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BACKGROUND: Drug-coated balloons (DCB) and drug-eluting stents (DES) represent the currently recommended treatments for in-stent restenosis (ISR). Optical coherence tomography (OCT) allows detailed neointimal characterisation which can guide treatment strategies. AIMS: The aims of this study were first, to assess the relation between neointimal pattern and clinical outcomes following in-stent restenosis (ISR) treatment, and second, to explore a potential interaction between neointimal pattern and treatment modality relative to clinical outcomes. METHODS: Patients undergoing OCT-guided treatment (DCB or DES) of ISR in three European centres were included. Based on the median of distribution of non-homogeneous neointima quadrants, patients were categorised into low and high inhomogeneity groups. RESULTS: A total of 197 patients (low inhomogeneity=100 and high inhomogeneity=97) were included. There were no significant differences in terms of major adverse cardiac events (MACE) (p=0.939) or target lesion revascularisation (TLR) (p=0.732) between the two groups. The exploratory analysis showed a significant interaction between neointimal pattern and treatment modality regarding MACE (pint=0.006) and TLR (pint=0.022). DES showed a significant advantage over DCB in the high (MACE: HR 0.26 [0.10-0.65], p=0.004; TLR: HR 0.28 [0.11-0.69], p=0.006), but not in the low inhomogeneity group (MACE: p=0.917; TLR: p=0.797). CONCLUSIONS: In patients with ISR treated with DCB or DES, there were no significant differences in terms of MACE or TLR between the low and high inhomogeneity groups. A significant interaction was observed between treatment modality and neointimal pattern with an advantage of DES over DCB in the high and no difference in the low inhomogeneity group. This warrants confirmation from prospective dedicated studies.

Background Evolut Pro (EVP) is a novel self-expandable aortic valve. This prosthesis consists of an external porcine pericardial wrap designed to reduce paravalvular leak (PVL), maintaining the benefits of its predecessor, the Evolut R (EVR). The aim was to compare the functional and clinical results in the short and medium term of the new EVP with the EVR system. Methods Consecutive patients receiving either the EVR (n=50) or the EVP (n=33) from June 2015 to October 2018 were compared. Baseline characteristics, cardiovascular imaging, procedural outcomes, short and mid-term follow-up outcomes were prospectively collected and assessed. Results Residual mild PVL was common and comparable in the two groups (EVR 79% vs. EVP 70%; P=0.4). In the EVR group, the presence of PVL was directly related to prosthesis size, but this correlation was not observed in the EVP group. Conduction abnormalities were more prevalent with the EVP, but these did not translate into a higher need of permanent pacemaker implantation. Vascular and bleeding complications were infrequent in both groups. At mid-term clinical follow-up (median survival time: EVR 11±0.3 months, EVP 12±0.2 months), the 1-year rate of adverse events was similar (EVR: 24%, EVP: 33%; P=0.3). Conclusions Both protheses are effective for the treatment of severe aortic stenosis with excellent results at mid-term clinical follow up. The EVP remains associated with a significant rate of residual mild PVL that appears to be similar to that observed with EVR.

Introduction and objectives COVID-19 is currently causing high mortality and morbidity worldwide. Information on cardiac injury is scarce. We aimed to evaluate cardiovascular damage in patients with COVID-19 and determine the correlation of high-sensitivity cardiac-specific troponin T (hs-cTnT) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) with the severity of COVID-19. Methods We included 872 consecutive patients with confirmed COVID-19 from February to April 2020. We tested 651 patients for high-sensitivity troponin T (hs-TnT) and 506 for NT-proBNP on admission. Cardiac injury was defined as hs-TnT > 14ng/L, the upper 99th percentile. Levels of NT-proBNP > 300 pg/mL were considered related to some extent of cardiac injury. The primary composite endpoint was 30-day mortality or mechanical ventilation (MV). Results Cardiac injury by hs-TnT was observed in 34.6% of our COVID-19 patients. Mortality or MV were higher in cardiac injury than noncardiac injury patients (39.1% vs 9.1%). Hs-TnT and NT-proBNP levels were independent predictors of death or MV (HR, 2.18; 95%CI, 1.23-3.83 and 1.87 (95%CI, 1.05-3.36), respectively) and of mortality alone (HR, 2.91; 95%CI, 1.211-7.04 and 5.47; 95%CI, 2.10-14.26, respectively). NT-ProBNP significantly improved the troponin model discrimination of mortality or MV (C-index 0.83 to 0.84), and of mortality alone (C-index 0.85 to 0.87). Conclusions Myocardial injury measured at admission was a common finding in patients with COVID-19. It reliably predicted the occurrence of mortality and need of MV, the most severe complications of the disease. NT-proBNP improved the prognostic accuracy of hs-TnT.

