventricular contraction was induced by intentional catheter contact with the myocardium within the left ventricle. PESP was calculated as a percent change of pre-to-post mean gradient. Multidetector computed tomography was used to measure the aortic valve calcification score, and subsequently, aortic valve calcification density. RESULTS: Twenty-eight patients (age, 77±10 years; 19 female) were included. Dobutamine stress echocardiography increased mean gradient from baseline of 25±7 mm Hg to 36±11 mm Hg; pre-premature ventricular contraction mean gradient was 25±7 mm Hg and increased to post-premature ventricular contraction mean gradient of 32±10 mm Hg, representing a PESP of 24±11%. A ≥20% in PESP resulted in 100% sensitivity, 77% specificity, 83% positive predictive value, and 100% negative predictive value for diagnosing severe aortic valve stenosis. There was a significant correlation between PESP and projected aortic valve area and aortic valve calcification density (R=-0.64, P=0.0003; R=0.057, P=0.014, respectively). CONCLUSIONS: In patients with low-gradient aortic valve stenosis, catheter-induced premature ventricular contractions during cardiac catheterization causing ≥20% PESP has a 100% sensitivity for severe aortic valve stenosis. Validation of this 20% cutoff in larger groups with correlation to clinical end points is required.

Antithrombotic therapies in Canadian atrial fibrillation patients with concomitant coronary artery disease: Insights from the CONNECT AF + PCI-II program.

BACKGROUND: Selecting the appropriate antithrombotic regimen for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) or have had medically managed acute coronary syndrome (ACS) remains complex. This multi-centre observational study evaluated patterns of antithrombotic therapies utilized among Canadian patients with AF post-PCI or ACS. METHODS AND RESULTS: By retrospective chart audit, 611 non-valvular AF patients [median (interquartile range) age 76 (69-83) years, CHADS2 score 2 (1-3)] who underwent PCI or had medically managed ACS between August 2018 and December 2020 were identified by 68 cardiologists across eight provinces in Canada. Overall, triple antithrombotic therapy [TAT: combined oral anticoagulation (OAC) and dual antiplatelet therapy (DAPT)] was the most common initial antithrombotic strategy, with use in 53.8 % of patients, followed by dual pathway therapy (32.7 % received OAC and a P2Y12 inhibitor, and 4.1 % received OAC and aspirin) and DAPT (9.3 %). Median duration of TAT was 30 (7, 30) days. Compared to the previous CONNECT AF + PCI-I program, there was an increased use of dual pathway therapy relative to TAT over time (P-value <.0001). DOACs (direct oral anticoagulants) represented 90.3 % of all OACs used overall, with apixaban being the most utilized (50.5 %). Proton pump inhibitors were used in 57.0 % of all patients, and 70.1 % of patients on ASA. Planned antithrombotic therapies at 1 year were: 76.2 % OAC monotherapy, 8.3 % OAC + ASA, 7.9 % OAC + P2Y12 inhibitor, 4.3 % DAPT, 1.3 % ASA alone, and <1 % triple therapy. CONCLUSION: In accordance with recent Canadian Cardiovascular Society guideline recommendations, we observed an increased use of dual pathway therapy relative to TAT over time in both AF patients post-PCI (elective and emergent) and in those with medically managed ACS. Additionally, DOACs have become the prevailing form of anticoagulation across all antithrombotic regimens. Our findings suggest that Canadian physicians are integrating evidence-based approaches to optimally manage the bleeding and thrombotic risks of AF patients post-PCI and/or ACS.

Canadian Spontaneous Coronary Artery Dissection Cohort Study: 3-Year Outcomes.

