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Introduction and objectives: The final diagnosis of a myocardial infarction with non-obstructive coronary arteries (MINOCA) is often hard to achieve. Angiographic findings may be suggestive of the presence of unstable plaques although it is common to discharge patients without an etiologic diagnosis. The high spatial resolution provided by the optical coherence tomography (OCT) allows the detection of vulnerable and unstable coronary plaques that are prone to rupture, erosion, and thrombi which may lead to more targeted individual therapies. The objective of this study is to assess the utility of OCT when achieving an etiologic diagnosis in selected patients with MINOCA and high clinical suspicion of atherosclerotic etiology. Methods: Registry of 27 patients recruited between September 2015 and January 2020 admitted to a single tertiary hospital with acute coronary syndrome and non-significant stenosis in the coronary angiography who underwent OCT. The baseline data of the study population, the angiographic and OCT findings, treatment and follow-up information were all collected. Results: The OCT imaging showed evidence of unstable plaques (thrombus, plaque erosion or plaque rupture) in 78% of patients, which lead to an etiologic diagnosis of MINOCA. Patients were predominantly males (89%), smokers (63%), middle-aged (median 53 years old) and with a low cardiovascular risk burden. The left anterior descending coronary artery was the most frequently compromised vessel (74%) and 95% of patients ended up receiving coronary stents. The mid-term follow-up was excellent. Conclusions: In our study, OCT imaging proved to be a valuable tool to achieve an etiologic diagnosis in a large proportion of selected patients with MINOCA which, as a result could lead to more specific and individualized treatments.

espanolIntroduccion y objetivos: A menudo resulta complejo diagnosticar a pacientes con infarto agudo de miocardio y estenosis coronarias no significativas en la coronariografia (MINOCA). En ocasiones, la angiografia muestra datos sugestivos de placa inestable, aunque no es infrecuente que estos pacientes acaben sin un diagnostico etiologico. La tomografia de coherencia optica (OCT) permite detectar placas vulnerables e inestables con rotura, erosion o trombo gracias a su elevada resolucion espacial, lo que podria implicar un cambio en el manejo de estos pacientes. El objetivo de este estudio es valorar la utilidad de la OCT para alcanzar un diagnostico final en casos seleccionados de MINOCA con alta sospecha de etiologia ateroesclerotica. Metodos: Registro de 27 pacientes desde septiembre de 2015 hasta enero de 2020 en los que se indica OCT en el contexto de sindrome coronario agudo y estenosis Resultados: La OCT evidencio la presencia de placa inestable con trombo, rotura de placa o erosion de placa en el 78% de los pacientes como causa del MINOCA. Los pacientes fueron predominantemente varones (89%), fumadores (63%), de mediana edad (53 anos de mediana), con poca carga de factores de riesgo y afectacion principalmente de la descendente anterior (74%). El 95% de los casos en que se detecto placa inestable fueron tratados con stent. La evolucion a medio plazo fue excelente. Conclusiones: En nuestra serie de pacientes con MINOCA y alta sospecha de causa ateroesclerotica, la OCT resulto ser una tecnica util para identificar la etiologia de la mayoria de ellos, lo que permitio adoptar una estrategia terapeutica mas especifica. EnglishIntroduction and objectives: The final diagnosis of a myocardial infarction with non-obstructive coronary arteries (MINOCA) is often hard to achieve. Angiographic findings may be suggestive of the presence of unstable plaques although it is common to discharge patients without an etiologic diagnosis. The high spatial resolution provided by the optical coherence tomography (OCT) allows the detection of vulnerable and unstable coronary plaques that are prone to rupture, erosion, and thrombi which may lead to more targeted individual therapies. The objective of this study is to assess the utility of OCT when achieving an etiologic diagnosis in selected patients with MINOCA and high clinical suspicion of atherosclerotic etiology. Methods: Registry of 27 patients recruited between September 2015 and January 2020 admitted to a single tertiary hospital with acute coronary syndrome and non-significant stenosis in the coronary angiography who underwent OCT. The baseline data of the study population, the angiographic and OCT findings, treatment and follow-up information were all collected. Results: The OCT imaging showed evidence of unstable plaques (thrombus, plaque erosion or plaque rupture) in 78% of patients, which lead to an etiologic diagnosis of MINOCA. Patients were predominantly males (89%), smokers (63%), middle-aged (median 53 years old) and with a low cardiovascular risk burden. The left anterior descending coronary artery was the most frequently compromised vessel (74%) and 95% of patients ended up receiving coronary stents. The mid-term follow-up was excellent. Conclusions: In our study, OCT imaging proved to be a valuable tool to achieve an etiologic diagnosis in a large proportion of selected patients with MINOCA which, as a result could lead to more specific and individualized treatments.

