Risk Score for Prediction of Dialysis After Transcatheter Aortic Valve Replacement

BACKGROUND

Dialysis is a rare but serious complication after transcatheter aortic valve replacement. We analyzed the large multicenter TRITAVI (transfusion requirements in transcatheter aortic valve implantation) registry in order to develop and validate a clinical score assessing this risk.

METHODS AND RESULTS

A total of 10 071 consecutive patients were enrolled in 19 European centers. Patients were randomly assigned (2:1) to a derivation and validation cohort. Two scores were developed, 1 including only preprocedural variables (TRITAVIpre) and 1 also including procedural variables (TRITAVIpost). In the 6714 patients of the derivation cohort (age 82±6 years, 48% men), preprocedural factors independently associated with dialysis and included in the TRITAVIpre score were male sex, diabetes, prior coronary artery bypass graft, anemia, nonfemoral access, and creatinine clearance <30 mL/min per m2. Additional independent predictors among procedural features were volume of contrast, need for transfusion, and major vascular complications. Both scores showed a good discrimination power for identifying risk for dialysis with C-statistic 0.78 for TRITAVIpre and C-statistic 0.88 for TRITAVIpost score. Need for dialysis increased from the lowest to the highest of 3 risk score groups (from 0.3% to 3.9% for TRITAVIpre score and from 0.1% to 6.2% for TRITAVIpost score). Analysis of the 3357 patients of the validation cohort (age 82±7 years, 48% men) confirmed the good discrimination power of both scores (C-statistic 0.80 for TRITAVIpre and 0.81 for TRITAVIpost score). Need for dialysis was associated with a significant increase in 1-year mortality (from 6.9% to 54.4%; P=0.0001).

CONCLUSIONS

A simple preprocedural clinical score can help predict the risk of dialysis after transcatheter aortic valve replacement.

A real-world multicenter study on left atrial appendage occlusion: The Italian multi-device experience

Background

Transcatheter left atrial appendage occlusion (LAAO) has emerged as an alternative treatment for stroke prevention in patients with atrial fibrillation (AF) at high risk of thromboembolism, who cannot tolerate long-term oral anticoagulation (OAC). Questions persist regarding effectiveness and safety of this treatment and the optimal post-interventional antithrombotic regimen after LAAO.

Methods

We retrospectively gathered data from 428 patients who underwent percutaneous LAAO in 6 Italian high-volume centres, aimed at describing the real-world utilization, safety, and effectiveness of LAAO procedures, also assessing the clinical outcomes associated with different antithrombotic strategies.

Results

Among the entire population, 20 (4.7 %) patients experienced a combination of pericardial effusion and periprocedural major bleeding: 8 (1.9 %) pericardial effusion, 1 (0.3 %) fatal bleeding, and 3 (0.7 %) non-fatal procedural major bleeding. Patients were discharged with different antithrombotic regimens: dual (DAPT) (27 %) or single (SAPT) (26 %) antiplatelet therapy, OAC (27 %), other antithrombotic regimens (14 %). Very few patients were not prescribed with antithrombotic drugs (6 %). At a medium 523 ± 58 days follow-up, 14 patients (3.3 %) experienced all-cause death, 6 patients (1.4 %) cardiovascular death, 3 patients (0.7 %) major bleeding, 10 patients (2.6 %) clinically relevant non-major bleeding, and 3 patients (0.7 %) ischemic stroke. At survival analysis, with DAPT as the reference group, OAC therapy was associated with better outcomes.

Conclusions

Our findings confirm that LAAO is a safe procedure. Different individualized post-discharge antithrombotic regimens are now adopted, likely driven by the perceived thrombotic and hemorrhagic risk. The incidence of both ischemic and bleeding events tends to be low.

Impact of dual antiplatelet therapy duration on clinical outcome after coronary bifurcation stenting: results from the EuroBifurcation Club registry

BACKGROUND

Optimal duration of dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) of a bifurcation stenosis is still debated. We evaluated the impact of DAPT duration on clinical outcomes in all-comers patients undergoing bifurcation PCI included in the European Bifurcation Club (EBC) registry.

