Long-term impact of intravascular ultrasound-guidance for percutaneous coronary intervention on unprotected left main. The IMPACTUS-LM, an observational, multicentric study

INTRODUCTION

The potential benefit on long term outcomes of Percutaneous Coronary Intervention (PCI) on Unprotected Left Main (ULM) driven by IntraVascular UltraSound (IVUS) remains to be defined.

METHODS

IMPACTUS LM-PCI is an observational, multicenter study that enrolled consecutive patients with ULM disease undergoing coronary angioplasty in 13 European high-volume centers from January 2002 to December 2015. Major Adverse Cardiovascular Events (MACEs) a composite of cardiovascular (CV) death, target vessel revascularization (TVR) and myocardial infarction (MI) were the primary endpoints, while its single components along with all cause death the secondary ones.

RESULTS

627 patients with ULM disease were enrolled, 213 patients (34%) underwent IVUS-guided PCI while 414 (66%) angioguided PCI. Patients in the two cohorts had similar prevalence of risk factors except for active smoking and clinical presentation. During a median follow-up of 7.5 years, 47 (22%) patients in the IVUS group and 211 (51%) in the angio-guided group underwent the primary endpoint (HR 0.42; 95% CI [0.31-0.58] p < 0.001). After multivariate adjustment, IVUS was significantly associated with a reduced incidence of the primary endpoint (adj HR 0.39; 95% CI [0.23-0.64], p < 0.001), mainly driven by a reduction of TVR (ad HR 0.30, 95% CI [0.15-0.62], p = 0.001) and of all-cause death (adj HR 0.47, 95% CI [0.28-0.82], p = 0.008). IVUS use, age, diabetes, side branch stenosis, DES and creatinine at admission were independent predictors of MACE.

CONCLUSIONS

In patients undergoing ULM PCI, the use of IVUS was associated with a reduced risk at long-term follow-up of MACE, all-cause death and subsequent revascularization.

Monotherapy with P2Y12-inhibitors after dual antiplatelet therapy: Filling gaps in evidence

BACKGROUND

Whether P2Y12 inhibitor monotherapy (P2Y12-I) is superior to aspirin following DAPT discontinuation post-PCI remains to be established.

METHODS

We updated our prior network meta-analysis where P2Y12-I and aspirin had been compared with DAPT or directly with each other. The focus is specifically on the available direct evidence, now consisting of the three head-to-head comparisons of P2Y12-I and aspirin in event-free PCI patients after DAPT. We include a Trial Sequential Analysis of the direct evidence based on meta-analytical literature.

RESULTS

The main finding reveals a 39% significantly lower risk of myocardial infarction with P2Y12-I (RR 0.61, 95% CI 0.47-0.78, p = 0.0001, I2 = 0%) with no difference in bleeding. Trial Sequential Analysis demonstrates clinically meaningful evidence for a reduction in the incidence of myocardial infarction with P2Y12-I that is also supported by statistical significance.

CONCLUSIONS

Accruing data highlight that P2Y12-I following DAPT discontinuation after PCI is associated with lower risk for MI and a similar risk for bleeding as compared with ASA. In light of potential limitations to the widespread adoption of life-long P2Y12-I treatment, clinicians should consider identifying selected patients who are expected to derive the highest benefit.

Prognostic Impact of Prefrailty and Frailty in Women Undergoing TAVR: Insights From the WIN-TAVI Registry

BACKGROUND

The risks of prefrail and frail women undergoing transcatheter aortic valve replacement (TAVR) have not been fully examined. The aim of the analysis was to assess the prognostic impact of prefrailty and frailty in women undergoing TAVR.

METHODS

Women at intermediate or high surgical risk with severe aortic stenosis undergoing TAVR from the prospective multicentre WIN-TAVI (Women's International Transcatheter Aortic Valve Implantation) registry were stratified based on the number of Fried frailty criteria (weight loss, exhaustion, low physical activity, slow gait, weakness) met: nonfrail (no criteria), prefrail (1 or 2 criteria), or frail (3 or more criteria). The primary outcome at 1 year was the Valve Academic Research Consortium 2 (VARC-2) efficacy end point, a composite of mortality, stroke, myocardial infarction, hospitalisation for valve-related symptoms or heart failure, and valve-related dysfunction; secondary outcomes included the composite of VARC-2 life-threatening or major bleeding.

RESULTS

Out of 1019 women, 297 (29.1%) met at least 1 frailty criterion: 264 (25.9%) had prefrailty and 33 (3.2%) frailty. The 1-year risk of the primary outcome was significantly higher in prefrail and frail (20.2%) than in nonfrail (14.9%) women (adjusted hazard ratio [aHR] 1.51, 95% confidence interval [CI] 1.07-2.12). The risk of VARC-2 life-threatening or major bleeding was higher in prefrail or frail (19.9%) than in nonfrail (10.0%) women (aHR 2.06, 95% CI 1.42-2.97). These risks were consistently increased in the prefrail and frail groups assessed separately.

CONCLUSIONS

In women undergoing TAVR, the presence of prefrailty or frailty conferred an increased risk of the VARC-2 efficacy end point and of VARC-2 life-threatening or major bleeding.

Aspirin-free antiplatelet strategies after percutaneous coronary interventions

Dual antiplatelet therapy (DAPT) with aspirin and a platelet P2Y12 receptor inhibitor is the standard antithrombotic treatment after percutaneous coronary interventions (PCI). Several trials have challenged guideline-recommended DAPT after PCI by testing the relative clinical effect of an aspirin-free antiplatelet approach-consisting of P2Y12 inhibitor monotherapy after a short course (mostly 1-3 months) of DAPT-among patients undergoing PCI without a concomitant indication for oral anticoagulation (OAC). Overall, these studies have shown P2Y12 inhibitor monotherapy after short DAPT to be associated with a significant reduction in the risk of bleeding without an increase in thrombotic or ischaemic events compared with continued DAPT. Moreover, the effects of the P2Y12 inhibitor monotherapy without prior DAPT or following a very short course of DAPT after PCI are being investigated in emerging studies, of which one has recently reported unfavourable efficacy results associated with the aspirin-free approach compared with conventional DAPT. Finally, P2Y12 inhibitor alone has been compared with aspirin alone as chronic therapy after DAPT discontinuation, thus challenging the historical role of aspirin as a standard of care for secondary prevention following PCI. A thorough understanding of study designs, populations, treatments, results, and limitations of trials testing P2Y12 inhibitor monotherapy vs. DAPT or vs. aspirin is required to consider adopting this treatment in clinical practice. This review addresses the use of aspirin-free antiplatelet strategies among patients undergoing PCI without a concomitant indication for OAC, providing an overview of clinical evidence, guideline indications, practical implications, ongoing issues, and future perspectives.

