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Aims To investigate the impact of statins on plaque progression according to high-risk coronary atherosclerotic plaque (HRP) features and to identify predictive factors for rapid plaque progression in mild coronary artery disease (CAD) using serial coronary computed tomography angiography (CCTA). Methods and results We analyzed mild stenosis (25–49%) CAD, totaling 1432 lesions from 613 patients (mean age, 62.2 years, 63.9% male) and who underwent serial CCTA at a ≥2 year inter-scan interval using the Progression of AtheRosclerotic PlAque DetermIned by Computed TomoGraphic Angiography Imaging (NCT02803411) registry. The median inter-scan period was 3.5 ± 1.4 years; plaques were quantitatively assessed for annualized percent atheroma volume (PAV) and compositional plaque volume changes according to HRP features, and the rapid plaque progression was defined by the ≥90th percentile annual PAV. In mild stenotic lesions with ≥2 HRPs, statin therapy showed a 37% reduction in annual PAV (0.97 ± 2.02 vs. 1.55 ± 2.22, P = 0.038) with decreased necrotic core volume and increased dense calcium volume compared to non-statin recipient mild lesions. The key factors for rapid plaque progression were ≥2 HRPs [hazard ratio (HR), 1.89; 95% confidence interval (CI), 1.02–3.49; P = 0.042], current smoking (HR, 1.69; 95% CI 1.09–2.57; P = 0.017), and diabetes (HR, 1.55; 95% CI, 1.07–2.22; P = 0.020). Conclusion In mild CAD, statin treatment reduced plaque progression, particularly in lesions with a higher number of HRP features, which was also a strong predictor of rapid plaque progression. Therefore, aggressive statin therapy might be needed even in mild CAD with higher HRPs. Clinical trial registration ClinicalTrials.gov NCT02803411

Aims The magnitude of alterations in which coronary arteries remodel and narrow over time is not well understood. We aimed to examine changes in coronary arterial remodelling and luminal narrowing by three-dimensional (3D) metrics from serial coronary computed tomography angiography (CCTA). Methods and results From a multicentre registry of patients with suspected coronary artery disease who underwent clinically indicated serial CCTA (median interscan interval = 3.3 years), we quantitatively measured coronary plaque, vessel, and lumen volumes on both scans. Primary outcome was the per-segment change in coronary vessel and lumen volume from a change in plaque volume, focusing on arterial remodelling. Multivariate generalized estimating equations including statins were calculated comparing associations between groups of baseline percent atheroma volume (PAV) and location within the coronary artery tree. From 1245 patients (mean age 61 ± 9 years, 39% women), a total of 5721 segments were analysed. For each 1.00 mm3 increase in plaque volume, the vessel volume increased by 0.71 mm3 [95% confidence interval (CI) 0.63 to 0.79 mm3, P < 0.001] with a corresponding reduction in lumen volume by 0.29 mm3 (95% CI −0.37 to −0.21 mm3, P < 0.001). Serial 3D arterial remodelling and luminal narrowing was similar in segments with low and high baseline PAV (P ≥ 0.496). No differences were observed between left main and non-left main segments, proximal and distal segments and side branch and non-side branch segments (P ≥ 0.281). Conclusions Over time, atherosclerotic coronary plaque reveals prominent outward arterial remodelling that co-occurs with modest luminal narrowing. These findings provide additional insight into the compensatory mechanisms involved in the progression of coronary atherosclerosis.

Background ESC guidelines for non-ST elevation acute coronary syndromes (NSTE-ACS) recommend against P2Y12 pre-treatment receptor inhibitors (P2Y12i) in patients undergoing early invasive management (< 24 h). The rationale is, in part, to prevent bleeding complications and the delay of coronary artery bypass graft surgery (CABG) in patients with suitable anatomy. This study aims to analyze the impact of P2Y12i pre-treatment on delay to CABG surgery in a real-world population with NSTE-ACS. Methods Single-centre retrospective cohort of consecutive patients with NSTE-ACS undergoing invasive evaluation in 2019. Those with previous CABG (n = 31) or non-obstructive coronary disease (n = 57) were excluded. Results Total cohort included 262 patients (mean age 68 ± 12 years, 69% male, 15% with unstable angina and mean GRACE score 134 ± 35). Median time from first medical contact to angiography was 2 (1–4) days. Overall, 168 (64%) patients underwent percutaneous coronary intervention, 47 (18%) were proposed for CABG and the remainder received conservative management. All patients considered for CABG received pre-treatment with P2Y12i, either clopidogrel or ticagrelor. Median time from angiography to CABG was 12 (7–15) days. Six patients experienced recurrent angina (13%) and 2 (4%) died before surgery due to refractory ventricular fibrillation. Those who underwent CABG under P2Y12i effect were more likely to receive blood and platelets transfusions (64.7% vs. 28.6%, P = 0.017 and 82.4% vs. 21.4%, P < 0.001, respectively), although there were no differences regarding major bleeding. Conclusion Pre-treatment with P2Y12i was a potential driver of CABG delay in our cohort. In the real-world, adopting the new recommendations of withholding pre-treatment might decrease this delay.