METHODS

We enrolled 2284 consecutive patients who completed at least 18 months follow-up. The cumulative occurrence of major adverse cardiac and cardiovascular events (MACCE), defined as a composite of overall-death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and stroke were evaluated. Bleedings classified as Bleeding Academic Research Consortium (BARC) ≥3 were evaluated too.

RESULTS

Patients were divided into 3 groups: short DAPT (<6-months, N.=375); standard DAPT (≥6-months but ≤12-months, N.=636); prolonged DAPT (>12-months, N.=1273). At 24 months follow-up MACCE-free survival was significantly lower in short DAPT patients (Log-Rank: 45.23, P for trend <0.001). MACCE occurred less frequently in the prolonged DAPT group (148 [11.6%]) as compared with both the short (83 [22.1%] HR: 0.48 [0.37-0.63], P<0.001) and standard DAPT groups (137 [21.5%] HR:0.51 [0.41-0.65], P<0.001). These differences remain after propensity score adjustment (respectively, HR: 0.27 [0.20-0.36] and HR: 0.44 [0.34-0.57]). Such finding was consistent in patients presenting with both acute and chronic coronary syndromes. BARC≥3 bleedings were 0.3% in the standard DAPT, 1.6% in short and 1.9% in prolonged DAPT groups.

CONCLUSIONS

In the "real-world" EBC registry of patients undergoing PCI of coronary artery bifurcation stenosis, a prolonged DAPT duration was associated with a significantly lower risk of MACCE and a potential increased risk of major bleedings.

Coronary angiography- or fractional flow reserve-guided complete revascularization in multivessel disease STEMI: A Bayesian hierarchical network meta-analysis

AIMS

To identify the best strategy to achieve complete revascularization (CR) in patients with ST-elevation myocardial infarction (STEMI) and multi-vessel disease (MVD).

METHODS AND RESULTS

We systematically reviewed the literature for randomized controlled trials (RCTs) comparing IRA-only PCI and CR guided by angiography or fractional flow reserve (FFR) in MVD-STEMI. Both frequentist (classical) and Bayesian network meta-analysis were performed, including a comparative hierarchy estimation of the probability to reduce the primary composite endpoint of all-cause death and new myocardial infarction (MI). We identified 11 RCTs, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the primary endpoint (OR: 0.73; 95%CI0.55-0.97). We observed non-significant difference between angiography and FFR guidance in reducing the primary endpoint (OR: 0.73, 95% CI 0.35-1.57). The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of all-cause death or new MI (SUCRA92%).

CONCLUSIONS

In patients with MVD-STEMI, CR is associated with a reduction in all-cause mortality and new MI compared with IRA-only PCI. Angio-guided CR is associated with the lowest risk of all-cause death or new MI, therefore the role of FFR-guidance in this setting is questionable.

CONDENSED ABSTRACT

Both frequentist and Bayesian network meta-analysis were performed to compare infarct-related artery (IRA)-only percutaneous coronary intervention (PCI) and complete revascularization (CR) guided by angiography or fractional flow reserve (FFR) in multivessel disease (MVD) and acute ST-elevation myocardial infarction (STEMI). Eleven randomized controlled trials were identified, including 8193 STEMI patients. Compared with IRA-only strategy, CR significantly reduced the incidence of the composite endpoint of all-cause death and new myocardial infarction without significant difference in angio-guided and FFR-guided CR. The Bayesian probability analysis ranked angio-guided CR as the best intervention yielding lowest risk of the composite endpoint and, therefore the role of FFR-guidance in this setting is questionable.

529 PERSPECTIVES ON CARDIAC OUTPUT EVALUATION IN PULMONARY HYPERTENSION PATIENTS UNDERGOING RIGHT HEART CATHETERIZATION

Background and aim

Right heart catheterization (RHC) is the gold standard for the diagnosing and classifying pulmonary hypertension (PH). Cardiac output (CO) and the derived cardiac index (CI) are cornerstones of the hemodynamic evalution allowing pulmonary vascular resistance (PVR) calculation and risk stratification. According to the current European Guidelines, CO should be assessed by the direct Fick method or thermodilution (TD). The indirect Fick (IF) method based on theorically estimated values for VO2, is deemed acceptable bul lacks reliability. Of note, data from the literature on a direct comparison among these three methods used for CO measurement are poor.

