Experience with the ACURATE neo and neo2 transcatheter aortic valves in Spain. The PRECISA (PRospective Evaluation Complementing Investigation with ACURATE devices) registry

BACKGROUND

Previous studies have documented a high rate of implantation success with the ACURATE neo2 valve, as well as a reduction in paravalvular leak (PVL) compared to its predecessor, the ACURATE neo. However, there are no studies that have reviewed and compared the long-term clinical and hemodynamic outcomes of these patients.

AIMS

This study aimed to evaluate the results of the ACURATE neo transcatheter aortic valve in a real-world context, and to compare the results of the outcomes of both generations of this device (ACURATE neo and ACURATE neo2), with a specific focus on procedural success, safety, and long-term effectiveness.

METHODS

A prospective study including all consecutive patients treated with the ACURATE neo device in seven hospitals was conducted (Clinical Trials Identification Number: NCT03846557). The primary endpoint consisted of a composite of adverse events, including mortality, aortic insufficiency, and other procedural complications. As the second-generation device (ACURATE neo2) replaced the ACURATE neo during the study period, hemodynamic and clinical results before admission, at 30 days, and at 1 year of follow-up were compared between the two generations.

RESULTS

A total of 296 patients underwent transcatheter aortic valve implantation with the ACURATE device, with 178 patients receiving the ACURATE neo and 118 patients receiving the ACURATE neo2. In the overall population, the absence of device success occurred in 14.5%. The primary reason for the absence of device success was the presence of para-valvular regurgitation ≥ 2. There were no instances of coronary occlusions, valve embolization, annulus rupture, or procedural deaths. ACURATE neo2 was associated with a significantly higher device success rate (91.7% vs. 82%, p = 0.04), primarily due to a significantly lower rate of para-valvular regurgitation, which remained significant at 1 year.

CONCLUSION

The use of ACURATE neo and neo2 transcatheter aortic valves is associated with satisfactory clinical results and an extremely low rate of complications. The ACURATE neo2 enables a significantly higher device success rate, primarily attributed to a significant reduction in the rate of PVL.

A streamlined pathway for transcatheter aortic valve implantation: the BENCHMARK study

BACKGROUND AND AIMS

There is significant potential to streamline the clinical pathway for patients undergoing transcatheter aortic valve implantation (TAVI). The purpose of this study was to evaluate the effect of implementing BENCHMARK best practices on the efficiency and safety of TAVI in 28 sites in 7 European countries.

METHODS

This was a study of patients with severe symptomatic aortic stenosis (AS) undergoing TAVI with balloon-expandable valves before and after implementation of BENCHMARK best practices. Principal objectives were to reduce hospital length of stay (LoS) and duration of intensive care stay. Secondary objective was to document patient safety.

RESULTS

Between January 2020 and March 2023, 897 patients were documented prior to and 1491 patients after the implementation of BENCHMARK practices. Patient characteristics were consistent with a known older TAVI population and only minor differences. Mean LoS was reduced from 7.7 ± 7.0 to 5.8 ± 5.6 days (median 6 vs. 4 days; P < .001). Duration of intensive care was reduced from 1.8 to 1.3 days (median 1.1 vs. 0.9 days; P < .001). Adoption of peri-procedure best practices led to increased use of local anaesthesia (96.1% vs. 84.3%; P < .001) and decreased procedure (median 47 vs. 60 min; P < .001) and intervention times (85 vs. 95 min; P < .001). Thirty-day patient safety did not appear to be compromised with no differences in all-cause mortality (0.6% in both groups combined), stroke/transient ischaemic attack (1.4%), life-threatening bleeding (1.3%), stage 2/3 acute kidney injury (0.7%), and valve-related readmission (1.2%).

CONCLUSIONS

Broad implementation of BENCHMARK practices contributes to improving efficiency of TAVI pathway reducing LoS and costs without compromising patient safety.

Ten-year prognostic impact of target versus non-target vessel failure after STEMI. Insight from the EXAMINATION-EXTEND trial

INTRODUCTION AND OBJECTIVES

After ST-segment myocardial infarction (STEMI), the impact of different adverse events on prognosis remains unknown. We aimed to assess very long-term predictors of patient-oriented composite endpoints (POCE) and investigate whether the occurrence of target vessel failure (TVF) vs a non-TVF event as the first event could potentially influence subsequent outcomes.

METHODS

The EXAMINATION-EXTEND trial randomized STEMI patients to receive either an everolimus-eluting stent or a bare-metal stent. The follow-up period was 10 years. Predictors of POCE (a composite of all-cause death, any myocardial infarction, or any revascularization) were evaluated in the overall study population. The patients were stratified based on the type of first event (TVF-first vs non-TVF-first) and were compared in terms of subsequent POCE. TVF was defined as a composite of cardiac death, TV myocardial infarction, or TV revascularization.

RESULTS

Out of the 1498 enrolled patients, 529 (35.3%) experienced a POCE during the 10-year follow-up. Independent predictors of POCE were age, diabetes mellitus, previous myocardial infarction, peripheral arterial disease, and multivessel coronary disease. The first event was a TVF in 296 patients and was a non-TVF in 233 patients. No significant differences were observed between TVF-first and non-TVF-first patients in terms of subsequent POCE (21.7% vs 39.3%, time ratio 1.79; 95%CI, 0.87-3.67;P=.12) or its individual components.

CONCLUSIONS

At the 10-year follow-up, approximately one-third of STEMI patients had experienced at least 1 POCE. Independent predictors of these events were age, diabetes, and more extensive atherosclerotic disease. The occurrence of a TVF or a non-TVF as the first event did not seem to influence subsequent outcomes.

TRIAL REGISTRATION NUMBER

NCT04462315.

Long-term survival after cardiac arrest in patients undergoing emergent coronary angiography

AIM

To determine long-term survival of patients after cardiac arrest undergoing emergent coronary angiography and therapeutic hypothermia.

METHODS

We analysed data from patients treated within the regional STEMI Network from January 2015 to December 2020. The primary endpoint was all-cause mortality at median follow-up. Secondary endpoints were periprocedural complications (arrhythmias, pulmonary edema, cardiogenic shock, mechanical complication, stent thrombosis, reinfarction, bleeding) and 6-month all-cause death. A landmark analysis was performed, studying two time periods; 0-6 months and beyond 6 months.