Background Minimally invasive alternatives to surgical closure of cardiac perforations are a recognized need, especially in critically ill patients in whom predicted surgical mortality is prohibitive. To the best of our knowledge, this is the first reported case of an iatrogenic left atrium (LA) puncture closed with a plug-based vascular closure device (VCD). Case summary During a palliative right-sided thoracentesis on a 73-year-old woman, with end-stage heart failure due to rheumatic valvular heart disease, an accidental puncture and insertion of a central venous catheter into an aneurysmatic LA occurred. This complication was successfully managed percutaneously, under transthoracic echocardiographic guidance, after cardiac computed tomography planning, using a plug-based VCD. Discussion This case demonstrates the possible utility of plug-based devices for iatrogenic LA perforation closure, when surgical risk is deemed prohibitive.

Funding Acknowledgements Type of funding sources: None. Background Randomized controlled trials comparing stress cardiac magnetic resonance (CMR) and single-photon emission computed tomography (SPECT) suggest similar diagnostic accuracy for detecting obstructive coronary artery disease (CAD). However, there are few data on whether or not this remains true in routine clinical practice. The aim of this study was to assess the clinical and angiographic characteristics of patients undergoing invasive coronary angiography (ICA) after a positive stress CMR or positive SPECT, and to compare their positive predictive value with published results from the CE-MARC trial. Methods In this retrospective tertiary-center analysis, we included 429 patients (mean age 67 ± 10 years, 28% women, 42% diabetic) undergoing ICA between January 2016 and December 2020, after a positive stress CMR or positive SPECT. Regarding stress test, an adenosine protocol was performed in all stress CMR and in 76.4% (n = 272) of stress SPECT. Stress test results, including ischemia location and severity, were classified as reported by their primary readers. Patients with missing data on key variables, and those in whom microvascular disease was considered likely in the original stress test report were excluded. Obstructive CAD was defined as any coronary artery stenosis ≥ 50% in a vessel compatible with the ischemic territory on stress testing. Results Out of the total 429 patients, 356 (83%) were referred after a positive SPECT, and 73 (17%) after a positive stress CMR. Patients did not differ regarding age, cardiovascular risk factors, previous revascularization or left ventricular dysfunction, but patients with SPECT were more frequently male (p = 0.046). Overall, 320 patients (75%) had obstructive CAD on ICA. The prevalence of obstructive CAD was similar in patients with positive SPECT vs. positive stress CMR (76.1% vs. 80.8%, respectively, p = 0.385). There were also no significant differences in the prevalence of left main or 3-vessel disease (9.0% vs. 9.6%, p = 0.871, and 19.7% vs. 23.3% p = 0.483, respectively). Revascularization was performed or planned in 59.3% of patients in the SPECT group, and 52.1% of those in the stress CMR group (p = 0.255). The positive predictive values of both techniques were similar to those reported in the CE-MARC trial (Figure), and would increase to 88.1% and 89.4% for SPECT and stress CMR, respectively, if patients reported as having only mild ischemia were excluded. Conclusion In this tertiary center analysis, stress CMR and SPECT showed similar positive predictive values, comparable to those reported in the CE-MARC trial.