BACKGROUND: Spontaneous coronary artery dissection (SCAD) is an important cause of myocardial infarction (MI) in young to middle-aged women. OBJECTIVES: We aim to define the long-term natural history of SCAD. METHODS: We performed a multicenter, prospective, observational study of patients with nonatherosclerotic SCAD presenting acutely from 22 North American centers. We recorded baseline demographics, in-hospital characteristics, precipitating and predisposing conditions, angiographic features (adjudicated), in-hospital and 3-year major adverse cardiovascular events (MACE). Cox regression multivariable analysis was performed. RESULTS: We prospectively enrolled 750 consecutive patients with SCAD from June 2014 to June 2018. Mean age was 51.7 ± 10.5 years, 88.5% were women (55.0% postmenopausal); 31.3% presented with ST-segment elevation myocardial infarction, and 68.3% with non-ST-segment elevation myocardial infarction. Precipitating emotional stressor was reported in 50.3%, and physical stressor in 28.9%. Predisposing conditions included fibromuscular dysplasia in 42.9% (56.4% in those with complete screening), peripartum state 4.5%, and genetic disorders 1.6%. Most patients were treated conservatively (84.3%); 14.1% underwent percutaneous coronary intervention (PCI), 0.7% coronary artery bypass graft. At 3.0-year median follow-up, mortality was 0.8%, recurrent MI 9.9% (extension of previous SCAD 3.5%, de novo recurrent SCAD 2.4%, iatrogenic dissection 1.9%), with overall MACE 14.0%. Presence of genetic disorders, peripartum SCAD, and extracoronary fibromuscular dysplasia were independent predictors of 3-year MACE. Patients who underwent PCI at index hospitalization had similar postdischarge MACE compared with no PCI. At 3 years, 80.0% remained on aspirin and 73.5% on beta-blockade. CONCLUSIONS: Long-term mortality and de novo recurrent SCAD was low in our contemporary large SCAD cohort that included low revascularization rate and high use of beta-blockade and aspirin. Genetic disorders, extracoronary fibromuscular dysplasia, and peripartum SCAD were independent predictors of long-term MACE.

A Practical Approach to Invasive Testing in Ischemia With No Obstructive Coronary Arteries (INOCA).

Up to 65% of women and approximately 30% of men have ischemia with no obstructive coronary artery disease (CAD; commonly known as INOCA) on invasive coronary angiography performed for stable angina. INOCA can be due to coronary microvascular dysfunction or coronary vasospasm. Despite the absence of obstructive CAD, those with INOCA have an increased risk of all-cause mortality and adverse outcomes, including recurrent angina and cardiovascular events. These patients often undergo repeat testing, including cardiac catheterization, resulting in lifetime healthcare costs that rival those for obstructive CAD. Patients with INOCA often remain undiagnosed and untreated. This review discusses the symptoms and prognosis of INOCA, offers a systematic approach to the diagnostic evaluation of these patients, and summarizes therapeutic management, including tailored therapy according to underlying pathophysiological mechanisms.

Jusqu'à 65 % des femmes et environ 30 % des hommes présentent une ischémie sans coronaropathie obstructive (INOCA [ischemia with no obstructive coronary artery disease]) révélée à la faveur d'une angiographie coronarienne invasive réalisée pour une angine stable. L'INOCA peut être attribuable à une dysfonction microvasculaire coronaire ou à un vasospasme coronaire. Malgré l'absence de coronaropathie obstructive, les patients atteints d'une INOCA présentent un risque accru de décès toutes causes confondues et d'événements indésirables, notamment l'angine récurrente et des événements cardiovasculaires. Ces patients sont souvent soumis à des examens répétés, dont le cathétérisme cardiaque, ce qui représente des dépenses de santé à vie qui rivalisent avec celles associées aux coronaropathies obstructives. Dans bien des cas, l'INOCA échappe au diagnostic et n'est pas traité. Dans le présent article de synthèse, nous nous penchons sur les symptômes et le pronostic de l'INOCA. Nous proposons une méthode systématique d'évaluation diagnostique de ces patients et résumons les modalités de sa prise en charge thérapeutique, notamment un traitement adapté aux mécanismes physiopathologiques sous-jacents.

Cardiac impairments in postacute COVID-19 with sustained symptoms: A review of the literature and proof of concept.

Although acute COVID-19 is known to cause cardiac damage in some cases, there is still much to learn about the duration and relative permanence of the damage that may occur. Long COVID is a condition that can occur when COVID-19 symptoms remain in the postviral acute period. Varying accounts of long COVID have been described across the literature, however, cardiac impairments are sustained in many individuals and cardiovascular assessment is now considered to be an expected follow-up examination. The purpose of this review and proof of concept is to summarize the current research related to the assessment of cardiac function, including echocardiography and blood biomarker data, during the follow-up period in patients who recovered from COVID-19. Following a literature review, it was found that right ventricular dysfunction along with global longitudinal strain and diastolic dysfunction are common findings. Finally, more severe acute myocardial injury during the index hospitalization appears to exacerbate cardiac function. The available literature implies that cardiac function must be monitored in patients recovered from COVID-19 who remain symptomatic and that the impairments and severity vary from person-to-person. The proof-of-concept analysis of patients with cardiac disease and respiratory disease in comparison to those with sustained symptoms from COVID-19 suggests elevated systolic time interval in those with sustained symptoms from COVID-19, thus reducing heart performance indices. Future research must consider the details of cardiac complications during the acute infection period and relate this to the cardiac function in patients with long COVID during mid- and long-term follow-up.

