Timing of Complete Revascularization with Multivessel PCI for Myocardial Infarction.

BACKGROUND: In patients with ST-segment elevation myocardial infarction (STEMI) with multivessel coronary artery disease, the time at which complete revascularization of nonculprit lesions should be performed remains unknown. METHODS: We performed an international, open-label, randomized, noninferiority trial at 37 sites in Europe. Patients in a hemodynamically stable condition who had STEMI and multivessel coronary artery disease were randomly assigned to undergo immediate multivessel percutaneous coronary intervention (PCI; immediate group) or PCI of the culprit lesion followed by staged multivessel PCI of nonculprit lesions within 19 to 45 days after the index procedure (staged group). The primary end point was a composite of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year after randomization. The percentages of patients with a primary or secondary end-point event are provided as Kaplan-Meier estimates at 6 months and at 1 year. RESULTS: We assigned 418 patients to undergo immediate multivessel PCI and 422 to undergo staged multivessel PCI. A primary end-point event occurred in 35 patients (8.5%) in the immediate group as compared with 68 patients (16.3%) in the staged group (risk ratio, 0.52; 95% confidence interval, 0.38 to 0.72; P<0.001 for noninferiority and P<0.001 for superiority). Nonfatal myocardial infarction and unplanned ischemia-driven revascularization occurred in 8 patients (2.0%) and 17 patients (4.1%), respectively, in the immediate group and in 22 patients (5.3%) and 39 patients (9.3%), respectively, in the staged group. The risk of death from any cause, the risk of stroke, and the risk of hospitalization for heart failure appeared to be similar in the two groups. A total of 104 patients in the immediate group and 145 patients in the staged group had a serious adverse event. CONCLUSIONS: Among patients in hemodynamically stable condition with STEMI and multivessel coronary artery disease, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. (Supported by Boston Scientific; MULTISTARS AMI ClinicalTrials.gov number, NCT03135275.).

[The Role of Percutaneous Coronary Revascularization in Chronic Coronary Syndromes]. / Perkutane koronare Revaskularisation beim chronischen Koronarsyndrom: wann sinnvoll, wann nicht?

The Role of Percutaneous Coronary Revascularization in Chronic Coronary Syndromes Abstract. Coronary heart disease represents the leading cause of morbidity and mortality worldwide. Optimal management of these patients is therefore crucial and includes lifestyle changes, optimal medical therapy, and coronary revascularization. This review summarizes diagnostic and therapeutic strategies of patients with chronic coronary syndromes, focusing on the 2019 European Society of Cardiology (ESC) guidelines for the diagnosis and management of chronic coronary syndromes. In particular, the role of invasive assessment and coronary revascularization in chronic coronary syndromes is discussed.

Rationale and design of the MULTISTARS AMI Trial: A randomized comparison of immediate versus staged complete revascularization in patients with ST-segment elevation myocardial infarction and multivessel disease.

About half of patients with acute ST-segment elevation myocardial infarction (STEMI) present with multivessel coronary artery disease (MVD). Recent evidence supports complete revascularization in these patients. However, optimal timing of non-culprit lesion revascularization in STEMI patients is unknown because dedicated randomized trials on this topic are lacking. STUDY DESIGN: The MULTISTARS AMI trial is a prospective, international, multicenter, randomized, two-arm, open-label study planning to enroll at least 840 patients. It is designed to investigate whether immediate complete revascularization is non-inferior to staged (within 19-45 days) complete revascularization in patients in stable hemodynamic conditions presenting with STEMI and MVD and undergoing primary percutaneous coronary intervention (PCI). After successful primary PCI of the culprit artery, patients are randomized in a 1:1 ratio to immediate or staged complete revascularization. The primary endpoint is a composite of all-cause death, non-fatal myocardial infarction, ischemia-driven revascularization, hospitalization for heart failure, and stroke at 1 year. CONCLUSIONS: The MULTISTARS AMI trial tests the hypothesis that immediate complete revascularization is non-inferior to staged complete revascularization in stable patients with STEMI and MVD.

Diagnostic performance of angiography-based quantitative flow ratio for the identification of myocardial ischemia as assessed by 13N-ammonia myocardial perfusion imaging positron emission tomography.

