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Cardiovascular disease continues to be the leading cause of morbidity and mortality in the United States. Despite advancements in medical care, there remain persistent racial, ethnic, and gender disparity in the diagnosis, treatment, and prognosis of individuals with cardiovascular disease. In this review we seek to discuss differences in pathophysiology, clinical course, and risk profiles in the management and outcomes of acute myocardial infarction and related high-risk states. We also seek to highlight the demographic and psychosocial inequities that cause disparities in acute cardiovascular care., Competing Interests: Disclosure C.E. Ventetuolo reports consulting fees from Regeneron, Janssen, and Merck, outside of the submitted work. J.D. Abbott reports consulting fees from Abbott, Medtronic, Penumbra. Research Boston Scientific, Shockwave, Med Alliance, Microport. All other authors do not have any financial disclosures to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Transcarotid access has emerged as the preferred access site for transcatheter aortic valve implantation (TAVI) in patients with prohibitive iliofemoral anatomy. This study aimed to compare outcomes with transcarotid with those of other accesses in patients who underwent TAVI. Cochrane, EMBASE, and MEDLINE databases were searched for all published studies that compared outcomes with transcarotid with those of other accesses (transfemoral, transaxillary/subclavian, transaortic, and transapical) in patients who underwent TAVI. The primary outcome was all-cause mortality. Secondary outcomes included major bleeding, major vascular complications, stroke, myocardial infarction, permanent pacemaker implantation, and peri-aortic valve insufficiency. We included 22 observational studies with a total of 11,896 patients. Outcomes were reported during hospitalization and at 1-month follow-up. The transcarotid approach had higher mortality at 1 month (3.7% vs 2.6%, p = 0.02) but lower major vascular complications during hospitalization (1.5% vs 3.4%, p = 0.04) than did transfemoral access. The transcarotid approach had lower major vascular complications (2% vs 2.3%, p = 0.04) than did the transaxillary/subclavian but higher major bleeding (5.3% vs 2.6%, p = 0.03). The transaortic approach was associated with higher in-hospital (11.7% vs 1.9%, p = 0.02) and 1-month mortality (14.4% vs 3.9%, p = 0.007) rates than was transcarotid access. The transcarotid approach numerically reduced mortality and the risk of major vascular complications and major bleeding compared with the transapical approach; however, this did not reach statistical significance. The transcarotid approach did not increase the risk of stroke compared with transfemoral or the other alternative accesses. In conclusion, the transcarotid or transaxillary/subclavian approach had associated comparable outcomes that were better than those of the transapical and transaortic approaches. There was no difference in stroke risk between transcarotid access and other accesses., Competing Interests: Disclosures The authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Management of non-ST elevation myocardial infarction (NSTEMI) has evolved over the years, but most published data are from younger patients. Data on the NSTEMI management in older patients remain limited. We performed a meta-analysis of randomized controlled trials to evaluate the long-term outcomes of invasive versus conservative strategies in older patients (>70 years old) with NSTEMI. Of 1,550 reports searched, 4 randomized controlled trials (1,126 patients) were included in the analysis, with a median follow-up of 1.25 years (range: 1 to 2.5 years). The median age of included patients was 83.6 (interquartile range: 2.8 years). The invasive strategy was associated with significantly lower risk of major adverse cardiac and cerebrovascular event (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.40 to 0.91, I 2  = 54%; 3 trials] and unplanned revascularization (OR 0.31, 95% CI 0.15 to 0.64, I 2  = 1.7%; 3 trials] than was the conservative strategy. There was no difference in all-cause mortality (OR 0.88, 95% CI 0.65 to 1.18, I 2  = 0%; 4 trials], myocardial infarction (OR 0.70, 95% CI 0.42 to 1.19, I 2  = 54.7%; 4 trials], or bleeding (OR 0.87, 95% CI 0.39 to 1.93, I 2  = 0%; 3 trials] between the strategies. In conclusion, the use of initial invasive strategy in older patients presenting with NSTEMI was associated with a significantly lower risk of major adverse cardiac and cerebrovascular event and unplanned revascularization than that of the initial conservative strategy without increased bleeding., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background Rheumatic immune mediated inflammatory diseases (IMIDs) are associated with high risk of acute coronary syndrome. The long-term prognosis of acute coronary syndrome in patients with rheumatic IMIDs is not well studied. Methods and Results We identified Medicare beneficiaries admitted with a primary diagnosis of myocardial infarction (MI) from 2014 to 2019. Outcomes of patients with MI and concomitant rheumatic IMIDs including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, dermatomyositis, or psoriasis were compared with propensity matched control patients without rheumatic IMIDs. One-to-three propensity-score matching was done for exact age, sex, race, ST-segment-elevation MI, and non-ST-segment-elevation MI variables and greedy approach on other comorbidities. The study primary outcome was all-cause mortality. The study cohort included 1 654 862 patients with 3.6% prevalence of rheumatic IMIDs, the most common of which was rheumatoid arthritis, followed by systemic lupus erythematosus. Patients with rheumatic IMIDs were younger, more likely to be women, and more likely to present with non-ST-segment-elevation MI. Patients with rheumatic IMIDs were less likely to undergo coronary angiography, percutaneous coronary intervention or coronary artery bypass grafting. After propensity-score matching, at median follow up of 24 months (interquartile range 9-45), the risk of mortality (adjusted hazard ratio [HR], 1.15 [95% CI, 1.14-1.17]), heart failure (HR, 1.12 [95% CI 1.09-1.14]), recurrent MI (HR, 1.08 [95% CI 1.06-1.11]), and coronary reintervention (HR, 1.06 [95% CI, 1.01-1.13]) ( P <0.05 for all) was higher in patients with versus without rheumatic IMIDs. Conclusions Patients with MI and rheumatic IMIDs have higher risk of mortality, heart failure, recurrent MI, and need for coronary reintervention during follow-up compared with patients without rheumatic IMIDs.