Background and aim The need for permanent pacemaker implantation (PPMI) is a burdensome complication of transcatheter aortic valve replacement (TAVR). Calcium distribution in the aortic-valvular complex (AVC) and, more recently, membranous septum (MS) length seem to be surrogate markers for conduction abnormalities after specific last generation balloon and self-expandable expandable valves. We sough to evaluate whether such pre-procedural association remains across the entire device spectrum. Methods Single-centre prospective study of 239 consecutive patients (140 women, median age of 84) with severe symptomatic aortic stenosis patients who underwent ECG-gated contrast-enhanced multi-detector computed tomography (MSCT) before TAVR since Jun/2017. Exclusion criteria were those with previous PPMI, previous bioprothesis, congenital bicuspid valve, and poor imaging quality. The J-score with an 850-Hounsfield unit threshold was used to detect areas of calcium in the region of interest. AVC was characterized by leaflet sector and region, using 3mensio Valves software 7.0 TM. An independent team retrospectively measured MS length blindly by determining the thinnest part of the interventricular septum in the coronal view in the better-defined systolic phase (usually at 40% of the R-R interval, Figure). Device selection (75.8% self-expandable devices, 20.1% balloon expandable, 3.1% other) and positioning were performed according to the operator criteria. Final implant depth was assessed based on the pre-release angiogram or final aortography. Results Mortality at 30-days was 1.3% and PPMI occurred in 43 patients (18%). Median MS length was 9.59mm (IQR: 3.11mm). After multivariable logistic regression analysis, MS length emerged as the single significant protective predictor for PPMI (OR: 0.14; 95% 95% CI: 0.05–0.42; p Conclusion In our experience, a short membranous septum was strongly and independently associated with new permanent pacemaker implantation, regardless of the device type. Our findings suggest that this simple measure should be routinely made to help device selection and implantation technique. Funding Acknowledgement Type of funding source: None

Background Progressive myocardial fibrosis takes part in left ventricular (LV) remodeling in aortic stenosis (AS) and drives the transition from hypertrophy to heart failure. Replacement fibrosis may be characterized by late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR). Aim To assess the prevalence and association between LGE and indexes of LV function in patients with severe aortic stenosis. Methods We prospectively studied 53 consecutive patients (age: 71±8 years [min. 51–max. 84], 54.7% men) with severe symptomatic AS, referred for surgical aortic valve replacement with no previous history of ischemic cardiomyopathy. Aortic valve mean gradient was 54.6 mmHg [IQR 46.6–63.2] and aortic valve area 0.74cm2 [IQR 0.61–0.89]; all patients with high gradient, 4 with low-flow. CMR with tissue characterization (T1 mapping, LGE and extracellular volume by ECV quantification – using 5SD from remote myocardium as signal intensity cut-off), was performed before surgery. AS severity indexes, LV mass, systolic and diastolic LV function indexes including global longitudinal strain (GLS) and torsion were compared in both groups of patients, with and without LGE. Results Mid-wall LGE was present in 36 patients (67.9%) with a median fraction of 6.0% [IQR 4.9–12.7%] of LV mass. Native T1 value and ECV were within normal ranges (median values: 1047ms [IQR 1028–1084]; 22% [IQR 18–25], respectively). Median CMR LV ejection fraction and mass were 64.5% [IQR 51.3–70.8%] (11 patients with reduced EF) and 76.5g/m2 [IQR 57.4–94.8g/m2], respectively. Median GLS was −13.9% [IQR −11.4 to −17.0%] and torsion was 24.2° [IQR 19.8–32.5°]. Patients with LGE had significantly higher LV mass (87.1g/m2 vs 63.3 g/m2, p=0.001), worse GLS (−14.4% vs −16.9%, p=0.041) and higher NT-proBNP values (1333.7ng/mL vs 559.9ng/mL, p=0.004) (Figure). Conclusions Non-ischemic LGE is common in this group of patients with severe symptomatic high gradient aortic stenosis. As it is more prevalent in patients with more pronounced LVH, lower longitudinal deformation and higher NT-proBNP values, it probably represents a more advanced stage of the disease. Funding Acknowledgement Type of funding source: None