Objectives. The aim of this study is to assess the utility of optical coherence tomography (OCT) in patients with exercise-related acute coronary syndrome (ACS) presenting with inconclusive angiographic findings. Background. Regular physical activity reduces the incidence of cardiovascular events. Nevertheless, the risk of ACS or sudden cardiac death (SCD) increases during sport. In adults older than 35 years, exercise-related ACS or SCD is associated with plaque rupture, but not infrequently patients present ambiguous angiographic findings. Methods. Between September 2015 and January 2020, patients admitted for ACS or SCD triggered by physical exertion and with coronary stenosis ≤50% were included in this prospective observational study. OCT was performed on the artery deemed to be responsible of the event. Results. Ten patients were enrolled, predominantly men (80%) of middle age (51 years old, IQR 41–63) with low cardiovascular risk burden. Cycling was the most frequent (50%) exercise-related trigger, 8 patients were regular sport practitioners, and 7 had the clinical event during strenuous exertion. Five patients presented with non-ST-elevation ACS, two with ST-elevation ACS, and three with SCD. Angiographic analysis showed nonsignificant stenosis in all patients (42% stenosis, IQR 36–46). OCT identified the etiology of the event in 9 patients (4 plaque erosion, 3 plaque rupture, 1 eruptive calcific nodule, and 1 coronary dissection). Treatment was adjusted according to OCT findings. Conclusions. OCT is a valuable technique to identify the etiology of exercise-related ACS or SCD in patients with nonobstructive coronary arteries and, as a result, may lead to a more specific treatment.

Resumen Introduccion y objetivos Los pacientes mayores de 75 anos con infarto agudo de miocardio con elevacion del segmento ST sometidos a angioplastia primaria en situacion de shock cardiogenico sufren una gran mortalidad. La identificacion previa al procedimento de variables predictoras de la posterior mortalidad seria muy util para guiar la toma de decisiones. Metodos Analisis del registro multicentrico de angioplastia primaria en pacientes mayores de 75 anos (ESTROFA MI + 75), que incluye a 3.576 pacientes. Se analizaron las caracteristicas y la evolucion clinica del subgrupo con shock cardiogenico para identificar predictores de supervivencia a 1 ano tras la angioplastia y elaborar un indice pronostico. Se valido el indice en una cohorte independiente. Resultados Se incluyo a 332 pacientes. Los predictores basales independientes fueron: la localizacion anterior (HR = 2,8; IC95%, 1,4-6,0; p = 0,005), una fraccion de eyeccion 6 h (HR = 3,2; IC95%, 1,6-7,5; p = 0,001). Se diseno un indice basado en estas variables (indice «6-ANT-40»). La supervivencia a 1 ano fue del 54,5% de aquellos con indice 0, el 32,3% con indice 1, el 27,4% con indice 2 y el 17% con indice 3 (p = 0,004, estadistico C = 0,70). En una cohorte independiente de 124 pacientes, las supervivencias a 1 ano fueron del 64,5, el 40,0, el 28,9 y el 22,2% respectivamente (p = 0,008; estadistico C = 0,68). Conclusiones Un indice basado en simples variables clinicas previas al procedimiento (localizacion anterior, fraccion de eyeccion 6 h) permite estimar la supervivencia tras una angioplastia primaria de los pacientes mayores con shock cardiogenico, y asi ayudar en la toma de decisiones.