ObjectiveTo investigate percutaneous coronary intervention (PCI) practice in an international cohort of patients with spontaneous coronary artery dissection (SCAD). To explore factors associated with complications and study angiographic and longer term outcomes.MethodsSCAD patients (n=215, 94% female) who underwent PCI from three national cohort studies were investigated and compared with a matched cohort of conservatively managed SCAD patients (n=221).ResultsSCAD-PCI patients were high risk at presentation with only 8.8% undergoing PCI outside the context of ST-elevation myocardial infarction/cardiac arrest, thrombolysis in myocardial infarction (TIMI) 0/1 flow or proximal dissections. PCI complications occurred in 38.6% (83/215), with 13.0% (28/215) serious complications. PCI-related complications were associated with more extensive dissections (multiple vs single American Heart Association coronary segments, OR 1.9 (95% CI: 1.06–3.39),p=0.030), more proximal dissections (proximal diameter per mm, OR 2.25 (1.38–3.67), p=0.001) and dissections with no contrast penetration of the false lumen (Yip-Saw 2 versus 1, OR 2.89 (1.12–7.43), p=0.028). SCAD-PCI involved long lengths of stent (median 46mm, IQR: 29–61mm). Despite these risks, SCAD-PCI led to angiographic improvements in those with reduced TIMI flow in 84.3% (118/140). Worsening TIMI flow was only seen in 7.0% (15/215) of SCAD-PCI patients. Post-PCI major adverse cardiovascular and cerebrovascular events (MACCE) and left ventricular function outcomes were favourable.ConclusionWhile a conservative approach to revascularisation is favoured, SCAD cases with higher risk presentations may require PCI. SCAD-PCI is associated with longer stent lengths and a higher risk of complications but leads to overall improvements in coronary flow and good medium-term outcomes in patients.

Introducción y objetivos: La enfermedad por coronavirus 2019 (COVID-19) se ha convertido en una enfermedad pandémica. Datos de estudios retrospectivos han mostrado una peor evolución en pacientes con enfermedad cardiovascular (ECV) y factores de riesgo cardiovascular (FRCV). Nuestro objetivo fue evaluar la relación entre la ECV y los FRCV con la evolución hospitalaria de pacientes con COVID-19. Métodos: Se diseñó un registro prospectivo que incluyó a pacientes consecutivos con COVID-19 ingresados en nuestro centro hospitalario. El periodo de inclusión abarcó desde el 27 de febrero al 7 de abril de 2020. Se monitorizaron los eventos clínicos hasta el 2 de mayo de 2020. Resultados: Se incluyó un total de 876 pacientes. La edad media fue de 62 ± 18 años; un 47% fueron > 65 años. Un 69% de los pacientes tenían al menos un FRCV; un 15% tenían ECV previa. Aquellos pacientes con ECV fueron significativamente más mayores (77 ± 11 frente a 60 ± 18 años; p 65 años (OR = 15; IC95% 5-43), la insuficiencia cardiaca (OR = 3.27; IC95%, 1.38-7.72) y la insuficiencia renal crónica (OR = 8.55; IC95%, 1.47-5.46) fueron predictores independientes de mortalidad hospitalaria por COVID-19. Conclusiones: En pacientes ingresados por COVID-19, la presencia de ECV o FRCV se asocia con un mayor riesgo de muerte durante la hospitalización. Una mayor edad, la historia de insuficiencia cardiaca y la insuficiencia renal crónica fueron predictores independientes de muerte por COVID-19.

Objectives This study sought to compare the performance of a novel drug-coated balloon (DCB) (Elutax SV, Aachen Resonance, Germany), with an everolimus-eluting stent (EES) (Abbott Vascular...

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

Aims To report the extent and distribution of myocardial injury and its impact on left ventricular systolic function with cardiac magnetic resonance imaging (CMR) following spontaneous coronary artery dissection (SCAD) and to investigate predictors of myocardial injury. Methods and results One hundred and fifty-eight angiographically confirmed SCAD-survivors (98% female) were phenotyped by CMR and compared in a case–control study with 59 (97% female) healthy controls (44.5 ± 8.4 vs. 45.0 ± 9.1 years). Spontaneous coronary artery dissection presentation was with non-ST-elevation myocardial infarction in 95 (60.3%), ST-elevation myocardial infarction (STEMI) in 52 (32.7%), and cardiac arrest in 11 (6.9%). Left ventricular function in SCAD-survivors was generally well preserved with small reductions in ejection fraction (57 ± 7.2% vs. 60 ± 4.9%, P < 0.01) and increases in left ventricular dimensions (end-diastolic volume: 85 ± 14 mL/m2 vs. 80 ± 11 mL/m2, P < 0.05; end-systolic volume: 37 ± 11 mL/m2 vs. 32 ± 7 mL/m2, P 4 were associated with larger infarcts [>10% left ventricular (LV) mass]. Conclusion The majority of patients presenting with SCAD have no or small infarctions and preserved ejection fraction. Patients presenting with STEMI, TIMI 0/1 flow, multivessel SCAD and those with features of connective tissue disorders are more likely to have larger infarcts.