Introduction New evidence on the role of myocardial revascularization in stable ischemic heart disease (SIHD), recently presented, showed that revascularization guided by the presence of moderate-to severe ischemia relieves angina more effectively than optimal medical therapy (OMT), without a significant benefit in hard clinical endpoints. Aim To assess the representativeness of the ISCHEMIA trial in a real-world population and compare management strategies between patients who fulfill the eligibility criteria of the trial (Group 1, G1) and those who do not (Group 2, G2). Methods and population Single centre retrospective analysis including all consecutive patients referred to coronary angiography (CA) for SIHD from January 2018 to December 2019. Patients were stratified in two groups (G1 and G2) according to the ISCHEMIA trial inclusion and exclusion criteria. G1 was compared with G2 and with a subset of G2 with obstructive coronary artery disease (CAD), defined as ≥70% luminal stenosis in at least one coronary artery or >50% for the left main. Results A total of 1020 patients underwent CA, of whom only 124 (12.2%) would have been eligible for the ISCHEMIA trial (G1). Overall, there were no significant differences in baseline characteristics between the two groups. G1 patients had more extensive and severe disease, presenting more frequently with proximal left anterior descending (LAD) involvement (26.6% vs 10.4%; p Conclusions Patients included in the ISCHEMIA trial are underrepresented in a real-world population of SIHD patients referred to coronary angiography. PCI rates were similar among patients with at least one significant coronary artery stenosis, regardless of previous evidence or severity of ischemia. Our findings underline the need for further refinement in criteria for revascularization in SIHD. Funding Acknowledgement Type of funding source: None

Introduction and aims The 12-lead ECG is highly inaccurate for localization of the site of origin of supraventricular and ventricular arrhythmias. Non-invasive mapping systems (ECGI) based on a high number of electrodes recording the electrical activity on the surface of the torso have already proven good accuracy for mapping different arrhythmic substrates. The aim of this study was to assess what is the minimal number of leads needed to obtain a precise mapping with the ECGI. Methods This study enrolled 14 patients (9 male, median age 50 (44-58) years) referred to our center for catheter ablation of premature ventricular contractions (PVC). Patients underwent pre-procedural ECGI using the epicardial and endocardial mapping system . This system uses the DICOM images from contrast computed tomography of the heart and up to 28 adhesive electrodes with 8 leads each, adding up to 224 body-surface leads. All patients underwent invasive electroanatomical mapping and ablation with the magnetic navigation system. We analysed the number of recording leads used to construct the non-invasive activation map of the PVCs and the accuracy and the spatial resolution of the map when comparing to the invasive map. We then reprocessed the exam, using progressively less leads until we only left the leads placed in the standard 12 lead ECG positions and evaluated the concordance with the invasive map as well as the spatial resolution. We considered an earliest activation site (EAS) area of 1 cm2 a good spatial resolution and using a ROC curve we calculated the minimal number of leads necessary to obtain a good spatial resolution. Results The median number of electrodes used for the initial map was 170 (138-177). Concordance between non-invasive and invasive site of origin occurred in 11 out of 14 patients. The results are presented in the Table. The minimal number of electrodes to have a good spatial resolution was 100. The area of EAS was significantly lower when using more than 100 leads, respectively 0.65 (0.5-1) cm2 versus 3 (1.6-5) cm2, p Conclusions The minimal number of leads to achieve a good spatial resolution was high. Reducing the number of leads resulted in a significant decrease in spatial resolution and a lower concordance rate. ECGI data Number of adhesive electrodes Median number of leads Amycard/Carto concordance Median area of EAS in the ECGI (cm2) Maximal nº electrodes 170 (138-177) 11/14 0.64 (0.5-0.9) 12 electrodes 76 (61-80) 11/14 1.6 (1.4-2.6) 6 electrodes (2 Ant, 2 Lat ,2 Post) 38 (32-44) 9/14 4.3 (3.2-5.4) 12 leads 12 0/14 - Ant anterior; Lat: lateral; Post: posterior; EAS: early activation site. Abstract Figure. Area of EAS according to the N of leads

Introduction Vascular calcification has been associated with worse outcomes in transfemoral TAVI (TF-TAVI). However, there is currently no simple method to assess it and identify different patterns of calcification in an objective and quantitative manner. The purpose of this study was to develop a quantitative score of aortic (Ao) and ileofemural (IF) calcification and to assess its ability to predict life-threatening bleeding (LTB) and major vascular complications during TF-TAVI. Methods Case-control single center retrospective study of patients undergoing TF-TAVI between Nov2015 and Aug2018 including 183 consecutive patients (99 women, mean age 83±3 years, mean Euroscore II - ESII - 6.0±4.1). The Vascular Calcium Score was calculated for the entire Ao and IF vessels using a modified Agatston score derived from contrast-enhanced CT images, with calcium threshold locally adjusted for luminal attenuation (mean attenuation + 5x SD). A luminal attenuation threshold >600UH impaired vascular calcium evaluation and patients were excluded. LTB and major vascular complications were adjudicated according to the VARC-2 classification and identified by chart review by and independent team. Results Thirty patients (16%) suffered major bleeding and 13 (7%) experienced LTB. Major vascular injury occurred in 11 patients (6%). The median total vascular calcium score (TCS) was 11752 AU (IQR: 6388–19844) and median IF score (IFS) was 2210AU (IQR: 865–4170). TCS indexed for body surface area (TCSi) was predictor of LTB (AUC: 0.78±0.07, p Conclusions A quantitative score for vascular calcification in contrast-enhanced CT images was developed. iTCS was independently associated with life-threatening bleeding and major vascular complications.

