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Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause of acute myocardial infarction. Coronary angiography remains the best diagnostic tool; however, clinical suspicion and experience is required to interpret angiographic findings. This study sought to assess the clinical implications of the "broken line" (BKL) angiographic pattern in a large, nationwide, cohort of patients with SCAD. The Spanish SCAD registry (NCT03607981) prospectively enrolled consecutive patients with SCAD. All angiograms were centrally analyzed and the BKL pattern was systematically assessed. The BKL angiographic pattern was found in 64 of 389 patients (16%). Patients with the BKL appearance were more frequently female (97 vs 87%, p0.05), presented more often as intramural hematoma (83 vs 58%, p0.001), had longer lesions (47 ± 29 vs 36 ± 22 mm, p0.01), and had severe tortuosity (25 vs 10%, p0.01) but showed better initial coronary flow (thrombolysis in myocardial infarction flow 2.6 ± 0.8 vs 2.1 ± 1.2, p0.01). Patients with BKL received more frequently conservative medical management (91 vs 76%, p0.01). At late clinical follow-up (median 29 months, interquartile range 17 to 38) predefined adverse events (death, myocardial infarction, revascularization, recurrent SCAD, or stroke) occurred less frequently (3.5 vs 15%, p0.05) in patients with the BKL appearance. The better clinical outcomes of patients in the BKL group persisted after adjusting for potential confounders (adjusted hazard ratio 0.2, 95% confidence interval 0.1 to 0.9, p0.05). In conclusion, patients with SCAD presenting the BKL angiographic pattern are more frequently female and present more often as intramural hematoma with longer lesions and severe vessel tortuosity but have better coronary flow. Patients with the BKL morphology have a favorable prognosis (NCT03607981).

Background This study aimed to assess the correlation between the standard of care, the index of microvascular resistance (IMR) versus the novel microvascular resistance (Rmicro) and to determine the pathologic cut-off value in a selected population with suspected coronary microvascular dysfunction (CMD). Methods One-hundred and twenty patients with high clinical suspicion of CMD due to ischemic symptoms in the absence of significant epicardial coronary lesions were prospectively included. Following a standardized systematic protocol, coronary flow reserve, IMR, fractional flow reserve, Q and Rmicro were measured in the left anterior descending coronary artery using a temperature/pressure sensor-tipped guidewire and a dedicated infusion catheter. Results There was a high prevalence of CMD with 50 (42%) patients showing an IMR ≥ 25. Median IMR was 23 [IQR: 14–34] and median Rmicro was 464 Woods Units (WU) [IQR: 354–636WU]. ROC analyses identified 500 WU as the optimal Rmicro cut-off to identify patients with an IMR ≥ 25, with an area under the ROC curve (C statistic) of 0.83 (95% CI: 0.74 to 0.89, p Conclusions Rmicro derived from continuous intracoronary thermodilution is an accurate index to measure microvascular resistances enabling the invasive diagnostic of CMD.

Introduction and objectives Spontaneous coronary artery dissection (SCAD) is an uncommon cause of acute coronary syndrome. The characteristics and in-hospital clinical course of patients with SCAD in Spain remain unknown. Methods We present data from consecutive patients included in the national prospective SCAD registry. Angiographic analysis was performed in a centralized core laboratory. Results Between June 2015 and April 2019, we included 318 patients with SCAD (358 lesions) from 31 centers. Median age was 53 years, and 88% were women. The most frequent presentation was non–ST-segment elevation acute myocardial infarction (53%). The most frequently involved artery was the left anterior descending coronary artery (44%), predominantly affecting the distal segments (39%) and secondary branches (54%). Most lesions (62%) appeared on angiography as intramural hematoma, without double lumen. Conservative management was selected as the initial approach in most patients (78%). During the index admission, 6% of patients had a major adverse event and 4 patients (1.3%) died. Independent predictors of adverse events were initial management with percutaneous coronary intervention (OR, 5.97; P = .004) and angiographic presentation as intramural hematoma (OR, 4.96; P = .028). Conclusions In Spain, SCAD affects mainly middle-aged women. In most patients, the initial management strategy was conservative with excellent in-hospital survival. Initial management with percutaneous coronary intervention and angiographic presentation as intramural hematoma were related to the presence of in-hospital adverse events. Registered at ClnicalTrials.gov (Identifier: NCT03607981).