Background: The impact of pre-existing atrial fibrillation (AF) on outcomes after noncardiac surgery is not clear., Objectives: We aimed to study the impact of AF on the risk of adverse outcomes after noncardiac surgery in a nationwide cohort., Methods: We identified Medicare beneficiaries admitted for noncardiac surgery from 2015 to 2019 and divided the study cohort into 2 groups: with and without AF. Noncardiac surgery was classified into vascular, thoracic, general, genitourinary, gynecological, orthopedics and neurosurgery, breast, head and neck, and transplant. We used propensity score matching on exact age, sex, race, urgency and type of surgery, revised cardiac risk index (RCRI) and CHA 2 DS 2 -VASc score, and tight caliper on other comorbidities. The study outcomes were 30-day mortality, stroke, myocardial infarction, and heart failure. We examined the incremental utility of AF in addition to RCRI to predict adverse events after noncardiac surgery., Results: The study cohort included 8,635,758 patients who underwent noncardiac surgery (16.4% with AF). Patients with AF were older, more likely to be men, and had higher prevalence of comorbidities. After propensity score matching, AF was associated with higher risk of mortality (OR: 1.31; 95% CI: 1.30-1.32), heart failure (OR: 1.31; 95% CI: 1.30-1.33), and stroke (OR: 1.40; 95% CI: 1.37-1.43) and lower risk of myocardial infarction (OR: 0.81; 95% CI: 0.79-0.82). Results were consistent in subgroup analysis by sex, race, type of surgery, and all strata of RCRI and CHA 2 DS 2 -VASc score. AF improved the discriminative ability of RCRI (C-statistic 0.73 to 0.76)., Conclusion: Pre-existing AF is independently associated with postoperative adverse outcomes after NCS., Competing Interests: Funding Support and Author Disclosures The current research was partly funded by philanthropic gifts by the Haslam Family, Bailey Family, and Khouri family to the Cleveland Clinic for Dr Milind Desai's research. Dr Desai is a consultant for Medtronic and Bristol Myers Squibb; and is on the executive steering committee of a trial sponsored by Bristol Myers Squibb. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