Introduction and objectives: The proportion of elderly patients undergoing primary angioplasty is growing. The present study describes the clinical profile, procedural characteristics, outcomes, and predictors of outcome. Methods: A 31-center registry of consecutive patients older than 75 years treated with primary angioplasty. Clinical and procedural data were collected, and the patients underwent clinical follow-up. Results: The study included 3576 patients (39.3% women, 48.5% with renal failure, 11.5% in Killip III or IV, and 29.8% with > 6 hours of chest pain). Multivessel disease was present in 55.4% and nonculprit lesions were additionally treated in 24.8%. Radial access was used in 56.4%, bivalirudin in 11.8%, thromboaspiration in 55.9%, and drug-eluting stents in 26.6%. The 1-month and 2-year incidences cardiovascular death were 10.1% and 14.7%, respectively. The 2-year rates of definite or probable thrombosis, repeat revascularization, and BARC bleeding > 2 were 3.1%, 2.3%, and 4.2%, respectively. Predictive factors were diabetes mellitus, renal failure, atrial fibrillation, delay to reperfusion > 6 hours, ejection fraction < 45%, Killip class III-IV, radial access, bivalirudin, drug-eluting stents, final TIMI flow of III, and incomplete revascularization at discharge. Conclusions: Notable registry findings include frequently delayed presentation and a high prevalence of adverse factors such as renal failure and multivessel disease. Positive procedure-related predictors include shorter delay, use of radial access, bivalirudin, drug-eluting stents, and complete revascularization before discharge. (C) 2016 Sociedad Espanola de Cardiologia. Published by Elsevier Espana, S.L.U. All rights reserved.

Resumen Introduccion y objetivos La proporcion de pacientes de edad avanzada que se someten a angioplastia primaria esta creciendo. Este estudio describe el perfil clinico, las caracteristicas de los procedimientos, la evolucion y los predictores pronosticos. Metodos Registro en 31 centros de pacientes consecutivos mayores de 75 anos tratados con angioplastia primaria. Se recogieron variables clinicas y del procedimiento y se efectuo seguimiento clinico. Resultados Se incluyo a 3.576 pacientes (el 39,3% mujeres, el 48,5% con insuficiencia renal, el 11,5% en Killip III o IV y el 29,8% con mas de 6 h de dolor). El 55,4% presentaba enfermedad multivaso y al 24,8% se les trato ademas lesiones no culpables. Se utilizo via radial en el 56,4%, bivalirudina en el 11,8%, aspiracion de trombo en el 55,9% y stents farmacoactivos en el 26,6%. La incidencia de muerte cardiaca al mes era del 10,1% y a los 2 anos, del 14,7%. A los 2 anos la trombosis definitiva o probable era del 3,1%; la revascularizacion de lesion tratada, del 2,3% y las hemorragias BARC > 2, del 4,2%. Los predictores pronosticos fueron: diabetes mellitus, insuficiencia renal, fibrilacion auricular, retraso > 6 h, fraccion de eyeccion III - IV , via radial, bivalirudina, stents farmacoactivos, flujo final TIMI III y revascularizacion incompleta al alta. Conclusiones En este registro destaca el frecuente retraso en la presentacion y la alta prevalencia de factores adversos como la insuficiencia renal o la enfermedad multivaso. Se identificaron como factores protectores relacionados con el procedimiento el menor retraso, el uso de via radial, la bivalirudina, los stents farmacoactivos y la revascularizacion completa antes del alta.

BACKGROUND AND OBJECTIVES: Patients older than 75 years with ST-segment elevation myocardial infarction undergoing primary angioplasty in cardiogenic shock have high mortality. Identification of preprocedural predictors of short- and long-term mortality could be useful to guide decision-making and further interventions. METHODS: We analyzed a nationwide registry of primary angioplasty in the elderly (ESTROFA MI+75) comprising 3576 patients. The characteristics and outcomes of the subgroup of patients in cardiogenic shock were analyzed to identify associated factors and prognostic predictors in order to derive a baseline risk prediction score for 1-year mortality. The score was validated in an independent cohort. RESULTS: A total of 332 patients were included. Baseline independent predictors of mortality were anterior myocardial infarction (HR 2.8, 95%CI, 1.4-6.0 P=.005), ejection fraction6hours (HR 3.2, 95%CI, 1.6-7.5; P=.001). A score was designed that included these predictive factors (score "6-ANT-40"). Survival at 1 year was 54.5% for patients with score 0, 32.3% for score 1, 27.4% for score 2 and 17% for score 3 (P=.004, c-statistic 0.70). The score was validated in an independent cohort of 124 patients, showing 1-year survival rates of 64.5%, 40.0%, 28.9%, and 22.2%, respectively (P=.008, c-statistic 0.68). CONCLUSIONS: A preprocedural score based on 3 simple clinical variables (anterior location, ejection fraction6 hours) may be used to estimate survival after primary angioplasty in elderly patients with cardiogenic shock and to guide preinterventional decision-making.