Heart Failure after Laboratory Confirmed Influenza Infection (FLU-HF).

Background: Influenza has been shown to exacerbate heart failure (HF). Importantly, no study to date has examined the relationship between HF hospitalizations (HFH) with laboratory confirmed influenza infections. This study evaluated the association between laboratory confirmed influenza infection and HFH in the two largest hospitals in Saskatchewan, Canada. Methods: We used a retrospective self-controlled case series design to evaluate the association between laboratory-confirmed influenza infection and HFH. We compared the incidence ratio for HFH during the influenza risk interval with the control interval. We defined the influenza risk interval as the seven days after a laboratory confirmed influenza result and the control interval as one year before and after the risk interval. Results: We identified 114 HFH that occurred within one year before and after a positive test result for influenza between April 1, 2010, and April 30, 2018. Of these, 28 (28 admissions per week) occurred during the risk interval and 86 (0.853 admissions per week) occurred during the control interval. The incidence ratio of a HFH during the risk interval as compared with the control interval was 33.53 (95% confidence interval [CI], 21.89 to 51.36). A decline in incidence was observed after day seven; between days 8 to 14 and 14 to 28 incidence ratios was 0.91 (95% CI, 0.13 to 6.52) and 0.91 (95% CI, 0.22 to 3.68) respectively. Conclusion: We have observed a significant association between acute influenza infection and HFH. However, further research with a larger sample size and involving a multicenter setting is warranted. Highlights: Influenza may contribute and exacerbate heart failure events especially during annual influenza season.Early identification of influenza among patients with heart failure, could lead to earlier treatment with antiviral medication, reduce unnecessary antibiotic use, and tail off the morbidity and mortality.In this study, despite our efficient study design, our sample size was limited to only the two largest hospitals in the province, possibly excluding a significant population in remote areas.

Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial.

BACKGROUND: Dietary restriction of sodium has been suggested to prevent fluid overload and adverse outcomes for patients with heart failure. We designed the Study of Dietary Intervention under 100 mmol in Heart Failure (SODIUM-HF) to test whether or not a reduction in dietary sodium reduces the incidence of future clinical events. METHODS: SODIUM-HF is an international, open-label, randomised, controlled trial that enrolled patients at 26 sites in six countries (Australia, Canada, Chile, Colombia, Mexico, and New Zealand). Eligible patients were aged 18 years or older, with chronic heart failure (New York Heart Association [NYHA] functional class 2-3), and receiving optimally tolerated guideline-directed medical treatment. Patients were randomly assigned (1:1), using a standard number generator and varying block sizes of two, four, or six, stratified by site, to either usual care according to local guidelines or a low sodium diet of less than 100 mmol (ie, <1500 mg/day). The primary outcome was the composite of cardiovascular-related admission to hospital, cardiovascular-related emergency department visit, or all-cause death within 12 months in the intention-to-treat (ITT) population (ie, all randomly assigned patients). Safety was assessed in the ITT population. This study is registered with ClinicalTrials.gov, NCT02012179, and is closed to accrual. FINDINGS: Between March 24, 2014, and Dec 9, 2020, 806 patients were randomly assigned to a low sodium diet (n=397) or usual care (n=409). Median age was 67 years (IQR 58-74) and 268 (33%) were women and 538 (66%) were men. Between baseline and 12 months, the median sodium intake decreased from 2286 mg/day (IQR 1653-3005) to 1658 mg/day (1301-2189) in the low sodium group and from 2119 mg/day (1673-2804) to 2073 mg/day (1541-2900) in the usual care group. By 12 months, events comprising the primary outcome had occurred in 60 (15%) of 397 patients in the low sodium diet group and 70 (17%) of 409 in the usual care group (hazard ratio [HR] 0·89 [95% CI 0·63-1·26]; p=0·53). All-cause death occurred in 22 (6%) patients in the low sodium diet group and 17 (4%) in the usual care group (HR 1·38 [0·73-2·60]; p=0·32), cardiovascular-related hospitalisation occurred in 40 (10%) patients in the low sodium diet group and 51 (12%) patients in the usual care group (HR 0·82 [0·54-1·24]; p=0·36), and cardiovascular-related emergency department visits occurred in 17 (4%) patients in the low sodium diet group and 15 (4%) patients in the usual care group (HR 1·21 [0·60-2·41]; p=0·60). No safety events related to the study treatment were reported in either group. INTERPRETATION: In ambulatory patients with heart failure, a dietary intervention to reduce sodium intake did not reduce clinical events. FUNDING: Canadian Institutes of Health Research and the University Hospital Foundation, Edmonton, Alberta, Canada, and Health Research Council of New Zealand.