There have been mixed results regarding the efficacy and safety of various percutaneous coronary intervention bifurcation techniques. An electronic search of Medline, Scopus, and Cochrane databases was performed for randomized controlled trials that compared the outcomes of any bifurcation techniques. We conducted a pairwise meta-analysis comparing the 1-stent versus 2-stent bifurcation approach, and a network meta-analysis comparing the different bifurcation techniques. The primary outcome was major adverse cardiac events (MACEs). The analysis included 22 randomized trials with 6,359 patients. At a weighted follow-up of 25.9 months, there was no difference in MACE between 1-stent versus 2-stent approaches (risk ratio [RR] 1.20, 95% confidence interval [CI] 0.92 to 1.56). Exploratory analysis suggested a higher risk of MACE with a 1-stent approach in studies using second-generation drug-eluting stents, if side branch lesion length ≥10 mm, and when final kissing balloon was used. There was no difference between 1-stent versus 2-stent approaches in all-cause mortality (RR 0.95, 95% CI 0.69 to 1.30), cardiovascular mortality (RR 1.07, 95% CI 0.68 to 1.68), target vessel revascularization (TVR) (RR 1.22, 95% CI 0.90 to 1.65), myocardial infarction (MI) (RR 1.04, 95% CI 0.69 to 1.56) or stent thrombosis (RR 1.10, 95% CI 0.68 to 1.78). Network meta-analysis demonstrated that double kissing crush technique was associated with lower MACE, MI, TVR, and target lesion revascularization, whereas culotte technique was associated with higher rates of stent thrombosis. In this meta-analysis of randomized trials, we found no difference between 1-stent versus 2-stent bifurcation percutaneous coronary intervention approaches in the risk of MACE during long-term follow-up. Among the various bifurcation techniques, double kissing crush technique was associated with lower rates of MACE, target lesion revascularization, TVR, and MI., Competing Interests: Disclosures Dr. Latib is a consultant and/or on the advisory board of Medtronic, Abbott, Boston Scientific, and Philips. Dr. Elgendy has disclosures unrelated to this manuscript content including receiving research grants from Caladrius Biosciences, Inc. Dr. Abbott is a consultant for Philips and Boston Scientific and has research funding from Abbott, Biosensors, and Sinomed. The other authors have no conflicts of interest to declare., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: The use of drug-coated balloons (DCBs) in small-vessel coronary artery disease (SVD) remains controversial., Methods: We performed a meta-analysis of all randomized controlled trials (RCTs) reporting the outcomes of DCB vs. DES in de-novo SVD. We included a total of 5 RCTs (1459 patients), with (DCB n = 734 and DES n = 725)., Results: Over a median follow-up duration of 6 months, DCB was associated with smaller late lumen loss (LLL) compared with DES (mean difference -0.12 mm) (95% confidence intervals (CI) [-0.21, -0.03 mm], p = 0.01). Over a median follow-up of 12 months, both modalities had similar risk of major adverse cardiovascular events (MACE) (8.7% vs. 10.2%; odds ratio (OR): 0.94, 95% CI [0.49-1.79], p = 084), all-cause mortality (1.17% vs. 2.38%; OR: 0.53, 95% CI [0.16-1.75], p = 0.30), target lesion revascularization (TLR) (7.9% vs. 3.9%; OR: 1.26, 95% CI [0.51-3.14], p = 0.62), and target vessel revascularization (TVR) (8.2% vs. 7.8%; OR: 1.06, 95% CI [0.40-2.82], p = 0.91). DCBs were associated with lower risk of myocardial infarction (MI) compared with DES (1.55% vs. 3.31%; OR: 0.48, 95% CI [0.23-1.00], p = 0.05, I2 = 0%)., Conclusion: PCI of SVD with DCBs is associated with smaller LLL, lower risk of MI, and similar risk of MACE, death, TLR, and TVR compared with DES over one year. DCB appears as an attractive alternative to DES in patients with de-novo SVD, but long-term clinical data are still needed., Competing Interests: Declaration of competing interest Emmanouil Brilakis: consulting/speaker honoraria from Abbott Vascular, American Heart Association (associate editor Circulation), Amgen, Biotronik, Boston Scientific, Cardiovascular Innovations Foundation (Board of Directors), ControlRad, CSI, Ebix, Elsevier, GE Healthcare, InfraRedx, Medtronic, Siemens, and Teleflex; research support from Regeneron and Siemens. Shareholder: MHI Ventures. Khaldoon Alaswad: consulting/speaker honoraria from Boston Scientific, Cardiovascular Systems Inc., Abbott Vascular, Teleflex. Mir Basir: Consulting/Speaker Abbott Vascular, Abiomed, Cardiovascular Systems, Chiesi, Zoll. Stéphane Rinfret: consulting/speaker honoraria from Abbott Vascular, Boston Scientific, Teleflex and Abiomed. All other authors have nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Acute myocardial infarction complicated by cardiogenic shock (AMICS) is associated with high mortality rates. Data has shown that intra-aortic balloon pump (IABP) support does not provide a survival benefit over optimal medical therapy in AMICS. Despite lack of supportive evidence, IABP is still commonly used in these clinical situations. The Impella percutaneous ventricular assist device (PVAD) (Abiomed, Denver, MA) rapidly deploys superior mechanical circulatory support (MCS) in patients with AMICS. However, the safety and efficacy of Impella in AMICS is a matter of ongoing investigation, and its role in AMICS management is not yet fully established., Methods: The databases of Pubmed, EMBASE and Cochrane Central databases were searched from inception to March 2020. Relevant randomized trials and observational studies comparing Impella versus IABP in AMICS were identified and a meta-analysis was performed using the random effect model. The efficacy endpoint of interest was short-term mortality (defined as in-hospital or 30-day mortality). The safety endpoints of interest were major bleeding, limb complications, stroke and hemolysis., Results: A total of 2 randomized trials and 5 observational studies with 3921 patients were included. No difference in short-term mortality between the two groups [RR 1.08, 95% CI 0.87-1.33, P = 0.49] was found. For safety endpoints, Impella was associated with significantly higher incidence of major bleeding [RR: 2.03, 95% CI 1.56-2.64, P < 0.0001], limb complications [RR: 3.67, 95% CI 1.56-8.65, P = 0.003] as well as hemolysis [RR: 9.46, 95% CI 1.75-51.22, P = 0.009] compared with IABP. No significant difference was observed for the incidence of stroke [RR: 1.07 95% CI 0.34-3.31 P = 0.91]., Conclusion: Impella support in AMICS patients was associated with a significantly increased risk of bleeding, limb complications and hemolysis without an improved short-term survival advantage compared with IABP., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Inc.)

