Effect of Ticagrelor Versus Clopidogrel on Aortic Stiffness in Patients With Coronary Artery Disease.

Background We compared the acute and midterm effect of ticagrelor versus clopidogrel on aortic stiffness. Methods and Results We studied 117 patients in a randomized, assessor-blinded, parallel-group trial. The acute effect of ticagrelor was studied in 58 patients randomized (1:1) to receive a loading dose of clopidogrel (600 mg) or ticagrelor (180 mg). Carotid-femoral pulse wave velocity (cf PWV ) was measured before, 3, and 24 hours after the loading dose. The midterm effect (30-day treatment period) was studied in 59 subjects who underwent percutaneous coronary intervention and were randomized to either clopidogrel (75 mg, OD) or ticagrelor (90 mg BID). cf PWV was measured before and at 30 days of treatment. Circulating markers of inflammation and endothelial function were measured at all study points. Repeated-measures analysis showed a significant main effect for treatment ( P=0.03), with the ticagrelor showing a reduction in cf PWV after treatment. cf PWV at 24 hours was significantly lower in the ticagrelor group compared with the clopidogrel group ( P=0.017) (maximal response reduction by 0.42±0.26 m/s). At 30 days, cf PWV decreased in the ticagrelor group, whereas there was no change with clopidogrel (-0.43±0.57 versus 0.12±0.14 m/s, P=0.004). There were no significant changes in both the acute and midterm study period in the pro-inflammatory and endothelial function parameters. Conclusions URL : https://www.clinicaltrials.gov . Unique identifier: NCT02071212. Ticagrelor decreases cf PWV for 24 hours after the loading dose and at 1 month post-percutaneous coronary intervention compared with clopidogrel. Considering that aortic stiffness is an independent predictor of cardiovascular events, this finding may have clinical implications regarding the beneficial effect of ticagrelor. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT02071212.

Distal Versus Traditional Radial Approach for Coronary Angiography.

PURPOSE: The aim of this study was to evaluate the efficacy and safety of distal radial (DR) versus traditional radial (TR) approach during coronary angiography. METHODS: Two hundred patients scheduled to undergo transradial coronary angiography were randomized between the two approaches. Primary endpoint of the study was switching to another access site due to inability of successful target artery cannulation. Secondary endpoints were time to cannulation, total procedure duration, number of attempts, number of skin punctures and duration of manual hemostasis. Secondary safety endpoints were the rate of moderate or severe spasm, arm hematoma EASY class III or more and radial artery occlusion at discharge. Quality of life endpoint was the patient's preference of cannulation method at 30 days. RESULTS: The primary endpoint was met in 30 patients (30%) from the DR group and 2 patients (2%) from the TR group (p < 0.001). The time of cannulation was longer in the DR group compared to the TR group (269 ±â€¯251 s vs 140 ±â€¯161 s, p < 0.001), but this did not affect the total procedural duration (925 ±â€¯896 s vs 831 ±â€¯424 s, p = 0.494). The number of attempts and the number of skin punctures were more in the DR group compared to the TR group (6.8 ±â€¯6.2 vs 3.4 ±â€¯4.5, p < 0.001 and 2.4 ±â€¯1.7 vs 1.6 ±â€¯1.2, p < 0.001, respectively). However, DR treated patients had faster manual hemostasis time compared to TR treated patients (568 ±â€¯462 s vs 841 ±â€¯574 s, p = 0.002). There were no differences recorded in the safety endpoints of moderate or severe spasm, EASY grade III or more radial hematomas or the incidence of radial artery occlusion after the procedure. Patients' preference to the randomized puncture sites was the same (79% vs 85%, p = 0.358). CONCLUSION: Distal radial approach is associated with lower successful cannulation rates and shorter manual hemostasis time compared to the traditional radial approach.

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.

Diagnosis and management of phantom tachycardias based on an electrophysiologically guided approach.

BACKGROUND: Non-documented palpitations, or phantom tachycardias, are palpitations deemed to be of unknown origin after evaluation with conventional diagnostic tools, such as 12-lead electrocardiogram and Holter recordings. Our aim was to determine the diagnostic value of an electrophysiologic study (EPS) and its role in the management of patients presenting with non-documented palpitations. METHODS: We performed EPS in 78 consecutive patients with repeatable, poorly tolerated symptoms of paroxysmal, non-documented tachycardia, the absence of structural heart disease and at least one 24-h Holter recording. The duration and frequency of palpitations was registered in each patient. RESULTS: Long-lasting palpitations (>1 hour) were present in 15.4% of patients. Half of patients reported symptoms less often than once per week. Only 13/78 patients (16.6%) had normal EPS findings, while dual pathways at the AV node ± echo beats were identified in another 13 patients without inducible tachycardia. At least one tachycardia event was induced in 52 patients (66.6%). AVNRT was provoked in 32 patients (41.2%). Ablation was performed in 14/52 patients with inducible tachycardia (26.9%). Slow pathway ablation was also performed in three patients with dual AV pathways and atrial echo-beats but without provoked tachycardia. Follow-up data were available in 52 patients, and 84.6% had fewer or no clinical recurrences. CONCLUSIONS: EPS is safe and of enhanced diagnostic value in patients with unexplained palpitations because only 1/6 had negative results. EPS also provided an explanation about the mechanism of arrhythmia and successfully guided the management of these patients, as well as enhanced improvement in the quality of life.