Cangrelor in contemporary patients with ST-segment elevation myocardial infarction pretreated with Ticagrelor: Pharmacodynamic data from the POMPEII study

Background

There are limited data to assess pharmacodynamic (PD) profiles of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) and receiving cangrelor after pretreatment with ticagrelor.

Methods

The PharmacOdynaMic effects of cangrelor in PatiEnts wIth acute or chronIc coronary syndrome undergoing percutaneous coronary intervention (POMPEII) registry (NCT04790032) is a prospective study conducted at Federico II University of Naples enrolling all patients undergoing PCI receiving cangrelor at operator's discretion. PD assessments were performed with 3 assays: (1) the gold standard light transmittance aggregometry (LTA) (20- and 5-μM adenosine diphosphate [ADP] stimuli); (2) VerifyNow P2Y12-test; (3) Multiplate electrode aggregometry (MEA), ADP-test.

Results

We analyzed 13 STEMI patients pretreated with ticagrelor within 1 h at the time they underwent primary PCI receiving cangrelor. All patients showed low maximal platelet aggregation at 30-minute during cangrelor infusion, as well as at 3 h and 4-6 h (corresponding to 1 h and 2-4 h after stopping cangrelor infusion) with no cases of high residual platelet reactivity. These results were consistent with all assays.

Conclusions

PD data show that in contemporary real-world STEMI patients pretreated within 1 h with ticagrelor undergoing primary PCI, adding cangrelor resulted in fast and potent platelet inhibition, thus suggesting that cangrelor may bridge the gap until ticagrelor reaches its effect.

Safety of cangrelor and transition to oral P2Y12 inhibitors in patients undergoing percutaneous coronary intervention: the ARCANGELO study

Aims

Cangrelor is the only intravenous P2Y12 inhibitor available. Safety, efficacy, and transitioning from cangrelor to oral P2Y12 inhibitors were recorded in patients with acute coronary syndrome (ACS). The ARCANGELO study aims to assess the safety of cangrelor on bleeding and the effects of the transition to oral P2Y12 inhibitors in a real-world setting according to the European Medical Agency's requirement.

Methods and results

Adult patients with ACS undergoing percutaneous coronary intervention (PCI) receiving cangrelor were included in the study. Patients were followed for 30 days. Incidence of bleeding events, major adverse cardiac events, and transition strategy to oral P2Y12 were recorded. Among 1004 ACS patients undergoing PCI, 995 (99.1%) were eligible for the analysis; 597 (60.0%) of them had ST-segment elevation myocardial infarction. A total of 925 (93.1%) patients underwent PCI by radial catheter access, and 972 (97.2%) received drug-eluting stents. All eligible patients received bolus and cangrelor infusion between 2 and 4 h in 95% of the cases. A total of 730 patients (73.4%) received ticagrelor, 127 (12.8%) prasugrel, and 138 (13.9%) clopidogrel as transition therapy. Bleeding, according to Bleeding Academic Research Consortium (BARC) criteria, within 30 days post-PCI occurred in 5.2% of patients (95% confidence interval: 3.9-6.8%); 0.5% experienced a moderate (BARC 3), and all others mild (BARC 1-2) bleeding events. Major adverse cardiac events occurred in 14 (1.4%) patients, principally all-cause mortality (n = 6 patients) and myocardial infarction (n = 7 patients).

Conclusion

The use of cangrelor in ACS patients undergoing PCI and the transition strategy to P2Y12 inhibitors are confirmed as safe and effective in daily practice.

Defining Strategies of Modulation of Antiplatelet Therapy in Patients With Coronary Artery Disease: A Consensus Document from the Academic Research Consortium

Antiplatelet therapy is the mainstay of pharmacologic treatment to prevent thrombotic or ischemic events in patients with coronary artery disease treated with percutaneous coronary intervention and those treated medically for an acute coronary syndrome. The use of antiplatelet therapy comes at the expense of an increased risk of bleeding complications. Defining the optimal intensity of platelet inhibition according to the clinical presentation of atherosclerotic cardiovascular disease and individual patient factors is a clinical challenge. Modulation of antiplatelet therapy is a medical action that is frequently performed to balance the risk of thrombotic or ischemic events and the risk of bleeding. This aim may be achieved by reducing (ie, de-escalation) or increasing (ie, escalation) the intensity of platelet inhibition by changing the type, dose, or number of antiplatelet drugs. Because de-escalation or escalation can be achieved in different ways, with a number of emerging approaches, confusion arises with terminologies that are often used interchangeably. To address this issue, this Academic Research Consortium collaboration provides an overview and definitions of different strategies of antiplatelet therapy modulation for patients with coronary artery disease, including but not limited to those undergoing percutaneous coronary intervention, and consensus statements on standardized definitions.

[SICI-GISE/SICOA Consensus document: Clinical follow-up of patients after acute coronary syndrome or percutaneous coronary intervention]

In the last decades, advances in percutaneous coronary intervention (PCI) strategies have significantly reduced the risk of procedural complications and in-hospital mortality of patients with acute coronary syndromes (ACS), thus increasing the population of stable post-ACS patients. This novel epidemiological scenario emphasizes the importance of implementing secondary preventive and follow-up strategies. The follow-up of patients after ACS or elective PCI should be based on common pathways and on the close collaboration between hospital cardiologists and primary care physicians. However, the follow-up strategies of these patients are still poorly standardized. This SICI-GISE/SICOA consensus document was conceived as a proposal for the long-term management of post-ACS or post-PCI patients based on their individual residual risk of cardiovascular adverse events. We defined five patient risk classes and five follow-up strategies including medical visits and examinations according to a specific time schedule. We also provided a short guidance for the selection of the appropriate imaging technique for the assessment of left ventricular ejection fraction and of non-invasive anatomical or functional tests for the detection of obstructive coronary artery disease. Physical and pharmacological stress echocardiography was identified as the first-line imaging technique in most of cases, while cardiovascular magnetic resonance should be preferred when an accurate evaluation of left ventricular ejection fraction is needed. The standardization of the follow-up pathways of patients with a history of ACS or elective PCI, shared between hospital doctors and primary care physicians, could result in a more cost-effective use of resources and potentially improve patient's long-term outcome.

Overcoming professional barriers encountered by women in interventional cardiology: an EAPCI statement

Despite the increasing proportion of female medical and nursing students, there is still a significant under-representation of women working as healthcare providers in interventional cardiology, with very few of them reaching senior leadership, academic positions, or acting principal investigators, as well as actively involved in company advisory boards. In this position paper, we will describe the current status of women working in interventional cardiology across Europe. We will also provide an overview of the most relevant determinants of the under-representation of women at each stage of the interventional cardiology career path and offer practical suggestions for overcoming these challenges.