The role of drug-coated balloons (DCBs) in patients with acute myocardial infarction (AMI) remains controversial. We performed a meta-analysis of all published studies comparing the outcomes of DCBs vs. stenting in AMI patients. Four studies with 497 patients (534 lesions) were included (three randomized controlled trials and one observational study). During a mean follow-up of 9 months (range 6-12 months), DCBs were associated with similar risk of major adverse cardiovascular events (5% vs. 4.4%; OR 1.24, 95% CI: [0.34, 4.51], p = 0.74, I 2  = 35%), all-cause mortality (0.02% vs. 0.04%; OR 077, 95% CI: [0.15, 3.91], p = 0.75, I 2  = 25%), cardiac death (0.01% vs. 0.02%; OR 0.64, 95% CI: [0.16, 2.64], p = 0.54), myocardial infarction (0% vs. 1.4%; OR 0.18, 95% CI: [0.01, 3.56], p = 0.26), and target lesion revascularization (3.7% vs. 2%; OR 1.74, 95% CI: [0.42, 7.13], p = 0.44, I 2  = 17%) compared with stenting. During a mean follow-up of 7 months (range 6-9 months), DCBs had similar late lumen loss compared with stenting (mean difference 0.04 mm, 95% CI [- 0.21-0.28], p = 0.77, I 2  = 92%). In patients with AMI, there was no statistical difference in the incidence of clinical and angiographic outcomes between AMI patients treated with DCB and DES. Larger studies with longer-term follow-up are needed to assess the clinical utility of DCBs in this setting., (© 2020. Japanese Association of Cardiovascular Intervention and Therapeutics.)

For decades, unfractionated heparin (UFH) has been widely used in catheterization laboratories for anticoagulation for percutaneous coronary intervention (PCI). The direct thrombin inhibitors, bivalirudin, has emerged as an alternative to UFH for PCI procedures, due to its lower bleeding risk. More recently, randomized trials and meta-analyses questioned the efficacy of bivalirudin, and demonstrated that bivalirudin might be associated with a higher incidence of ischemic events and in particular stent thrombosis. In this review, we discuss the pharmacology of bivalirudin along with the clinical evidence comparing bivalirudin versus UFH in patients undergoing PCI for various indications., (© 2015 John Wiley & Sons Ltd.)