Novel effects of acute COVID-19 on cardiac mechanical function: Two case studies.

The spread of the novel coronavirus 2019 (COVID-19) has caused a global pandemic. The disease has spread rapidly, and research shows that COVID-19 can induce long-lasting cardiac damage. COVID-19 can result in elevated cardiac biomarkers indicative of acute cardiac injury, and research utilizing echocardiography has shown that there is mechanical dysfunction in these patients as well, especially when observing the isovolumic, systolic, and diastolic portions of the cardiac cycle. The purpose of this study was to present two case studies on COVID-19 positive patients who had their cardiac mechanical function assessed every day during the acute period to show that cardiac function in these patients was altered, and the damage occurring can change from day-to-day. Participant 1 showed compromised cardiac function in the systolic time, diastolic time, isovolumic time, and the calculated heart performance index (HPI), and these impairments were sustained even 23 days post-symptom onset. Furthermore, Participant 1 showed prolonged systolic periods that lasted longer than the diastolic periods, indicative of elevated pulmonary artery pressure. Participant 2 showed decreases in systole and consequently, increases in HPI during the 3 days post-symptom onset, and these changes returned to normal after day 4. These results showed that daily observation of cardiac function can provide detailed information about the overall mechanism by which cardiac dysfunction is occurring and that COVID-19 can induce cardiac damage in unique patterns and thus can be studied on a case-by-case basis, day-to-day during infection. This could allow us to move toward more personalized cardiovascular medical treatment.

Contemporary use of guideline-based higher potency P2Y12 receptor inhibitor therapy in patients with moderate-to-high risk non-ST-segment elevation myocardial infarction: Results from the Canadian ACS reflective II cross-sectional study.

BACKGROUND: After myocardial infarction, guidelines recommend higher-potency P2Y12 receptor inhibitors, namely ticagrelor and prasugrel, over clopidogrel. HYPOTHESIS: We aimed to determine the contemporary use of higher-potency antiplatelet therapy in Canadian patients with non-ST-elevation myocardial infarction (NSTEMI). METHODS: A total of 684 moderate-to-high risk NSTEMI patients were enrolled in the prospective Canadian ACS Reflective II registry at 12 Canadian hospitals and three clinics in five provinces between July 2016 and May 2018. Multivariable logistic regression modeling was performed to assess factors independently associated with higher-potency P2Y12 receptor inhibitor use at discharge. RESULTS: At hospital discharge, 78.3% of patients were treated with a P2Y12 receptor inhibitor. Among patients discharged on a P2Y12 receptor inhibitor, use of higher-potency P2Y12 receptor inhibitor was 61.4%. After adjustment, treatment in-hospital with PCI (OR 4.48, 95%CI 3.34-6.03, p < .0001) was most strongly associated with higher use of higher-potency P2Y12 receptor inhibitor, while oral anticoagulant use at discharge (OR 0.03, 95%CI 0.01-0.12, p < .0001), and atrial fibrillation (OR 0.40, 95%CI 0.17-0.98, p = .046) were most strongly associated with lower use of higher-potency P2Y12 receptor inhibitor. Use of higher-potency P2Y12 receptor inhibitor varied across provinces (range, 21.6%-78.9%). DISCUSSION: In contemporary Canadian practice, approximately 60% of moderate-to-high risk NSTEMI patients discharged on a P2Y12 receptor inhibitor are treated with a higher-potency P2Y12 receptor inhibitor. In addition to factors that increase risk of bleeding, interprovincial differences in practice patterns were associated with use of higher-potency P2Y12 receptor inhibitor at discharge. Opportunities remain for further optimization of evidence-based, guideline-recommended antiplatelet therapy use.

A Literature Review of Cannabis and Myocardial Infarction-What Clinicians May Not Be Aware Of.