Pre-procedural oral anticoagulant use is associated with cardiovascular events in women after transcatheter aortic valve replacement: An analysis from the WIN-TAVI cohort

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has become an accepted treatment for patients with severe aortic stenosis (AS). Predicting which patients are at risk for adverse clinical outcomes after TAVI remains difficult, especially in women.

AIM

To identify predictors of adverse events in the WIN-TAVI cohort.

METHODS

The WIN-TAVI study is an observational registry of 1019 women undergoing TAVI for severe symptomatic AS. Follow-up was 1 year. The primary outcome was defined according to VARC-2: a composite of mortality, stroke, myocardial infarction or hospitalization for valve-related symptoms or heart failure. The secondary outcome was a composite of cardiovascular mortality or hospitalization for valve-related symptoms or heart failure.

RESULTS

We included 1019 women with severe AS (mean age of 82.5 ± 6.3 years). At 1 year, 16.4% of the patients experienced the primary endpoint and 12.6% the secondary endpoint. The use of oral anticoagulants (OAC) was the strongest independent predictor of the primary outcome (adjusted hazard ratio [aHR] 1.51, 95% confidence interval [CI] 1.079-2.106, p = 0.016). Independent predictors of the secondary endpoint were age (aHR 1.04 per year, 95% CI 1.01-1.074, p = 0.016) and use of OAC (aHR: 1.79, 95% CI 1.24-2.60, p = 0.002). OAC use was not associated with higher bleeding risk.

CONCLUSION

Pre-procedural use of OAC was the strongest predictor of adverse outcomes during 1-year follow-up, likely reflecting a combination of high-risk factors and comorbidities, but was not related to increased bleeding risk.

122 A SWORD IN THE STONE - A STEMI AFTER MIAVR

Background

Minimally invasive aortic valve replacement (MIAVR) is defined as a surgical aortic valve replacement which involves smaller chest incisions (mini-sternotomy and right anterior mini-thoracotomy approaches) and minimized degree of surgical intrusiveness. Compared with conventional surgery, it has been shown to reduce postoperative mortality, providing faster and shorter recovery, requires less rehabilitations resources and consequently cost reduction. Even though MIAVR has considered as a safe and acceptable surgical technique, higher learning curve and requirement for re-training should be endorsed as procedural limitations. Among procedural related complications, embolic events still remain the most serious.

Clinical case

A 70-year-old man, due to increasing dyspnea and chest pain came to emergency department. His medical history was notable for cigarettes smoke, dyslipidemia, non insuline dependent type 2 diabetes mellitus and hypertension. No abnormal electrocardiografic alterations. A transtoracic echocardiogram was performed showing, Left ventricular ejection fraction 50%, no wall motion abnormalities and thickened, ipomobil and calcified aortic valve cusps assessing a diagnosis of severe aortic stenosis. He was conducted to the cath-lab for a diagnostic coronary angiogram which showed a no-significant atherosclerotic disease. After Heart Team evaluation, MIAVR was the suitable and optimal management indicated for the patient.

Four hours after ending surgical procedure, ST segment elevation suddenly appears on DII, DIII and aVF leads. Emergency coronary angiogram showed an acute occlusion of the proximal circumflex artery.

After several unsuccessful attempts to cross the occlusion with different types of workhorse guidewires, we considered the cause of uncrossability was not a thrombus but a debris calcium embolus detached from valve apparatus.

After failed attempts using FineCross, SuperCross 90° provided adequate support to gaining access and enhancing the penetrating power of guidewire; we put the guidewire distally through the Mo2 with partial flow regain. Then we proceeded to modify the plaque geometry with a NC balloon to help crossing guidewire through distal Cx. So we’ve passed over the lesion gaining Cx periphery with a Fielder XT guidewire and we’ve proceeded to prepare the lesion thorugh progressive NC balloon dilatations. At the end we’ve implanted a 3.5/15 mm DES on mid Cx.

Conclusion

As MIAVR has being more common in the last twenty years, it is useful knowing how to manage any possible related peri-operative complications. Calcific valve is a very uncommon source of coronary debirs embolization. Coronary embolism is associated to worse outcomes: early diagnosis and revascularization must be required. Knowledge of CTO techniques and materials (guidewires, microcatheters) for a “non-CTO” dedicated operators could be useful in several scenarios, such as that encountered in the present case.

508 ELIGIBILITY TO DUAL PATHWAY INHIBITION THERAPY IN PATIENTS WITH CORONARY OR PERIPHERAL ARTERY DISEASE

Background

The VOYAGER PAD and COMPASS trials established the benefit of dual pathway inhibition (DPI) with aspirin and low dose rivaroxaban for eligible patients with peripheral artery disease (PAD) undergoing revascularisation and for those with PAD or chronic coronary syndromes (CCS), respectively. However, in-hospital implementation of DPI remains slow in clinical practice, also due to eligibility uncertainties.

Purpose

To assess the eligibility to DPI among contemporary patients hospitalised in cardiology and vascular surgery units, and to evaluate clinical outcomes of patients presenting with revascularised PAD according to their eligibility to the DPI strategy.

Methods

We analysed data from patients with revascularised PAD included in the prospective institutional RAPID (RivAroxaban for PerIpheral artery Disease) and applied the VOYAGER PAD criteria to identify patients eligible to DPI and the frequency and distribution of exclusion criteria. Clinical outcomes were compared between patients eligible and not eligible to DPI. The primary efficacy outcome was the composite of cardiovascular death, acute limb ischemia, or unplanned limb revascularization, while the primary safety outcome was major bleeding according to the Bleeding Academic Research Consortium definition (i.e., type 3 or 5). Secondary outcomes included the individual components of the primary efficacy outcome, all-cause death, clinically relevant bleeding and minor bleeding. Finally, to explore the residual potential for DPI applicability in clinical practice, COMPASS criteria were also applied to a contemporary CCS cohort from the institutional registry enrolling coronary artery disease patients undergoing invasive management, and the frequency and characteristics of DPI eligibility between PAD and CCS were compared.

Results

From May 2021 to August 2022, 122 patients (mean age 70.9±10.1 years, 74.6% male) were included in the RAPID registry. Based on VOYAGER PAD eligibility criteria, 62 patients (50.8%) were eligible to DPI. Main reasons for exclusion were oral anticoagulation (13.1%), prior stroke or transient ischemic attack (11.5%), high bleeding risk (46.7%), or concurrent indications for dual antiplatelet therapy (0.8%). In the CCS registry, 1,389 patients were enrolled in the same period (mean age 70.3±10.5 years, 75.6% male). CCS patients who were eligible to DPI were 276 (19.9%). Main reasons for exclusion were concurrent need for dual antiplatelet therapy (27.1%), high bleeding risk (44.8%), need for oral anticoagulation (21.4%), severe heart failure (9.9%), absence of CAD or PAD (35.3%), and end-stage renal disease (2.6%). To provide updated follow-up information, clinical outcomes will be made available for presentation on December 2022.