RESULTS

From a total of 24,125 patients in the regional STEMI network, 494 patients who suffered from cardiac arrest were included and divided into two groups: treated with (n = 119) and without therapeutic hypothermia (n = 375). At median follow-up (16.0 [0.2-33.3] months), there was no difference in the adjusted mortality rate between groups (51.3 % with hypothermia vs 48.0 % without hypothermia; HRadj1.08 95%CI [0.77-1.53]; p = 0.659). There was a higher frequency of bleeding in the hypothermia group (6.7 % vs 1.1 %; ORadj 7.99 95%CI [2.05-31.2]; p = 0.002), without difference for the rest of periprocedural complications. At 6-month follow-up, adjusted all-cause mortality rate was similar between groups (46.2 % with hypothermia vs 44.5 % without hypothermia; HRadj1.02 95%CI [0.71-1.47]; p = 0.900). Also, no differences were observed in the adjusted mortality rate between 6 months and median follow-up (9.4 % with hypothermia vs 6.3 % without hypothermia; HRadj2.02 95%CI [0.69-5.92]; p = 0.200).

CONCLUSIONS

In a large cohort of patients with cardiac arrest within a regional STEMI network, those treated with therapeutic hypothermia did not improve long-term survival compared to those without hypothermia.

Optical coherence tomography assessment of pulmonary vascular remodeling in advanced heart failure. The OCTOPUS-CHF study

INTRODUCTION AND OBJECTIVES

Pulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data.

METHODS

This observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery.

RESULTS

OCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient=0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25mm had significantly higher mean pulmonary pressures (37.00 vs 25.00mmHg; P=.004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P=.017).

CONCLUSIONS

Direct morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.

Impact of Age at the Time of the First ST-Elevation Myocardial Infarction on 10-Year Outcomes (from the EXAMINATION-EXTEND Trial)

The aim of this substudy of the EXAMINATION-EXTEND was to analyze 10-year outcomes according to the patient's age at the time of the first ST-elevation myocardial infarction (STEMI). Of 1,498 patients with STEMI included in the EXAMINATION-EXTEND study, those with a previous history of coronary ischemic even or ischemic stroke were excluded from this analysis. The remaining 1,375 patients were divided into 4 age groups: <55, 55 to 65, 65 to 75, and >75 years. The primary end point was 10-year patient-oriented composite end point (POCE) of all-cause death, any MI, or any revascularization. At 10-year follow-up, patients aged <55 years (adjusted hazard ratio [HR] 0.24, 95% confidence interval [CI] 0.18 to 0.31, p = 0.001), 55 to 65 years (adjusted HR 0.26, 95% CI 0.20 to 0.34, p = 0.001), and 65 to 75 years (adjusted HR 0.38, 95% CI 0.30 to 0.50, p = 0.001) showed lower risk of POCE than those aged >75 years, led by a lower incidence of all-cause death (<55 : 6% vs 55 to 65: 11.9% vs 65 to 75: 25.7% vs >75 years: 61.6%, p = 0.001). Cardiac death was more prevalent in the older group (<55: 3.7% vs 55 to 65: 5.8% vs 65 to 75: 10.9% vs >75 years: 35.5%, p = 0.001). In the landmark analyses, between 5- and 10-year follow-up, young patients exhibited a higher incidence of any revascularization (<55: 7.4% vs 55 to 65: 4.9% vs 65 to 75: 1.8% vs >65 years: 1.6%, p = 0.001). In conclusion, in patients with a first STEMI, advanced age was associated with high rates of POCE at 10-year follow-up due to all-cause and cardiac death. Conversely, younger patients exhibited a high risk of revascularization at long-term follow-up.

Pulmonary Vascular Remodeling and Prognosis in Patients Evaluated for Heart Transplantation: Insights from the OCTOPUS-CHF Study

OBJECTIVE

In patients with advanced heart failure, the intravascular optical coherence tomography (OCT) of subsegmental pulmonary artery measurements is correlated with right heart catheterization parameters. Our aim was to study the prognostic value of pulmonary OCT, right heart catheterization data, and the echocardiographic estimation of pulmonary pressure in patients studied for elective heart transplants.

METHODS

This research is an observational, prospective, multicenter study involving 90 adults with a one-year follow-up.

RESULTS

A total of 10 patients (11.1%) died due to worsening heart failure before heart transplantation, 50 underwent a heart transplant (55.6%), and 9 died in the first year after the transplant. The patients with and without events (mortality or heart failure-induced hospitalization) had similar data regarding echocardiography, right heart catheterization, and pulmonary OCT (with a median estimated pulmonary artery systolic pressure of 42.0 mmHg, interquartile range (IQR) of 30.3-50.0 vs. 47.0 mmHg, IQR 34.6-59.5 and p = 0.79, median pulmonary vascular resistance of 2.2 Wood units, IQR 1.3-3.7 vs. 2.0 Wood units, IQR 1.4-3.2 and p = 0.99, and a median pulmonary artery wall thickness of 0.2 ± 0.5 mm vs. 0.2 ± 0.6 mm and p = 0.87).

CONCLUSION

Pulmonary vascular remodeling (evaluated with echocardiography, right heart catheterization, and pulmonary OCT) was not associated with prognosis in a selected sample of adults evaluated for elective heart transplants. Pulmonary OCT is safe and feasible for the evaluation of these patients.

Antiplatelet efficacy of ticagrelor versus clopidogrel in Mediterranean patients with diabetes mellitus and chronic coronary syndromes: A crossover pharmacodynamic investigation

Introduction

Patients with diabetes mellitus (DM) have augmented platelet reactivity and diminished responsiveness to clopidogrel. Ticagrelor, a more potent P2Y12 inhibitor, is clinically superior to clopidogrel in acute coronary syndromes, although its role in chronic coronary syndromes (CCS) is still the subject of debate. The aim of this investigation was to compare the pharmacodynamic effectiveness of ticagrelor and clopidogrel in Mediterranean DM patients with CCS.

Materials and methods

In this prospective, randomized, crossover study, patients (n = 20) were randomized (1:1) to receive, on top of aspirin therapy, either ticagrelor 180 mg loading dose (LD)/90 mg maintenance dose (MD) b.i.d. or clopidogrel 600 mg LD/75 mg MD o.d. for 1 week in a crossover fashion with a 2–4 week washout period between regimens. Platelet function measurements were performed at 4 timepoints in each period (baseline, 2 h and 24 h after LD, and 1 week), including light transmission aggregometry (LTA, primary endpoint), VASP assay, Multiplate and VerifyNow P2Y12.

