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International audience; Background: in patients with ST-segment elevation myocardial infarction and multivessel disease, percutaneous coronary intervention for non-culprit lesions is superior to treatment of the culprit lesion alone. The optimal timing for non-infarct-related artery revascularization - immediate versus staged - has not been investigated adequately. Aim: we aimed to assess clinical outcomes at 1 year in patients with ST-segment elevation myocardial infarction with multivessel disease using immediate versus staged non-infarct-related artery revascularization. Methods: outcomes were analysed in patients from the randomized FLOWER-MI trial, in whom, after successful primary percutaneous coronary intervention, non-culprit lesions were assessed using fractional flow reserve or angiography during the index procedure or during a staged procedure during the initial hospital stay, ≤5 days after the index procedure. The primary outcome was a composite of all-cause death, non-fatal myocardial infarction and unplanned hospitalization with urgent revascularization at 1 year. Results: among 1171 patients enrolled in this study, 1119 (96.2%) had complete revascularization performed during a staged procedure, and 44 (3.8%) at the time of primary percutaneous coronary intervention. During follow-up, a primary outcome event occurred in one of the patients (2.3%) with an immediate strategy and in 55 patients (4.9%) with a staged strategy (adjusted hazard ratio 1.44, 95% confidence interval 0.39-12.69; P=0.64). Conclusions: staged non-infarct-related artery complete revascularization was the strategy preferred by investigators in practice in patients with ST-segment elevation myocardial infarction with multivessel disease. This strategy was not superior to immediate revascularization, which, in the context of this trial, was used in a small proportion of patients. Further randomized studies are needed to confirm these observational findings.

International audience

Summary Background Transfemoral percutaneous transcatheter aortic valve implantation (TF-TAVI) is a safe, reproducible and established procedure, mainly performed under local anaesthesia, which is mostly administered and monitored by a dedicated anaesthesia team (regular approach). Our centre has developed a standardized pathway of care, and eligible patients are selected for a minimalist TF-TAVI, entirely managed by operators without the presence of the anaesthesia team in the operating room, like most interventional coronary procedures (“percutaneous coronary intervention-like” approach [PCI approach]). Aim To compare the safety and efficacy of TF-TAVI performed with the PCI approach versus the regular approach. Methods The analysis population comprised all patients who underwent TF-TAVI with the PCI or regular approach in our institution from November 2016 to July 2019. The two co-primary endpoints were early safety composite and early efficacy composite at 30 days as defined by the Valve Academic Research Consortium-2. The PCI (n = 137) and Regular (n = 221) approaches were compared using the propensity score based method of inverse probability of treatment weighting. Results No differences were observed after comparison of TAVI performed with the PCI or regular approach regarding the composite safety endpoint (7.3% vs. 11.3%; odds ratio 0.63, 95% confidence interval 0.37 to 1.07; P = 0.086) or the composite efficacy endpoint (4.4% vs. 6.3%; odds ratio 0.78, 95% confidence interval 0.41 to 1.49; P = 0.45). Conclusions This study suggests that the efficacy and safety of TF-TAVI entirely managed by a PCI approach for selected patients are not different to those when TF-TAVI is performed with the attendance of a full anaesthesia care team. The PCI approach appears to be a safe and efficient clinical pathway, providing an appropriate and rational utilization of anaesthesiology resources, and could be used for the majority of TF-TAVI procedures.