Conclusions

Approximately one patient out of two with revascularised PAD and only one fifth of patients with CCS undergoing invasive management were eligible to DPI. According to these results, unlike candidates to the VOYAGER PAD strategy, candidates to the COMPASS strategy are more likely to be identified in an outpatient than hospital setting.

47 UNDER THE BRIDGE: OFF-LABEL CANGRELOR FOR PCI PATIENTS UNDERGOING NON CARDIAC SURGERY

Background

Dual antiplatelet therapy (DAPT) reduces the risk of stent thrombosis after percutaneous intervention (PCI), but it is estimated that approximately 5 to 10% of PCI patients undergo major noncardiac surgeries within 12 months from the procedure, which requires DAPT interruption. The interruption of DAPT reduces the risk of perioperative bleeding, but increases the risk of stent thrombosis. Peri-operative “bridge” therapy with cangrelor, a reversible and competitive intravenous P2Y12 receptor inhibitor with rapid on/offset of action, may offer a solution for high-risk patients undergoing major noncardiac surgery who require DAPT interruption. However, the use of cangrelor for this indication is currently off-label.

Clinical Scenario

A 58-year-old man was admitted to ER with increasing dyspnea and oppressive chest pain on exertion. A diagnosis of non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was made and PCI of the left main-left anterior descendent artery segment and the right coronary artery was performed with implantation of four drug-eluting stents. DAPT was prescribed for 12 months with acetylsalicylic acid 100 mg daily and ticagrelor 90 mg twice daily. The day after the procedure, due to gross hematuria with clots formation; the hemoglobin level fell to 8 g/dL and a transfusion was required. Subsequent abdominal echocardiography revealed two bladder neoformations that required further endoscopic evaluation and transurethral resection of bladder tumor (TURBT). In preparation for such invasive procedure, DAPT required interruption despite the high risk of catastrophic consequences.

Methods

After ticagrelor interruption, cangrelor was started intravenously at a rate of 0.6 mcg/Kg/min for 5 days and stopped 2 hours before the TURBT procedure, which was performed with minimal blood loss and no ischemic complications. Cangrelor infusion was re-started 2 hours after surgery at the same initial rate and planned for 12 hours if no sudden bleeding occurred. The day after the TURBT procedure cangrelor was stopped and DAPT was re-initiated with aspirin 100 mg daily and clopidogrel 75 mg daily (after a 600 mg loading dose). The patient was discharged 2 days later without any new bleeding or ischemic event.

Conclusions

Premature discontinuation of DAPT is a strong predictor of stent thrombosis in patients undergoing PCI who require major noncardiac surgery. Cangrelor represents a viable option for managing high-risk individuals who require prolonged P2Y12 receptor blockade with rapid onset and offset of action despite discontinuation of oral therapy. This use is currently off-label due to lack of well powered randomized clinical trials of bridge therapy.

Monitoring antiplatelet therapy: where are we now?

Single antiplatelet therapy represents the cornerstone of thrombosis prevention in atherosclerotic cardiovascular disease. Dual antiplatelet therapy (DAPT), consisting of aspirin plus a P2Y12 inhibitor, is the standard of care for patients with acute coronary syndrome or undergoing both coronary and peripheral percutaneous interventions. Recent data suggest the efficacy of DAPT also after minor stroke. In this setting, a large body of evidence has documented that genetic and acquired patients' characteristics may affect the magnitude of platelet inhibition induced by antiplatelet agents. The implementation of tools allowing the identification and prediction of platelet inhibition has recently been shown to improve outcomes, leading to an optimal balance between antithrombotic efficacy and bleeding risk. We are therefore clearly moving towards tailored antiplatelet therapy. The aim of this paper is to summarize the available evidence on the evaluation of platelet inhibition in patients with coronary, peripheral, or cerebrovascular atherosclerosis. We will here focus on antiplatelet therapy based on both aspirin and P2Y12 inhibitors. In addition, we provide practical insights into the clinical settings in which it appears reasonable to implement antiplatelet therapy monitoring.

339 INTRAVENOUS CANGRELOR VERSUS ORAL TICAGRELOR IN PATIENTS WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION UNDERGOING PRIMARY PERCUTANEOUS CORONARY INTERVENTION: A PROPENSITY SCORE-MATCHED ANALYSIS

Background

In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI), potent oral inhibitors of the adenosine diphosphate (ADP)–activated platelet P2Y12 receptor (i.e., prasugrel, ticagrelor) are recommended in addition to acetylsalicylic acid, given as a loading dose as soon as possible, and followed by a maintenance dose. However, the onset of action of oral P2Y12 inhibitors is relatively slower in STEMI patients. In comparison with oral P2Y12 inhibitors, cangrelor has several pharmacokinetic advantages due to its intravenous route of administration, including platelet inhibition within minutes. There is no randomized study so far comparing cangrelor with ticagrelor. The aim of this study was to investigate the comparative effectiveness of intravenous cangrelor and ticagrelor pre-treatment in STEMI patients undergoing primary PCI.

Methods

We looked for patients with STEMI undergoing primary PCI at a single high-volume center who were naïve from oral P2Y12 inhibitors at presentation and who received cangrelor (in-lab) or ticagrelor pretreatment. The primary endpoint of the study was a composite of all-cause death, myocardial infarction (MI), definite or probable stent thrombosis and unplanned repeat revascularization within hospital discharge. Secondary outcomes were represented by individual components of the primary composite endpoint, cardiovascular death, non-cardiovascular death, and major bleeding within 72 hours from PCI. Propensity score matching was used to account for potential confounders.

Results

A total of 396 patients with STEMI (October 2019-March 2022) met the eligibility criteria and entered the analysis; of them, 186 (47%) received intravenous cangrelor. The ticagrelor loading dose was administered before invasive coronary angiography in 210 patients (53%). In the unadjusted analysis, no statistically significant difference between cangrelor and ticagrelor was observed with respect to the primary composite outcome (odds ratio [OR], 1.49, 95% CI, 0.79 to 2.82; P=0.22) and all the other secondary outcomes. Consistently, after propensity-score matching of 133 matched pairs of patients receiving cangrelor or ticagrelor, no significant differences emerged with respect to the primary outcome (OR, 1.12, 95% CI, 0.44 to 2.85; P=0.81) and all the other secondary outcomes.

Conclusion

In patients with STEMI undergoing primary who were naïve from oral P2Y12 inhibitors at presentation cangrelor and ticagrelor yielded similar results. Thanks to its pharmacologic characteristics, cangrelor could be especially useful in the acute setting.