Increasing legalization and expanding medicinal use have led to a significant rise in global cannabis consumption. With this development, we have seen a growing number of case reports describing adverse cardiovascular events, specifically, cannabis-induced myocardial infarction (MI). However, there are considerable knowledge gaps on this topic among health care providers. This review aims to provide an up-to-date review of the current literature, as well as practical recommendations for clinicians. We also focus on proposed mechanisms implicating cannabis as a risk factor for MI. We performed a comprehensive literature search using the MEDLINE, Cochrane, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Turning Research into Practice (TRIP) PRO databases for articles published between 2000 and 2018. A total of 92 articles were included. We found a significant number of reports describing cannabis-induced MI. This was especially prevalent among young healthy patients, presenting shortly after use. The most commonly proposed mechanisms included increased autonomic stimulation, altered platelet function, vasospasm, and direct toxic effects of smoke constituents. However, it is likely that the true pathogenesis is multifactorial. We should increase our pretest probability for MI in young patients presenting with chest pain. We also recommend against cannabis use in patients with known coronary artery disease, especially if they have stable angina. Finally, if patients are adamant about using cannabis, health care providers should recommend against smoking cannabis, avoidance of concomitant tobacco use, and use of the lowest delta-9-tetrahydrocannabinol dose possible. Data quality is limited to that of observational studies and case report data. Therefore, more clinical trials are needed to determine a definitive cause-and-effect relationship.

Depuis la légalisation du cannabis et l'élargissement de son utilisation à des fins médicales, la consommation de cannabis a beaucoup augmenté dans le monde, et l'on observe de plus en plus de cas de manifestations cardiovasculaires indésirables induites par le cannabis, notamment des cas d'infarctus du myocarde (IM). Les professionnels de la santé manquent toutefois de connaissances à ce sujet. Nous présentons donc une revue à jour de la littérature récente, ainsi que des recommandations pratiques à l'intention des cliniciens. Nous traitons également des mécanismes qui pourraient expliquer pourquoi le cannabis pourrait être un facteur de risque d'IM. Nous avons effectué une recherche documentaire exhaustive dans les bases de données MEDLINE, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature) et TRIP (Turning Research into Practice) PRO afin de relever les articles pertinents publiés entre 2000 et 2018. Au total, 92 publications ont été retenues. Nous avons relevé un grand nombre de cas d'IM induit par le cannabis. Ce phénomène était particulièrement répandu chez les patients jeunes et en santé, et survenait peu de temps après la consommation. Les mécanismes les plus souvent proposés pour expliquer ce type d'IM comprenaient l'augmentation de la stimulation du système nerveux autonome, une altération de la fonction plaquettaire, l'induction d'un vasospasme et les effets toxiques directs des constituants de la fumée. Il est toutefois probable que la véritable pathogenèse soit multifactorielle. Il conviendrait de soupçonner un IM avant même d'effectuer des tests chez les patients jeunes présentant une douleur thoracique. Nous déconseillons en outre l'usage du cannabis chez les patients ayant reçu un diagnostic de coronaropathie, en particulier s'ils souffrent d'angine stable. Enfin, si un patient tient absolument à consommer du cannabis, les professionnels de la santé devraient lui recommander de ne pas le fumer, d'éviter de fumer la cigarette en concomitance et de prendre la dose de delta 9-transtétrahydrocannabinol la plus faible possible. La qualité des données présentées est limitée étant donné qu'il s'agit de données tirées d'études observationnelles et d'exposés de cas; d'autres essais cliniques s'imposent donc afin de déterminer avec plus de certitude l'existence d'une relation de cause à effet.

Provision of a DAPT Score to Cardiologists and Extension of Dual Antiplatelet Therapy Beyond 1 Year After ACS: Randomized Substudy of the Prospective Canadian ACS Reflective II Study.