Results

The ticagrelor LD achieved greater platelet inhibitory effect than clopidogrel LD, assessed with LTA (20 μM ADP as agonist), at 2 h (34.9 ± 3.9% vs. 63.6 ± 3.9%; p &lt; 0.001) and 24 h (39.4 ± 3.5% vs. 52.3 ± 3.8%; p = 0.014). After 1 week of therapy, platelet reactivity was again significantly inferior with ticagrelor compared to clopidogrel (30.7 ± 3.0% vs. 54.3 ± 3.0%; p &lt; 0.001). The results were consistent with the other platelet function assays employed.

Conclusion

In Mediterranean patients with DM and CCS, ticagrelor provides a more potent antiplatelet effect than clopidogrel after the LD and during the maintenance phase of therapy.

Clinical trial registration

[ClinicalTrials.gov], identifier [NCT02457130].

Magnesium-based resorbable scaffold vs permanent metallic sirolimus-eluting stent in patients with ST-segment elevation myocardial infarction: 3-year results of the MAGSTEMI randomised controlled trial

BACKGROUND

The long-term safety and performance of magnesium-based bioresorbable scaffolds (MgBRS) in ST-segment-elevation myocardial infarction (STEMI) patients are uncertain.

AIMS

The aim of this study was to report the 3-year clinical outcomes of the MAGSTEMI trial.

METHODS

This investigator-driven, multicentre, randomised, single-blind, controlled trial randomised STEMI patients 1:1 to MgBRS or to permanent metallic sirolimus-eluting stents (SES) at 11 academic centres. The main secondary endpoints included device-oriented composite endpoints (DoCE) and patient-oriented composite endpoints (PoCE), their individual components, any bleeding, and device thrombosis rate. All endpoints were defined according to the Academic Research Consortium. Events were adjudicated by an independent committee.

RESULTS

Three-year clinical follow-up was obtained in 142 (90.0%) patients. At 3-year follow-up, MgBRS were associated with a higher rate of DoCE than SES (13 [17.6%] vs 5 [6.6%], diff -11.0 [95% CI: -21.3 to -0.7]; p=0.038). This difference was driven by an increased incidence of DoCE within the first year of follow-up. In the landmark analysis, there was no difference between 1 and 3 years (0 [0.0%] vs 1 [1.4%]; p=1.000). The difference in the rate of DoCE was driven by a higher incidence of target lesion revascularisation (TLR) in the MgBRS group compared to SES (12 [16.2%] vs 4 [5.3%]; diff -10.9% [95% CI: -20.7 to -1.2]; p=0.030). The difference in TLR was observed during the first year, with no further differences observed between 1 and 3 years (0 [0.0%] vs 1 [1.4%]; p=1.000).

CONCLUSIONS

At 3-year follow-up, MgBRS were associated with a higher rate of TLR, which was clustered within the first year, compared to SES.

Complete revascularization optimizes patient outcomes in multivessel coronary artery disease: Data from the e-Ultimaster registry

OBJECTIVES

The aim of this analysis was to assess the effect of the coronary revascularization strategy during index admission on clinical outcomes among patients undergoing percutaneous coronary intervention (PCI) with multivessel coronary artery disease (MVD).

BACKGROUND

The value of complete revascularization (CR) over incomplete revascularization (IR) in MVD patients is not fully established.

METHODS

Patients with MVD defined as ≥2 major epicardial vessels with ≥50% stenosis were selected from the observational all-comer e-Ultimaster registry. Patients were treated with a sirolimus-eluting thin-strut coronary stent. Completeness of revascularization was physician assessed at the index procedure or an eventually staged procedure during the index hospitalization. Outcomes measures at 1 year were target lesion failure (TLF) (composite of cardiac death, target vessel-related myocardial infarction [MI], and clinically driven target lesion revascularization [TLR]), and patient-oriented composite endpoint (POCE) (all-cause mortality, MI, or revascularization). The inverse probability of treatment weights (IPTW) methodology was used to perform a matched analysis.

RESULTS

The registry recruited 37,198 patients of whom 15,441 (41.5%) had MVD. CR on hospital discharge was achieved in 7413 (48.0%) patients and IR in 8028 (52.0%) patients. Mean age was 64.6 ± 11.1 versus 65.7 ± 11.0 years (p < 0.01), male gender 77.9% and 77.3% (p = 0.41) and diabetes 31.3% versus 33.4% (p = 0.01) for CR and IR, respectively. Chronic stable angina patients more commonly underwent CR (47.6% vs. 36.8%, p < 0.01). After propensity weighted analysis, 90.5% of CR patients were angina-free at 1 year compared with 87.5% of IR patients (p < 0.01). TLF (3.3% vs. 4.4%; p < 0.01), POCE (6.8% vs. 10.8%; p < .01), and all-cause mortality (2.3% vs. 3.1%; p < .01) were all lower in CR patients.

CONCLUSIONS

A physician-directed use of a CR strategy utilizing sirolimus-eluting thin-strut stent results in optimized clinical outcomes and less angina in an all-comer population. Our findings suggest that a CR should be aimed for.

[Components of geriatric assessment and therapeutic adherence in elderly patients with acute myocardial infarction]

BACKGROUND AND OBJECTIVE

Poor therapeutic adherence after acute myocardial infarction (AMI) can lead to early serious complications. Information on the impact of geriatric assessment on adherence is scarce. The objective of this study was to analyze, in older patients with AMI, the impact of geriatric assessment on therapeutic adherence 12 months after admission.

MATERIALS AND METHODS

A previous study randomized patients aged >75 years who had presented an AMI to a nursing health education program versus conventional management, evaluating the impact of this intervention on therapeutic adherence after 12 months. In-hospital geriatric assessment was performed. For this substudy, the adherence predictors were analyzed using binary logistic regression. Those patients who obtained adherence in the 4 tools were considered adherent: the Morisky-Green, Haynes-Sackett test, attendance at visits and correct withdrawal of drugs from the pharmacy.

RESULTS

A total of 119 patients with a mean age of 82.2 years were included. At one year, a total of 42 patients (35.3%) were adherent. The predictors of poor adherence in the final model were male sex, worse glomerular filtration rate, cognitive impairment, nutritional risk, not living alone and not belonging to the intervention group.

CONCLUSIONS

The data of this series show a low therapeutic adherence in the elderly after an AMI. Cognitive impairment or nutritional risk was significantly associated with poorer adherence, contrary to a nursing intervention, which highlights the importance of health education and supervision in high-risk patients.

Predictors of primary percutaneous coronary intervention delay in cases of myocardial infarction diagnosed in hospitals without hemodynamic support systems

OBJECTIVES

The need for primary percutaneous coronary intervention in hospitals without hemodynamic support capability is associated with delays between first medical contact (FMC) and reperfusion. It is important to identify factors involved in delays, particularly if they are relevant to the organization of emergency services.