Uno de los objetivos criticos de la estrategia de salud en la cardiopatia isquemica es la atencion urgente del infarto agudo de miocardio con elevacion del ST (IAMCEST) y mas concretamente del sindrome coronario agudo con elevacion del ST, en los que el tiempo asistencial es critico. Esta inmediatez del tratamiento (ya sea mecanica o farmacologica) se deberia reflejar en los resultados de morbimortalidad. En 2003, tras la evidencia cientifica de la necesidad de una revascularizacion mecanica (intervencion coronaria percutanea primaria) en el infarto agudo de miocardio con elevacion del segmento ST, se establecio esta opcion terapeutica en el hospital de referencia de nuestra comunidad (programa de intervencion coronaria percutanea primaria). En marzo de 2008, tras multiples reuniones con diferentes estamentos y centros, se puso en marcha el Registro Comunitario de la Asistencia al Sindrome Coronario Agudo con Elevacion del ST (Registro Codigo Infarto de las Illes Balears). Se realiza: a) deteccion y documentacion de todos los casos diagnosticados de IAMCEST en la comunidad autonoma; b) evaluacion sistematica de los resultados asistenciales del IAMCEST y su ajuste a los objetivos asistenciales (tiempos, morbimortalidad, complicaciones, tratamientos, etc.); c) identificacion y abordaje de las desviaciones respecto a los objetivos; d) conocimiento exhaustivo e implicacion en el proyecto de todos los dispositivos asistenciales, y e) seguimiento al mes, a los 6 meses y al ano del alta hospitalaria tras el proceso agudo del IAMCEST

Objectives This study sought to evaluate second-generation drug-eluting stent (DES) thrombosis in clinical practice. Background First-generation DES are associated with a significant incidence of late thrombosis. There is paucity of data regarding real practice late thrombosis incidence and predictors with second-generation DES, zotarolimus-eluting stent (ZES), and everolimus-eluting stents (EES). Methods A prospective, large-scale, non-industry-linked multicenter registry was designed. Complete clinical-procedural data and systematic follow-up of all patients treated with these stents was reported in a dedicated registry supported by the Spanish Working Group on Interventional Cardiology. Results From 2005 to 2008, 4,768 patients were included in 34 centers: 2,549 treated with ZES, and 2,219 with EES. The cumulative incidence of definite/probable thrombosis for ZES was 1.3% at 1 year and 1.7% at 2 years and for EES 1.4% at 1 year and 1.7% at 2 years (p = 0.8). The increment of definite thrombosis between the first and second year was 0.2% and 0.25%, respectively. In a propensity score analysis, the incidence remained very similar. Ejection fraction (adjusted hazard ratio [HR]: 0.97; 95% confidence interval [CI]: 0.95 to -0.99; p = 0.008), stent diameter (adjusted HR: 0.37; 95% CI: 0.17to 0.81; p = 0.01) and bifurcations (adjusted HR: 2.1; 95% CI: 1.14 to 3.7; p = 0.02) emerged as independent predictors of thrombosis. In the subgroup of patients with bifurcations, the use of ZES was independently associated with a higher thrombosis rate (adjusted HR: 4; 95% CI: 1.1 to 13; p = 0.03). Conclusions In a real practice setting, the incidence of thrombosis at 2 years with ZES and EES was low and quite similar. The incidence of very late thrombosis resulted lower than was reported in registries of first-generation DES. In the subset of bifurcations, the use of ZES significantly increased the risk of thrombosis.

Primary angioplasty is the best reperfusion treatment in ST elevated myocardial infarction. The prevalence of very elderly patients (> 75 years) undergoing primary angioplasty is progressively increasing as population is ageing. The benefit of the new generation drug-eluting stents over bare metal

A 53-year-old Chinese male smoker with no other risk factors was admitted with non-ST elevation myocardial infarction. Echocardiography ( Panels A and B ; see Supplementary data online, Video S1 ) revealed moderate to severe (Grade 3) aortic regurgitation with left ventricle dilatation and severe global left ventricular dysfunction. Coronarography ( Panel C ; see Supplementary data online, Video S2 ) showed …