We present the case of a 42-year-old woman admitted due to ST-segment elevation acute coronary syndrome. The coronary angiography revealed the presence of an occluded mid-distal left anterior descending coronary artery (LAD) (figure 1A, asterisk) with an image suggestive of intramural hematoma (IMH) consistent with spontaneous coronary artery dissection (figure 1A, arrow). Guidewires were passed through the distal and diagonal LAD that resulted in flow recovery (figure 1B, line and arrowheads outlining the IMH). The intravascular ultrasound (IVUS) confirmed the presence of a large 25 cm long IMH (figure 2A,D). After dilatation with a 2.0 mm/6 mm cutting balloon (Wolverine, Boston Scientific, United States) (figure 1C, asterisks) flow improved leaving a mild residual stenosis (figure 1D). After a few minutes the retention of contrast in the LAD was confirmed (figure 3A, ellipse) followed by ischemic changes on the electrocardiogram. The angiography revealed the presence of 2 regions of critical stenosis with aggravated distal flow abnormalities (figure 3B, lines outlining the IMH, arrowheads showing the stenotic regions). A 2.25 mm/33 mm drug-eluting stent was implanted (Ultimaster Tansei, Terumo, Japan) (figure 3C, asterisks) and later dilated up to 2.75 mm with excellent angiographic (figure 3D) and IVUS results (figure 2E,F). The entire...

Mujer de 42 años que ingresa por un síndrome coronario agudo con elevación del segmento ST. La coronariografía mostró oclusión de la descendente anterior (DA) medio-distal (figura 1A, asterisco), con una imagen sugestiva de hematoma intramural (HIM), compatible con disección coronaria espontánea (figura 1A, flecha). Se pasaron guías a la DA distal y diagonal, con recuperación de flujo (figura 1B, línea y puntas de flecha delimitan el HIM). La ecografía intravascular (IVUS) confirmó la presencia de un amplio HIM de 25 mm de longitud (figura 2A-D). Tras dilatar con balón de corte 2,0/6 mm (Wolverine, Boston Scientific, Estados Unidos) (figura 1C, asteriscos) se obtuvo mejoría del flujo y una estenosis residual leve (figura 1D). Pasados escasos minutos se evidenció retención de contraste en la DA (figura 3A, elipse) y aparecieron cambios isquémicos en el electrocardiograma. La angiografía mostró 2 zonas de estenosis crítica con empeoramiento del flujo distal (figura 3B, líneas delimitan el HIM, puntas de flecha muestran las zonas de estenosis). Se implantó un stent farmacoactivo de 2,25/33 mm (Ultimaster Tansei, Terumo, Japón) (figura 3C, asteriscos), que se dilató hasta 2,75 mm con excelente resultado por angiografía (figura 3D) e IVUS (figura 2E,F). El resumen del procedimiento se muestra...

Key Points Question What is the prevalence of fibromuscular dysplasia, aneurysms, dissection, and tortuosity in extracoronary arteries of patients who developed a spontaneous coronary artery dissection (SCAD)? Findings In this case series including 173 patients with SCAD, using magnetic resonance angiography with blinded interpretation of the findings, 32% of the patients had fibromuscular dysplasia, 8% had aneurysms, and 2% had dissections; the prevalence of arterial tortuosity was similar in cases and controls. Extracoronary vascular events over a median 5-year follow-up were rare. Meaning The findings of this blinded analysis suggest that, in patients with SCAD, severe multivessel fibromuscular dysplasia, aneurysms, and dissections are infrequent and seldom associated with clinically evident vascular events., Importance Spontaneous coronary artery dissection (SCAD) has been associated with fibromuscular dysplasia (FMD) and other extracoronary arterial abnormalities. However, the prevalence, severity, and clinical relevance of these abnormalities remain unclear. Objective To assess the prevalence and spectrum of FMD and other extracoronary arterial abnormalities in patients with SCAD vs controls. Design, Setting, and Participants This case series included 173 patients with angiographically confirmed SCAD enrolled between January 1, 2015, and December 31, 2019. Imaging of extracoronary arterial beds was performed by magnetic resonance angiography (MRA). Forty-one healthy individuals were recruited to serve as controls for blinded interpretation of MRA findings. Patients were recruited from the UK national SCAD registry, which enrolls throughout the UK by referral from the primary care physician or patient self-referral through an online portal. Participants attended the national SCAD referral center for assessment and MRA. Exposures Both patients with SCAD and healthy controls underwent head-to-pelvis MRA (median time between SCAD event and MRA, 1 [IQR, 1-3] year). Main Outcome and Measures The diagnosis of FMD, arterial dissections, and aneurysms was established according to the International FMD Consensus. Arterial tortuosity was assessed both qualitatively (presence or absence of an S curve) and quantitatively (number of curves ≥45%; tortuosity index). Results Of the 173 patients with SCAD, 167 were women (96.5%); mean (SD) age at diagnosis was 44.5 (7.9) years. The prevalence of FMD was 31.8% (55 patients); 16 patients (29.1% of patients with FMD) had involvement of multiple vascular beds. Thirteen patients (7.5%) had extracoronary aneurysms and 3 patients (1.7%) had dissections. The prevalence and degree of arterial tortuosity were similar in patients and controls. In 43 patients imaged with both computed tomographic angiography and MRA, the identification of clinically significant remote arteriopathies was similar. Over a median 5-year follow-up, there were 2 noncardiovascular-associated deaths and 35 recurrent myocardial infarctions, but there were no primary extracoronary vascular events. Conclusions and Relevance In this case series with blinded analysis of patients with SCAD, severe multivessel FMD, aneurysms, and dissections were infrequent. The findings of this study suggest that, although brain-to-pelvis imaging allows detection of remote arteriopathies that may require follow-up, extracoronary vascular events appear to be rare., This case series examines the prevalence of fibromuscular dysplasia and other extracoronary events in patients who develop spontaneous coronary artery dissection.