MATERIAL AND METHODS

Analysis of a registry of patients treated in hospitals without advanced hemodynamic support systems in a catchment area with an established care network for acute ST-segment elevation myocardial infarction (STEMI). The registry included care times.

RESULTS

The network served 2542 patients with a mean (SD) age of 63 (13) years. FMC-to-reperfusion time was within 120 minutes in 42% of the cases. Nine of the hospitals had a chest-pain unit in the emergency department, and this factor was an independent predictor of FMC-to-reperfusion times of 120 minutes or less (odds ratio, 0.64; 95% CI, 0.54–0.77; P < .0001); the time was shortened by 11 minutes in such hospitals. FMC-to-reperfusion was delayed beyond 120 minutes in relation to the following factors: shock and need for intubation at start of care, age, gender, FMC at night, left bundle branch block, and Killip class. One-month and 1-year mortality rates increased in hospitals without hemodynamic support systems in proportion to reperfusion delay, by 1.7% and 3.5% if the delay was 106 minutes or less and by 7.3% and 12.4% if the delay was 176 minutes or longer (P < .0001).

CONCLUSION

FMC-to-reperfusion time in STEMI exceeds recommendations in 58% of the hospitals without hemodynamic support systems and delay is inversely proportional to the availability of an emergency department chest pain unit. One-month and 1-year mortality is proportional to the degree of delay.

Can an individualized adherence education program delivered by nurses improve therapeutic adherence in elderly people with acute myocardial infarction?: A randomized controlled study

BACKGROUND

The ageing of the population is leading to an increase in the number of elderly patients with acute myocardial infarction. These patients are at higher risk for complications and poor medication adherence, which in turn are associated with higher healthcare resource expenditures. Nursing programmes might help to improve adherence in these complex patients.

OBJECTIVE

The objective of this study was to assess the impact of a nursing intervention on therapeutic adherence in elderly patients after myocardial infarction compared to a control group.

DESIGN

A single-blind, randomized controlled trial.

SETTINGS

Heart disease institute of a tertiary care hospital.

PARTICIPANTS

Patients aged ≥75 years with myocardial infarction undergoing percutaneous coronary intervention.

METHODS

A comprehensive geriatric assessment was performed during the admission in all patients (N=143). Patients were randomly allocated to a nursing intervention group (n=68) or a usual care group (n=75). In patients from the intervention group, a nursing intervention programme was performed 3 months after admission based on education support and patient monitoring to improve therapeutic adherence. The main outcome measured was 12-months therapeutic adherence, as defined by a combination of measurement tools (Morisky-Green and Hayness-Sacket scales, attendance at visits and withdrawal of medication from the pharmacy). Therapeutic adherence was assessed by nurses blinded to the assignment group.

RESULTS

The mean age was 82.2 years. The proportion of comorbidities was significant (diabetes mellitus 51/143 (35.7%), hypertension 110/143 (76.9%), prior stroke 22/143 (15.4%)). Likewise, the proportion of geriatric syndromes was noticeable (frailty 26/143 (18.2%), risk of malnutrition 38/143 (26.6%), cognitive impairment 28/143 (19.6%)). Most patients (92.3%) had a low educational level. A total of 119 patients achieved 12-month assessment adherence. Among these patients, the proportions of adherence were as follows: Morisky-Green test: 76/119 (63.9%), Haynes-Sackett test 99/119 (83.2%), medical visits compliance 95/119 (79.8%), and correct acquisition of drugs in the pharmacy 74/119 (62.2%). A total of 42/119 patients (35.3%) were adherent as defined by the combination of the 4 measures. Therapeutic adherence at 12 months was achieved in a significantly higher proportion of patients from the nursing intervention group (51.9% vs 21.5%, p<0.001).

CONCLUSION

A significant proportion of elderly patients with myocardial infarction were non-adherent at 12 months. The proportion of adherent patients was highly variable according to the different tools used. A structured nursing intervention was independently associated with a higher adherence rate, as assessed by a multidimensional measurement, in this subset of complex high-risk elderly patients with myocardial infarction.

TRIAL REGISTRATION

Registered with www.clinicaltrials.gov (NCT04662762).

Risk factors for in-hospital mortality in patients with acute myocardial infarction during the COVID-19 outbreak

INTRODUCTION AND OBJECTIVES

Despite advances in treatment, patients with acute myocardial infarction (AMI) still exhibit unfavorable short- and long-term prognoses. In addition, there is scant evidence about the clinical outcomes of patients with AMI and coronavirus disease 2019 (COVID-19). The objective of this study was to describe the clinical presentation, complications, and risk factors for mortality in patients admitted for AMI during the COVID-19 pandemic.

METHODS

This prospective, multicenter, cohort study included all consecutive patients with AMI who underwent coronary angiography in a 30-day period corresponding chronologically with the COVID-19 outbreak (March 15 to April 15, 2020). Clinical presentations and outcomes were compared between COVID-19 and non-COVID-19 patients. The effect of COVID-19 on mortality was assessed by propensity score matching and with a multivariate logistic regression model.

RESULTS

In total, 187 patients were admitted for AMI, 111 with ST-segment elevation AMI and 76 with non-ST-segment elevation AMI. Of these, 32 (17%) were diagnosed with COVID-19. GRACE score, Killip-Kimball classification, and several inflammatory markers were significantly higher in COVID-19-positive patients. Total and cardiovascular mortality were also significantly higher in COVID-19-positive patients (25% vs 3.8% [P <.001] and 15.2% vs 1.8% [P=.001], respectively). GRACE score> 140 (OR, 23.45; 95%CI, 2.52-62.51; P=.005) and COVID-19 (OR, 6.61; 95%CI, 1.82-24.43; P=.02) were independent predictors of in-hospital death.

CONCLUSIONS

During this pandemic, a high GRACE score and COVID-19 were independent risk factors associated with higher in-hospital mortality.

[Risk factors for in-hospital mortality in patients with acute myocardial infarction during the COVID-19 outbreak]

INTRODUCTION AND OBJECTIVES

Despite advances in treatment, patients with acute myocardial infarction (AMI) still exhibit unfavorable short- and long-term prognoses. In addition, there is scant evidence about the clinical outcomes of patients with AMI and coronavirus disease 2019 (COVID-19). The objective of this study was to describe the clinical presentation, complications, and risk factors for mortality in patients admitted for AMI during the COVID-19 pandemic.