Summary Background Coronary artery disease (CAD) is the leading cause of systolic heart failure (HF). Cardiac magnetic resonance imaging (CMR) is a non-invasive technique that detects a myocardial infarction scar as subendocardial or transmural late gadolinium enhancement (st-LGE). Aim We sought to evaluate whether a lack of st-LGE could rule out CAD in new-onset systolic HF of unknown aetiology. Methods We included 232 consecutive patients with new-onset HF and left ventricular ejection fraction ≤ 35% who underwent both coronary angiography and CMR to assess HF aetiology. CAD was defined as the presence of coronary artery stenosis ≥ 50% on a coronary angiogram. We assessed sensitivity, specificity, and positive and negative likelihood ratios (PLR and NLR) of the presence of st-LGE to detect underlying CAD. A complementary meta-analysis of 11 studies (including ours) was also performed. Results In our study, 49 (21.1%) patients had CAD. The sensitivity and specificity of the presence of st-LGE to detect CAD were 69 and 92%, respectively. PLR and NLR were 8.47 and 0.33, respectively. In the meta-analysis, 1227 patients were included, and the prevalence of CAD ranged from 19.2 to 68.3%. Sensitivity, specificity, PLR and NLR were 87% (95% confidence interval [CI] 0.80–0.92), 93% (95% CI 0.89–0.96), 12.91 (95% CI 7.70–21.64) and 0.14 (95% CI 0.09–0.22), respectively. Altogether, 55 patients presented CAD with no st-LGE; inversely, 75 patients presented st-LGE with no CAD. Conclusion With a CMR specificity of 93%, the absence of st-LGE rules out significant underlying CAD in patients with systolic HF of unknown aetiology in most cases.

SummaryOver the past two decades, the use of multiple biomarkers has changed cardiovascular disease management. Recently, several trials have assessed the diagnostic and prognostic performances of copeptin, especially in patients with heart failure or acute coronary syndromes. Primary results are interesting, with copeptin looking promising for: the management of patients who present at emergency departments early after chest pain onset and the risk stratification of patients with heart failure. The purpose of this article is to review the data on the place of copeptin in the management of patients with chest pain or heart failure.

Low-density lipoprotein cholesterol (LDL-C) reduction is an integral part of the management of patients with coronary artery disease (CAD).To assess attainment of LDL-C goals during long-term treatment of patients with stable CAD, and to determine predictors of goal attainment and the prognostic impact of reaching LDL-C70mg/dL (1.8mmol/L) in a real-life setting.Data were obtained for 4080 outpatients with stable CAD included in the multicentre CORONOR study. Five-year follow-up was achieved for 3991 (97.8%) patients.At inclusion, a recent (1 year) measurement of LDL-C was available in 3757 (92.1%) patients. LDL-C70mg/dL was reached by 885 (23.6%) patients. Independent predictors of LDL-C70mg/dL were diabetes mellitus, statin treatment, treatment with renin-angiotensin system inhibitors, previous myocardial infarction and short time since last coronary event. The adjusted hazard ratio (HR) for the composite endpoint (cardiovascular death, myocardial infarction, ischemic stroke or coronary revascularization) during the 5-year follow-up was 1.31 (95% confidence interval [CI]: 1.09-1.58; P=0.004) for LDL-C≥70mg/dL versus70mg/dL. When compared with patients with LDL-C70mg/dL, the adjusted HRs for LDL-C 70-99mg/dL and ≥100mg/dL (2.6mmol/L) were 1.27 (95% CI: 1.05-1.55; P=0.016) and 1.38 (95% CI: 1.12-1.70; P=0.003), respectively. When LDL-C was used as a continuous variable, the adjusted HRs for increases of 10mg/dL (0.3mmol/L) and 1mmol/L were 1.05 (95% CI: 1.03-1.08) and 1.21 (95% CI: 1.10-1.33), respectively.In this observational study, only a minority of stable CAD patients had LDL-C70mg/dL. The patients who reached their LDL-C goal had the lowest risk of cardiovascular events.