The objective of our study is to compare CO evaluation by the DF method (DFCO) with CO assessed by IF (IFCO) and TD (TDCO). Secondly, we aimed at assessing the impact of CO estimation by different methods on PVR measurement and therefore on PH hemodynamic classification. This might translate into relevant diagnostic, prognostic and therapeutic implications.

Methods

27 patients underwent RHC. Breath-by breath VO2 was measured through a Rudolph mask connected with a two-way respiratory valve to a metabolic cart and averaged over the course of 12 to 15 minutes. DFCO was calculated using the following formula: VO2 (ml/min)/(arteriovenous oxygen content difference×10). For IFCO, the same formula was used with VO2 computed by the Dehmer and the LaFarge-Miettinen formulas. TDCO was obtained through the injection of 10 ml of cold saline solution (0-4°C), in the right atrium and by measuring the temperature variation in the pulmonary artery.

Results

RHC revealed PH in 23 patients (85%) Average VO2 by Dehmer formula differed significantly from direct measurement (228.9 ± 27.9 ml/min and 204.4 ± 43.6 ml/min respectively; P = 0.017). By using LaFarge formula, mean estimated VO2 differed from direct measurement without reaching statistical significance (185.3 ± 31.9 ml/min and 204.4 ± 43.6 ml/min respectively, P= 0.072). Average CO values did not differ significantly from each other (DFCO 4.2 ± 1.5 L/min; IFCO 4.7 ± 1.3 L/min; TDCO 4.6 ± 1.2 L/min; P=NS for all pairwise comparisons) and showed significant Pearson's correlation. Out of 27 cases, TDCO differed for more (± 0.5 L/min) than 10% as compared to DFCO in 17 (63%). IFCO differed consistently from DFCO in 12 (44%) and IFCO from TDCO in 17 (63%).

Despite discrepancies among different CO measurement methods, Cohen's kappa coefficient showed good agreement between the three methods in high PVR (≥3 WU) estimation (IF vs DF 0.79; TD vs DF 0.83 and IF vs TD 0.92 respectively).

Conclusions

Our results indicate consistent discrepancies among different approaches for VO2 and CO measurement, however this did not impact over PVR assessment and therefore in PH classification. Probably, this is due to the small sample size and the low number of patients (8 of 27) with values around the pathological cut-off for PVR (3 WU).

Further studies are needed to better investigate the magnitude of CO measurement discrepancies among different methods on PVR calculation and hemodynamic classification.

On site cardiac surgery for structural heart interventions: a fence to mend?

Current evidence supports device-based transcatheter interventions for the management of patients with structural heart disease, proving well their safety and efficacy; transcatheter aortic valve implantation (TAVI), transcatheter edge-to-edge repair (TEER) of mitral or tricuspid valves, and left atrial appendage occlusion (LAAO) are expanding their role in contemporary practice. Currently, guidelines recommend performing TAVI in ‘Heart Valve Center’ with interventional cardiology and institutional on-site cardiac surgery (iOSCS), while no site limitation has been defined for TEER and LAAO. The growing number of candidates for transcatheter interventions generates long waiting times with negative consequences on mortality, morbidity, hospitalization, and functional deterioration. Therefore, a debate on the feasibility of TAVI in centres without iOSCS has been set up. Data from randomized controlled trials and registries failed to document any difference in outcomes and in conversion rate to emergent surgical bailout in centres with or without iOSCS; on the other hand, a direct relationship with TAVI complications has been clearly documented for learning curve and centre volume. Therefore, the role of iOSCS for TAVI, as well as for other transcatheter interventions, should be carefully explored.