Objectives This study used optical coherence tomography to investigate the mechanism of false lumen (FL) formation in spontaneous coronary artery dissection (SCAD) by studying: 1) differences between fenestrated and nonfenestrated SCAD; 2) vasa vasorum density; and 3) light attenuation characteristics of the FL. Background SCAD is an increasingly recognized cause of acute coronary syndromes, characterized by FL formation and compression of the true lumen (TL). The mechanisms underlying FL formation remain poorly understood. Methods A total of 65 SCAD patients (68 vessels) who underwent acute OCT imaging as part of routine clinical care were included. Images were classified by the absence or presence of a connection (fenestration) between the TL and FL. Indexed measurements of TL stenosis, external elastic lamina (EEL) area, FL area, and light attenuation of the FL were assessed. Vasa vasorum densities of SCAD cases were compared with those in control non-SCAD myocardial infarction cases. Results In nonfenestrated cases, there was significantly larger expansion of the EEL area (9.1% vs. −1.9%; p Conclusions These observational data suggest that the absence of a fenestration leads to increased FL pressure and compression of the TL. Although vasa vasorum may still be implicated in pathogenesis, increased vasa vasorum density could be an epiphenomenon of vascular healing.

Background Air pollutants increase the risk of myocardial infarction. Air pollution-induced atherosclerotic plaque destabilization may be related to inflammation, but the specific inflammatory alterations remain unclear. Purpose The aim of this prospective study was to assess the inflammatory changes in circulating immune cells and microRNAs in patients with acute coronary syndrome related to short-term exposure to PM2.5. Methods We prospectively included all consecutive patients admitted between March 2017 and July 2018 with the diagnosis of acute coronary syndrome (STEMI, NSTEMI, unstable angina) and coronary angiography in the acute phase of the disease. We also included a control group of patients with stable angina. For each patient we collected air concentrations of PM2.5 from the closest meteorological station to the patient residence obtaining the previous 24-hour average before hospital admission. All patients underwent systematic circulating inflammatory cell analysis. A selection of patients underwent miRNAs analysis. Results A total of 261 patients were included. According to PM2.5 exposure, 31 patients were selected for miRNA analyses. STEMI patients exposed to PM2.5 showed a reduction of CD4+ regulatory T (Treg) cells (Figure 1A). In the microRNA assessment, PM2.5 exposure was associated with higher circulating levels of let-7f-5p, miR-223-3p, miR-423-3p, miR-197-3p, miR-335–5, miR-376c-3p and miR-501-3p. Regarding clinical presentation, PM2.5 exposure in STEMI and NSTEMI patients was associated with an increase of miR-let-7f-5p, whereas miR-423-3p and miR-146a-5p were increased only in STEMI patients (Figure 1B). Conclusions STEMI related to PM2.5 short-term exposure is associated to specific changes involving CD4+CD25+Foxp3+ Treg cells and miR-146a-5p. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Ministerio de Ciencia e Innovaciόn; Fundaciόn BBVA Equipos de Investigaciόn Científica 2018 and from Caixa Banking Foundation; Sociedad Espanola de Cardiologia; Ministerio de Ciencia, Innovaciόn y Universidades, Carlos III Institute of Health-Fondo de Investigaciόn Sanitaria; Comunidad de Madrid; Fondo Europeo de Desarrollo Regional