Summary Background Large interindividual variability exists in clopidogrel response. Clopidogrel low response correlates with poor prognosis after percutaneous coronary intervention. Some authors also suggest intraindividual variability over time. Aim To assess the impact of initial clinical presentation on clopidogrel low response. Methods In this prospective study, clopidogrel response was assessed in 100 patients. Fifty patients presenting with acute coronary syndromes (ACS group) were compared with 50 patients with stable coronary artery disease matched 1:1 for age, sex, body mass index and diabetes (stable group). All patients were tested 18–24 h after a 600 mg loading dose of clopidogrel using the VerifyNow-P2Y12 test (results expressed as platelet reaction units [PRUs]). Patients under chronic clopidogrel therapy or treated with glycoprotein IIb/IIIa inhibitors, bivalirudin or thrombolytics were excluded. Results Mean age was 61 ± 12 years in each group; 28% of patients in each group were diabetic; mean body mass index was 27.6 ± 5.6 kg/m 2 in the ACS group and 27.9 ± 5.9 kg/m 2 in the stable group ( p = 0.80). Mean PRU values were 197 ± 81 in the ACS group and 159 ± 94 in the stable group ( p = 0.03). By multivariable analysis, the ACS group was significantly associated with a higher PRU value ( p = 0.02). There were significantly more clopidogrel low responders (PRU value > 230) in the ACS group (38% vs. 18%; p = 0.04). Conclusion Our study confirms that initial clinical presentation, especially ACS, is a strong predictor of clopidogrel low response; this suggests that the evolution of coronary artery disease for one patient influences the clopidogrel response over time. These results are in accordance with recent trials showing a benefit for more aggressive antiplatelet therapy in ACS patients.

Summary Background Limited recent data are available in the literature on whether the presence of left ventricular systolic dysfunction (LVSD) affects the therapeutic management of patients with stable coronary artery disease (CAD). Aims The objectives of this study were to analyse prevalence, effect on therapeutics and prognosis of LVSD in stable CAD. Methods We prospectively included 4184 CAD outpatients free from any myocardial infarction or coronary revascularization for > 1 year. Left ventricular ejection fraction (EF) was available for 4124 (98.6%) patients. Follow-up was performed at 2 years. All events were adjudicated blindly. Results The mean EF was 57.5 ± 10.8%, and 201 (4.9%) patients had an EF ≤ 35%. The prescription of renin–angiotensin system inhibitors and beta-blockers was inversely related to EF, and reached > 90% in patients with EF ≤ 35%. Seventy-five (37.3%) of the patients with EF ≤ 35% received a mineralocorticoid receptor antagonist. Eighty-five (42.3%) of the patients with EF ≤ 35% had an implantable cardioverter defibrillator. Clinical follow-up data were obtained for 4090 patients (99.2%). Event rates were higher in patients with low EF (adjusted hazard ratio [95% confidence interval] for EF ≤ 35%, with EF ≥ 60% as reference: 3.93 [2.60–5.93] and 7.12 [3.85–13.18], for all-cause death and cardiovascular death, respectively). Conclusions In patients with stable CAD, LVSD is well taken into account by cardiologists, with extensive use of evidence-based medications and interventions. Despite this, LVSD remains a major prognostic indicator in this population.

Summary Aim To assess the feasibility and safety of a hybrid myocardial revascularization strategy combining “exclusive arterial” conventional coronary artery bypass grafting (CABG) followed by early drug-eluting stent (DES) implantation in multivessel coronary artery disease (CAD). Methods Eighteen consecutive patients with multivessel CAD were enrolled prospectively. Within 48 hours of CABG using left internal mammary artery (IMA) to left anterior descending (LAD) coronary artery with or without right IMA to non-LAD vessel in an open chest approach, DESs were implanted systematically in an additional vessel after a clopidogrel 300-mg preloading dose. This group was compared with 18 matched patients who underwent standard CABG alone using left IMA to LAD and at least one additional graft. Results Baseline clinical characteristics were similar in both groups. There were 46 grafts in the CABG group and 28 in the hybrid group. In the hybrid group, 27.8% of patients were treated off-pump versus none in the CABG group; a median of 2 (interquartile range: 1–2) stents was implanted per patient. The hybrid procedure was associated with shorter durations of cardiopulmonary bypass (77 [67–100] min versus 97 [90–105] min, P = 0.049). Major bleeding rates were higher in the CABG group, but the difference was not statistically significant (44.4% versus 11.1%, P = 0.06). Re-intervention for bleeding was not needed in either group. One (5.6%) myocardial infarction occurred in hospital in each group following CABG. At 1 year, the cumulative rates of major adverse cardiac events (death, myocardial infarction, target vessel revascularization) were similar (11.2% in hybrid group versus 5.6% in CABG group, P = 0.99). One death occurred in the CABG group and one target vessel revascularization in the hybrid group. Conclusion A hybrid revascularization strategy, combining conventional CABG with exclusive arterial conduits followed by early DES implantation, is feasible. One-year event rates compare favourably to those with traditional CABG alone.