Predictive Value of Left Atrial and Ventricular Strain for the Detection of Atrial Fibrillation in Patients With Cryptogenic Stroke

Background and Aims

Cryptogenic stroke (CS) is associated with a high rate of recurrences and adverse outcomes at long-term follow-up, especially due to its unknown etiology that often leads to ineffective secondary prevention. Asymptomatic atrial fibrillation (AF) could play an important pathophysiological role. Some studies have pointed to left atrial (LA) and left ventricular (LV) systolic and diastolic dysfunction as surrogate markers of AF. The aim of the study is to evaluate the relationship between echocardiographic parameters of LA and LV function, and the occurrence of AF revealed by continuous ECG monitoring in a cohort of patients with CS.

Methods

Single-center prospective cohort study. Seventy-two patients with CS with insertable cardiac monitors (ICM) underwent transthoracic echocardiography (TTE). TTE was focused on LA and LV function, including both standard and longitudinal strain-derived parameters. All detected AF episodes lasting more than 2 min were considered.

Results

Continuous ECG monitoring revealed subclinical AF in 23 patients (32%) at an average of 6.5 months after ICM implantation. Many echocardiographic parameters, indicating LA volume and LV systolic/diastolic function, were significantly associated with the occurrence of AF, suggesting the worst atrial function in the AF group. Furthermore, multivariable regression analysis revealed that peak atrial contraction strain and left ventricular strain were independently associated with AF (adjusted OR = 0.72, CI 95% 0.48–0.90, p = 0.005, and adjusted OR = 0.69, CI 95% 0.46–0.95, p = 0.041, respectively).

Conclusion

In patients with CS, LA and LV strain analysis add predictive value for the occurrence of AF over clinical and morpho-functional echocardiographic parameters. Impaired booster pump strain and LV longitudinal strain are strong and independent predictors of AF.

Timing of mechanical circulatory support during primary angioplasty in acute myocardial infarction and cardiogenic shock: Systematic review and meta-analysis

OBJECTIVES

We aim to define whether the timing of microaxial left ventricular assist device (IMLVAD) implantation might impact on mortality in acute myocardial infarction (AMI) cardiogenic shock (CS) patients who underwent primary percutaneous coronary intervention (PPCI).

BACKGROUND

Despite the widespread use of PPCI, mortality in patients with AMI and CS remains high. Mechanical circulatory support is a promising bridge to recovery strategy, but evidence on its benefit is still inconclusive and the optimal timing of its utilization remains poorly explored.

METHODS

We compared clinical outcomes of upstream IMLVAD use before PPCI versus bailout use after PPCI in patients with AMI CS. A systematic review and meta-analysis of studies comparing the two strategies were performed. Effect size was reported as odds ratio (OR) using bailout as reference group and a random effect model was used. Study-level risk estimates were pooled through the generic inverse variance method (random effect model).

RESULTS

A total of 11 observational studies were identified, including a pooled population of 6759 AMI-CS patients. Compared with a bailout approach, upstream IMLVAD was associated with significant reduction of 30-day (OR = 0.65; 95% confidence interval [CI] = 0.51-0.82; I²  = 43%, adjusted OR = 0.54; 95% CI = 0.37-0.59; I²  = 3%, test for subgroup difference p = 0.30), 6-month (OR = 0.51; 95% CI = 0.27-0.96; I²  = 66%), and 1-year (OR = 0.56; 95% CI = 0.39-0.79; I²  = 0%) all-cause mortality. Incidence of access-related bleeding, acute limb ischemia and transfusion outcomes were similar between the two strategies.

CONCLUSION

In patients with AMI-CS undergoing PPCI, upstream IMLVAD was associated with reduced early and midterm all-cause mortality when compared with a bailout strategy.

Factors for heterogeneous outcomes of angina and myocardial ischemia without obstructive coronary atherosclerosis

BACKGROUND AND OBJECTIVES

The absence of obstructive coronary artery disease (CAD) in patients with angina is common, but its prognosis is debated. We investigated outcomes of such patients to identify predictors of cardiovascular events.

