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Background The efficacy and safety of ticagrelor versus prasugrel in patients with acute coronary syndrome and prior myocardial infarction (MI) remain unstudied. We aimed to assess the treatment effect of ticagrelor versus prasugrel according to prior MI status in patients with ACS. Methods and Results Patients with acute coronary syndrome planned for an invasive strategy and randomized to ticagrelor or prasugrel in the ISAR‐REACT (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment) 5 trial were included. The primary end point was the composite of 1‐year all‐cause death, MI, or stroke; the secondary safety end point was the composite of 1‐year Bleeding Academic Research Consortium type 3 to 5 bleeding. The study included 4015 patients (prior MI=631 patients; no prior MI=3384 patients). As compared with patients without prior MI, the primary end point occurred more frequently in patients with prior MI (12.6% versus 7.2%; hazard ratio [HR], 1.78 [95% CI, 1.38–2.29]); the secondary safety end point appears to differ little between patients with and without prior MI (5.8% versus 5.7%, respectively; HR, 1.02 [95% CI, 0.71–1.45]). With regard to the primary end point, ticagrelor versus prasugrel was associated with an HR of 1.62 (95% CI, 1.03–2.55) in patients with prior MI and an HR of 1.28 (95% CI, 0.99–1.65) in patients without prior MI ( P int =0.37). With regard to the secondary safety end point, ticagrelor versus prasugrel was associated with an HR of 1.28 (95% CI, 0.56–2.91) in patients with prior MI and an HR of 1.13 (95% CI, 0.82–1.55) in patients without prior MI ( P int =0.79). Conclusions Patients with acute coronary syndrome and prior MI are at higher risk for recurrent ischemic but not bleeding events. Prasugrel is superior to ticagrelor in reducing the risk of ischemic events without a tradeoff in bleeding regardless of prior MI status. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01944800.

Background: The relative efficacy and safety of more potent P2Y 12 inhibitors in patients with acute coronary syndrome and high bleeding risk (HBR) undergoing percutaneous coronary intervention remains unclear. We aimed to study the treatment effect of ticagrelor and prasugrel in percutaneous coronary intervention patients presenting with acute coronary syndrome and HBR. Methods: This post hoc analysis of the ISAR-REACT 5 trial (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5) included patients with acute coronary syndrome undergoing percutaneous coronary intervention, randomized to ticagrelor or prasugrel, in whom HBR was defined as per Academic Research Consortium criteria. The primary (efficacy) end point was the composite of all-cause death, myocardial infarction, or stroke. The secondary (safety) end point was Bleeding Academic Research Consortium type 3 to 5 bleeding. Outcomes were assessed 12 months after randomization. Results: Out of the 3239 patients included in this analysis, 486 fulfilled the criteria for Academic Research Consortium-HBR definition (HBR group; ticagrelor, n=230 and prasugrel, n=256), while 2753 did not (non-HBR group; ticagrelor, n=1375 and prasugrel, n=1378). Compared with the non-HBR group, the HBR group had a higher risk for the primary (hazard ratio [HR]=3.57 [95% CI, 2.79–4.57]; P P P for interaction=0.12) or secondary ( P for interaction=0.80) end points. Conclusions: In patients with acute coronary syndrome undergoing percutaneous coronary intervention, HBR status increased both ischemic and bleeding risk without significant impact on the relative efficacy and safety of either ticagrelor or prasugrel. These results warrant confirmation in larger cohorts. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01944800.