Summary Background Thrombus aspiration (TA) has been associated with high rates of thrombotic material retrieval, which results in improved myocardial reperfusion. In addition, a recent study has shown that systematic TA for treatment of ST-segment elevation myocardial infarction (STEMI) related to de novo lesions improves patient outcomes. Aims Evaluation of a single-centre experience of TA before percutaneous coronary intervention (PCI) for stent thrombosis (ST) treatment. Methods Between 2004 and 2006, we indexed 24 patients presenting with definite ST. All patients underwent TA (Export Medtronic ® 6F catheter) followed by PCI for ST treatment. Baseline clinical and angiographic characteristics, and complications related to the TA device were indexed. Results The median time of ST occurrence was 7 days. All patients except one presented with STEMI. Bare-metal and drug-eluting ST represented 70.8% and 29.2% of cases, respectively. Mean stent length was 18.8 ± 5.6 mm; mean stent diameter was 2.8 ± 0.4 mm; mean number of implanted stents was 1.58 ± 0.7. There was no failure to cross the catheter and no TA device-related complications were reported. The numbers of patients with initial thrombolysis in myocardial infarction (TIMI) flow grades 0, 1 and 2 were 15 (62.5%), 3 (12.5%) and 6 (25.0%), respectively. No patient had TIMI flow grade 3 before TA. After TA, 16 (66.7%) patients had TIMI flow grade 3; final procedural success was obtained in 23 (95.8%) patients. The 1-year death rate was 12.5%. Conclusions In our experience, TA before PCI for ST treatment shows promising results, providing high rates of immediate reperfusion and final angiographic success, and low death rates, compared with the literature.

SummaryBackgroundIn-stent restenosis remains the major limitation of percutaneous coronary intervention (PCI), particularly after bare-metal stent (BMS) implantation. Drug-eluting stents (DES) decrease in-stent restenosis, which is thought to have minimal clinical consequences, but may increase the risk of stent thrombosis and its attendant high mortality rate.AimsTo assess the clinical consequences of in-stent restenosis, including severity of associated illness and acute and 1-year outcomes and to compare DES and BMS in-stent restenosis.MethodsUsing our prospective PCI registry, we compared data from 1958 consecutive patients hospitalized with BMS in-stent restenosis between January 2000 and April 2003 and all 190 patients with DES in-stent restenosis admitted between April 2003 and September 2006. Risk-adjusted outcomes were calculated using propensity-score matching.ResultsAn unstable presentation was noted in 78.1% of 2148 patients. Patients with DES in-stent restenosis presented more often with acute myocardial infarction (4.3% versus 1.6%, p