The stent in the high-bleeding risk patient: antiplatelet monotherapy?

Dual antiplatelet therapy (DAPT) is the recommended treatment after percutaneous coronary intervention (PCI). The introduction into clinical practice of new drug-eluting stents (DESs) with significantly improved safety profiles has made it possible to shorten the DAPT. Randomized studies have established the superiority of DES over bare metal stents in high-bleeding risk (HBR) patients treated with antiplatelet monotherapy after 1 month of DAPT from PCI. This regimen has been adopted in randomized trials comparing different DES in patients with HBR. Furthermore, antiplatelet monotherapy after 1 month of DAPT from PCI has been shown to reduce bleeding risk without increasing ischaemic events compared with a conventional DAPT regimen (3-12 months) in a recent randomized study that included HBR patients treated with DES. Parallel to the trend of shortening DAPT, there is growing debate about which antiplatelet monotherapy is optimal after discontinuation of DAPT, with some recent studies exploring the paradigm shift from aspirin monotherapy to P2Y12 inhibitor monotherapy. Finally, future studies are underway to evaluate the clinical effect of monotherapy with ticagrelor or prasugrel directly after implantation of DES thus eliminating DAPT.

Use of cangrelor in patients with acute coronary syndromes undergoing percutaneous coronary intervention: Study design and interim analysis of the ARCANGELO study

BACKGROUND

The itAlian pRospective Study on CANGrELOr (ARCANGELO) was aimed to assess the safety of using cangrelor during percutaneous coronary intervention (PCI) in patients with acute coronary syndromes (ACS) in the daily practice.

HYPOTHESIS

The safety of cangrelor after the transition to oral P2Y12 inhibitors was evaluated as the incidence of bleeding outcomes in the 30 days following PCI according to postauthorization safety study guidelines.

METHODS

Adults with ACS who were treated with cangrelor in one of the 28 centers involved in the study. Patients who consented to participate were followed in the 30 days following their PCI. Bleedings (Bleeding Academic Research Consortium [BARC] classification), major adverse cardiac events (MACEs), and adverse events were recorded. The interim results at two-thirds of the enrollment period are presented.

RESULTS

A total of 17 bleedings were observed in the 320 patients who completed the study at this stage. All bleedings were classified as BARC Type 1-2, except for one case of Type 3a (vessel puncture site hematoma). Four patients experienced MACEs (2 acute myocardial infarctions, 1 sudden cardiac death, 1 noncardiovascular death due to respiratory distress, and multiorgan failure). None of the bleedings was rated as related to cangrelor.

CONCLUSIONS

The interim results of the ARCANGELO study provide a preliminary confirmation that the use of cangrelor on patients with ACS undergoing PCI is not associated with severe bleedings.

Impact of Small Valve Size on 1-Year Outcomes After Transcatheter Aortic Valve Implantation in Women (from the WIN-TAVI Registry)

Although most patients with small aortic annulus are women, there is paucity of data on the prognostic impact of small aortic prosthesis in women who underwent transcatheter aortic valve implantation (TAVI). Therefore, we aimed to evaluate the impact of small valve size on 1-year clinical outcomes after TAVI in women. The Women's INternational Transcatheter Aortic Valve Implantation is an all-women registry evaluating patients with severe aortic stenosis who underwent TAVI. Based on the size of the aortic bioprosthesis implanted, women were stratified into small (≤23 mm) and nonsmall (>23 mm) valve. The primary efficacy endpoint was the Valve Academic Research Consortium-2 composite of all-cause death, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure or valve-related dysfunction at 1-year follow-up. Of 934 women who underwent TAVI, 388 (41.5%) received a small valve. Women with a small valve size had a lower body mass index, lower surgical risk scores, were less likely to suffer from atrial fibrillation, less often required postdilation and had a lower rate of residual aortic regurgitation grade ≥2. The occurrence of the Valve Academic Research Consortium-2 efficacy endpoint was similar between women treated with small and nonsmall valve (16.0% vs 16.3%, p = 0.881; adjusted hazard ratio 1.34, 95% confidence interval 0.90 to 2.00). Likewise, there were no significant differences in the occurrence of other secondary endpoints after multivariable adjustment. In conclusion, women with severe aortic stenosis who underwent TAVI with the implantation of a small valve bioprosthesis had similar 1-year outcomes as those receiving a nonsmall bioprosthesis.

Sex Differences in Outcomes After Percutaneous Coronary Intervention or Coronary Artery Bypass Graft for Left Main Disease: From the DELTA Registries

Background

Controversy exists over whether sex has significant interaction with revascularization strategy for unprotected left main coronary artery disease. Higher mortality has been reported among women treated with percutaneous coronary intervention compared with coronary artery bypass grafting.

Methods and Results

The DELTA (Drug‐Eluting Stents for Left Main Coronary Artery Disease) and DELTA‐2 registries are international, multicentric registries evaluating the outcomes of subjects undergoing coronary revascularization for unprotected left main coronary artery disease. The primary outcome was a composite of death, myocardial infarction, or cerebrovascular accidents. The population consisted of 6253 patients, including 1689 (27%) women. Women were older and more likely to have diabetes and chronic kidney disease than men (P<0.05). At a median follow‐up of 29 months (interquartile range 12–49), a significant interaction between sex and revascularization strategy was observed for the primary end point (p_int=0.012) and all‐cause death (p_int=0.037). Among women, compared with percutaneous coronary intervention, coronary artery bypass grafting was associated with lower risk of the primary end point (event rate 9.5% versus 15.3%; adjusted hazard ratio [AHR], 0.53; 95% CI, 0.35–0.79, P<0.001) and all‐cause death (event rate 5.6% versus 11.7% AHR, 0.50; 95% CI, 0.30–0.82) and no significant differences were observed in men.

Conclusions

In women undergoing coronary revascularization for unprotected left main coronary artery disease, coronary artery bypass grafting was associated with lower risk of death, myocardial infarction, or cerebrovascular accidents whereas no significant differences between coronary artery bypass grafting and percutaneous coronary intervention were observed in men. Further dedicated studies are needed to determine the optimal revascularization strategy in women with unprotected left main coronary artery disease.

Edoxaban versus Vitamin K Antagonist for Atrial Fibrillation after TAVR

BACKGROUND

The role of direct oral anticoagulants as compared with vitamin K antagonists for atrial fibrillation after successful transcatheter aortic-valve replacement (TAVR) has not been well studied.