Introduction and objectives: Spontaneous coronary artery dissection (SCAD) is a rare but increasingly recognized cause for acute coronary syndrome. The optimal management and treatment of SCAD is still unknown. Methods: Data analysis of a prospective protocol including centralized care management of a consecutive series of patients with SCAD diagnosed between January 2010 and December 2018. Major adverse cardiovascular events included all-cause mortality, new myocardial infarction, coronary revascularization, ventricular arrhythmia, heart failure or stroke. Results: A total of 33 consecutive patients were included (41 lesions). Intravascular imaging modalities were used to confirm the diagnosis in 42% patients. None of the patient showed images of thrombus formation in the true lumen. Conservative treatment was the initial approach in most of the cases (82%). No deaths were reported during the index admission, but 15% experienced major adverse cardiovascular events. The coronary computed tomography angiography performed in 58% of patients during the admission identified SCADs in 79% of the patients. Most of the patients managed with conservative treatment received only 1 antiplatelet agent for a limited period of time (17 months [9-35]). During a median clinical follow-up of 33 months [13-49], 82% of patients did not have any adverse events. The angiographic surveillance obtained in 48% of patients at the 6-month follow-up confirmed the complete healing of the SCAD image in 86% of the patients. The screening for extracoronary vascular findings (97% of patients) resulted in a high prevalence of abnormalities (59%). Conclusions: The unrestricted use of intravascular imaging modalities showed no thrombus in the true lumen of patients with SCAD. In patients managed with conservative treatment, a limited course of antiplatelet monotherapy is safe and provides good clinical outcomes. Performing a coronary computed tomography angiography in the acute phase of SCAD is useful at the follow-up. The screening for extracoronary vascular findings confirmed a high prevalence of abnormalities.

Sr. Editor: La disección coronaria espontánea (DCE) es una afección de baja incidencia que causa síndromes coronarios agudos1,2. Si bien en la última década se han realizado avances sustanciales en el conocimiento de la fisiopatología, el diagnóstico, el manejo clínico y el pronóstico de la DCE, el grado en que dicho conocimiento se ha incorporado a la comunidad médica es incierto. Por este motivo, se decidió realizar una investigación descriptiva en la que se reflejasen el conocimiento y la actitud respecto a la DCE de los cardiólogos intervencionistas con ejercicio profesional en España. Los autores elaboraron un cuestionario de 24 preguntas que abarcaron aspectos como la presentación clínica, el diagnóstico y el tratamiento agudo y poscrítico de la DCE3. La iniciativa recibió la aprobación y el respaldo de la Sección de Hemodinámica y Cardiología Intervencionista de la Sociedad Española de Cardiología. La encuesta se cerró en diciembre de 2018 con 161 respuestas procedentes de 72 centros (26 encuestados no completaron la variable «centro»). La figura 1 muestra las respuestas sobre el diagnóstico. Dos terceras partes de los encuestados asociaron la DCE a un perfil de mujer joven sin factores de riesgo o en el embarazo/puerperio. Respecto a la manifestación angiográfica, el patrón más...

A 41-year-old woman presented with an inferolateral ST-segment elevation myocardial infarction. Coronary angiography confirmed the presence of a long narrowing involving the right coronary artery posterolateral branch (figure 1A, white arrows). Spontaneous coronary artery dissection was suspected and optical coherence tomography (OCT) imaging was considered by the operator for confirmation purposes. Advancing the OCT catheter was difficult due to lack of support and it was decided to only interrogate the proximal aspect of the branch (figure 1B, arrow). OCT revealed the presence of an intramural hematoma without entry tear (figure 1C; asterisks denote wire artefact). At that moment the patient complained of chest pain that remained after removing the OCT catheter. The presence of functional branch occlusion (figure 1D, asterisk), with Thrombolysis in Myocardial Infarction (TIMI) grade 1 flow, was confirmed. Coronary flow was re-established through gentle dilation (4 atm) using a 1.5 mm balloon. Final TIMI grade 2 flow was achieved (figure 1E, asterisks) and the patient became asymptomatic. Her subsequent clinical course was uneventful. Coronary angiography performed 3 months later confirmed the complete healing of the dissected segment (figure 1F, arrows).