Plaque erosion (PE) is a well-known pathological substrate in patients with acute myocardial infarction. The precise etiologic diagnosis of patients with myocardial infarction and nonobstructive coronary arteries is of great importance to inform both revascularization decisions and antithrombotic

A 67-year-old woman, a heavy smoker and with hypothyroidism, presented with a non–ST-segment elevation myocardial infarction with negative T waves on the inferior leads. Coronary angiography revealed a focal stenosis in the mid right coronary artery (arrow in [Figure 1A][1]) but no other coronary

A 54-year-old man presenting with an acute myocardial infarction and a total occlusion of the circumflex coronary artery was treated with a magnesium resorbable vascular scaffold (MgRS) (25 mm in length), that was carefully post-dilated at high pressure (20 bar) with a noncompliant balloon, with

Resumen Introduccion y objetivos La hormona tiroidea afecta al metabolismo de todos los tejidos del organismo. El objetivo es analizar la prevalencia y las implicaciones de las alteraciones tiroideas en una cohorte de pacientes consecutivos con diseccion coronaria espontanea (DCE). Metodos Se evaluo a 73 pacientes diagnosticados de DCE y se compararon las caracteristicas y la evolucion clinica de los pacientes eutiroideos frente a los hipotiroideos. Se comparo posteriormente la prevalencia de alteraciones tiroideas y las caracteristicas clinicas de estos pacientes con las de 73 pacientes con sindrome coronario agudo pero sin DCE emparejados por edad, sexo y presentacion clinica. Resultados La media de edad fue 55 ± 12 anos y el 26% tenia hipotiroidismo. Los pacientes con DCE e hipotiroidismo eran todas mujeres (el 100 frente al 69%; p = 0,01), tenian disecciones mas distales (el 74 frente al 41%; p = 0,03), en arterias en tirabuzon (el 68 frente al 41%; p = 0,03) y recibieron tratamiento mas conservador (el 79 frente al 41%; p = 0,007). Durante un seguimiento medio de 4,1 ± 3,8 anos, la tasa de eventos adversos fue del 23%, sin diferencias segun el estado de la funcion tiroidea. La prevalencia de hipotiroidismo fue significativamente mayor en los pacientes con DCE que en el grupo con sindrome coronario agudo sin DCE (el 26 frente al 8%; p = 0,004). Conclusiones Hay una elevada prevalencia de hipotiroidismo en los pacientes con DCE. Los pacientes hipotiroideos con DCE son mas frecuentemente mujeres, tienen disecciones mas distales y en arterias en tirabuzon y reciben tratamiento mas conservador.

A 63-year-old man presented with an acute coronary syndrome 15 years after revascularization of the left anterior descending coronary artery with 2 bare-metal stents. Coronary angiography revealed a severe, heavily calcified, lesion in a large obtuse marginal branch ([Figure 1A][1]) and diffuse in

Introduction and objectives Stent thrombosis (ST) is a rare but potentially serious complication. Optical coherence tomography (OCT) provides high-resolution images and additional information to angiography in the study of this event. Methods Prospective study of patients with ST undergoing reintervention with OCT imaging. Results The study included a total of 40 consecutive patients with ST. Mean age was 69 ± 13 years and 83% were male. Early ST (≤ 30 days) was observed in 16 patients and late ST (> 30 days) in 24 patients. Stent thrombosis occurred in 17 bare-metal stents and 23 drug-eluting stents. In 34 patients (85%), adequate OCT images were obtained at the time of the ST. The predominant mechanism in early ST was stent malapposition (39%). In late ST, high frequencies of uncovered (46%) and malapposed struts (17%) were observed, especially in patients with drug-eluting stents. Furthermore, the presence of neoatherosclerosis was very high (67%) in patients with late ST. After intervention, improvements were observed in malapposition length and the amount of residual thrombus. Conclusions OCT allows identification of the underlying mechanisms potentially involved in ST. This imaging modality is helpful in guiding reintervention in these patients, which improves the area and length of malapposition, as well as the maximal residual thrombus area.

Resumen Introduccion y objetivos La trombosis del stent (TS) es una complicacion infrecuente pero potencialmente grave. La tomografia de coherencia optica (OCT) ofrece imagenes de alta resolucion e informacion adicional a la angiografia en el estudio de esta enfermedad. Metodos Estudio prospectivo en el que se incluyo a todos los pacientes con una TS a los que se realizo una OCT durante el procedimiento. Resultados Se incluyo a un total de 40 pacientes con TS consecutivos, con una media de edad de 69 ± 13 anos; el 83% eran varones. Las TS fueron precoces (≤ 30 dias) en 16 pacientes y tardias (> 30 dias) en 24. En 17 pacientes la TS se produjo en stents convencionales y en 23, en farmacoactivos. En 34 casos (85%) se realizo estudio con OCT en el momento de la TS. En las TS precoces, el mecanismo predominante (39%) fue la malaposicion del stent . En las TS tardias se observaron frecuentemente (46%) struts no recubiertos y areas de malaposicion (17%), especialmente en pacientes con stents farmacoactivos. Ademas, la presencia de neoateroesclerosis fue muy elevada (67%) en los pacientes con TS tardia. Tras la intervencion se observo una mejora en la longitud de la malaposicion y la cantidad de trombo en el stent . Conclusiones La OCT permite conocer los mecanismos subyacentes potencialmente implicados en la TS y guiar el intervencionismo en estos pacientes. La reintervencion disminuye el area y la longitud de la malaposicion, asi como la cantidad de trombo residual.