METHODS

We conducted a multicenter, prospective, randomized, open-label, adjudicator-masked trial comparing edoxaban with vitamin K antagonists in patients with prevalent or incident atrial fibrillation as the indication for oral anticoagulation after successful TAVR. The primary efficacy outcome was a composite of adverse events consisting of death from any cause, myocardial infarction, ischemic stroke, systemic thromboembolism, valve thrombosis, or major bleeding. The primary safety outcome was major bleeding. On the basis of a hierarchical testing plan, the primary efficacy and safety outcomes were tested sequentially for noninferiority, with noninferiority of edoxaban established if the upper boundary of the 95% confidence interval for the hazard ratio did not exceed 1.38. Superiority testing of edoxaban for efficacy would follow if noninferiority and superiority were established for major bleeding.

RESULTS

A total of 1426 patients were enrolled (713 in each group). The mean age of the patients was 82.1 years, and 47.5% of the patients were women. Almost all the patients had atrial fibrillation before TAVR. The rate of the composite primary efficacy outcome was 17.3 per 100 person-years in the edoxaban group and 16.5 per 100 person-years in the vitamin K antagonist group (hazard ratio, 1.05; 95% confidence interval [CI], 0.85 to 1.31; P = 0.01 for noninferiority). Rates of major bleeding were 9.7 per 100 person-years and 7.0 per 100 person-years, respectively (hazard ratio, 1.40; 95% CI, 1.03 to 1.91; P = 0.93 for noninferiority); the difference between groups was mainly due to more gastrointestinal bleeding with edoxaban. Rates of death from any cause or stroke were 10.0 per 100 person-years in the edoxaban group and 11.7 per 100 person-years in the vitamin K antagonist group (hazard ratio, 0.85; 95% CI, 0.66 to 1.11).

CONCLUSIONS

In patients with mainly prevalent atrial fibrillation who underwent successful TAVR, edoxaban was noninferior to vitamin K antagonists as determined by a hazard ratio margin of 38% for a composite primary outcome of adverse clinical events. The incidence of major bleeding was higher with edoxaban than with vitamin K antagonists. (Funded by Daiichi Sankyo; ENVISAGE-TAVI AF ClinicalTrials.gov number, NCT02943785.).

Impact of direct oral anticoagulants on evolution of post-thrombotic syndrome

BACKGROUND

The effect of direct oral anticoagulants (DOACs) on evolution of a post-thrombotic syndrome (PTS) is unknown.

METHODS AND RESULTS

This retrospective study included patients (n = 98) with a PTS occurring after a proximal deep-vein thrombosis (DVT). The PTS progression was assessed by the Villalta scale change over time from when patients were started on DOACs for the prevention of DVT recurrence according to current guidelines. The PTS evolution was compared between patients with good (n = 63) vs. poor (n = 35) DOACs adherence, defined by using a medication possession ratio cut point of 0.80. The mean follow-up was 41.7 ± 17.7 and 27.5 ± 10.5 months in patients with good or poor adherence, respectively. The primary endpoint of PTS improvement (defined when the Villalta score became <5 and/or decreased by ≥30% from baseline) was higher in patients with good vs. poor adherence (66.7% vs. 20%, p < 0.001). None of the patients in the good adherence group experienced at any time of follow-up the co-primary endpoint of PTS worsening (defined as the Villalta score increase ≥30%), which instead occurred in 12 (34.3%) of those with poor adherence (p < 0.001). All study-defined primary endpoints occurred within 2 years. The mean values of the Villalta partial scores related to the subjective symptoms (patient-rated) and to the potentially reversible physician-rated signs were significantly improved in the good adherence group, while they were unchanged among patients with poor adherence.

CONCLUSIONS

In this study a good vs. poor DOACs adherence was associated with a more favorable progression of PTS over a long-term follow-up. Larger studies are needed to explore the clinical efficacy of DOACs on PTS manifestations.

Incidence, predictors and clinical impact of permanent pacemaker insertion in women following transcatheter aortic valve implantation: Insights from a prospective multinational registry

OBJECTIVES

To describe the incidence, predictors, and clinical impact of permanent pacemaker insertion (PPI) following transcatheter aortic valve replacement (TAVR) in women.

BACKGROUND

Data on pacemaker insertion complicating TAVR in women are scarce.

METHODS

The Women's International Transcatheter Aortic Valve implantation (WIN-TAVI) is a prospective registry evaluating the safety and efficacy of TAVR in women. We included patients without preprocedural pacemakers and divided them into two groups: (1) PPI and (2) no-PPI. We identified PPI predictors using logistic regression and studied its clinical impact on the Valve Academic Research Consortium (VARC)-2 efficacy and safety endpoints.

RESULTS

Out of 1019 patients, 922 were included in the analysis. Post-TAVR PPI occurred in 132 (14.3%) patients. Clinical and procedural characteristics were similar in both groups. Pre-existing right bundle branch block (RBBB) was associated with a high risk of post-TAVR PPI (OR 3.62, 95% CI 1.85-7.06, p < 0.001), while implantation of balloon-expandable prosthesis was associated with a lower risk (OR 0.47, 95% CI 0.30-0.74, p < 0.001). Post-TAVR PPI prolonged in-hospital stay by a median of 2 days (11 [9-16] days in PPI vs. 9 [7-14] days in no-PPI, p = 0.005), yet risks of VARC-2 efficacy and safety endpoints at 1 year were similar in both groups (_adj HR 0.95, 95% CI 0.60-1.52, p = 0.84 and _adj HR 1.22, 95% CI 0.83-1.79, p = 0.31, respectively).

CONCLUSION

Pacemaker implantation following TAVR is frequent among women and is associated with pre-existing RBBB and valve type. PPI prolongs hospital stay, albeit without any significant impact on 1-year outcomes.

Tackling the gap in platelet inhibition with oral antiplatelet agents in high-risk patients undergoing percutaneous coronary intervention

Introduction: Oral P2Y₁₂ inhibitors represent the mainstay therapy for the prevention of thrombotic complications in patients presenting with an acute coronary syndrome and/or undergoing percutaneous coronary intervention (PCI). However, the onset of antiplatelet action of the oral P2Y₁₂ inhibitors is affected by their need to be absorbed in the gastrointestinal (GI) tract before becoming systemically available.Areas covered: Following oral intake of P2Y₁₂ inhibitors, the timeframe required for GI absorption leads to a window of inadequate antiplatelet protection during which patients are at increased thrombotic risk. The onset of action of the oral P2Y₁₂ inhibitors is even further delayed in high-risk patients, underscoring the need to define strategies to bridge the gap in platelet inhibitory effects following their intake.Expert opinion: Multiple mechanisms may impair GI absorption leading to a delay in the onset of action of oral P2Y₁₂ inhibitors. Several strategies have been tested to overcome the gap in platelet inhibition in high-risk patients undergoing PCI. These include administration of crushed or chewed tablets to improve the dissolution rate and use of opioid receptor antagonists or metoclopramide to counteract impairment of gastric motility induced by opioids. However, intravenous antiplatelet therapies represent the most effective strategy to bridge such gap in platelet inhibition.