BACKGROUND: Quantitative flow ratio (QFR) is a novel, adenosine-free method for functional lesion interrogation based on 3-dimensional quantitative coronary angiography and computational algorithms. We sought to investigate the diagnostic performance of QFR versus myocardial perfusion imaging positron emission tomography (MPI-PET), which yields the highest accuracy for detection of myocardial ischemia. METHODS: Diagnostic performance of QFR versus MPI-PET was assessed in consecutive patients undergoing both clinically indicated coronary angiography and 13N-ammonia MPI-PET within a six-month period. RESULTS: Out of 176 patients (439 coronary arteries), 19.3% were women. Percent area stenosis was 45 [32-58] %. Myocardial ischemia on 13N-ammonia MPI-PET was detected in 106 (24.1%) vessel territories and hemodynamic significance defined as contrast-flow vessel QFR ≤ 0.80 was observed in 83 (18.9%) vessels. Diagnostic accuracy, sensitivity, and specificity of contrast-flow vessel QFR for the prediction of myocardial ischemia on 13N-ammonia MPI-PET were 92.5 (95% CI 89.6-94.7) %, 73.6 (95% CI 64.1-81.7) %, and 98.5 (95% CI 96.5-99.5) %, respectively. The AUCs for contrast-flow vessel QFR, percent diameter stenosis, and percent area stenosis were 0.85 (95% CI 0.81-0.88, p < 0.001), 0.76 (95% CI 0.71-0.79, p < 0.001) and 0.75 (95% CI 0.70-0.79, p < 0.001), respectively. CONCLUSIONS: QFR, a novel diagnostic tool for functional coronary lesion assessment, provides good diagnostic agreement with MPI-PET and superior diagnostic accuracy for the detection of myocardial ischemia as compared to anatomic indices. Future studies will have to determine the non-inferiority of QFR to fractional flow reserve with respect to clinical outcomes.

[Therapeutic Strategies in Patients with Stable Coronary Artery Disease: The Role of Coronary Revascularization]. / Moderne Therapie der stabilen koronaren Herzkrankheit: Der Stellenwert der koronaren Revaskularisation.

Therapeutic Strategies in Patients with Stable Coronary Artery Disease: The Role of Coronary Revascularization Abstract. Coronary artery disease is the leading cause of death worldwide. Prevention and optimal treatment of patients with coronary artery disease is therefore crucial. Lifestyle changes, optimal medical therapy and aggressive risk factor control represent key elements in the management of patients with stable coronary artery disease. Coronary revascularization of flow-limiting coronary artery stenoses is indicated to reduce myocardial ischemia and related symptoms. This review summarizes treatment strategies of patients with stable coronary artery disease, focusing on the 2018 European Society of Cardiology (ESC) guidelines of myocardial revascularization.

Gender and age differences in outcomes of patients with acute coronary syndromes referred for coronary angiography.

OBJECTIVES: The number of elderly patients undergoing coronary revascularization is steadily increasing, and data on the impact of gender on outcomes are scarce. This study sought to assess gender-related differences in outcomes in elderly patients with acute coronary syndromes (ACS). METHODS: We investigated outcomes in elderly ACS patients referred for coronary angiography and prospectively enrolled in the Swiss ACS Cohort between December 2009 and October 2012. Adjudicated major adverse cardiovascular and cerebrovascular events (MACCE) included all-cause death, non-fatal myocardial infarction, clinically indicated repeat coronary revascularization, definite stent thrombosis, and transient ischemic attack/stroke. RESULTS: Among 2,168 patients recruited, 481 (22%) patients were >75 years of age (37% women). In patients >75 years, 1-year MACCE rates were 15% and 23% in women and men (OR 0.59, 95% CI 0.36-0.97, P = 0.04), respectively, and differences remained significant after adjustments for baseline variables (adjusted OR 0.48, 95% CI 0.26-0.90, P = 0.02). Women >75 years had a lower cardiovascular mortality (6% versus 12%, adjusted OR 0.31, 95% CI 0.12-0.81, P = 0.02). In patients ≤75 years, 1-year MACCE rates did not differ between gender (10% and 8% for women and men, adjusted OR 1.28, 95% CI 0.77-2.14, P = 0.34). Rates of TIMI major bleeding for women and men were 4% and 4% in patients >75 years (P = 0.96), and 5% and 3% in those ≤75 years (P = 0.11). CONCLUSIONS: The low rates of MACCE observed in elderly women in this patient cohort suggest that with current interventional strategies the gender gap in ACS management has been attenuated.