Acute ST-elevation myocardial infarction (STEMI) with simultaneous multiple coronary thrombosis has been described, however; the available information about the clinical presentation and management of this condition is scarce. We searched the Medline and Web of Science databases from 1990 until August 2014 for all case reports, case series, and observational studies that reported simultaneous multi-vessel thrombosis at the time of the primary percutaneous coronary intervention (PCI). We excluded the articles that reported an identifiable cause for coronary thrombosis. A total of 29 articles were retrieved yielding 56 patients. Patients were predominantly males (88%) with a mean age of 59 years. Cardiogenic shock was the predominant presentation (41%). Simultaneous thrombosis of the left anterior descending and right coronary arteries was the commonest angiographic finding (50%). Primary PCI was the main treatment modality and an intra-aortic balloon pump was utilized in 38% of the cases. The in-hospital mortality was 5%. Simultaneous multi-vessel thrombosis at the time of STEMI presents a rare condition. The cases reported in the literature presented with a high incidence of cardiogenic shock. Larger studies are needed to address the proper management and evaluate the outcomes associated with this condition., (Copyright © 2015. Published by Elsevier Inc.)

Background: The optimal stent for use in saphenous vein graft (SVG) intervention is still debatable. Multiple randomized trials have compared drug-eluting stents (DES) to bare metal stents (BMS) in SVG interventions with conflicting results.Methods: Authors searched the online databases for randomized controlled trials (RCTs) comparing DES to BMS in SVG percutaneous coronary interventions (PCI). We performed a meta-analysis using a random effects model to calculate the odds ratio for outcomes of interest.Results: Authors studied six RCTs that included 1592 patients undergoing PCI of SVG. The mean follow up was 42 months. Patients mean age was the same in both groups: 70.3 years in the DES group (approximately 93.3% male) and 70.3 years in the BMS group (approximately 93.8% male). Vein graft age was 13.4 years in the DES PCI arm vs. 13.4 years in the BMS PCI arm. Four of the six trials reported data on embolic protection device use: 67% (303/452) in the DES arm vs. 67.9% (309/455) in the BMS arm. The primary outcome of long-term all-cause mortality was not different between DES vs. BMS (15.2% vs. 14.1%, OR 1.12, 95% CI 0.67-1.88; P = 0.66). Secondary outcomes were also similar between DES and BMS: major adverse cardiovascular events (31.6% vs. 33.1%, OR 0.79, 95% CI 0.45-1.38; P = 0.41); cardiac death (9% vs. 8.6%, OR 1.12, 95% CI 0.55-2.30; P = 0.75); myocardial infarction (8% vs. 9.5%, OR 0.84, 95% CI 0.47-1.51; P = 0.57); target lesion revascularization (16.4% vs. 14.4%, OR 0.98, 95% CI 0.50-1.92; P = 0.95); and target vessel revascularization (19% vs. 19.4%, OR 0.75, 95% CI 0.41-1.34; P = 0.33).Conclusion: At a mean follow-up of 42 months, no difference was observed in clinical outcomes between DES and BMS in SVG interventions. [ABSTRACT FROM AUTHOR]

Objectives: To examine whether routine thrombus aspiration (TA) is associated with improved myocardial salvage in patients with ST-elevation myocardial infarction (STEMI) presenting ≥12 h after onset of symptoms.Background: TA is a recognized treatment option in patients with STEMI undergoing primary percutaneous coronary intervention (PPCI) especially in the setting of heavy thrombus burden. However, data on the role of TA in STEMI patients presenting late after onset of symptoms are limited.Methods: In this single-center prospective randomized study, patients with subacute STEMI presenting ≥12 and ≤48 h after symptom onset were randomized to primary PCI with or without manual TA in a 1:1 ratio. The primary endpoint was the myocardial salvage index assessed with Single Photon Emission Computed Tomography (SPECT) on admission and 4 days later.Results: A total of 60 patients underwent randomization. Baseline characteristics were comparable between groups. TA was associated with improved myocardial salvage index compared with control group (60.1 ± 11.1% vs 28.1 ± 21.3%; P = <0.001). Furthermore, TA was associated with improved post-procedural TIMI flow (2.9 ± 0.3 vs 2.5 ± 0.6; P = 0.003), myocardial blush grade (2.9 ± 0.3 vs 2.2 ± 0.8, P = <0.001), and reduction in left ventricular end-diastolic dimensions (50.4 ± 4.3 mm vs 54.4 ± 5.8 mm, P = 0.004) compared with the control group. Clinical outcomes at 30 days and 6 months were similar between both groups.Conclusions: TA might be associated with improved reperfusion and myocardial salvage especially in STEMI patients presenting after 12 h from symptom onset who are likely to have a heavy thrombus burden. [ABSTRACT FROM AUTHOR]