Background: Data on the comparative efficacy and safety of ticagrelor versus prasugrel in patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention are limited. We assessed the efficacy and safety of ticagrelor versus prasugrel in a head-to-head comparison in patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention. Methods: In this prespecified subgroup analysis, we included 1653 patients with ST-segment–elevation myocardial infarction randomized to receive ticagrelor or prasugrel in the setting of the ISAR REACT-5 trial (Intracoronary Stenting and Antithrombotic Regimen: Rapid Early Action for Coronary Treatment 5). The primary end point was the incidence of death, myocardial infarction, or stroke at 1 year after randomization. The secondary end point was the incidence of bleeding defined as BARC (Bleeding Academic Research Consortium) type 3 to 5 bleeding at 1 year after randomization. Results: The primary end point occurred in 83 patients (10.1%) in the ticagrelor group and in 64 patients (7.9%) in the prasugrel group (hazard ratio, 1.31 [95% CI, 0.95–1.82]; P =0.10). One-year incidence of all-cause death (4.9% versus 4.7%; P =0.83), stroke (1.3% versus 1.0%; P =0.46), and definite stent thrombosis (1.8% versus 1.0%; P =0.15) did not differ significantly in patients assigned to ticagrelor or prasugrel. One-year incidence of myocardial infarction (5.3% versus 2.8%; hazard ratio, 1.95 [95% CI, 1.18–3.23]; P =0.010) was higher with ticagrelor than with prasugrel. BARC type 3 to 5 bleeding occurred in 46 patients (6.1%) in the ticagrelor group and in 39 patients (5.1%) in the prasugrel group (hazard ratio, 1.22 [95% CI, 0.80–1.87]; P =0.36). Conclusions: In patients with ST-segment–elevation myocardial infarction undergoing primary percutaneous coronary intervention, there was no significant difference in the primary end point between prasugrel and ticagrelor. Ticagrelor was associated with a significant increase in the risk for recurrent myocardial infarction. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01944800.

The authors discuss minimally invasive and noninvasive cardiac output monitoring technologies available in the clinical practice and how to evaluate these systems objectively.

BACKGROUND Invasive coronary angiography (ICA) still causes a significant amount of radiation exposure for patients and operators. In February 2017, the Azurion system was introduced, a new-generation fluoroscopy image acquisition and processing system. Radiation exposure in patients undergoing ICA was assessed comparing the novel Azurion 7 F12 angiography system to its predecessor Allura Xper in a randomized manner. METHODS Radiation exposure was prospectively analyzed in 238 patients undergoing diagnostic ICA. Patients were randomly assigned to the novel Azurion system (119 patients) or its predecessor Allura Xper system (119 patients). In each patient, 8 predefined standard projections (5 left coronary artery, 3 right coronary artery) were performed. Image quality was quantified by grading of the images on the basis of a 5-point grading system. RESULTS Radiation dose area product was significantly lower in the Azurion group 109 (interquartile range [IQR 75-176] cGy cm) compared with the Allura Xper group 208 [IQR 134-301] cGy cm (P

The life expectancy of HIV-infected patients has recently been increasing. Although the mortality and morbidity associated with AIDS is decreasing, those associated with cardiovascular diseases and percutaneous coronary intervention (PCI) are receiving greater attention. Only limited data regarding coronary restenosis are available in these patients.In this prospective, systematic angiographic follow-up study, we enrolled HIV patients who underwent PCI for de-novo lesions and subsequent routine angiographic follow-up for 6-8 months. Angiographic restenosis was defined as stenosis of at least 50% of the in-segment area.Univariate and multivariate analyses were performed to evaluate restenosis and its predictors.Between May 2002 and March 2014, 47 patients with HIV underwent PCI in two high-volume centers in Munich, Germany. Of these patients, 41 with 131 de-novo lesions underwent invasive surveillance. One-quarter of the lesions treated subsequently presented with restenosis. Univariate analysis indicated that CD8 T-cell levels (P = 0.006), serum cholesterol (P = 0.042) and low-density lipoprotein-cholesterol (P = 0.042) levels at baseline, total number of stents (P = 0.047), and C-reactive protein level (P = 0.001) at follow-up were associated with restenosis. Multivariate analysis indicated that CD8 T-cell levels (P = 0.006) and persistent C-reactive protein elevation at 6-month follow-up (P = 0.00013) were independent predictors of restenosis.Inflammation, represented by CD8 T-cell levels, and persistent C-reactive protein elevation are independent predictors of angiographic restenosis and should therefore be closely monitored in HIV patients undergoing PCI.