Prognostic Value of SYNTAX Score II in Patients with Acute Coronary Syndromes Referred for Invasive Management: A Subanalysis from the SPUM and COMFORTABLE AMI Cohorts.

AIMS: To assess the incremental prognostic value of SYNTAX score II (SxSII) as compared to anatomical SYNTAX Score (SxS) and GRACE risk score in patients with acute coronary syndromes who underwent percutaneous coronary intervention. METHODS AND RESULTS: SxSII and SxS were determined in 734 ACS patients. Patients were enrolled in the prospective Special Program University Medicine ACS and the COMFORTABLE AMI cohorts and later on stratified according to tertiles of SxSII (SxSIILow ≤21.5 (n=245), SxSIIMid 21.5-30.6 (n=245), and SxSIIHigh ≥30.6 (n=244). The primary endpoint of adjudicated all-cause mortality and secondary endpoints of MACE (cardiac death, repeat revascularization, and myocardial infarction) and MACCE (all-cause mortality, cerebrovascular events, MI, and repeat revascularization) were determined at 1-year follow-up. SxSII provided incremental predictive information for risk stratification when compared to SxS and GRACE risk score (AUC 0.804, 95% CI 0.77-0.84, p < 0.001 versus 0.67, 95% CI 0.63-0.72, p=0.007 versus 0.69, 95% CI 0.6-0.8, p=0.002), respectively. In a multivariable Cox regression analysis, we found that unlike SxS (adjusted HR 1.013, 95% CI (0.96-1.07), p=0.654), SxSII was significantly associated with all-cause mortality (HR = 1.095, 95% CI (1.06-1.11), p < 0.001). This was also true for the prediction of both secondary outcomes MACE (n=60) and MACCE (n=70) with an adjusted HR = 1.055, 95% CI (1.03-1.08), p < 0.001, and HR = 1.065, 95% CI (1.04-1.09), p < 0.001. CONCLUSION: In patients with ACS who underwent PCI, SxSII is an independent predictor of mortality during 1-year follow-up. SxSII shows superiority in discriminating risk compared to conventional SxS and GRACE for all-cause mortality.

Predictive value of the age, creatinine, and ejection fraction (ACEF) score in patients with acute coronary syndromes.

BACKGROUND: This study sought to investigate the predictive value of the age, creatinine, and ejection fraction (ACEF) score in patients with acute coronary syndromes (ACS). The ACEF score (age/left ventricular ejection fraction +1 [if creatinine > 176 µmol/L]) has been established in patients evaluated for coronary artery bypass surgery. Data on its predictive value in all-comer ACS patients undergoing percutaneous coronary intervention are scarce. METHODS: A total of 1901 patients prospectively enrolled in the Swiss ACS Cohort were included in the analysis. Optimal ACEF score cut-off values were calculated by decision tree analysis, and patients divided into low-risk (≤1.45), intermediate-risk (>1.45 and ≤2.0), and high-risk groups (>2.0). The primary endpoint was all-cause mortality. Major adverse cardiac and cerebrovascular events (MACCE) included all-cause death, non-fatal myocardial infarction, clinically indicated repeat coronary revascularization, definite stent thrombosis, and transient ischemic attack/stroke. RESULTS: One-year rates of all-cause death increased across ACEF score groups (1.6% versus 5.6% versus 23.0%, p < 0.001). In multivariate analysis, the ACEF score was related with an increased risk of all-cause mortality (adjusted HR 3.53, 95% CI 2.90-4.31, p < 0.001), MACCE (adjusted HR 2.23, 95% CI 1.88-2.65, p < 0.001), and transient ischemic attack/stroke (adjusted HR 2.58, 95% CI 1.71-3.89, p < 0.001) at 1 year. Rates of Thrombolysis in Myocardial Infarction (TIMI) major and Global use of Strategies to Open Occluded Coronary Arteries (GUSTO) severe bleeding paralleled the increased ischemic risk across the groups (p < 0.001). CONCLUSIONS: The ACEF score is a simple and useful risk stratification tool in patients with ACS referred for coronary revascularization.

Intracardiac versus transesophageal echocardiography for left atrial appendage occlusion with watchman.