Objectives This study sought to assess the value of bioresorbable vascular scaffolds (BVS) in patients with in-stent restenosis (ISR). Background Currently both drug-eluting stents (DES) and drug-eluting balloons (DEB) are recommended in patients with ISR. However, the value of BVS in this setting remains unclear. Methods RIBS VI (Restenosis Intra-stent: drug-eluting Balloon vs everolimus-eluting Stent) was a prospective multicenter study (19 Spanish sites) that included 141 patients treated with BVS for either bare-metal stent (BMS) ISR or DES-ISR. Late angiography was scheduled at 6 to 9 months. Inclusion/exclusion criteria were similar to those used in the RIBS IV (patients with DES-ISR) and RIBS V (patients with BMS-ISR) trials, where DEB (n = 249) was compared with everolimus (EES)-DES (n = 249). Results of BVS in RIBS VI were compared with those obtained with DEB and EES in the RIBS IV and V trials. Results On late angiography (n = 134; 95% of eligible) the in-segment minimal lumen diameter (primary endpoint) was 1.87 ± 0.5 mm, late lumen loss was 0.23 ± 0.4 mm, and restenosis rate was 11%. At 1-year follow-up (100% of patients) no patient died, 4 (2.8%) experienced a myocardial infarction, and 16 (11.3%) required target lesion revascularization. One patient (0.7%) who discontinued antiplatelet therapy experienced definitive BVS thrombosis. Freedom from cardiac death, myocardial infarction, and target lesion revascularization was 86%. The minimal lumen diameter at follow-up after BVS was similar to that obtained with DEB (1.88 ± 0.6 mm; p = NS) but smaller than that achieved after EES (2.16 ± 0.7 mm; p Conclusions This study suggests the safety and efficacy of BVS in patients with ISR. In this challenging anatomic scenario BVS obtained late angiographic and clinical results similar to DEB but inferior to EES. (Restenosis Intrastent: Bioresorbable Vascular Scaffolds Treatment [RIBS VI]; NCT02672878 )

Resumen Introduccion y objetivos La rapidez en la instauracion de la reperfusion coronaria es crucial para los pacientes con sindrome coronario agudo con elevacion del segmento ST. El objetivo del estudio es determinar los factores asociados al retraso en la demanda de atencion medica desde el inicio de los sintomas. Metodos Se realizo un estudio de cohortes prospectivo de pacientes consecutivos con infarto y elevacion del ST. Se utilizo un modelo de regresion logistica multiple para identificar los factores asociados de manera independiente con mayor retraso en la peticion de asistencia sanitaria. Resultados Se incluyo a 444 pacientes consecutivos (media de edad, 63 anos; el 76% varones, el 20% diabeticos). La mediana del tiempo total de isquemia fue de 225 (160-317) min; la mediana del retraso en la demanda de atencion medica, 110 (51-190) min. Los pacientes mas ancianos (edad > 75 anos; odds ratio = 11,6), las mujeres (odds ratio = 3,4), los diabeticos (odds ratio = 2,3) y los que solicitaron asistencia desde su propio domicilio (odds ratio = 2,2) son los que mas tardaron en pedir atencion. El mayor retraso en la demanda de atencion medica se asocio a una mayor mortalidad durante el ingreso hospitalario (el 9,8 frente al 2,7%; p Conclusiones Los pacientes ancianos, las mujeres y los diabeticos con infarto de miocardio y elevacion del ST presentan mayor retraso en la demanda de atencion medica. El retraso en la demanda de atencion medica se asocia con mayor mortalidad durante el ingreso y al ano.