Mujer de 41 años que se presenta con un infarto de miocardio con elevación del segmento ST inferolateral. La coronariografía confirmó la presencia de una lesión larga en una rama posterolateral de la coronaria derecha (figura 1A, flechas blancas). El operador optó por realizar una tomografía de coherencia óptica (OCT) para confirmar la sospecha de disección coronaria espontánea. Como era difícil avanzar el catéter de la OCT, debido a la falta de soporte, se optó por interrogar únicamente el aspecto más proximal de esta rama (figura 1B, flecha). La OCT reveló la presencia de un hematoma intramural sin rotura intimal como puerta de entrada (figura 1C; los asteriscos señalan el artefacto de la guía). En ese momento, la paciente se quejó nuevamente de dolor torácico que se mantuvo hasta la retirada del catéter de la OTC. Se confirmó la presencia de oclusión funcional de la rama estudiada (figura 1D, asterisco) con flujo grado TIMI 1 (Thrombolysis in Myocardial Infarction). Se reestableció el flujo coronario mediante dilatación cuidadosa (balón de 1,5 mm de diámetro a 4 atmósferas). Finalmente se alcanzó un flujo TIMI 2 (figura 1E, asteriscos) con desaparición de los síntomas. La evolución clínica posterior cursó sin eventos. La angiografía coronaria que se realizó 3 meses después confirmó la reparación total del vaso con curación de todo el segmento que inicialmente mostraba la disección (figura 1F, flechas).

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.

© 2021 The Authors., [Background]: Spontaneous Coronary Artery Dissection (SCAD) is an important cause of acute coronary syndromes, particularly in young to middle-aged women. Differentiating acute SCAD from coronary atherothrombosis remains a major clinical challenge. [Methods]: A case-control study was used to explore the usefulness of circulating miRNAs to discriminate both clinical entities. The profile of miRNAs was evaluated using an unbiased human RT-PCR platform and confirmed using individual primers. miRNAs were evaluated in plasma samples from acute SCAD and atherothrombotic acute myocardial infarction (AT-AMI) from two independent cohorts; discovery cohort (SCAD n = 15, AT-AMI n = 15), and validation cohort (SCAD n = 11, AT-AMI n = 41) with 9 healthy control subjects. Plasma levels of IL-8, TGFB1, TGBR1, Endothelin-1 and MMP2 were analysed by ELISA assays. [Findings]: From 15 differentially expressed miRNAs detected in cohort 1, we confirmed in cohort 2 the differential expression of 4 miRNAs: miR-let-7f-5p, miR-146a-5p, miR-151a-3p and miR-223-5p, whose expression was higher in SCAD compared to AT-AMI. The combined expression of these 4 miRNAs showed the best predictive value to distinguish between both entities (AUC: 0.879, 95% CI 0.72–1.0) compared to individual miRNAs. Functional profiling of target genes identified an association with blood vessel biology, TGF-beta pathway and cytoskeletal traction force. ELISA assays showed high plasma levels of IL-8, TGFB1, TGFBR1, Endothelin-1 and MMP2 in SCAD patients compared to AT-AMI. [Interpretation]: We present a novel signature of plasma miRNAs in patients with SCAD. miR-let-7f-5p, miR-146a-5p, miR-151a-3p and miR-223-5p discriminate SCAD from AT-AMI patients and also shed light on the pathological mechanisms underlying this condition. [Funding]: Spanish Ministry of Economy and Competitiveness (MINECO): Plan Nacional de Salud SAF2017-82886-R, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Fundación BBVA a equipos de Investigación Científica 2018 and from Caixa Banking Foundation under the project code HR17-00016 to F.S.M. Instituto de Salud Carlos III (AES 2019): PI19/00565 to F.R, PI19/00545 to P.M. CAM (S2017/BMD-3671-INFLAMUNE-CM) from Comunidad de Madrid to FSM and PM. The UK SCAD study was supported by BeatSCAD, the British Heart Foundation (BHF) PG/13/96/30608 the NIHR rare disease translational collaboration and the Leicester NIHR Biomedical Research Centre., Spanish Ministry of Economy and Competitiveness (MINECO): Plan Nacional de Salud SAF2017-82886-R, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV). Fundación BBVA a equipos de Investigación Científica 2018 and from Caixa Banking Foundation under the project code HR17-00016 to F.S.M. Instituto de Salud Carlos III (AES 2019): PI19/00565 to F.R, PI19/00545 to P.M. CAM (S2017/BMD-3671-INFLAMUNE-CM) from Comunidad de Madrid to FSM and PM. The UK SCAD study was supported by BeatSCAD, the British Heart Foundation (BHF) PG/13/96/30608 the NIHR rare disease translational collaboration and the Leicester NIHR Biomedical Research Centre.