Background It has been accepted for years that idiopathic premature ventricular contractions (PVCs) with origin in the right ventricular outflow tract (RVOT) are benign. They are thought to result from triggered activity and most studies do not describe abnormal findings during electroanatomical mapping Dispersion of ventricular repolarization is associated with the susceptibility to ventricular arrhythmias and may indicate the presence of diseased myocardium. The activation recovery interval (ARI) has been used as a surrogate measure of ventricular action potential duration and refractory period. Purpose The aim of this study was to use the new non-invasive epicardial and endocardial mapping system (NEES) to study patients with RVOT PVCs in order to evaluate the ARI in the epicardium of RVOT during sinus rhythm (SR). Methods Non-invasive mapping was performed with the NEES, based on body surface electrocardiograms of a maximum of 224 electrodes and computed tomography imaging data. Unipolar electrograms were reconstructed on the epicardial and endocardial surfaces. Patients were excluded if they had structural heart disease, previous ablation or conduction abnormalities. ARI was defined as the interval between times of minimum derivative of the QRS and the maximum derivative of the T wave in the unipolar electrograms. We evaluated the ARI map in patients with RVOT PVCs and in a control group of patients without PVCs (Figure). We assessed the maximum value of ARI (Max ARI), the minimum value of ARI (Min ARI) and the difference between the Max ARI and the Min ARI (Diff ARI). Results We studied 8 patients with RVOT PVCs and 8 patients without PVCs. The results are presented in the table. Demographic and NEES data RVOT PVCs (n=8) Control (n=8) P value* Demographic data Age in years, median (IQR) 53 (48–65) 59 (52–67) 0.536 Male gender, n (%) 4 (50) 6 (75) 0.608 NEES data Max ARI in msec, median (IQR) 285 (236–331) 228 (197–298) 0.195 Min ARI in msec, median (IQR) 176 (138–192) 216 (185–255) 0.161 ARI diff in msec, median (IQR) 111 (83–147) 15 (4–34) NEES map Conclusion In this group of patients we found a significantly higher dispersion of the ARI measurements through the epicardium of the RVOT in patients with PVCs in comparison with patients without PVCs.

The relation between body mass index (BMI) and coronary artery disease (CAD) extension remains controversial. The aim of this study was to evaluate the correlation between BMI and CAD extension documented by coronary computed tomography angiography (CCTA).Prospective registry including 1706 consecutive stable patients that performed CCTA (dual source scanner) for the evaluation of CAD. The population was stratified by BMI: normal 530 (31.1%), overweight 802 (47.0%) and obesity 374 (21.9%). BMI was significantly higher in patients with CAD (27.7 ± 4.3 vs 26.8 ± 4.3 kg/m(2), p 0.001); these patients were also older, more often male and had higher prevalence of diabetes, hypertension and dyslipidemia. By multivariate analysis (logistic regression) BMI remains an independent predictor of CAD (odds ratio (OR) 1.03, 95% confidence interval (CI) 1.01-1.06; p = 0.012). Regarding the severity of CAD, BMI was not significantly different among patients with and without obstructive CAD (27.7 ± 4.3 vs 27.2 ± 4.3 kg/m(2), p = 0.120). In 319 patients (4516 segments; 4077 evaluable), a detailed atherosclerotic burden was evaluated and compared among BMI classes, defined according to the presence of plaque and the degree of stenosis. Obstructive CAD was identified in 16.9% of the patients and 45.1% had non-obstructive CAD. The discriminative threshold for high burden, established by the segment involvement score (SIS), was5 segments with plaque (15.4% patients). The prevalence of SIS5 among the BMI classes was: 18.7%, 13.7% and 13.6% for normal, overweight and obesity respectively (p values for the specific classes versus all other patients: 0.241, 0.450 and 0.663).In this population of stable patients undergoing CCTA for suspected CAD, BMI was an independent predictor of its presence, but was not correlated with the coronary disease severity.