SummaryIntravascular ultrasound imaging has been pivotal in the understanding of coronary artery disease and the development of percutaneous coronary intervention. The ability to analyse vessel walls and measure atherosclerotic lesions more accurately has enabled the field of invasive cardiology to overcome the limits of angiography. In fact, intravascular ultrasound measurements correlate with functional measurement of coronary blood flow, as a result interest in their use for the diagnosis of lesion severity in ambiguous lesions and for left main trunk analysis has grown. On the interventional side, intravascular ultrasound is used to determine the major predictors of restenosis and stent thrombosis, which are the main pitfalls of percutaneous coronary intervention. In the bare-metal stent era, intravascular ultrasound-guided percutaneous coronary intervention was associated with a reduction in restenosis rates because it enabled identification and treatment of the risk factors for complications. Although drug-eluting stents have provided a great technological advance in percutaneous coronary intervention, further reducing the rate of in-stent restenosis, they have not abolished restenosis completely; intravascular ultrasound has also been used in this setting to identify the mechanisms responsible for drug-eluting stent restenosis. As in the bare-metal stent era, identification of the predictors of restenosis and stent thrombosis and their subsequent treatment may offer the promise of improved outcome in the drug-eluting stent era. This review focuses on the potential benefit of intravascular ultrasound-guided percutaneous coronary intervention with regard to restenosis and stent thrombosis in the bare-metal stent and drug-eluting stent eras.

Background In patients with coronary artery disease (CAD), non-optimal use of evidence-based medications is associated with an increased risk of adverse outcome. Aims To assess the prevalence and correlates of non-optimal secondary medical prevention in patients with stable CAD. Methods We included 4184 consecutive outpatients with stable CAD. Treatment at inclusion was classified as optimal/non-optimal regarding the four major classes of secondary prevention drugs: antithrombotics; statins; angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs); and beta-blockers. For each treatment, the prescription was considered non-optimal if the drug was missing despite a class IA indication according to international guidelines. To assess the information globally, non-optimal secondary prevention was defined as at least one major treatment missing. Results The proportions of patients with non-optimal treatment were 0.7%, 7.8%, 12.9% and 10.3% for antithrombotics, statins, ACE inhibitors/ARBs and beta-blockers, respectively. Non-optimal secondary medical prevention was observed in 16.8% of cases. By multivariable analysis, the correlates of non-optimal secondary medical prevention were long time interval since last coronary event (P

Summary Background The ideal duration of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI) is under debate. Lesion length is a well-recognized predictor of PCI complexity and long-term outcome. Aim To evaluate the determinants and impact on outcome of long-term DAPT in a retrospective cohort of patients treated for a long coronary lesion. Methods Patients ( n = 460) who underwent PCI for a long lesion (> 30 mm) were divided into two groups according to antiplatelet regimen at 1 year: patients who stopped DAPT before 1 year (single antiplatelet therapy group; n = 168) and patients who continued DAPT for longer than 1 year ( n = 292). Results Mean lesion length was 35.7 ± 7.1 mm. The proportion of patients who continued DAPT after 1 year was 63.5%. The main determinants of long-term DAPT were initial presentation as myocardial infarction and implantation of a drug-eluting stent. Median follow-up was 37.4 (23–51) months after the 1-year period following the index PCI. Long-term DAPT was highly associated with a lower risk of all-cause and cardiovascular mortality by multivariable analysis and after adjustment for other predictors: hazard ratios 0.11 (95% confidence interval 0.03–0.32) and 0.15 (95% confidence interval 0.04–0.62), respectively. No increase in major bleeding was noted. Conclusion In a contemporary practice, nearly two-thirds of patients who undergo PCI for a long lesion are treated with DAPT for several years. Our results suggest that long-term DAPT is beneficial in this subset of patients identified as being at high risk.

Stent thrombosis remains a major pitfall of stent implantation in contemporary percutaneous coronary intervention, leading to high rates of death and nonfatal myocardial infarction (MI). Recently, the emergence of drug-eluting stents (DES) has raised concerns regarding the occurrence of late and very late stent thrombosis. Last year, a standardized definition of stent thrombosis was established to provide consistency in the reporting of this complication and to enable accurate and reliable data to be described for both types of stents: bare metal and drug eluting. Subsequent to the publication of this new definition, many updated data have been reported in the literature. On the other hand, antiplatelet therapy response variability is a recent concept and its real place in the pathogenesis of stent thrombosis is yet to be determined. In this article, we review the definition of and predictors for stent thrombosis focusing on DES use and variability in response to antiplatelet therapy, prognosis and treatment.