Restoration of biomechanics is a major goal in THA. Imageless navigation enables intraoperative control of leg length equalization and offset reconstruction. However, the effect of navigation compared with intraoperative fluoroscopy is unclear.We asked whether intraoperative use of imageless navigation (1) improves the relative accuracy of leg length and global and femoral offset restoration; (2) increases the absolute precision of leg length and global and femoral offset equalization; and (3) reduces outliers in a reconstruction zone of ± 5 mm for leg length and global and femoral offset restoration compared with intraoperative fluoroscopy during minimally invasive (MIS) THA with the patient in a lateral decubitus position.In this prospective study a consecutive series of 125 patients were randomized to either navigation-guided or fluoroscopy-controlled THA using sealed, opaque envelopes. All patients received the same cementless prosthetic components through an anterolateral MIS approach while they were in a lateral decubitus position. Leg length, global or total offset (representing the combination of femoral and acetabular offset), and femoral offset differences were restored using either navigation or fluoroscopy. Postoperatively, residual leg length and global and femoral offset discrepancies were analyzed on magnification-corrected radiographs of the pelvis by an independent and blinded examiner using digital planning software. Accuracy was defined as the relative postoperative difference between the surgically treated and the unaffected contralateral side for leg length and offset, respectively; precision was defined as the absolute postoperative deviation of leg length and global and femoral offset regardless of lengthening or shortening of leg length and offset throughout the THA. All analyses were performed per intention-to-treat.Analyzing the relative accuracy of leg length restoration we found a mean difference of 0.2 mm (95% CI, -1.0 to +1.4 mm; p = 0.729) between fluoroscopy and navigation, 0.2 mm (95 % CI, -0.9 to +1.3 mm; p = 0.740) for global offset and 1.7 mm (95 % CI, +0.4 to +2.9 mm; p = 0.008) for femoral offset. For the absolute precision of leg length and global and femoral offset equalization, there was a mean difference of 1.7 ± 0.3 mm (p0.001) between fluoroscopy and navigation. The biomechanical reconstruction with a residual leg length and global and femoral offset discrepancy less than 5 mm and less than 8 mm, respectively, succeeded in 93% and 98%, respectively, in the navigation group and in 54% and 95%, respectively, in the fluoroscopy group.Intraoperative fluoroscopy and imageless navigation seem equivalent in accuracy and precision to reconstruct leg length and global and femoral offset during MIS THA with the patient in the lateral decubitus position.

Background Postextrasystolic blood pressure potentiation (PESP), the pulse wave augmentation after an extrasystolic beat, is typically enhanced in heart failure (HF) patients. This study prospectively tested the association of PESP and mortality in cardiac patients. Methods and Results Consecutive patients (n=941; mean age, 61 years; 19% female) presenting with acute myocardial infarction were enrolled between May 2000 and March 2005 and followed up until August 2010. The main study outcome was 5‐year all‐cause mortality. Patients underwent noninvasive 30‐minute recordings of ECG and continuous blood pressure. PESP presence was based on the ratio between the first postectopic pulse wave amplitude and the mean of the subsequent 9 pulse wave amplitudes. A ratio above 1 was prospectively defined as PESP present. Ventricular premature complexes (VPCs) suitable for PESP quantification were present in recordings of 220 patients. PESP was present in 62 of these patients. Patients without suitable VPCs were classified as PESP absent. During the follow‐up, 72 patients died. Among the 220 patients in whom PESP was measurable, 27 died. Under univariable analysis, PESP was a significant predictor of death ( P P P P P P P =0.001) were independently associated with outcome. The combination of PESP presence and LVEF ≤35% identified a subgroup of patients with a particularly high mortality of 46.7%. Separate validation reproduced the finding in an unrelated population of 146 HF patients. Conclusions PESP, which likely reflects abnormalities of myocardial calcium cycling, predicts the mortality risk in postinfarction patients. Clinical Trial Registration URL: ClinicalTrials.gov . Unique identifier: NCT00196274.