The LAmbreTM device is a novel system designed for left atrial appendage closure (LAAC). First registries showed a high rate of device implantation success. However, few mid-term results are available. We present our 1- and 12-month follow-up results for this device. This prospective, single-center registry included consecutive patients with nonvalvular atrial fibrillation who underwent LAAC with the LAmbreTM device. Transesophageal echocardiography (TEE) was performed at 1-month follow-up. In total, 55 patients were included. The population was elderly (75 ± 9.4 years), with a high proportion of comorbidities. The mean CHA2DS2-VASc and HAS-BLED scores were 4.6 ± 1.6 and 3.9 ± 1.0, respectively. Previous history of a major bleeding event was present in 37 patients (67.3%). Procedural success was achieved in 54 patients (98.2%). Device success was achieved in 100% of patients in whom device implantation was attempted (54 patients). Major in-hospital device-related complications included mortality of one patient (1.8%) and pericardial tamponade in two patients (3.6%), the incidence of stroke was 0%. No thrombus or significant leaks (≥5 mm) were observed on 1-month TEE. At 12 months, adverse events were overall death (1.8%), transient ischemic attack/ischemic stroke (1.8%), and major bleeding events (Bleeding Academic Research Consortium (BARC) 3a and 3c, 11%). In this high-risk population, the LAmbreTM device seems to be a safe and effective option for LAAC with a remarkable mid-term performance.

Background Currently drug-eluting stents (DES) and drug-eluting balloons are recommended in patients with in-stent restenosis (ISR). However, the efficacy of bioresorbable vascular scaffolds (BVS) after scoring balloon (SCB) predilation in these patients is unknown. Methods RIBS VI (NCT02672878) and RIBS VI 'Scoring' (NCT03069066) are prospective multicentre studies assessing the value of BVS in patients with ISR. Inclusion and exclusion criteria were identical in both studies. Results of conventional BVS implantation (112 patients) were compared with those obtained with systematic SCB therapy before BVS (108 patients). Angiographic follow-up was scheduled for all patients. Results On late angiography (93% of eligible patients) the in-segment minimal lumen diameter (primary end-point) (1.88 +/- 0.5 vs. 1.90 +/- 0.4 mm, P = 0.81), % diameter stenosis (28 +/- 17 vs. 29 +/- 15%), late lumen loss (0.23 +/- 0.4 vs. 0.22 +/- 0.4 mm) and binary restenosis rate (8.5 vs. 9.3%) were similar in the conventional BVS and SCB + BVS groups, respectively. At 1-year follow-up (100% of patients) target lesion revascularization (TLR) requirement (9.8 vs. 11.1%) was similar with the two strategies. Freedom from cardiac death, myocardial infarction and TLR was 88% and 87%, respectively. Results remained unchanged after adjusting for potential baseline confounders and were consistent in 10 prespecified subgroups. Conclusion This study suggests that results of conventional BVS implantation in patients with ISR are not improved by systematic predilation with SCB. ID: NCT02672878 (RIBS VI) and NCT03069066 (RIBS VI 'Scoring'). Copyright (c) 2020 Wolters Kluwer Health, Inc. All rights reserved.

Background Spontaneous coronary artery dissection (SCAD) is a rare cause of acute coronary syndrome (ACS). Clinical features, angiographic findings, management and outcomes of SCAD in elderly patients remain unknown. Methods The Spanish multicenter prospective SCAD registry included 318 consecutive patients with SCAD diagnosis. Patients were classified according to age in two groups: Results A total of 55 patients (17%) were 65 or older (Table). Elderly patients had more often hypertension (29% vs 76%, p Conclusions Elderly patients with SCAD show different clinical and angiographic characteristics and they receive distinct management. Short-term outcomes do not significantly differ from those seen in younger patients. Funding Acknowledgement Type of funding source: None

Background In-stent restenosis (ISR) represents the more frequent modality of stent failure. The currently recommended treatment strategies are represented by repeat drug-eluting stent (DES) implantation or drug-coated balloon (DCB) angioplasty. Optical coherence tomography can display important information regarding mechanisms of stent failure as well as neointimal characterization. Purpose Aim of the present study was to determine the impact of treatment modality (DES vs. DCB) as well as neointimal characteristics (homogeneous vs. non-homogeneous) as determined by intravascular OCT, on clinical outcomes and explore whether there is an interaction between neointimal pattern of ISR and treatment modality. Methods Patients presenting with ischemic symptoms and/or evidence of myocardial ischemia in three European centers and undergoing intravascular OCT prior to percutaneous coronary intervention (PCI) for ISR, were retrospectively included in this study. Characterization of neointimal tissue was performed at the frame displaying the maximal %AS as well as the 5 preceding and following analyzed frames. Each frame was subdivided in 4 quadrants (90°) and the neointimal characteristics separately characterized for each of them. Based on its optical characteristics, neointimal tissue was categorized as homogeneous, heterogeneous, layered or neoatherosclerosis. Based on the dominant neointimal type, the study population was divided in two groups, (predominantly homogeneous and non-homogeneous). Primary endpoints of the study were represented by major adverse cardiac events (MACE) and its idividual components (death, cardiac death, myocardial infarction and target lesion revascularization (TLR)) at 2 years follow-up. Results A total of 197 patients undergoing OCT prior to PCI for ISR were included in this study. 100 patients were classified as having predominantly homogeneous and 97 as having predominantly non-homogeneous neointima. No association was found between predominant OCT pattern (homogenous vs. non-homogenous) and MACE at 2 years follow-up (HR=1.01, 95% CI: 0.59–1.75; p=0.94), or the individual MACE components. Analogously, no significant differences in terms of MACE at 2 years were found between predominantly homogeneous vs. non-homogeneous neointima in the patient subgroup receiving a DES (p=0.10) and in that undergoing DCB treatment (p=0.11). However, a significant interaction was found between neointimal tissue pattern and treatment modality in terms of MACE (p=0.02) aa well as death or MI (p=0.016). Predominantly non-homogeneous neointima in patients treated with DCB was associated with a higher incidence of MACE. Conclusions Our results indicate that there is a significant interaction between treatment modality of ISR (DES vs. DCB) and neointimal pattern as determined by intravascular OCT. These results land initial support to an OCT-guided treatment of ISR and should be confirmed by larger trials. Funding Acknowledgement Type of funding source: None