Antithrombotic Management of Elderly Patients With Coronary Artery Disease

Antithrombotic therapy represents the mainstay of treatment in patients with coronary artery disease (CAD), including elderly patients who are at increased risk for ischemic recurrences. However, the elderly population is also more vulnerable to bleeding complications. Numerous mechanisms, including abnormalities in the vasculature, thrombogenicity, comorbidities, and altered drug response, contribute to both increased thrombotic and bleeding risk. Age-related organ changes and drug-drug interactions secondary to polypharmacy lead to distinct pharmacokinetic and pharmacodynamic profiles of antithrombotic drugs. Overall these factors contribute to the risk-benefit profiles of antithrombotic therapies in elderly subjects and underscore the need for treatment regimens that can reduce bleeding while preserving efficacy. Given that the prevalence of CAD, as well as concomitant diseases with thromboembolic potential, such as atrial fibrillation, increases with age and that the elderly population is in continuous growth, understanding the safety and efficacy of different antithrombotic regimens is pivotal for patient-centered care. In the present overview the authors appraise the available data on the use of antithrombotic therapy in older patients with CAD to assist with the management of this high-risk population and define knowledge gaps that can set the basis for future research.

Residual mitral regurgitation impact on outcomes after mitraclip therapy: five-year follow-up from the GRASP registry

Funding Acknowledgements

Type of funding sources: None.

Background – Although percutaneous mitral valve repair is an attractive alternative treatment option for patients with severe mitral regurgitation (MR) at high surgical risk, residual MR is commonly observed after the procedure and little is known about its impact on outcomes after MitraClip therapy, expecially in patients with severe left ventricular (LV) impairment.

Purpose – The aim of this prospective, observational study was to evaluate the impact of residual MR (MR ≤1+ vs. MR &gt;1+) on long-term outcomes of mitral valve repair with the MitraClip System in high surgical risk patients presenting with moderate-to-severe or severe MR and with severe reduction of LV ejection fraction (EF).

Methods – Patients enrolled in the prospective Getting Reduction of Mitral Insufficiency by Percutaneous Clip Implantation (GRASP) with functional MR and EF ≤30% who were eligible at almost five-year follow-up were included in the present analysis.  The primary endpoint was death at 5-year follow-up.  Also echocardiographic parameters at baseline and 5-year follow-up and rehospitalization rates were assessed.

Results – A total of 139 patients were included: 92 (66.2%) with post-procedural residual MR ≤1+ and 47 (33.8%) with residual MR &gt; 1+ (41 patients with residual MR 2+, 5 with residual MR 3+, 1 with residual MR 4+).  Comparable clinical and echocardiographic baseline characteristics were observed between the two groups except for NYHA functional class IV and implanted pace-maker (more frequent in patients with residual MR &gt;1+) and previous myocardial infarction (more frequent  in patients with residual MR ≤1+). At 5-year follow-up, no significant differences were reported in the primary endpoint (49.6% in patients with residual MR ≤ 1+ vs. 65.3% in patients with residual MR &gt; 1+, p 0.203) and in cardiac death (37.8% in patients with residual MR ≤ 1+ vs. 42.6% in patients with residual MR &gt; 1+, p 0.921). Cox regression analysis identified residual MR &gt; 1+ as an independent predictor of re-hospitalization (HR 0.51, 95% CI 0.28-0.92, p =0.026). At 5-year follow-up,  a significant reduction in left ventricular end-systolic volume was  observed in patients with residual MR ≤ 1+.

Conclusions – At 5-year follow no significant differences in survival emerged in patients with severe  LV dysfunction undergoing MitraClip therapy regardless residual MR. Nevertheless residual MR &gt; 1+ emerged as an indipendent predictor of re-hospitalization.

Suitability for elderly with heart disease of a QR code-based feedback of drug intake: Overcoming limitations of current medication adherence telemonitoring systems

BACKGROUND

Current medication adherence telemonitoring systems have several limitations prompting the need for simpler, low-cost and widely applicable tools. To meet these needs, we propose a novel method consisting in sending a digital feedback of medication intake by just reading a pre-defined Quick Response (QR) code attached on the pills box.

METHODS

To assess the potential clinical applicability of the proposed QR code-based task, its feasibility was tested among elderly with heart diseases. The primary endpoint was the learning success defined as a correct execution of all QR code-based digital task steps within 10 min. Study outcomes were compared between patients 65-75 years old (younger cohort) and those aged >75 years (older cohort) admitted to the Cardiology ward of a tertiary center.

RESULTS

A total of 262 patients were included: 128 (48.9%) were younger and 134 (51.1%) older. Despite a baseline low smartphone use in the overall population (41.2%), patients learning success of the digital task was as high as 75.6%, with lower rates among older vs. younger (67.9% vs. 83.6%, p = 0.005). After adjustment no significant independent association between age and success in learning the QR code-based task was found. Differently, increasing age was a negative independent predictor of smartphone use. The learning time was overall small, but longer in the older group (126 ± 100 vs. 100 ± 60 s, p = 0.03).

CONCLUSIONS

The QR code-based digital task was highly feasible for elderly with heart diseases suggesting its potential large-scale clinical application and encouraging the investigation of QR code-based systems for medication adherence telemonitoring.

Timing of cardioversion in atrial fibrillation: the sooner the better?

Management of recent-onset (<36 h) atrial fibrillation (AF) in the emergency room is highly variable, particularly concerning the type and timing of cardioversion, and the logistics of the treatment pathway. In clinical practice, it is fairly common for patients with recent-onset AF an attempt at re-establishing sinus rhythm, either with electric or pharmacologic cardioversion, as soon as feasible. Nonetheless, a 'wait-and-see' approach, and potentially delayed cardioversion, could represent a valid alternative to early cardioversion, considering that, often, in recent-onset AF, sinus rhythm is re-established spontaneously, thus repealing the need for active cardioversion, hence avoiding the possible risks of treatment. These concepts form the rationale for a recent multicentric randomized trial, Rate Control vs. Electrical Cardioversion Trial 7 - Acute Cardioversion vs. Wait and See (RACE 7 ACWAS), comparing the efficacy of delayed cardioversion, within 48 h from symptoms onset, in case of lack of spontaneous conversion, with early cardioversion in symptomatic patients with recent-onset AF. In patients presenting to the emergency department with recent-onset, symptomatic AF, a wait-and-see approach was non-inferior to early cardioversion in maintaining the sinus rhythm at 4 weeks. Nonetheless a system employing a delayed cardioversion strategy increases the costs of treatment, complicates the treatment pathway, and could represent a psychological burden for the patients. Accordingly, delayed cardioversion could not represent a practical choice for many hospitals with limited resources and without an adequate outpatient organization.