BACKGROUND: Extension of dual antiplatelet therapy (DAPT) beyond 1 year after acute coronary syndrome is associated with a reduction in ischemic events but also increased bleeding. The DAPT score identifies individuals likely to derive overall benefit or harm from DAPT extension. We sought to evaluate the impact of providing the DAPT score to treating physicians on the decision to extend DAPT beyond 1 year after non-ST-segment elevation myocardial infarction. METHODS: Moderate to high-risk non-ST-segment elevation myocardial infarction patients were enrolled from July 2016 to May 2018 in 13 Canadian hospitals by 52 cardiologists. Participating cardiologists were randomly assigned 1:1 to receive their individual patients' DAPT scores before the 1-year follow-up visit vs not receiving their patients' DAPT scores. Rates of DAPT extension were compared among the randomized groups. RESULTS: At 1 year, 370 of the 585 (63.2%) patients discharged on DAPT were receiving DAPT. Among patients on DAPT at 1 year, the median (25th, 75th percentile) DAPT score was 2 (1,3). DAPT was extended beyond 1 year in 36.2% randomly assigned to provision of DAPT score vs 35.7% in the control group (P = 0.93). In the subgroup of patients with DAPT score ≥ 2, DAPT extension was 49.5% in the DAPT score provision arm vs 40.4% in the control arm (P = 0.22); among patients with DAPT score < 2, DAPT termination was 78.6% in the DAPT score provision arm vs 70.6% in the control arm (P = 0.26) (P value for interaction = 0.1). CONCLUSIONS: In this exploratory randomized trial, provision of the DAPT score to treating physicians had no impact on the duration of DAPT treatment beyond 1 year.

INTRODUCTION: La prolongation de la bithérapie antiplaquettaire au-delà d'un an après un syndrome coronarien aigu est associée à la réduction des accidents ischémiques, mais aussi à l'augmentation des hémorragies. Le score de bithérapie antiplaquettaire permet de déterminer les individus susceptibles d'obtenir des avantages globaux ou des inconvénients de la prolongation de la bithérapie antiplaquettaire. Nous avons cherché à évaluer les répercussions de l'obtention du score de bithérapie antiplaquettaire par les médecins traitants sur la décision quant à la prolongation de la bithérapie antiplaquettaire au-delà d'un an après l'infarctus du myocarde sans élévation du segment ST. MÉTHODES: De juillet 2016 à mai 2018, 52 cardiologues de 13 hôpitaux du Canada ont inscrit des patients exposés à un risque modéré à élevé d'infarctus du myocarde sans élévation du segment ST. Nous avons réparti de façon aléatoire selon un rapport 1:1 les cardiologues participants qui recevaient les scores de bithérapie antiplaquettaire individuels de leurs patients avant la consultation de suivi après un an vs ceux qui ne recevaient pas les scores de bithérapie antiplaquettaire de leurs patients. Nous avons comparé les taux de prolongation de la bithérapie antiplaquettaire des groupes répartis de façon aléatoire. RÉSULTATS: Après un an, 370 (63,2 %) patients sur 585 qui avaient eu à la sortie de l'hôpital une bithérapie antiplaquettaire recevaient la bithérapie antiplaquettaire. Parmi les patients qui prenaient la bithérapie antiplaquettaire après un an, le score médian de bithérapie antiplaquettaire (25e, 75e percentiles) était de 2 (1, 3). La bithérapie antiplaquettaire était prolongée au-delà d'un an chez 36,2 % des patients répartis de façon aléatoire qui avaient un score de bithérapie antiplaquettaire vs 35,7 % dans le groupe témoin (P = 0,93). Dans le sous-groupe de patients qui avaient un score de bithérapie antiplaquettaire ≥ 2, la prolongation de la bithérapie antiplaquettaire était de 49,5 % dans le bras qui avait un score de bithérapie antiplaquettaire vs 40,4 % dans le bras témoin (P = 0,22); parmi les patients qui avaient un score de bithérapie antiplaquettaire < 2, la cessation de la bithérapie antiplaquettaire était de 78,6 % dans le bras qui avait un score de bithérapie antiplaquettaire vs 70,6 % dans le bras témoin (P = 0,26) (valeur P pour l'interaction = 0,1). CONCLUSIONS: Dans cet essai exploratoire à répartition aléatoire, l'obtention du score de la bithérapie antiplaquettaire par les médecins traitants n'a pas engendré de répercussions sur la durée de la bithérapie antiplaquettaire au-delà d'un an.

Management of Acute Coronary Syndromes Beyond the First Year: A Canadian Clinical Practice Survey.