METHODS

This prospective, multicenter, cohort study included all consecutive patients with AMI who underwent coronary angiography in a 30-day period corresponding chronologically with the COVID-19 outbreak (March 15 to April 15, 2020). Clinical presentations and outcomes were compared between COVID-19 and non-COVID-19 patients. The effect of COVID-19 on mortality was assessed by propensity score matching and with a multivariate logistic regression model.

RESULTS

In total, 187 patients were admitted for AMI, 111 with ST-segment elevation AMI and 76 with non-ST-segment elevation AMI. Of these, 32 (17%) were diagnosed with COVID-19. GRACE score, Killip-Kimball classification, and several inflammatory markers were significantly higher in COVID-19-positive patients. Total and cardiovascular mortality were also significantly higher in COVID-19-positive patients (25% vs 3.8% [P < .001] and 15.2% vs 1.8% [P = .001], respectively). GRACE score > 140 (OR, 23.45; 95%CI, 2.52-62.51; P = .005) and COVID-19 (OR, 6.61; 95%CI, 1.82-24.43; P = .02) were independent predictors of in-hospital death.

CONCLUSIONS

During this pandemic, a high GRACE score and COVID-19 were independent risk factors associated with higher in-hospital mortality.Full English text available from:www.revespcardiol.org/en.

Impact of COVID-19 on ST-segment elevation myocardial infarction care. The Spanish experience

Introduction and objectives

The COVID-19 outbreak has had an unclear impact on the treatment and outcomes of patients with ST-segment elevation myocardial infarction (STEMI). The aim of this study was to assess changes in STEMI management during the COVID-19 outbreak.

Methods

Using a multicenter, nationwide, retrospective, observational registry of consecutive patients who were managed in 75 specific STEMI care centers in Spain, we compared patient and procedural characteristics and in-hospital outcomes in 2 different cohorts with 30-day follow-up according to whether the patients had been treated before or after COVID-19.

Results

Suspected STEMI patients treated in STEMI networks decreased by 27.6% and patients with confirmed STEMI fell from 1305 to 1009 (22.7%). There were no differences in reperfusion strategy (> 94% treated with primary percutaneous coronary intervention in both cohorts). Patients treated with primary percutaneous coronary intervention during the COVID-19 outbreak had a longer ischemic time (233 [150-375] vs 200 [140-332] minutes, P < .001) but showed no differences in the time from first medical contact to reperfusion. In-hospital mortality was higher during COVID-19 (7.5% vs 5.1%; unadjusted OR, 1.50; 95%CI, 1.07-2.11; P < .001); this association remained after adjustment for confounders (risk-adjusted OR, 1.88; 95%CI, 1.12-3.14; P = .017). In the 2020 cohort, there was a 6.3% incidence of confirmed SARS-CoV-2 infection during hospitalization.

Conclusions

The number of STEMI patients treated during the current COVID-19 outbreak fell vs the previous year and there was an increase in the median time from symptom onset to reperfusion and a significant 2-fold increase in the rate of in-hospital mortality. No changes in reperfusion strategy were detected, with primary percutaneous coronary intervention performed for the vast majority of patients. The co-existence of STEMI and SARS-CoV-2 infection was relatively infrequent.

New Electrocardiographic Algorithm for the Diagnosis of Acute Myocardial Infarction in Patients With Left Bundle Branch Block

Background

Current electrocardiographic algorithms lack sensitivity to diagnose acute myocardial infarction (AMI) in the presence of left bundle branch block.

Methods and Results

A multicenter retrospective cohort study including consecutive patients with suspected AMI and left bundle branch block, referred for primary percutaneous coronary intervention between 2009 and 2018. Pre‐2015 patients formed the derivation cohort (n=163, 61 with AMI); patients between 2015 and 2018 formed the validation cohort (n=107, 40 with AMI). A control group of patients without suspected AMI was also studied (n=214). Different electrocardiographic criteria were tested. A total of 484 patients were studied. A new electrocardiographic algorithm (BARCELONA algorithm) was derived and validated. The algorithm is positive in the presence of ST deviation ≥1 mm (0.1 mV) concordant with QRS polarity, in any lead, or ST deviation ≥1 mm (0.1 mV) discordant with the QRS, in leads with max (R|S) voltage (the voltage of the largest deflection of the QRS, ie, R or S wave) ≤6 mm (0.6 mV). In both the derivation and the validation cohort, the BARCELONA algorithm achieved the highest sensitivity (93%–95%), negative predictive value (96%–97%), efficiency (91%–94%) and area under the receiver operating characteristic curve (0.92–0.93), significantly higher than previous electrocardiographic rules (P<0.01); the specificity was good in both groups (89%–94%) as well as the control group (90%).

Conclusions

In patients with left bundle branch block referred for primary percutaneous coronary intervention, the BARCELONA algorithm was specific and highly sensitive for the diagnosis of AMI, leading to a diagnostic accuracy comparable to that obtained by ECG in patients without left bundle branch block.

Antithrombotic Therapy After Transcatheter Aortic Valve Implantation

The development of transcatheter aortic valve implantation has represented one of the greatest advances in the cardiology field in recent years and has changed clinical practice for patients with aortic stenosis. Despite the continuous improvement in operators’ experience and techniques, and the development of new generation devices, thromboembolic and bleeding complications after transcatheter aortic valve implantation remain frequent, and are a major concern due to their negative impact on prognosis in this vulnerable population. In addition, the optimal antithrombotic regimen in this scenario is not known, and current recommendations are mostly empirical and not evidence based. The present review aims to provide an overview of the current status of knowledge, including relevant on-going randomised trials, on antithrombotic treatment strategies after transcatheter aortic valve implantation.

Rationale and design of the optical coherence tomography observation of pulmonary ultra-structural changes in heart failure (OCTOPUS-CHF) study

BACKGROUND

The assessment of vascular remodeling using optical coherence tomography (OCT) has been previously described in some types of pulmonary hypertension. However, evidence about its feasibility and clinical utility for evaluation of pulmonary arterial vasculopathy in advanced heart failure (HF) is scarce. Optical Coherence Tomography Observation of Pulmonary Ultra-Structural Changes in Heart Failure (OCTOPUS-CHF) study is designed to study the correlation between OCT-morphometric parameters and hemodynamic data measured or derived from right heart catheterization (RHC).

METHODS

OCTOPUS-CHF is an observational, prospective, multicentre study aiming to recruit 100 patients with advanced HF referred for heart transplantation (HTx) evaluation. As part of such evaluation, all patients will undergo RHC in order to rule out severe pulmonary hypertension. After RHC, a Dragonfly™ OPTIS™ imaging catheter will be used to perform OCT evaluation of a right-lower-lobe pulmonary artery with a luminal diameter ≤ 5 mm. The primary objective is to study the correlation of OCT parameters with hemodynamic RHC data. The secondary objective is to determine if OCT parameters improve prognostic stratification.