Background: The optimal interventional technique for addressing coronary bifurcation lesions is debatable. Long-term clinical outcomes with provisional stenting (PS) compared with a two-stent (TS) strategy for bifurcation lesions are scarce. We aim to perform the first meta-analysis of randomised controlled trials (RCTs) to explore long-term outcomes comparing both strategies.Methods: An electronic search was performed for online databases until August 2016 for RCTs comparing PS with TS for bifurcation lesions reporting outcomes at 1 year of follow-up or more. Random effects model risk ratios (RRs) were calculated for outcomes of interest.Results: Eight RCTs with a total of 2778 patients reported long-term clinical outcomes. At mean follow-up of 3.0±1.6 years, PS was associated with lower risk of all-cause mortality (RR=0.66; 95% CI 0.45 to 0.98; p=0.04) compared with TS for bifurcation lesions. No difference was observed with PS compared with TS regarding major adverse cardiac events (MACE), myocardial infarction (MI), target lesion revascularisation (TLR) or stent thrombosis (ST). In a sensitivity analysis limited to trials with follow-up duration ≥3 years, PS was associated with lower risk of all-cause mortality (RR=0.57; 95% CI 0.36 to 0.88; p=0.01), MACE (RR=0.71; 95% CI 0.52 to 0.97; p=0.03) and MI (RR=0.45; 95% CI 0.21 to 0.96; p=0.04) compared with TS, at mean follow-up of 4.6±0.7 years. The risk of TLR and ST remained similar with both strategies (RR=0.81; 95% CI 0.57 to 1.15; p=0.24; and RR=0.75; 95% CI 0.19 to 2.84; p=0.67 respectively). Meta-regression analyses identified increased risk of MACE with PS in patients presenting with acute coronary syndrome (p=0.05).Conclusion: PS may be associated with a long-term mortality benefit compared with a TS strategy for coronary bifurcation lesions. [ABSTRACT FROM AUTHOR]

Background: Data regarding long-term clinical outcomes with everolimus-eluting bioresorbable vascular scaffold (BVS) versus second-generation drug-eluting stents (DES) are scarce.Methods: We searched online databases until October 2016 for studies comparing BVS versus DES reporting outcomes at 2 years of follow-up. We performed a meta-analysis comparing BVS with DES across the spectrum of coronary artery disease (CAD). Random effects model OR was calculated for outcomes of interest including device-oriented composite events (DOCE; defined as composite of cardiac mortality, target vessel myocardial infarction (TV-MI), and ischaemia-driven target lesion revascularisation (TLR)), all-cause mortality, definite stent thrombosis, TV-MI and TLR.Results: A total of 2360 patients enrolled in five studies met criteria for inclusion in this analysis. At 2 years, BVS was associated with higher rates of DOCE (6.9% vs 4.5%, OR=1.53; 95% CI 1.06 to 2.23; p=0.02), absolute risk increase (ARI) 2.4%, relative risk increase (RRI) 53%, TV-MI (4% vs 1.8%, OR=1.94; 95% CI 1.02 to 3.67; p=0.04), ARI 2.2%, RRI 122% and definite stent thrombosis (2.1% vs 0.6%, OR=3.39; 95% CI 1.46 to 7.88; p=0.005), ARI 1.5%, RRI 250% compared with DES. No differences in all-cause mortality (OR=0.86; 95% CI 0.26 to 2.81; p=0.80) and TLR (OR=1.44; 95% CI 0.81 to 2.54; p=0.21) were observed between both groups.Conclusions: BVS may be associated with worse long-term clinical outcomes compared with DES. Randomised clinical trials are encouraged to expeditiously report long-term safety and efficacy outcomes and identify predictors of adverse events with BVS compared with DES. [ABSTRACT FROM AUTHOR]

Background: Large randomized trials have shown conflicting evidence regarding the cardiovascular safety of dipeptidyl-peptidase 4 (DPP-4) inhibitors. Systematic reviews have been limited by incomplete data and inclusion of observational studies. This study aimed to systematically evaluate the cardiovascular safety of DPP-4 inhibitors in patients with type 2 diabetes. Methods: Electronic databases were searched for randomized trials that compared DPP-4 inhibitors versus placebo and reported cardiovascular outcomes. The main outcome assessed in this analysis was heart failure. Other outcomes included all-cause mortality, cardiovascular mortality, myocardial infarction, and ischemic stroke. Summary odds ratios (ORs) were primarily constructed using Peto's model. Results: A total of 90 trials with 66,730 patients were included. Compared with placebo, DPP-4 inhibitors were associated with a non-significant increased risk of heart failure [OR 1.11, 95% confidence interval (CI) 0.99-1.25, P = 0.07] at a mean of 108 weeks. The risk of all-cause mortality (OR 1.03, 95% CI 0.94-1.12, P = 0.53), cardiovascular mortality (OR 1.02, 95% CI 0.92-1.14, P = 0.72), myocardial infarction (OR 0.98, 95% CI 0.88-1.09, P = 0.69), and ischemic stroke (OR 0.99, 95% CI 0.85-1.15, P = 0.92) was similar between both groups. Conclusion: In patients with type 2 diabetes, the safety profile of DPP-4 inhibitors is similar to placebo. As a class, there is only weak evidence for an increased risk of heart failure. [ABSTRACT FROM AUTHOR]