BACKGROUND: Antithrombotic management following acute coronary syndromes (ACSs) has evolved significantly. However, given lingering uncertainty as to when an ACS may be considered stable, there is the possibility of practice divergence beyond the first year. METHODS: An online adaptive survey describing patients with varying cardiac and extracardiac ischemic risk was developed in order to asses self-reported physician practice intentions pertaining to the antithrombotic management of ACS patients who lack a formal indication for therapeutic anticoagulation. Provincial "champions" (Prince Edward Island not represented) were identified to ensure dissemination of the survey within their jurisdictions via 3 coordinated e-mailings; the survey was made available in French and English from November 2018 through January 2019. RESULTS: A total of 135 practitioners responded to the survey (response rate 15%). Surveys were fully completed in all cases. Nearly all respondents (97%) were cardiologists; 76% worked at an academic center, and 54% had been in practice ≥ 10 years. Most respondents (81%-90%, depending on the scenario) preferred ticagrelor-based dual antiplatelet therapy as the initial ACS treatment. However, beyond 12 months, management decisions differed significantly according to the balance of cardiac and extracardiac risk. CONCLUSIONS: This study provides a first look at how the introduction of rivaroxaban 2.5 mg might be integrated into the clinical management of ACS patients beyond the first year in Canada. Whether to pursue dual antiplatelet therapy or transition early to low-dose rivaroxaban plus acetylsalicylic acid will likely be driven by patient clinical characteristics and perceived cardiac vs extra-cardiac ischemic risk.

CONTEXTE: La prise en charge antithrombotique des patients ayant subi un syndrome coronarien aigu (SCA) a sensiblement évolué au fil du temps. Toutefois, compte tenu de l'incertitude qui persiste quant aux critères définissant un SCA stable, il est possible que les pratiques divergent après la première année. MÉTHODOLOGIE: Nous avons mis au point un questionnaire adaptatif en ligne décrivant les cas de patients présentant divers degrés de risque d'ischémie cardiaque ou extracardiaque, afin d'évaluer les objectifs autodéclarés des médecins quant à la prise en charge antithrombotique des patients ayant subi un SCA chez qui une anticoagulothérapie n'est pas formellement indiquée. Des « champions ¼ provinciaux (l'Île-du-Prince-Édouard n'étant pas représentée) ont été désignés pour assurer la diffusion du questionnaire dans leur province respective en trois envois par courriel coordonnés; le questionnaire était offert en français et en anglais, et l'enquête s'est déroulée de novembre 2018 à janvier 2019. RÉSULTATS: Au total, 135 praticiens ont répondu au sondage (taux de réponse : 15 %). Tous les participants ont répondu à toutes les questions. Presque tous les participants (97 %) étaient cardiologues; 76 % des participants travaillaient dans un centre universitaire, et 54 % exerçaient depuis 10 ans ou plus. La plupart des participants (de 81 à 90 %, selon le scénario) préféraient une bithérapie antiplaquettaire à base de ticagrélor comme premier traitement après un SCA. Toutefois, les décisions quant au traitement au-delà des 12 premiers mois suivant le SCA variaient considérablement selon le risque cardiaque et extracardiaque résiduel évalué. CONCLUSIONS: L'étude constitue une première évaluation de la façon dont le rivaroxaban à 2,5 mg pourrait être intégré à la stratégie canadienne de prise en charge des patients au-delà de la première année suivant le SCA. Le choix de poursuivre la bithérapie antiplaquettaire ou de faire promptement la transition vers un traitement associant rivaroxaban à faible dose et acide acétylsalicylique dépendra vraisemblablement des caractéristiques cliniques du patient et du risque d'ischémie cardiaque et extracardiaque perçu.

Precautions and Procedures for Coronary and Structural Cardiac Interventions During the COVID-19 Pandemic: Guidance from Canadian Association of Interventional Cardiology.

The globe is currently in the midst of a COVID-19 pandemic, resulting in significant morbidity and mortality. This pandemic has placed considerable stress on health care resources and providers. This document from the Canadian Association of Interventional Cardiology- Association Canadienne de Cardiologie d'intervention, specifically addresses the implications for the care of patients in the cardiac catheterization laboratory (CCL) in Canada during the COVID-19 pandemic. The key principles of this document are to maintain essential interventional cardiovascular care while minimizing risks of COVID-19 to patients and staff and maintaining the overall health care resources. As the COVID-19 pandemic evolves, procedures will be increased or reduced based on the current level of restriction to health care services. Although some consistency across the country is desirable, provincial and regional considerations will influence how these recommendations are implemented. We believe the framework and recommendations in this document will provide crucial guidance for clinicians and policy makers on the management of coronary and structural procedures in the CCL as the COVID-19 pandemic escalates and eventually abates.

Characteristics and usefulness of unintended premature ventricular contraction during invasive assessment of aortic stenosis.