CONCLUSIONS

The OCTOPUS-CHF study will investigate the feasibility and clinical utility of pulmonary arterial vasculopathy evaluation with OCT in advanced HF patients and its correlation with hemodynamic RHC data. The ability of OCT-morphometric parameters to improve prognostic stratification will also be tested.

Magnesium-Based Resorbable Scaffold Versus Permanent Metallic Sirolimus-Eluting Stent in Patients With ST-Segment Elevation Myocardial Infarction: The MAGSTEMI Randomized Clinical Trial

BACKGROUND

The use of poly-l-lactide acid-based bioresorbable scaffolds is limited in daily clinical practice because of safety concerns and lack of physiological benefit. Magnesium-based bioresorbable scaffold (MgBRS) presents a short resorption period (<1 year) and have the potential of being thromboresistant and exhibiting early restoration of vasomotor function. To date, however, no randomized clinical trial has investigated the performance of MgBRS. Therefore, this study aimed to compare the in-stent/scaffold vasomotion between MgBRS and permanent metallic sirolimus-eluting stent (SES) at 12-month follow-up in ST-segment-elevation myocardial infarction patients.

METHODS

This investigator-driven, multicenter, randomized, single-blind, controlled trial randomized ST-segment-elevation myocardial infarction patients 1:1 to SES or MgBRS at 11 academic centers. The primary end point was the rate of increase (≥3%) after nitroglycerin in mean lumen diameter of the in-stent/scaffold segment at 12 months with superiority of MgBRS over SES in the as-treated population. The main secondary end points included angiographic parameters of restenosis, device-oriented composite end point, their individual components, and device thrombosis rate. Besides, endothelial-dependent vasomotor response to acetylcholine (ie, endothelial function) was also assessed in a subgroup of patients (n=69).

RESULTS

Between June 2017 and June 2018, 150 ST-segment-elevation myocardial infarction patients were randomized (MgBRS, n=74; SES, n=76). At 1 year, the primary end point was significantly higher in the MgBRS arm (56.5% versus 33.8%; P=0.010). Conversely, late lumen loss was significantly lower in the SES group (in-segment: 0.39±0.49mm versus 0.02±0.27mm, P<0.001; in-device: 0.61±0.55mm versus 0.06±0.21mm; P<0.001). The device-oriented composite end point was higher in the MgBRS arm driven by an increase in ischemia-driven target lesion revascularization rate (12[16.2%] versus 4[5.2%], P=0.030). Definite thrombosis rate was similar between groups (1[1.4%] in the MgBRS arm versus 2[2.6%] in the SES group; P=1.0). Endothelial function assessment at device segment evidenced a more pronounced vasoconstrictive response to maximal dose of acetylcholine in the MgBRS arm (-8.3±3.5% versus -2.4±1.3% in the SES group, P=0.003).

CONCLUSIONS

When compared to SES, MgBRS demonstrated a higher capacity of vasomotor response to pharmacological agents (either endothelium-independent or endothelium-dependent) at 1 year. However, MgBRS was associated with a lower angiographic efficacy, a higher rate of target lesion revascularization, without thrombotic safety concerns.

CLINICAL TRIAL REGISTRATION

URL: https://www.clinicaltrials.gov. Unique identifier: NCT03234348.

Risk-adjusted early invasive strategy in patients with non-ST-segment elevation acute coronary syndrome in Intensive Cardiac Care Units

OBJECTIVE

Current guidelines recommend a risk-adjusted early invasive strategy (EIS) in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). The present study assesses the application if this strategy, the conditioning factors and prognostic impact upon patients with NSTEACS admitted to Intensive Cardiac Care Units (ICCU).

DESIGN

A prospective cohort study was carried out.

SETTING

The ICCUs of 8 hospitals in Catalonia (Spain).

PATIENTS

Consecutive patients with NSTEACS between October 2017 and March 2018. The risk profile was defined by the European Society of Cardiology criteria.

INTERVENTIONS

EIS was defined as the performance of coronary angiography within the first 6hours in patients at very high-risk or within 24hours in high-risk patients.

OUTCOME VARIABLES

Mortality or readmission at 6 months.

RESULTS

A total of 629 patients were included (mean age 66.6 years), of whom 225 (35.9%) were at very high risk, and 392 (62.6%) at high risk. Most patients (96.2%) underwent an invasive strategy. EIS was performed in 284 patients (45.6%), especially younger patients with fewer comorbidities. These patients had a shorter ICCU and hospital stay, as well as a lesser incidence of ACS, revascularization and death or readmission at 6 months. After adjusting for confounders, the association between EIS and death or readmission at 6 months remained significant (hazard ratio: .66, 95% confidence interval .45-.97; P=.035).

CONCLUSIONS

The EIS was performed in a minority of NSTEACS admitted to ICCU, being associated with better outcomes.

Thrombocytopenia after transcatheter aortic valve implantation. A comparison between balloon-expandable and self-expanding valves

BACKGROUND

Thrombocytopenia after transcatheter aortic valve implantation (TAVI) is common and has been related to higher mortality and major complications. No comparison between balloon-expandable (BEV) and self-expanding valves (SEV) regarding drop platelet count (DPC) has been reported to date. The objectives of this study were to analyze the differences in DPC between BEVs or SEVs and their prognostic implications in clinical outcomes.

METHODS

We retrospectively analyzed patients undergoing TAVI. Platelet counts after TAVI were collected. Two groups were created: DPC ≤ 30% and DPC > 30%. VARC-2 criteria were used to define outcomes.

RESULTS

Study population was composed of 195 patients (age 77.5 ± 6.7, 57.4% males). All of them but one experienced DPC (mean DPC 31.9 ± 15.3%). DPC was significantly higher among the patients treated with BEV compared to those treated with SEV (36.3 ± 15.1% vs 27.7 ± 14.4, P < 0.001). After multivariate analysis, the use of BEV was independently associated with a higher rate of DPC > 30% (67.4% vs 36.0%; OR 3.4; 95% CI, 1.42-8.16). At 30 days, the DPC > 30% was associated with a higher rate of life-threatening/major bleeding, major vascular complications, in-hospital sepsis and mortality. At one year, there were no statistically significant differences in the mortality rate between groups (6.35% vs 10.0%, HR 1.54; 95% CI, 0.56-4.25).