METHODS

We selected 1014 patients with angina, evidence of myocardial ischemia at the electrocardiogram (ECG) exercise test or imaging stress tests, and nonobstructive CAD (absence of lumen diameter reduction ≥50%) at coronary angiography between 1999 and 2015. Note that, 1905 age- and risk factors-matched asymptomatic subjects served as "real-world" comparators. The primary endpoint was the occurrence of all-cause death or myocardial infarction.

RESULTS

At 6-years median follow-up (interquartile range, 3-9 years), the primary endpoint occurred in 53 patients (5.5%, 0.92/100 person-years). Besides similar event rates compared with asymptomatic subjects (hazard ratio [HR] 0.85, 95% confidence interval [CI] 0.62-1.15, p = 0.28), the index population showed a very heterogeneous prognosis. Patients with nonobstructive CAD (HR 1.85, 95% CI 1.02-3.37, p = 0.04, compared with "normal" coronary arteries) and ischemia at imaging tests (HR 2.11, 95% CI 1.07-4.14, p = 0.03, compared with ischemia detected only at the ECG exercise test) were at higher risk and those with both these components showing even >10-fold event rates as compared with the absence of both. Three-hundred and twenty-five patients (34%) continued to experience angina, 69 (7.2%) underwent repeat coronary angiography, and 14 (1.5%) had consequent coronary revascularization for atherosclerosis progression.

CONCLUSION

Apart from the impaired quality of life, angina without obstructive CAD has an overall benign but very heterogeneous prognosis. Nonobstructive CAD and myocardial ischemia at imaging tests both confer a higher risk.

606 Predictive value of left atrial and left ventricular strain for the detection of atrial fibrillation in patients with cryptogenic stroke

Aims

Cryptogenic stroke (CS) is associated with high rate of recurrences and adverse outcomes at long-term follow-up, especially in light of its unknown etiology that often leads to ineffective secondary prevention. In such scenario, asymptomatic misdiagnosed atrial fibrillation (AF) episodes could play an important pathophysiological role. Some studies have pointed left atrial (LA) and left ventricular (LV) systolic and diastolic dysfunction as surrogate markers of AF. The aim of this study was to evaluate the relationship between echocardiographic parameters of LA and LV function, and the occurrence of AF revealed by continuous electrocardiogram (ECG) monitoring in a cohort of CS patients.

Methods and results

This is a single-centre prospective cohort study. Seventy-two CS patients with continuous ECG monitoring with insertable cardiac monitor (ICM) underwent transthoracic echocardiography (TTE). TTE was focused on LA and LV function, including both standard and longitudinal strain-derived parameters. All detected AF episodes lasting more than 2 min were considered. Patients with and without AF were homogeneous in all baseline characteristics, except for CHA2DS2-VASc score, which was significantly higher in AF group, and prevalence of hypercholesterolaemia, that was significantly higher in no-AF group. ICM revealed AF in 23 patients (32%), on average 196 days after ICM implantation. Among echocardiographic parameters, LV ejection fraction (LVEF, P = 0.007), LA end systolic area (LAES area, P = 0.006), LA volume index (LAVI, P = 0.008), total LA emptying fraction (LATEF, P = 0.013), E velocity (P = 0.042), pulmonary veins AR duration (P = 0.01), septal and median TDI E/e′ (respectively, P = 0.045 and P = 0.039), peak atrial longitudinal strain (PALS) in 4-chamber and in 2-chamber view (respectively, P &lt; 0.001 and P = 0.011), peak atrial contraction strain (PACS, P &lt; 0.001), LA conduit strain (P = 0.005), and LV longitudinal strain (LVLS, P = 0.001) were significantly associated to the occurrence of AF, suggesting worst atrial function in AF group. Furthermore, multivariable regression analysis revealed that PACS and LV strain were the only echocardiographic parameters independently associated with AF [confidence interval (CI) 95%: 0.48–0.90, P = 0.005 and CI 95%: 0.46–0.95, P = 0.041 respectively].

Conclusions

In a cohort of CS patients, continuous ECG monitoring with ICM revealed subclinical AF episodes in about one-third of patients. In such population, LA and LV strain analysis add predictive value for occurrence of AF over clinical and morpho-functional echocardiographic parameters. Impaired booster pump strain and LVLS strain are strong and independent predictors of AF.