BACKGROUND: Postextrasystolic potentiation (PESP)-associated augmentation in left ventricular-aorta pressure gradient (LVAoG) observed after incidental premature ventricular contraction (PVC) during resting echocardiography is similar to dobutamine stress echocardiography (DSE)-associated augmentation in LVAoG in patients with low-flow, low-gradient (LF-LG) aortic stenosis (AS). What is not known is whether a similar relationship exists when unintended PVC causes PESP during cardiac catheterization in patients with AS. METHODS: We retrospectively reviewed all catheterizations performed for patients with at least moderate AS who had LVAoG assessment. Univariate and multivariate analyses were conducted to determine the predictors of pre- and post-PVC mean LVAoG ≥ 40 mmHg. RESULTS: Between September 2015 to September 2017, of 140 individuals undergoing cardiac catheterization, 34 met study criteria. Mean pre-PVC gradient was 38.9 ± 22.8 mmHg. All patients exhibited PESP-associated augmentation of LVAoG by an average of 28 ± 12%. In multivariate analysis, the only significant predictor of post-PVC mean LVAoG ≥ 40 mmHg was preserved LV function (OR 6.81; 95% CI 1.41-32.82, p = 0.02). Inability to generate ≥ 40 mmHg of mean LVAoG post-PVC had 100% specificity for nonsevere AS in our observational cohort. CONCLUSIONS: Unintended but interpretable PVCs occurred in one in four patients with AS undergoing cardiac catheterization with measurable hemodynamics. All of our patients with PVCs, regardless of underlying LVEF, exhibited PESP-associated augmentation of LVAoG. Our exploratory analysis suggests that inability to generate ≥40 mmHg of mean LVAoG post-PVC is highly specific for nonsevere AS.

Iron deficiency in heart failure: getting to the guidelines.

PURPOSE OF REVIEW: Iron deficiency is a common condition affecting approximately 50% of patients with heart failure. The purpose of this review is to explore the impact of iron deficiency on patients' quality of life and outcomes. Moreover, how intravenous replacement, even in the absence of anemia, can improve these outcomes. RECENT FINDINGS: The role of iron deficiency anemia has long been a part of assessing reversible and treatable contributors to patients' symptoms in heart failure. Recent studies have demonstrated how vital identifying not only anemic patients but those who are iron deficient without anemia, may allow us to impact their quality of life by several different measures. The latter appears to be the case not only for reduced ejection fraction but also impacts patients with preserved ejection fraction who have very few other modalities which improve symptoms. SUMMARY: Iron deficiency in heart failure is common, and with improvements in diagnosis and management, it has led to a better understanding of the importance of iron deficiency in cardiac failure and function.

Canadian spontaneous coronary artery dissection cohort study: in-hospital and 30-day outcomes.

AIMS: Spontaneous coronary artery dissection (SCAD) was underdiagnosed and poorly understood for decades. It is increasingly recognized as an important cause of myocardial infarction (MI) in women. We aimed to assess the natural history of SCAD, which has not been adequately explored. METHODS AND RESULTS: We performed a multicentre, prospective, observational study of patients with non-atherosclerotic SCAD presenting acutely from 22 centres in North America. Institutional ethics approval and patient consents were obtained. We recorded baseline demographics, in-hospital characteristics, precipitating/predisposing conditions, angiographic features (assessed by core laboratory), in-hospital major adverse events (MAE), and 30-day major adverse cardiovascular events (MACE). We prospectively enrolled 750 SCAD patients from June 2014 to June 2018. Mean age was 51.8 ± 10.2 years, 88.5% were women (55.0% postmenopausal), 87.7% were Caucasian, and 33.9% had no cardiac risk factors. Emotional stress was reported in 50.3%, and physical stress in 28.9% (9.8% lifting >50 pounds). Predisposing conditions included fibromuscular dysplasia 31.1% (45.2% had no/incomplete screening), systemic inflammatory diseases 4.7%, peripartum 4.5%, and connective tissue disorders 3.6%. Most were treated conservatively (84.3%), but 14.1% underwent percutaneous coronary intervention and 0.7% coronary artery bypass surgery. In-hospital composite MAE was 8.8%; peripartum SCAD patients had higher in-hospital MAE (20.6% vs. 8.2%, P = 0.023). Overall 30-day MACE was 8.8%. Peripartum SCAD and connective tissue disease were independent predictors of 30-day MACE. CONCLUSION: Spontaneous coronary artery dissection predominantly affects women and presents with MI. Despite majority of patients being treated conservatively, survival was good. However, significant cardiovascular complications occurred within 30 days. Long-term follow-up and further investigations on management are warranted.