CONCLUSIONS

In this study, the use of BEV was associated with a higher risk of DPC after TAVI. A DPC rate > 30% was associated with an increased risk of major complications at 30 days.

Frailty in elderly patients undergoing primary percutaneous coronary intervention

BACKGROUND

The prevalence of frailty, cognitive impairment and disability and its prognostic impact in patients with myocardial infarction undergoing primary percutaneous coronary intervention is unknown.

AIMS

The aim of this study was to assess the prevalence of frailty and other ageing-related variables and their association with inhospital mortality in consecutive elderly ST-segment elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention in a tertiary care hospital.

METHODS

We prospectively included patients aged 75 years or older with STEMI undergoing primary percutaneous coronary intervention. The nursing team provided pre-discharge, standardised questionnaires and tests to each patient to study the presence of frailty (FRAIL scale), comorbidity (Charlson index), disability (Barthel test, Lawton-Brody index), nutritional risk (MNA-SF test) and cognitive status (Pfeiffer test). The association between ageing-related variables and mortality was assessed by binary logistic regression.

RESULTS

A total of 259 patients were included with a mean age of 82.6±6 years, 57.9% men. A total of 51 patients (19.7%) were frail, 26 presented with moderate or severe disability (10%), and 82 were at risk of malnutrition (31.7%). Frailty was associated with a higher prevalence of diabetes, hypertension and previous stroke, and a higher inhospital mortality (21.6% vs. 3.4%; P<0.001). After adjusting for potential confounders, this association remained significant (odds ratio 3.96; 95% confidence interval 1.16-13.56; P=0.028).

CONCLUSION

A not negligible proportion of elderly patients with STEMI fulfilled the frailty criteria. Frailty was independently associated with mortality. A very simple, feasible geriatric assessment by trained nurses can contribute to predict mortality.

Invasive strategy and frailty in very elderly patients with acute coronary syndromes

AIMS

Current guidelines recommend an early invasive strategy in patients with non-ST-segment elevation acute coronary syndromes (NSTEACS). The role of an invasive strategy in frail elderly patients remains controversial. The aim of this substudy was to assess the impact of an invasive strategy on outcomes according to the degree of frailty in these patients.

METHODS AND RESULTS

The LONGEVO-SCA registry included unselected NSTEACS patients aged ≥80 years. A geriatric assessment, including frailty, was performed during hospitalisation. During the admission, we evaluated the impact of an invasive strategy on the incidence of cardiac death, reinfarction or new revascularisation at six months. From 531 patients included, 145 (27.3%) were frail. Mean age was 84.3 years. Most patients underwent an invasive strategy (407/531, 76.6%). Patients undergoing an invasive strategy were younger and had a lower proportion of frailty (23.3% vs. 40.3%, p<0.001). The incidence of cardiac events was more common in patients managed conservatively, after adjusting for confounding factors (sub-hazard ratio [sHR] 2.32, 95% confidence interval [CI]: 1.26-4.29, p=0.007). This association remained significant in non-frail patients (sHR 3.85, 95% CI: 2.13-6.95, p=0.001), but was not significant in patients with established frailty criteria (sHR 1.40, 95% CI: 0.72-2.75, p=0.325). The interaction invasive strategy-frailty was significant (p=0.032).

CONCLUSIONS

An invasive strategy was independently associated with better outcomes in very elderly patients with NSTEACS. This association was different according to frailty status.

Impact of acute exacerbations on platelet reactivity in chronic obstructive pulmonary disease patients

Background

A higher risk of atherothrombotic cardiovascular events, which are platelet-driven processes, has been described during acute exacerbations of chronic obstructive pulmonary disease (AECOPD). However, the relevance of platelet reactivity during AECOPD and whether this is affected by antiplatelet agents are not fully elucidated to date. This study aimed to evaluate whether platelet reactivity is augmented during an exacerbation in COPD patients with and without antiplatelet therapy and its association with systemic inflammatory parameters.

Materials and methods

Prospective, observational, ex vivo investigation was conducted in consecutive patients suffering an exacerbation of COPD. Platelet reactivity was assessed during AECOPD and at stable state. Platelet function assays included: 1) vasodilator-stimulated phosphoprotein assay expressed as P2Y₁₂ reactivity index (PRI), 2) multiple electrode aggregometry and 3) optical aggregometry. Systemic inflammatory parameters such as leukocyte count, interleukin-6 and fibrinogen were also assessed.

Results

Higher platelet reactivity was observed during AECOPD compared to stability measured by vasodilator-stimulated phosphoprotein (PRI: 75.2%±1.9% vs 68.8%±2.4%, p=0.001). This augmented platelet aggregability was also observed in the subset of patients on antiplatelet therapy (PRI: 72.8%±3.1% vs 61.7%±7.5%, p=0.071). Consistent findings were observed with all other platelet function tests. Patients with greater enhancement of inflammatory markers during AECOPD were more likely to present a higher increase in platelet reactivity.

Conclusion

Platelet reactivity is increased during AECOPD, which may contribute to the augmented cardiovascular risk of these patients. Additionally, the increase in platelet reactivity might be associated with an increment in inflammatory markers during exacerbations.

Assessment of Smith Algorithms for the Diagnosis of Acute Myocardial Infarction in the Presence of Left Bundle Branch Block

INTRODUCTION AND OBJECTIVES

Recently, a new electrocardiography algorithm has shown promising results for the the diagnosis of acute myocardial infarction in the presence of left bundle branch block (LBBB). We aimed to assess these new electrocardiography rules in a cohort of patients referred for primary percutaneous coronary intervention (pPCI).

METHODS

Retrospective observational cohort study that included all patients with suspected myocardial infarction and LBBB on the presenting electrocardiogram, referred for pPCI to 4 tertiary hospitals in Barcelona, Spain.

RESULTS

A total of 145 patients were included. Fifty four (37%) had an ST-segment elevation myocardial infarction (STEMI) equivalent. Among patients with STEMI, 25 (46%) presented in Killip class III or IV, and in-hospital mortality was 15%. Smith I and II rules performed better than Sgarbossa algorithms and showed good specificity (90% and 97%, respectively) but their sensitivity was 67% and 54%, respectively. In a strategy guided by Smith I or Smith II rules, 18 (33%) or 25 (46%) patients with STEMI would have not received a pPCI, respectively. Moreover, the severity and prognosis of STEMI patients was similar regardless of the positivity of Smith rules. Cardiac biomarkers were positive in 54% of non-STEMI patients, limiting their usefulness for initial diagnostic screening.