Aims Regarding prognosis, patients with a non-ST elevation acute coronary syndrome (ACS) are a very heterogeneous population, with varying risks of early and long-term adverse events. Early risk stratification at admission seems to be essential for a tailored therapeutic strategy. We sought to compare the prognostic value of three ACS risk scores (RSs) and their ability to predict benefit from myocardial revascularization performed during initial hospitalization. Methods and results We studied 460 consecutive patients admitted to our coronary care unit with an ACS [age: 63±11 years, 21.5% female, 55% with myocardial infarction (MI)]. For each patient, the Thrombolysis In Myocardial Infarction (TIMI), Platelet glycoprotein IIb/IIIa in Unstable agina: Receptor Suppression Using Integrilin (PURSUIT), and Global Registry of Acute Coronary Events (GRACE) RSs were calculated using specific variables collected at admission. Their prognostic value was evaluated by the combined endpoint of death or MI at 1 year. The best cut-off value for each RS, calculated with receiver operating characteristic curves, was used to assess the impact of myocardial revascularization on the combined incidence of death or MI. Death or MI at 1 year was 15.4% (32 deaths/49 MIs). The best predictive accuracy for death or MI at 1 year was obtained by the GRACE RS (AUC) [area under the curve: 0.715; confidence interval (CI: 0.672–0.756)] but the performance of the PURSUIT RS (AUC: 0.630; CI: 0.584–0.674), and TIMI RS (AUC: 0.585; CI: 0.539–0.631) was also good. We found a statistically significant interaction between the risk stratified by the best cut-off value for the GRACE and PURSUIT RSs and myocardial revascularization, with a better prognosis for the high-risk patients. The high-risk patients represented 36.7, 28.7, and 57.8% of the population, for the GRACE, PURSUIT, and TIMI RSs, respectively. Conclusion The RSs studied demonstrated a good predictive accuracy for death or MI at 1 year and enabled the identification of high-risk subsets of patients who will benefit most from myocardial revascularization performed during initial hospital stay.

Aims: Radial access was associated with a significant reduction in major bleeding, compared to femoral access, in the treatment of ST segment Elevation Myocardial Infarction (STEMI). It is not yet clear its impact on in-hospital mortality. The aims of this study are to compare in-hospital mortality in patients undergoing primary PCI via radial access or femoral access, based on the Portuguese Interventional Cardiology Registry (PICR), and evaluate the interaction with the use of glycoprotein IIbIIIa (GP IIbIIIa) inhibitors. Methods and results: 6559 consecutive pts with STEMI undergoing primary PCI prospectively included in the PICR from Jan/2007 to Dec/2012. Radial access was used in 1384 pts (21%) and femoral access in 5175 (81.9%). We compared demographic and clinical variables between the 2 groups. Independent predictors of in-hospital mortality were identified by multivariate analysis. The interaction with the use of GP IIbIIIa inhibitors was also evaluated. In-hospital mortality occurred in 3.3% of pts undergoing primary PCI via femoral access and in 0.8% of pts undergoing primary PCI via radial access (p

Introduction: Radial access has gained attention in cardiac catheterization laboratories in the last few years, due to both logistic and clinical reasons, and is being used with increasing frequency worldwide. However, concerns have been raised about the potential increase in the risks of Stroke/Transient Ischemic Attack rates [stroke/TIA]. Aim: To assess the association between the risk of stroke and radial artery vascular access site in current practice of both diagnostic and interventional cardiac procedures. Methods: We retrospectively analyzed the data from of 16.710 diagnostic and interventional procedures, in which there was manipulation of the aortic arch, included in a large volume single-center prospective registry between Jan'2006 and Nov'2012. Radial artery was used as the primary vascular access site in 4.195 cases and 36 patients converted from femoral to radial: the radial-to-femoral conversion rate was 7%. Target cases were identified by cross-matching patients who underwent both cardiac catheterization and cranial-CT during the same admission episode (n=67). Procedure-related events were adjudicated according to a definite diagnosis established by a neurologist, as those occurring within 48 hours after the procedure. For patients discharged before that, subsequent reporting was used. In order to reduce bias, radial procedures were considered as those in which transradial assess was used either primarily of after conversion. Results: Transradial approach increased from 0.7% in 2006 to 75% in 2012, with a sharp change between 2009 and 2010 (5.5% to 36%). Total incidence of stroke/TIA was 0.16% (n=27) and did not change significantly over the study period, despite the increase in radial procedures (p=0.26 for the comparison between years). Overall, we could not demonstrate a significant difference in stroke/TIA rates between patients undergoing cardiac catheterization via radial vs. femoral artery (0.14% vs. 0.16%; p=0.81). Results were consistent in 4 pre-specified sub-groups according to sex, age (≥65 y.o. vs. younger), interventional vs. diagnostic and ACS vs. stable. After correction for important differences in baseline characteristics (using a logistic regression model) radial assess site was not a predictor of stroke/TIA (OR 0.86; 95% CI 0.27-2.7; p=0.80). Conclusion: Stroke/TIA rates were within range of international reports. Our observational study suggests that widening the use of the transradial approach for cardiac catheterization is not associated with an increased risk of clinically relevant procedure-related neurologic complications.