BACKGROUND: Left atrial appendage occlusion (LAAO) is mostly performed by transesophageal echocardiography (TEE) guidance. Intracardiac echocardiography (ICE) may be an alternative imaging modality for LAAO that precludes the need for general anesthesia or sedation. METHODS AND RESULTS: All consecutive single center, single operator LAAO candidates were analyzed. Baseline clinical and procedural characteristics and in-hospital outcomes were compared between patients in whom a Watchman was implanted with ICE vs. TEE guidance. In 76 consecutive patients the Watchman device was deployed under ICE in 32 patients (42%) and under TEE guidance in 44 patients (58%). Baseline characteristics were comparable between groups, except that patients in the TEE group were older (81 [75-85] years vs. 75 [68-80] years, P = 0.007). Total injected contrast media as well as fluoroscopy time were comparable between groups (90 ml [54-140] vs. 85 ml [80-110], P = 0.86 and 7.9 min [6.4-15.5] vs. 9.8 min [7.0-13.2], P = 0.51, for TEE vs. ICE, respectively). However, time from femoral venous puncture to transseptal puncture and to closure was longer in the ICE group (14 min [7.3-20] vs. 6 min [3.3-11], P = 0.007 and 48 min [40-60] vs. 34.5 min [27-44], P = 0.003, respectively). In the TEE group one patient suffered esophageal erosion with bleeding, which was managed conservatively and one non-LAAO related in-hospital mortality occurred in an 88-year-old patient. Device implantation success rate was 100% in both groups. No device embolization, no significant peri-device leak, no tamponade, no stroke, and no access site bleeding occurred in any patient. Total hospital stay for stand-alone LAAO was comparable between groups (2 days [2-2] vs. 2 days [2-3.3], P = 0.17, in ICE vs. TEE, respectively). CONCLUSIONS: ICE guidance for LAAO with the Watchman device is feasible and comparable to TEE and may become the preferred imaging modality for LAAO. © 2016 Wiley Periodicals, Inc.

Safety and efficacy profile of bioresorbable-polylactide-polymer-biolimus-A9-eluting stents versus durable-polymer-everolimus- and zotarolimus-eluting stents in patients with acute coronary syndrome.

BACKGROUND: Comparative data on long-term safety and efficacy of bioresorbable-polymer-BES versus durable-polymer-EES/ZES in ACS setting have hitherto been lacking. We sought to assess the safety and efficacy of bioresorbable-polymer-biolimus-A9-eluting stents (BES) compared with thin-strut-durable-polymer-everolimus- and zotarolimus-eluting stents (EES/ZES) in patients with acute coronary syndrome (ACS) undergoing PCI. METHODS AND RESULTS: Between 2007 and 2012, 1,547 patients were implanted with new-generation drug-eluting stents (DES). Out of these, 369 received BES and 1,178 EES/ZES. The primary endpoint was probable/definite stent thrombosis (ST) while the secondary endpoint was a composite of all-cause death, myocardial infarction (MI), target vessel revascularization (TVR) and definite ST up to 5 years. As stent assignment was not random, we performed a propensity score matching (PSM), with 1:3 ratio, to account for potential confounders. Primary analysis demonstrated no significant differences between both groups for the primary endpoint of ST (BES vs. EES/ZES: 1.6% vs. 1.9%; mean-event-time = 1,797 days vs. 1,795 days, respectively; P = 0.75) and composite safety endpoint (BES vs. EES/ZES: 12.5% vs. 12.9%; mean-event-time = 1,631 days vs. 1,620 days, respectively; P = 0.88). Results regarding the 5-year-ST- and safety endpoint remained non-significant after PSM (P = 0.85, P = 0.56; respectively). After stratification based on cardiovascular risk, no difference regarding ST and composite outcome measure has been documented between both stent groups in high-risk- and low-risk patients. The type of stent did neither predict ST (HR 1.11, 95%CI 0.45-2.74, P = 0.82) nor composite safety endpoint (HR 0.93, 95%CI 0.67-1.30, P = 0.69). CONCLUSIONS: Long-term safety and efficacy of bioresorbable-polymer-BES and durable-polymer-EES/ZES appear comparable in patients with ACS. © 2016 Wiley Periodicals, Inc.

A broken heart in a broken car.

Takotsubo syndrome (TTS) is still a relatively understudied and often undetected disease. It is usually preceded by emotional or physical triggers. We here report a case of TTS following a car accident. Typical apical ballooning with moderate reduction of left ventricular ejection fraction (LVEF) and increased level of pro-B-type natriuretic peptide (BNP) as well as slightly increased creatine kinase and troponin T values were found in this 76-year-old female patient, 6 h after a car accident. At 10 weeks follow-up, we observed a normalization of regional wall motion, LVEF, electrocardiogram and pro-BNP. TTS is an acute heart failure syndrome and an important differential diagnosis of acute coronary syndrome.