CONCLUSIONS

Diagnosis of STEMI in the presence of LBBB remains a challenge. Smith rules can be useful but are limited by suboptimal sensitivity. The search for new electrocardiography algorithms should be encouraged to avoid unnecessary aggressive treatments in the majority of patients, while providing timely reperfusion to a high-risk subgroup of patients.

Preserved endothelial vasomotor function after everolimus-eluting stent implantation

AIMS

To compare the degree of endothelial dysfunction (ED) in patients treated with everolimus-eluting stent (EES) versus bare metal stent (BMS) implantation.

METHODS AND RESULTS

This is an observational study. A total of 30 elective patients (15 treated with EES and 15 with BMS) were recruited. All patients underwent coronary angiography and intracoronary acetylcholine (Ach) test at different doses at six months after stent implantation. Quantitative coronary angiography analysis was performed to evaluate the changes in mean luminal diameter (MLD) of the segments distal to the distal stent edge after increasing doses of Ach. Both EES and BMS groups had similar baseline characteristics except for stent length (18.6±2.5 vs. 16.5±2.5 mm; p=0.033) and diameter (3.1±0.2 vs. 3.4±0.3 mm; p=0.007). The vasomotion test showed that EES had 3.14% of MLD decrease after Ach infusion and BMS had 2.35% of vasoconstriction (p=0.62). After adjustment for baseline characteristics, no statistical difference was observed between groups.

CONCLUSIONS

In our study EES implantation was associated with a low degree of ED and had a similar vasomotion response as compared to BMS. Prospective randomised investigations are warranted to confirm these findings.

Cost-effectiveness of a European ST-segment elevation myocardial infarction network: results from the Catalan Codi Infart network

OBJECTIVES

To evaluate the cost-effectiveness of the ST-segment elevation myocardial infarction (STEMI) network of Catalonia (Codi Infart).

DESIGN

Cost-utility analysis.

SETTING

The analysis was from the Catalonian Autonomous Community in Spain, with a population of about 7.5 million people.

PARTICIPANTS

Patients with STEMI treated within the autonomous community of Catalonia (Spain) included in the IAM CAT II-IV and Codi Infart registries.

OUTCOME MEASURES

Costs included hospitalisation, procedures and additional personnel and were obtained according to the reperfusion strategy. Clinical outcomes were defined as 30-day avoided mortality and quality-adjusted life-years (QALYs), before (N=356) and after network implementation (N=2140).

RESULTS

A substitution effect and a technology effect were observed; aggregate costs increased by 2.6%. The substitution effect resulted from increased use of primary coronary angioplasty, a relatively expensive procedure and a decrease in fibrinolysis. Primary coronary angioplasty increased from 31% to 89% with the network, and fibrinolysis decreased from 37% to 3%. Rescue coronary angioplasty declined from 11% to 4%, and no reperfusion from 21% to 4%. The technological effect was related to improvements in the percutaneous coronary intervention procedure that increased efficiency, reducing the average length of the hospital stay. Mean costs per patient decreased from €8306 to €7874 for patients with primary coronary angioplasty. Clinical outcomes in patients treated with primary coronary angioplasty did not change significantly, although 30-day mortality decreased from 7.5% to 5.6%. The incremental cost-effectiveness ratio resulted in an extra cost of €4355 per life saved (30-day mortality) and €495 per QALY. Below a cost threshold of €30,000, results were sensitive to variations in costs and outcomes.

CONCLUSIONS

The Catalan STEMI network (Codi Infart) is cost-efficient. Further studies are needed in geopolitical different scenarios.

The TITAN-AMI multicenter registry evaluating the usage of Titan2 stent in patients with ST segment elevation myocardial infarction. Final result at 12-month follow-up

AIM

Primary percutaneous coronary intervention with stent implantation is the recommended treatment for patients with ST elevation myocardial infarction (STEMI). Data from randomised trials showed good performance by a titanium-nitric-oxide coated stent in this context. The aim of this study was to confirm these data.

METHODS

A multicentre registry was compiled in 23 hospitals in Spain in an all-comers population. We selected patients with STEMI from a global Titan AMI registry that included patients with acute coronary syndrome. Primary endpoint was the composite of cardiac death, non-fatal myocardial infarction, stent thrombosis and target lesion revascularisation, at 12-month follow-up.

RESULTS

The study included 893 patients with STEMI. We included all possibilities for PCI: 86.6% primary, 5% facilitated after successful fibrinolysis and 8.4% rescue PCI after failed fibrinolysis. The primary endpoint was reached in 8.4% of the patients: cardiac death 2.7%, reinfarction 3.4%, target lesion revascularisation 3.5% and definite or probable stent thrombosis 2.8%. The majority of stent thromboses presented in the first 30 days after PCI.

CONCLUSION

A bioactive stent (titanium-nitric-oxide coated stent) is a possible alternative for the treatment of patients with STEMI. One-year follow-up showed better results than those presented by a regular bare-metal stent or first-generation drug-eluting stent in terms of stent thrombosis.

Sirolimus-eluting stent versus bare metal stent in diabetic patients: the final five-year follow-up of the DIABETES trial

AIMS

The DIABETES (DIABETes and sirolimus-Eluting Stent) trial is a prospective, multicentre, randomised, controlled trial aimed at demonstrating the efficacy of sirolimus-eluting stent (SES) as compared to bare metal stent (BMS) implantation in diabetic patients. The aim of the present analysis was to assess the five-year clinical follow-up of the patients included in this trial.

METHODS AND RESULTS

One hundred and sixty patients (222 lesions) were included: 80 patients were randomised to SES and 80 patients to BMS. Patients were eligible for the study if they were identified as non-insulin-dependent diabetics (NIDDM) or insulin-dependent diabetics (IDDM), with significant native coronary stenoses in ≥1 vessel. There was a sub-randomisation according to diabetes status. Clinical follow-up was extended up to five years. Five-year clinical follow-up was obtained in 96.2%. Overall, MACE at five years was significantly lower in the SES group as compared with the BMS arm, mainly due to a significant reduction in TLR. There were no significant differences in cardiac death or myocardial infarction (MI). This was also observed in both prespecified subgroups IDDM and NIDDM. In the SES group, the incidence density of definite/probable stent thrombosis was 0.53 per 100 person-years, whereas in the BMS group it was 0.8 per 100 person-years. Independent predictors of MACE were: SES implantation (p<0.001), multivessel stent implantation (p=0.04), and creatinine levels (p=0.001).

CONCLUSIONS

Five-year follow-up of the DIABETES trial suggests the effect of SES in reducing TLR is similar in both IDDM and NIDDM. No major safety concerns in terms of ST, MI or mortality were observed.