Introduction: The role of intracoronary (IC) eptifibatide in primary percutaneous coronary intervention (PPCI) for ST segment elevation myocardial infarction (STEMI) and whether time of patient presentation affects this role are unclear. We sought to evaluate the benefit of IC eptifibatide use during primary PCI in early STEMI presenters compared to late STEMI presenters. Methods: We included 70 patients who presented with STEMI and were eligible for PPCI. On the basis of symptom-to-door time, patients were classified into two arms: early (<3 h, n = 34) vs late (≥3 h, n = 36) presenters. They were then randomized to local IC eptifibatide infusion vs standard care (control group). The primary end point was post-PCI myocardial blush grade (MBG) in the culprit vessel. Other end points included corrected TIMI frame count (cTFC), ST segment resolution (STR) ≥70%, and peak CKMB. Results: In the early presenters arm, no difference was observed in MBG results ≥2 in the IC eptifibatide and control groups (100% vs 82%; p = 0.23). In the late presenters arm, the eptifibatide subgroup was associated with improved MBG ≥2 (100% vs 50%; p = 0.001). IC eptifibatide in both early and late presenters was associated with less cTFC (early presenters 19 vs. 25.6, p = 0.001; late presenters 20 vs. 31.5, p < 0.001) and less peak CKMB (early presenters 210 vs 260 IU/L, p = 0.006; late presenters 228 vs 318 IU/L, p = 0.005) compared with the control group. No difference existed between both groups in STR index in early and late presenters. Conclusion: IC eptifibatide might improve the reperfusion markers during PPCI for STEMI patients presenting after 3 h from onset of symptoms. A large randomized study is recommended to ascertain the benefits of IC eptifibatide in late presenters on clinical outcomes. [ABSTRACT FROM AUTHOR]

There has been an evolution in the disease severity and complexity of patients presenting to the cardiac intensive care unit (CICU). There are limited data evaluating the role of palliative care in contemporary CICU practice. PubMed Central, CINAHL, EMBASE, Medline, Cochrane Library, Scopus, and Web of Science databases were evaluated for studies on palliative care in adults (≥18 years) admitted with acute cardiovascular conditions – acute myocardial infarction, cardiogenic shock, cardiac arrest, advanced heart failure, post-cardiac surgery, spontaneous coronary artery dissection, Takotsubo cardiomyopathy, and pulmonary embolism – admitted to the CICU, coronary care unit or cardiovascular intensive care unit from 1/1/2000 to 8/8/2022. The primary outcome of interest was the utilization of palliative care services. Secondary outcomes of included studies were also addressed. Meta-analysis was not performed due to heterogeneity. Of 5711 citations, 30 studies were included. All studies were published in the last seven years and 90 % originated in the United States. Twenty-seven studies (90 %) were retrospective analyses, with a majority from the National Inpatient Sample database. Heart failure was the most frequent diagnosis (47 %), and in-hospital mortality was reported in 67 % of studies. There was heterogeneity in the timing, frequency, and background of the care team that determined palliative care consultation. In two randomized trials, there appeared to be improvement in quality of life without an impact on mortality. Despite the growing recognition of the role of palliative care, there are limited data on palliative care consultation in the CICU. • Palliative care has been studied infrequently in the cardiac intensive care unit (CICU). • The CICU population has undergone a significant shift in disease severity and complexity. • Multiple barriers to palliative care utilization exist in contemporary literature. [ABSTRACT FROM AUTHOR]