The Electrocardiogram After Transcatheter Aortic Valve Replacement Determines the Risk for Post-Procedural High-Degree AV Block and the Need for Telemetry Monitoring.

OBJECTIVES: The study sought to identify predictors for delayed high-degree atrioventricular block (AVB) in patients undergoing transcatheter aortic valve replacement (TAVR) and determine the need and required duration of telemetry monitoring. BACKGROUND: Little is known about predictors and timing of high-degree AVB. METHODS: A total of 1,064 patients (52% women) without a permanent pacemaker undergoing TAVR at 3 centers in Switzerland were investigated. Electrocardiograms (ECGs) at baseline and post-TAVR were analyzed to identify atrioventricular and interventricular conduction disorders. RESULTS: Periprocedural high-degree AVB occurred in 92 (8.7%), delayed high-degree AVB in 71 (6.7%), up to 8 days post-procedure. In multivariate analysis, delayed high-degree AVB occurred more frequently in men (odds ratio: 2.4, 95% confidence interval: 1.3 to 4.5; p < 0.01), and in patients with conduction disorders post-TAVR (odds ratio: 10.8; 95% confidence interval: 4.6 to 25.5; p < 0.01). Patients in sinus rhythm without conduction disorders post-TAVR did not develop delayed high-degree AVB (0 of 250, 0%). Similarly, the risk in patients with atrial fibrillation but no other conduction disorders was very low (1 of 102, 1%). There was no patient developing delayed high-degree AVB who had a stable ECG for 2 days or more. CONCLUSION: Patients without conduction disorders post-TAVR did not develop delayed high-degree AVB. Such patients may not require telemetry monitoring. All other patients should be monitored until the ECG remains stable for at least 2 days. This algorithm should be validated in a separate patient population.

Multi-vessel revascularization in ST-segment elevation myocardial infarction: where do we stand?

In summary, current evidence suggests that it appears to be better to do something rather than nothing. However, the question of single vs. staged complete revascularization, the best timing of the staged PCI (during the index admission or within weeks) and the question of stratification for evidence of ischaemia remain to be answered in upcoming trials. Meanwhile, complete revascularization should not be routinely performed ad-hoc, but based on individual and careful patient and lesion assessments

Simulated Prosthesis Overlay for Patient-Specific Planning of Transcatheter Aortic Valve Implantation Procedures.

OBJECTIVE: We tested the hypothesis that simulated three-dimensional prosthesis overlay procedure planning may support valve selection in transcatheter aortic valve implantation (TAVI) procedures. METHODS: Preoperative multidimensional computed tomography (MDCT) data sets from 81 consecutive TAVI patients were included in the study. A planning tool was developed, which semiautomatically creates a three-dimensional model of the aortic root from these data. Three-dimensional templates of the commonly used TAVI implants are spatially registered with the patient data and presented as graphic overlay. Fourteen physicians used the tool to perform retrospective planning of TAVI procedures. Results of prosthesis sizing were compared with the prosthesis size used in the actually performed procedure, and the patients were accordingly divided into three groups: those with equal size (concordance with retrospective planning), oversizing (retrospective planning of a smaller prosthesis), and undersizing (retrospective planning of a larger prosthesis). RESULTS: In the oversizing group, 85% of the patients had new pacemaker implantation. In the undersizing group, in 66%, at least mild paravalvular leakage was observed (greater than grade 1 in one third of the cases). In 46% of the patients in the equal-size group, neither of these complications was observed. CONCLUSIONS: Three-dimensional prosthesis overlay in MDCT-derived patient data for patient-specific planning of TAVI procedures is feasible. It may improve valve selection compared with two-dimensional MDCT planning and thus yield better outcomes.

Calcification Characteristics of Low-Flow Low-Gradient Severe Aortic Stenosis in Patients Undergoing Transcatheter Aortic Valve Replacement.