The ‘dreaded PFO’: anatomical and functional features of high risk for stroke

Patent foramen ovale (PFO) has a high prevalence in general population and can be implicated in cryptogenic stroke among young people. Recent trials have shown that transcatheter PFO closure is superior to medical treatment in the secondary prevention of ischaemic stroke. The benefit in the reduction of stroke recurrence is particularly evident in patients who have documentation of a PFO with high-risk characteristics. Therefore, after the assessment of a clear causal relationship with the event, a thoughtful documentation of anatomic (height, length, presence of an aneurysmatic or a floppy atrial septum, a prominent Eustachian valve or Chiari’s network, an acute angle with the inferior vena cava) and functional high-risk characteristics is mandatory.

Early Adverse Impact of Transfusion After Transcatheter Aortic Valve Replacement: A Propensity-Matched Comparison From the TRITAVI Registry

BACKGROUND

There is no consensus on the benefit of red blood cell (RBC) transfusion after transcatheter aortic valve replacement.

METHODS

The multicenter Transfusion Requirements in Transcatheter Aortic Valve Implantation (TRITAVI) registry retrospectively included patients after transfemoral transcatheter aortic valve replacement; propensity score-matching identified pairs of patients with and without RBC transfusion. The primary end point was 30-day mortality; nonfatal myocardial infarction, cerebrovascular accident, and stage 2 to 3 acute kidney injury at 30 days were secondary end points. We repeated propensity score-matching according to the hemoglobin nadir, hemoglobin drop, and in the subgroup of uncomplicated patients, without major vascular complications or major bleeding.

RESULTS

Among 2587 patients, RBC transfusion was administered in 421 cases (16%). The primary end point occurred in 104 (4.0%) patients, myocardial infarction in 9 (0.4%), cerebrovascular accident in 38 (1.5%), and acute kidney injury in 125 (4.8%) cases. In the 842 propensity-matched patients, RBC transfusion was associated with increased mortality (hazard ratio, 2.07 [95% CI, 1.06-4.05]; P=0.034) and acute kidney injury (hazard ratio, 4.35 [95% CI, 2.21-8.55]; P<0.001). Interaction testing between RBC transfusion and mortality was not statistically significant in the above-mentioned subgroups, and such association was not documented in the corresponding propensity score-matched cohorts. In the multivariable Cox proportional hazards regression model, major vascular complications (P=0.044), major bleeding (P=0.041), and RBC transfusion (P=0.048) were independent correlates of 30-day mortality.

CONCLUSIONS

RBC transfusion correlates with increased mortality and acute kidney injury early after transcatheter aortic valve replacement and is an independent predictor of 30-day mortality, irrespective of periprocedural major bleeding and vascular complications. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03740425.

The impact of the extent of side branch disease on outcomes following bifurcation stenting

OBJECTIVES

To define the impact of side branch (SB) lesion length on clinical outcomes after percutaneous coronary intervention (PCI) on bifurcation lesions.

BACKGROUND

The role of the SB lesion length remains questionable in PCI planning and its implication on clinical outcome is controversial.

METHODS

Data from the retrospective multicenter EBC-P2BiTO registry were analyzed. The primary endpoint was the occurrence of major adverse cardiac events (MACE), defined as the composite of cardiac death, myocardial infarction excluding periprocedural, or stent thrombosis at 13 months median follow-up (IQR 11-28). By using propensity scores for inverse probability of treatment weighting (IPTW), the comparison of treatment groups was adjusted to correct for potential confounding.

RESULTS

Among 1,252 patients, SB was normal in 489 (39%), diseased in 763 (61%) cases. MACE occurred in 68 patients (5.4%). The optimal discriminant SB lesion length for MACE was ≥10 mm, with an area under the curve of 0.71 (p < .01). The incidence of MACE was higher among patients with SB lesions ≥10 mm (8%) than with normal SB (4.1%) (hazard ratio [HR], 2.8; 95% confidence interval [CI], 1.5-5.3; p = .001, IPTW-adjusted) or SB lesions <10 mm (5.1%) (HR, 1.5; 95% CI, 1.1-3.3; p = .048, IPTW-adjusted), being similar between these last two groups.