Treatment of patients with in-stent restenosis (ISR) remains a challenge. This study sought to compare the efficacy of everolimus-eluting stents (EESs) and drug-eluting balloons (DEBs) with paclitaxel in patients with ISR. A pooled analysis of the Restenosis Intra-Stent of Drug-Eluting Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent (RIBS IV) and Restenosis Intra-Stent of Bare-Metal Stents: Drug-Eluting Balloon vs Everolimus-Eluting Stent (RIBS V) randomized trials was performed using patient-level data. In both trials, EESs were compared with DEBs in patients with ISR (RIBS V included 189 patients with bare-metal ISR; RIBS IV included 309 patients with drug-eluting ISR). Inclusion and exclusion criteria were identical in both trials. A total of 249 patients were allocated to EES and 249 to DEB. Clinical follow-up at 1 year was obtained in all (100%) patients and late angiography (median 249 days) in 91% of eligible patients. Compared with patients treated with DEBs, patients treated with EESs obtained better short-term results (postprocedural minimal lumen diameter 2.28 ± 0.5 vs 2.12 ± 0.4 mm, p

Resumen Introduccion y objetivos El sindrome de tako-tsubo es una entidad de etiologia y epidemiologia inciertas, capaz de semejarse a un infarto y que, aunque suele tener buen pronostico, no esta exenta de complicaciones. El objetivo del presente trabajo es caracterizar esta enfermedad en nuestro medio a traves de un registro (REgistro nacional multicentrico sobre sindome de TAKOtsubo). Metodos El registro prospectivo incluyo a 202 pacientes incidentes en 23 hospitales entre 2012-2013. Se recogieron las caracteristicas clinicas, analiticas, electrocardiograficas y de imagen, asi como los eventos durante el seguimiento. Se incluyo a los pacientes cuando sus medicos consideraron probado el caso, y la incidencia de la enfermedad se calculo en funcion de los cateterismos solicitados con el diagnostico presunto de sindrome coronario agudo. Resultados Los casos fueron predominantemente mujeres (90%), con una media de edad de 70 anos y frecuentes factores de riesgo cardiovascular, hipertension arterial (67%), dislipemia (41%), diabetes mellitus (15%) y tabaquismo (15%). Sin clara distribucion semanal o estacional, se calculo una incidencia del 1,2%. El dolor toracico fue el sintoma predominante, con algun desencadenante (psiquico, fisico o ambos) en el 72%, y la mayoria consulto en las primeras 6 h. La estancia mediana fue de 7 dias; aparecio algun sintoma de insuficiencia cardiaca en el 34,0% y arritmias en el 26,7% y murio el 2,4%. Conclusiones El sindrome de tako-tsubo es una enfermedad poco incidente, que afecta predominantemente a mujeres posmenopausicas, en mas de la mitad de los casos tras una situacion psicologicamente estresante. Se caracteriza por dolor anginoso, sin distribucion estacional; aunque no esta exenta de morbimortalidad, conlleva buen pronostico.

Results Left ventricular ejection fraction (LVEF) at the 6 months MRI was higher after IV metoprolol (48.7 � 9.9% vs. 45.0 � 11.7% in control subjects; adjusted treatment effect 3.49%; 95% confidence interval [CI]: 0.44% to 6.55%; p ¼ 0.025). The occurrence of severely depressed LVEF (� 35%) at 6 months was significantly lower in patients treated with IV metoprolol (11% vs. 27%, p ¼ 0.006). The proportion of patients fulfilling Class I indications for an implantable cardioverter-defibrillator (ICD) was significantly lower in the IV metoprolol group (7% vs. 20%, p ¼ 0.012). At a median follow-up of 2 years, occurrence of the pre-specified composite of death, heart failure admission, reinfarction, and malignant arrhythmias was 10.8% in the IV metoprolol group versus 18.3% in the control group, adjusted hazard ratio (HR): 0.55; 95% CI: 0.26 to 1.04; p ¼ 0.065. Heart failure admission was significantly lower in the IV metoprolol group (HR: 0.32; 95% CI: 0.015 to 0.95; p ¼ 0.046).

We read with great interest the study from the Vancouver General Hospital confirming that spontaneous healing occurs during follow-up in most patients with spontaneous coronary artery dissection (SCAD) [(1)][1]. This is the largest study (n = 156/182 lesions) assessing the angiographic fate (median

The use of isotretinoin has been associated with mild changes in the metabolic profile of adolescents. In very rare cases, a possible association with myocardial infarction, stroke and thromboembolic events has been reported. In this report we describe the potential association of isotretinoin with the occurrence of an acute myocardial infarction in a very young girl. OCT provided unique visualization of the culprit lesion.