Background: The use and impact of intravascular imaging in ST-elevation myocardial infarction (STEMI) patients has received limited study.Methods: We queried the National Inpatient Sample database (NIS) between January 2016 and December 2017 to identify hospitalizations of STEMI patients who underwent percutaneous coronary intervention (PCI). We used a 1:2 propensity-score (PS) matched analysis to compare in-hospital outcomes in patients with vs. without use of intravascular imaging. We conducted a multivariable regression analysis to identify variables independently associated with in-hospital mortality.Results: We identified 252,970 weighted discharges of PCI in STEMI patients, 5.5% of which included intravascular imaging. Patients in whom intravascular imaging was used were more likely to have acute stent thrombosis (4.7% vs. 1.4%, p < 0.001) and present with anterior STEMI (48.1% vs. 39.1%, p < 0.001). After PS matching (intravascular imaging n = 14,015, no intravascular imaging n = 28,025), the use of intravascular imaging was associated with lower in-hospital mortality (3.6% vs. 4.8%, p = 0.010). The risk of in-hospital complications and discharge to a facility (nursing facility or short-term acute hospital) was similar between both groups before and after PS matching. The use of intravascular imaging was associated with a higher index hospitalization cost [$25,218 vs. $20,515, p < 0.001]. On multivariable analysis, intravascular imaging was independently associated with lower in-hospital mortality [OR 0.735 (95% CI 0.662-0.816), p < 0.001].Conclusion: Intravascular imaging was used in 5.5% of PCIs in STEMI patients and was independently associated with lower in-hospital mortality and higher index hospitalization cost. [ABSTRACT FROM AUTHOR]

Objective: To examine the outcomes with intravascular brachytherapy (IVBT) in recurrent in-stent restenosis (ISR).Background: Recurrent ISR can be challenging to treat and IVBT can be used for recurrent ISR but has received limited study.Methods: We performed a systematic review and meta-analysis of five observational studies, including 917 patients (1014 lesions) with recurrent ISR, defined as having at least two prior ISR episodes with previous treatment with a stent, who underwent treatment with IVBT. Outcomes of interest included target vessel revascularization (TVR), myocardial infarction (MI), and all-cause mortality.Results: During a mean follow-up of 24 ± 7 months, the incidence of TVR was 29.2% (95% CI 18.0-40.4%). The incidence of MI and all-cause mortality were 4.3% (95% CI 1.7%-6.9%) and 7.3% (95% CI 3.2-11.5%), respectively. At one- and two-years after PCI the incidence of TVR was 17.5% (95% CI 13.6%-21.4%) and 26.7% (95% CI 16.6%-36.9%), respectively and the incidence of MI was 3.1% (95% CI 2-4.2%) and 3.9% (95% CI 1-6.8%), respectively.Conclusion: Intravascular brachytherapy can be used to treat recurrent ISR, although TVR is needed in approximately one of four patients at two years. [ABSTRACT FROM AUTHOR]

Background: Contemporary data regarding the temporal changes in prevalence and outcomes of hospitalizations with Prinzmetal angina are limited.Methods: We queried the National Inpatient Sample Database for the years 2002-2015 to identify hospitalizations with Prinzmetal angina. We described the temporal trends and outcomes in patients with Prinzmetal angina.Results: A total of 97,280 hospitalizations with Prinzmetal angina were identified. There was a significant increase in the number of hospitalizations with Prinzmetal angina (3678 in 2002 vs 8633 in 2015, Ptrend <.001) as well as the proportion of hospitalizations with Prinzmetal angina among those with chest pain (Ptrend <.001). There was an increase in the rates of in-hospital mortality (0.24% in 2002 vs 0.85% in 2015, Ptrend = .02), which corresponded to a progressive increase in the burden of comorbidities among patients with Prinzmetal angina. Age >65 years, history of heart failure, chronic kidney disease, chronic liver disease, and acute myocardial infarction upon presentation were independent predictors of in-hospital mortality. Compared with patients with acute myocardial infarction without Prinzmetal angina, those with Prinzmetal angina presenting with acute myocardial infarction had a lower incidence of in-hospital mortality (odds ratio 0.24, 95% confidence interval 0.14-0.41).Conclusions: In this large national analysis, there has been an increase in the prevalence of hospitalizations with Prinzmetal angina. Older age, heart failure, chronic kidney disease, chronic liver disease, and acute myocardial infarction were predictors of higher mortality among patients with Prinzmetal angina. Patients with Prinzmetal angina who developed acute myocardial infarction had more favorable outcomes compared with myocardial infarction without Prinzmetal angina. [ABSTRACT FROM AUTHOR]