Purpose: Transradial approach (TRA) has become increasingly common for coronary angiography and intervention (CA/PCI) and a wealth of knowledge exists about its feasibility. Nevertheless radial injury and occlusion do occur and little is known about the success rate with its repeated use. Evidence of a long lasting use of the TRA might encourage a shift toward this access route. We aimed to evaluate the feasibility of a second TRA its predictors of failure. Methods: In a dual centre prospective registry, patients who underwent a first procedure by right TRA were identified. Whenever a second coronary angiography was necessary during follow-up, and the interventionalist's clinical assessment was favourable, the right TRA was again used. We compared the rates of crossover to another access and sought predictors of crossover. Results: From January 2009 to October 2012, 6392 patients (median age 66, interquartile range 16; 67% male; 37% due to ACS) who underwent a first procedure (36% PCI) by right TRA were identified; the crossover rate to another access was 5.8%. During the study period, a second TRA was performed in 686 of these patients in whom the interventionalist's clinical assessment was favourable; the crossover rate to another access was 6.9% and similar to the first TRA (Chi-square p=0.267). Three independent predictors of failure in the latter group were identified by binary logistic regression, with the following adjusted odds-ratio (95% confidence interval): female sex 3.67 (1.98-6.8), use of 10 cm (vs. 25 cm) introducer sheath 3.52 (1.73-7.16) and previous valvular surgery 3.02 (1.06-8.61). No differences with statistical significance were observed regarding advanced age, low body surface area, need for intervention or smaller sheath diameter. Conclusions: A second transradial approach is as feasible as the first. The use of shorter sheaths, female sex and previous valvular surgery patients reduce success in subsequent radial access.

Purpose: To evaluate the performance of classic risk factors, alone or associated in scores, in identifying a higher than expected coronary atherosclerotic burden. Methods: We assessed 2069 consecutive patients (56% men, mean age 58±11 years) undergoing coronary CT angiography (CCTA) with Calcium Score (CaSc) for suspected coronary artery disease. A higher than expected atherosclerotic burden was defined as a CaSc >75th percentile (CaSc>p75) according to age and sex-adjusted nomograms. The ability of traditional risk factors to predict a CaSc>p75 was assessed in a customized logistic regression model (clinical score) and by the calculation of the HeartScore. The Population Attributable Risk (PAR) of the various risk factors for CaSc>p75 was also calculated. Results: The median CaSc was 3.0 [IQR 0.0-98.0], with 362 patients (17.5%) having CaSc>p75. The median HeartScore was 3.0 [IQR 1.0-4.0]. With the exception of hypertension, all classic risk factors were independent predictors of CaSc>p75: diabetes mellitus, dyslipidemia, smoking and family history (all OR 1.3-2.2, p≤ 0.026). The areas under the ROC curves to predict CaSc>p75 were 0.64 for the clinical score (95% CI 0.61-0.67, p p75 were in the two lower quartiles of the clinical score (Figure). Altogether, the various classical risk factors seem to explain only 56% of the prevalence of CaSc>p75 (adjusted PAR 0.56). Conclusion: Despite the statistical association of CV risk factors with a higher than expected atherosclerotic burden, they seem to justify only half of its prevalence. Even when integrated in scores, the predictive power of these risk factors is relatively modest, exposing the limitations of a risk stratification based solely on demographic and clinical risk factors.