Low-flow low-gradient severe aortic stenosis (LFLGAS) is associated with worse outcomes. Aortic valve calcification patterns of LFLGAS as compared to non-LFLGAS have not yet been thoroughly assessed. 137 patients undergoing transcatheter aortic valve replacement (TAVR) with preprocedural multidetector computed tomography (MDCT) and postprocedural transthoracic echocardiography were enrolled. Calcification characteristics were assessed by MDCT both for the total aortic valve and separately for each leaflet. 34 patients had LFLGAS and 103 non-LFLGAS. Total aortic valve calcification volume (p < 0.001), mass (p < 0.001), and density (p = 0.004) were lower in LFLGAS as compared to non-LFLGAS patients. At 30-day follow-up, mean transaortic pressure gradients and more than mild paravalvular regurgitation did not differ between groups. In conclusion, LFLGAS and non-LFLGAS express different calcification patterns which, however, did not impact on device success after TAVR.

Prosthesis-Specific Predictors of Paravalvular Regurgitation after Transcatheter Aortic Valve Replacement: Impact of Calcification and Sizing on Balloon-Expandable versus Self-Expandable Transcatheter Heart Valves.

BACKGROUND AND AIM OF THE STUDY: The study aim was to investigate prosthesis-specific predictors for paravalvular aortic regurgitation (PAR) in self-expandable versus balloon-expandable transcatheter heart valves (THVs). PAR is frequently observed after transcatheter aortic valve replacement (TAVR). As self-expandable and balloon-expandable THVs engage differently with the native aortic valve structures, factors that impact PAR may differ between the prosthesis types. METHODS: A total of 137 TAVR patients who underwent pre-procedural multidetector computed tomography and post-procedural transthoracic echocardiography were studied. Predictors for PAR, including annulus area oversizing and aortic valve calcification mass and volume, were analyzed in a multivariate model. RESULTS: The Medtronic CoreValve (MCV) prosthesis was utilized in 68 patients (50%), and the Edwards SAPIEN (ES) prosthesis in 69 (50%). More than mild PAR was observed in 43 patients (32%). Among MCV patients, aortic valve calcification volume and mass were higher in those with more than mild PAR than in those with none or mild PAR (p = 0.04, p = 0.03, respectively). Among ES patients, the annulus area and perimeter oversizing were lower in those with more than mild PAR compared to those with no or mild PAR (p = 0.001). By univariate and multivariate logistic regression analysis, aortic valve calcification mass was the only independent predictor for PAR in MCV patients (p = 0.02), whereas in ES patients it was THV undersizing (p = 0.002), irrespective of the calcific burden. CONCLUSION: For self-expandable THVs, aortic valve calcification mass was the strongest predictor of PAR, whereas for balloon-expandable THVs it was prosthesis undersizing. Hence, in patients evaluated for TAVR these parameters should guide the selection of prosthesis type.

Safety profile of prasugrel and clopidogrel in patients with acute coronary syndromes in Switzerland.

OBJECTIVE: To assess safety up to 1 year of follow-up associated with prasugrel and clopidogrel use in a prospective cohort of patients with acute coronary syndromes (ACS). METHODS: Between 2009 and 2012, 2286 patients invasively managed for ACS were enrolled in the multicentre Swiss ACS Bleeding Cohort, among whom 2148 patients received either prasugrel or clopidogrel according to current guidelines. Patients with ST-elevation myocardial infarction (STEMI) preferentially received prasugrel, while those with non-STEMI, a history of stroke or transient ischaemic attack, age ≥75 years, or weight <60 kg received clopidogrel or reduced dose of prasugrel to comply with the prasugrel label. RESULTS: After adjustment using propensity scores, the primary end point of clinically relevant bleeding events (defined as the composite of Bleeding Academic Research Consortium, BARC, type 3, 4 or 5 bleeding) at 1 year, occurred at a similar rate in both patient groups (prasugrel/clopidogrel: 3.8%/5.5%). Stratified analyses in subgroups including patients with STEMI yielded a similar safety profile. After adjusting for baseline variables, no relevant differences in major adverse cardiovascular and cerebrovascular events were observed at 1 year (prasugrel/clopidogrel: cardiac death 2.6%/4.2%, myocardial infarction 2.7%/3.8%, revascularisation 5.9%/6.7%, stroke 1.0%/1.6%). Of note, this study was not designed to compare efficacy between prasugrel and clopidogrel. CONCLUSIONS: In this large prospective ACS cohort, patients treated with prasugrel according to current guidelines (ie, in patients without cerebrovascular disease, old age or underweight) had a similar safety profile compared with patients treated with clopidogrel. CLINICAL TRIAL REGISTRATION NUMBER: SPUM-ACS: NCT01000701; COMFORTABLE AMI: NCT00962416.