CONCLUSIONS

In bifurcation PCI, SB lesion length ≥ 10 mm identifies patients at higher risk of MACE than those with <10 mm SB lesions and those without SB disease, considering that no differences were observed among these last two groups. Careful planning is mandatory when approaching bifurcations with long SB lesions.

P1962Impact of Dual Antiplatelet Therapy duration on clinical outcome after stent implantation for coronary bifurcation lesions: results from the Euro Bifurcation Club - P2BiTO - registry

Background

Duration of Dual Antiplatelet Therapy (DAPT) following Acute Coronary Syndromes (ACS) or Stable Coronary Artery Disease (SCAD) treated with coronary stenting is still debated. Although current guidelines consider several “clinical” criteria to decide for short DAPT (<6 months), standard DAPT (12 months) and prolonged DAPT (>12 months), the relationship between DAPT duration, treatment of bifurcations and its impact on clinical outcome has been poorly investigated in real world registries.

Purpose

We evaluated the impact of DAPT duration on clinical outcomes in consecutive all-comers patients treated with stenting of coronary artery bifurcation lesions included in the Euro Bifurcation Club -P2BiTO - registry.

Methods

Data on 5036 consecutive patients who underwent PCI on coronary bifurcation at 17 major coronary intervention centres between January 2012 and December 2014 were collected. The primary endpoint of the study was the cumulative occurrence of Major Adverse Cardiac Events (MACCE), defined as a composite of overall-death death, non-fatal myocardial infarction (MI), target vessel revascularization (TVR) and stroke during the follow-up; the secondary endpoints were the single occurrence of any of the above mentioned events.

Results

Data on DAPT duration was available for 3992 patients (79%). Patients were divided into 3 groups: Group 1) DAPT <6-months (n=720); Group 2) DAPT >6-months but <12-month (n=1602); Group 3) DAPT >12-months (n=1670). Follow up was completed in 3935 (98%) patients with a median of 20 months (C.I.=12–28). At 24 months after the index procedure, MACCE occurred more frequently in the DAPT <6-month group (Group 1) as compared with both Group 2 and 3 (respectively, 102 (14%) versus 154 (10%) and 164 (10%), HR: 0.72 (0.64–0.82), p<0.001). This difference remains after adjustment for clinical and angiographic characteristics (HR: 0.66 (0.58–0.77), p<0.001). On the contrary, no significant difference was found between Group 2 and Group 3 patients. At the Kaplan-Meier analysis (Figure 1), freedom from MACCE survival was significantly lower in patients receiving DAPT for less than 6 months (Log-Rank: 29.5, p<0.001).

Figure 1. Kaplan-Meier curves

Conclusions

In the P2BiTO registry, short DAPT duration of less than 6 months was associated with a significantly higher risk of MACCE compared to longer DAPT in a real-world registry of patients treated for coronary artery bifurcation stenosis.

Calcific lesion preparation for coronary bifurcation stenting

Bifurcating coronary lesions are a very common challenge in interventional cardiology because of the technical complexity in their treatment, the risk of side branch occlusion and an overall worse outcome when compared to non-bifurcating lesions. The presence of calcifications represents further complexity due to the difficulty in device delivery and stent expansion as well as enhanced risk of side branch occlusion. Rotational and orbital atherectomy, scoring and cutting balloons, coronary lithoplasty are available tools which have been introduced over the last three decades to overcome such issue. Nevertheless, their application in different contexts of bifurcations presents specific caveats and the studies directed at comparing such techniques have never been expressly oriented in the subset of the bifurcating lesion. In this paper, we review these devices and their usefulness in bifurcations by analyzing consistent data from clinical trials, and we propose a practical algorithm for the treatment of severely calcified bifurcating lesions according to their anatomical features.