Impact of diabetes mellitus on female subjects undergoing transcatheter aortic valve implantation: Insights from the WIN-TAVI international registry

BACKGROUND

Female subjects constitute half of all transcatheter aortic valve implantation (TAVI) candidates, but the association between important comorbidities such as diabetes mellitus (DM) and clinical outcomes after TAVI remains unclear in this group.

METHOD

WIN-TAVI is a real-world international registry of exclusively female subjects undergoing TAVI. The study population was stratified into those with (DM) and those without DM (NDM). Valve Academic Research Consortium (VARC)-2 efficacy (composite of all-cause death, stroke, myocardial infarction, hospitalization for valve-related symptoms or worsening congestive heart failure, or valve-related dysfunction) was the primary endpoint for this analysis.

RESULTS

Of the 1012 subjects included in this study, 264 (26.1%) had DM at baseline. DM patients were younger but had a higher burden of comorbidities. There were no differences in VARC-2 efficacy events between DM and NDM patients at 30 days or 1 year. Conversely, patients with DM had a lower risk of VARC-2 life threatening bleeding at 30 days and 1 year after TAVI compared to NDM patients, which remained significant even after multivariable adjustment (HR, 0.34, 95% CI, 0.12-0.99; p = .047). In the subgroup analysis, insulin-dependent DM was not associated with an increased risk of adverse outcomes.

CONCLUSIONS

Among female patients undergoing TAVI, more than one-fourth of the subjects presented with DM. At 1-year follow-up, DM was associated with lower bleeding complications and no increase in the risk of other adverse events, including mortality, after TAVI.

[Management of antithrombotic therapy in patients with bleeding after percutaneous coronary intervention]

Bleeding is a frequently encountered complication in patients undergoing percutaneous coronary intervention (PCI) treated with a dual antiplatelet therapy regimen with aspirin plus an oral inhibitor of the P2Y12 platelet receptor (clopidogrel, prasugrel, ticagrelor) or with the combination of antiplatelet drugs and an anticoagulant in patients who have a specific indication for chronic anticoagulation therapy such as atrial fibrillation. The management of antithrombotic therapy during post-PCI bleeding is considerably challenging due to the intrinsic difficulty in estimating the balance between the bleeding risk - increased by antiplatelet and/or anticoagulant therapy - and the thrombotic risk associated with the possible discontinuation of these drugs. Currently, there are no data derived from dedicated studies in this setting and therefore the management of antithrombotic therapy in patients who suffer a hemorrhagic complication after PCI is guided by consensus documents that provide suggestions for the different types of bleeding, based on the severity of the latter. In light of the European documents available, this article will discuss the possible management strategies of antithrombotic therapy (antiplatelet and/or anticoagulant) in the different types of bleeding that can occur in patients undergoing PCI.

Edwards SAPIEN Versus Medtronic Aortic Bioprosthesis in Women Undergoing Transcatheter Aortic Valve Implantation (from the Win-TAVI Registry)

We sought to analyze outcomes of women receiving balloon-expandable valves (BEV) or self-expanding valves (SEV) in contemporary transcatheter aortic valve implantation (TAVI). WIN TAVI (Women's INternational Transcatheter Aortic Valve Implantation) is the first all-female TAVI registry to study the safety and performance of TAVI in women. We compared women treated with BEV (n = 408, 46.9%) versus those treated with SEV (n = 461, 53.1%). The primary efficacy end point was the Valve Academic Research Consortium-2 (VARC-2) composite of 1-year all-cause death, stroke, myocardial infarction, hospitalization for valve-related symptoms or heart failure or valve-related dysfunction. Women receiving SEV had higher surgical risk scores, higher rate of previous stroke and pulmonary hypertension whereas women receiving BEV were more frequently denied surgical valve replacement due to frailty. BEV patients were less likely to require post-dilation and had significantly lower rates of residual aortic regurgitation grade ≥2 (9.8% vs 4.7%, p = 0.007). At 1 year, the crude incidence and adjusted risk of the primary VARC-2 efficacy end point was similar between groups (17.1% with SEV and 14.3% with BEV, p = 0.25; hazards ratio 1.09, 95% confidence interval 0.68 to 1.75). Conversely the crude rate and adjusted risk of new pacemaker implantation was higher with SEV than BEV (15% vs 8.6%, p = 0.001; hazards ratio 1.97, 95% confidence interval 1.13 to 3.43). A subanalysis on new generation valves showed no difference in the need for pacemaker implantation between the 2 devices (10.1% vs 8.0%, p = 0.56). In conclusion, in contemporary TAVI, SEV are used more frequently in women with greater co-morbidities. While there were no differences in unadjusted and adjusted risk of 1-year primary efficacy end point between the valve types, there was a greater need for permanent pacemakers after SEV implantation.

Tailoring P2Y12 Inhibiting Therapy in Elderly Patients With Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

See Article Schmucker et al

Pharmacodynamics During Transition Between Platelet P2Y12 Inhibiting Therapies

Several platelet P2Y₁₂ inhibiting agents, both oral and intravenous, are available for clinical use. The oral P2Y₁₂ inhibitors comprise clopidogrel, prasugrel, and ticagrelor. Cangrelor is the only intravenous P2Y₁₂ inhibitor. Numerous pharmacodynamic studies have been performed to assess the impact of P2Y₁₂ inhibitor switching on platelet reactivity profiles and to define the optimal strategy if switching is needed, with the goal of minimizing the risk of having inadequate platelet inhibition due to potential drug-drug interactions occurring during the drug overlap phase. This article provides an overview of pharmacodynamic studies assessing switching between P2Y₁₂ inhibitors and recommendations on switching modalities based on these findings.

Antithrombotic pharmacotherapy after transcatheter aortic valve implantation: an update

Introduction: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for a large proportion of patients with severe aortic stenosis. Despite numerous technological and clinical advances, TAVI remains associated with thrombotic complications requiring antithrombotic pharmacotherapy, which exposes to the risk of bleeding, especially in elderly individuals. The optimal antithrombotic regimen following TAVI is uncertain and several investigations are ongoing. Areas covered: Clinical guidelines are mostly driven by observational trials and experts' opinions, thus resulting into low-grade level of evidence. The aim of the current review is to critically explore the epidemiology, pathophysiology and prognostic value of thrombotic and bleeding events after TAVI, and to review the current literature on antithrombotic strategies following the procedure. Expert opinion: Thrombotic and bleeding events remain major complications occurring in the frail population that is currently offered TAVI. Waiting for upcoming evidence from ongoing randomized clinical trials, tailoring antithrombotic therapies based on patients' characteristics, values and circumstances is a preferable approach.