An 82-year-old man with hypertension, diabetes mellitus type 2, and chronic renal failure under hemodialysis was admitted with rest angina. Coronary angiography showed 2-vessel coronary artery disease, with significant stenosis in the first and second diagonal branches that were small vessels, and a

Introduccion y objetivos. Este estudio se diseno para comparar la incidencia de nefropatia por contraste (NC) y los cambios en la creatinina serica (CrS) tras el uso del contraste isoosmolar iodixanol o el contraste de baja osmolaridad ioversol en pacientes diabeticos sometidos a coronariografia y/o intervencion coronaria percutanea (ICP). Algunos estudios indican que el iodixanol reduce el riesgo de NC en pacientes con disfuncion renal, con o sin diabetes. Los pacientes diabeticos pueden tener cierto grado de disfuncion renal a pesar de tener niveles normales de CrS. Metodos. Se incluyeron 250 pacientes diabeticos consecutivos a los que se realizo coronariografia y/o ICP. Los pacientes incluidos durante los primeros 7 meses del estudio recibieron ioversol, y los incluidos en los siguientes 11 meses recibieron iodixanol. El objetivo primario del estudio fue la incidencia de NC. Los predictores independientes de NC y el incremento medio de CrS 72 h tras el contraste fueron objetivos secundarios. Resultados. La incidencia total de NC fue del 5,6%. La incidencia de NC fue significativamente menor con iodixanol que con ioversol (el 2,5 frente al 8,3%; odds ratio = 0,255; intervalo de confianza del 95%, 0,068-0,952; p = 0,047). Una menor tasa de filtrado glomerular estimada (60,8 ± 29 frente a 75,3 ± 25 ml/min/1,73 m2; odds ratio = 0,975; intervalo de confianza del 95%, 0,952-0,997; p = 0,03) y el uso de ioversol se demostraron predictores independientes de NC. Conclusiones. En pacientes diabeticos sometidos a coronariografia diagnostica y/o ICP, el contraste isoos-molar iodixanol mostro menor incidencia de NC que el contraste de baja osmolaridad ioversol.

We report a patient with undilatable in-stent restenosis (ISR) presenting 11 years after initial stent implantation. Optical coherence tomography (OCT) disclosed severe calcified neoatherosclerosis as the underlying substrate of ISR ([Figures 1A and 1B][1]). Multiple high-pressure inflations with

Patients who are on a waiting list for cardiac transplantation often have a clinical profile that satisfies current recommendations for the implantation of an implantable cardioverter–defibrillator for the primary prevention of sudden death. The prospect that transplantation may take place within the shortto-medium term puts the effectiveness of this therapy in doubt. We investigated the incidence of therapy delivered by implantable cardioverter–defibrillators implanted for primary prevention in patients awaiting cardiac transplantation. Recent changes in the incidence of sudden death at our center were also investigated. Data on 308 patients listed for heart transplantation between 1998 and 2008 were reviewed. An implantable cardioverter–defibrillator was indicated for primary prevention at initial evaluation in 17 patients. Of these, 53% received appropriate implantable cardioverter–defibrillator therapy while carrying an implantable cardioverter–defibrillator for a mean period of 7.8 months ( 4.8). Only one patient received inappropriate therapy and none had any complications associated with device use. The frequency of sudden death has decreased over the course of recent years.

Thrombus aspiration (TA) during primary PCI has demonstrated to be of value in reducing infarct size. In “in vitro” studies larger caliber devices have demonstrated a better aspiration power. Whether this difference may translate into a net clinical benefit in this setting remains unsettled. We

A 72-old-year-man was admitted for an inferior ST-segment elevation acute myocardial infarction. Seven years earlier, a 2.75 × 15-mm bare-metal stent (BMS) was successfully implanted in the posterolateral branch of the right coronary artery (RCA) at another institution. Emergent coronary

Neoatherosclerosis has been described as a cause of in-stent restenosis (ISR), particularly in patients treated with drug-eluting stents (DESs). Although neoatherosclerosis may present as calcified plaques, the occurrence of a "calcified nodule" within the stent has not been previously reported. We describe optical coherence tomographic findings in a patient presenting with a calcified nodule causing "undilatable" ISR 2 years after implantation of a DES. The clinical and technical implications of this novel pattern of neoatherosclerosis are discussed.

Current guidelines recommend the use of fractional flow reserve (FFR) for guiding the decision for coronary revascularization. Recently, new parameters are being validated for intracoronary ischemia detection.There are few data on the intrinsic biological variability of these measurements. The

The instantaneous wave-free ratio (iFR) is a vasodilator-free pressure-only measure of the hemodynamic severity of coronary stenoses that is comparable to the classical fractional flow reserve (FFR) in diagnostic categorization. The use of iFR might thus replace FFR and avoid potential complications