Background Spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS) constitute two relatively common non-atherosclerotic causes of acute cardiac syndrome particularly frequent in women. Methods Herein we compared the baseline clinical and angiographic characteristics and in-hospital outcomes of 2 large prospective registries on SCAD and TTS. Results A total of 318 SCAD and 106 TTS patients were included (88% women). Patients in the TTS group were older (Table) and presented a higher prevalence of cardiovascular risk factors. Precipitating triggers were more frequent in TTS patients (42% vs. 56%, P=0.009) but emotional stress was more common in the SCAD group (25% vs. 15%, P=0.037). SCAD patients had higher troponin and creatine-kinase levels. The left anterior descending coronary artery was the most frequently involved vessel (44%). Left ventricular dysfunction (ejection fraction 57±10 vs. 40±10%, P Conclusions TTS patients are older and present a higher prevalence of cardiovascular risk factors than SCAD patients. They also present a worse in-hospital prognosis with higher mortality. Funding Acknowledgement Type of funding source: None

Aims Spontaneous coronary artery dissection (SCAD) is a relatively rare but well-known cause of acute coronary syndrome. Clinical features, angiographic findings, management and outcomes of SCAD in old patients (>65 years of age) remain unknown. Methods and results The Spanish multicentre prospective SCAD registry (NCT03607981), included 318 consecutive patients with SCAD. Data were collected between June 2015 and April 2019. All angiograms were analysed in a centralized corelab. For the purposes of this study, patients were classified according to age in two groups Conclusion Older patients with SCAD show different clinical and angiographic characteristics compared with younger patients. Initial treatment strategy was different between groups, though in-hospital outcomes do not significantly differ (NCT03607981).

Spontaneous coronary artery dissection (SCAD) is a relatively infrequent cause of acute coronary syndrome that usually affects young to middle-aged women. Mainly because of its low prevalence, until recently, most of the evidence on this condition was derived from case reports and small series. Over the last 5 years, more robust evidence has become available from larger retrospective and prospective cohorts of patients with SCAD. The increase in knowledge and recognition of this entity has led to the publication of expert consensus on both sides of the Atlantic. However, new data are continuously accumulating from larger cohorts of patients with SCAD, bringing new light to this little-understood condition. The aim of this article is to update the knowledge on SCAD, including new information from recent studies published since the consensus documents from the European Society of Cardiology and the American Heart Association.

Background: The prognostic value of a prolonged QT interval in SARS-Cov2 infection is not well known. Objective: To determine whether the presence of a prolonged QT on admission is an independent factor for mortality in SARS-Cov2 hospitalized patients. Methods: Single-center cohort of 623 consecutive patients with positive polymerase-chain-reaction test (PCR) to SARS Cov2, recruited from 27 February to 7 April 2020. An electrocardiogram was taken on these patients within the first 48 h after diagnosis and before the administration of any medication with a known effect on QT interval. A prolonged QT interval was defined as a corrected QT (QTc) interval &gt, 480 milliseconds. Patients were followed up with until 10 May 2020. Results: Sixty-one patients (9.8%) had prolonged QTc and only 3.2% had a baseline QTc &gt, 500 milliseconds. Patients with prolonged QTc were older, had more comorbidities, and higher levels of immune-inflammatory markers. There were no episodes of ventricular tachycardia or ventricular fibrillation during hospitalization. All-cause death was higher in patients with prolonged QTc (41.0% vs. 8.7%, p &lt, 0.001, multivariable HR 2.68 (1.58&ndash, 4.55), p &lt, 0.001). Conclusions: Almost 10% of patients with COVID-19 infection have a prolonged QTc interval on admission. A prolonged QTc was independently associated with a higher mortality even after adjustment for age, comorbidities, and treatment with hydroxychloroquine and azithromycin. An electrocardiogram should be included on admission to identify high-risk SARS-CoV-2 patients.