ST segment/heart rate hysteresis improves the diagnostic accuracy of ECG stress test for coronary artery disease in patients with left ventricular hypertrophy

BACKGROUND

The exercise electrocardiographic stress test (ExET) is the most widely used non-invasive diagnostic method to detect coronary artery disease. However, the sole ST depression criteria (ST-max) have poor specificity for coronary artery disease in patients with left ventricular hypertrophy. We hypothesised that ST-segment depression/heart rate hysteresis, depicting the relative behaviour of ST segment depression during the exercise and recovery phase of the test might increase the diagnostic accuracy of ExET for coronary artery disease detection in such patients.

METHODS

In three cardiology centres, we studied 113 consecutive patients (mean age 66 ± 2 years; 88% men) with hypertension-related left ventricular hypertrophy at echocardiography, referred to coronary angiography after an ExET. The following ExET criteria were analysed: ST-max, chronotropic index, heart rate recovery, Duke treadmill score, ST-segment depression/heart rate hysteresis.

RESULTS

We detected significant coronary artery disease at coronary angiography in 61 patients (53%). At receiver-operating characteristic analysis, ST-segment depression/heart rate hysteresis had the highest area under the curve value (0.75, P < 0.001 when compared with the 'neutral' receiver-operating characteristic curve value of 0.5). Area under the curve values were 0.68 (P < 0.01) for the chronotropic index, 0.58 (P = NS) for heart rate recovery, 0.57 (P = NS) for ST-max and 0.52 (P = NS) for the Duke treadmill score.

CONCLUSIONS

Among currently available ExET diagnostic variables, ST-segment depression/heart rate hysteresis offers a substantially better diagnostic accuracy for coronary artery disease than conventional criteria in patients with hypertension-related left ventricular hypertrophy.

Cardiovascular morbidity and mortality related to orthostatic hypotension: a meta-analysis of prospective observational studies

BACKGROUND

Whether orthostatic hypotension (OH) is a risk factor for cardiovascular morbidity and death is uncertain. Currently available evidence derives from non-homogeneous and partly ambiguous studies.

OBJECTIVE

We aimed at assessing the relationship between OH and death or major adverse cardiac and cerebrovascular events (MACCEs) by integrating results of previous studies.

METHODS

We performed a meta-analysis of prospective observational studies reporting on the association between prevalent OH, mortality, and incident MACCE, published from 1966 through 2013. Mantel-Haenszel pooled estimates of relative risk (RR) and 95% confidence intervals (CIs) for all-cause death were assessed as the primary endpoint at the longest follow-up; incident coronary heart disease (CHD), heart failure (HF), and stroke were assessed as secondary endpoints. We also performed post hoc subgroup analyses stratified by age and a meta-regression analysis.

RESULTS

We identified a total of 13 studies, including an overall population of 121 913 patients, with a median follow-up of 6 years. Compared with the absence of OH, the occurrence of OH was associated with a significantly increased risk of all-cause death (RR 1.50; 95% CI 1.24-1.81), incident CHD (RR 1.41; 95% CI 1.22-1.63), HF (RR 2.25; 95% CI 1.52-3.33), and stroke (RR 1.64; 95% CI 1.13-2.37). When analysed according to age, pooled estimates of RR (95% CI) for all-cause death were 1.78 (1.25-2.52) for patients <65 years old, and 1.26 (0.99-1.62) in the older subgroup.

CONCLUSION

Orthostatic hypotension is associated with a significantly increased risk of all-cause death, incident CHD, HF, and stroke.

[Nitrates in cardiology: current role and areas of uncertainty]

Nitrates have been commonly used in the therapy of cardiovascular disease for more than 150 years. In spite of this longevity and the popularity of their use, it appears somewhat paradoxical that their use is not consistent among cardiologists, both as to their indications and as to their mode of administration. In part this results from their contradictory pharmacodynamics: when given acutely, their effectiveness is indisputable; however, their long-term efficacy is substantially limited by the development of tolerance and the induction of endothelial dysfunction, which may have negative prognostic implications. This review, reporting the most recent biochemical and pathophysiological acquisitions, re-examines the role of nitrates in cardiovascular medicine, reporting, comparing and commenting international guidelines.