Early endovascular aneurysm repair after percutaneous coronary interventions.

OBJECTIVE: The objective of this study was to report long-term results of early endovascular aortic aneurysm repair after percutaneous coronary intervention (PCI). METHODS: This was a retrospective analysis of all patients presenting with abdominal aortic aneurysm and coronary artery disease treated during the same hospitalization by endovascular aortic aneurysm repair performed soon after PCI. Primary outcomes were perioperative mortality, perioperative complications, survival after treatment, and freedom from reintervention. RESULTS: A total of 20 patients were included, and all completed both procedures. No deaths or abdominal aortic aneurysm ruptures occurred between the PCI and the aortic intervention. Perioperative mortality was 5% as one patient died of mesenteric ischemia after endovascular aneurysm repair. Major cardiovascular vascular complications occurred in four patients (20%) and included non-ST-segment elevation myocardial infarction (one) and access vessel complication (three). Mean follow-up was 94 (range, 1-164; standard deviation, 47) months. Estimated survival at 1 year, 2 years, 5 years, and 10 years was 90%, 90%, 90%, and 60%, respectively. A reoperation was required in six patients. Estimated freedom from reintervention at 1 year, 2 years, 5 years, and 10 years was 83%, 83%, 78%, and 72%, respectively. CONCLUSIONS: Our study indicates that early endovascular aneurysm repair performed within a week after PCI may be a reasonable approach in patients with large or symptomatic aneurysms.

Acute coronary syndromes in octogenarians referred for invasive evaluation: treatment profile and outcomes.

BACKGROUND: With increasing life expectancy in the western world, the aging population will compose a significant portion of the demographic. Notably, cardiovascular disease is particularly prevalent in the elderly population. The aim of the present study is to investigate the outcomes of octogenarians referred for urgent coronary angiography in the setting of acute coronary syndromes (ACS). METHODS: Between June 2007 and June 2012, consecutive patients with ACS were referred for evaluation and percutaneous intervention. Subsequently, the in-hospital death and major adverse cardiovascular events (MACE) at 30 days were analyzed. Multivariate analysis was performed to identify the predictors for death and MACE. RESULTS: In patients ≥80 years (n = 296) ST-segment elevation myocardial infarction (STEMI) occurred in 46.6%, non-ST-segment elevation myocardial infarction (NSTEMI) in 45.9%, and 7.4% had unstable angina. On the other hand, in patients <80 years (n = 2,316) STEMI was observed in 53.4%, NSTEMI in 37.8% and unstable angina in 9.0%. The primary end-point of total mortality was significantly higher in octogenarians (7.4 vs. 4.5%, p = 0.026). Similarly, the secondary end-point comprising overall MACE rate was significantly higher among the elderly (12.5 vs. 7.3%, p = 0.002). Within the group of octogenarians, no relation between age and outcomes was noted (for death: OR 0.99, 95% CI 0.84-1.16, p = 0.915; and for MACE: OR 1.10, 95% CI 0.88-1.36, p = 0.412); however, in patients <80 years, age was related to outcomes (for death: OR 1.05, 95% CI, 1.02-1.08, p = 0.003; and for MACE: OR 1.03, 95% CI, 1.01-1.05, p = 0.011). In a multivariate analysis, systolic blood pressure (OR 0.97 95% CI 0.94-0.99, p = 0.0058), maximal value of creatine kinase (OR 1.00, 95% CI 1.00-1.00, p = 0.033), and maximal value of NT-proBNP (OR 1.00, 95% CI 1.00-1.00, p = 0.0225) were independent predictors for death, while systolic blood pressure (OR 0.98, 95% CI 0.96-0.99, p = 0.0384) and maximal value of C-reactive protein (OR 1.01, 95% CI 1.00-1.01, p = 0.0265) were associated with overall MACE. CONCLUSIONS: Here we confirm that in-hospital death and MACE rate remain significantly elevated in octogenarians in spite of implementation of modern therapies. However, our real-world registry strongly suggests that early revascularization appears safe and effective in elderly patients. Furthermore, we have identified that systolic blood pressure, creatine kinase, NT-proBNP, and C-reactive protein are strong predictors for outcomes in octogenarians.