Search

Clinical outcomes of patients suffering periprocedural myocardial injury and undergoing incomplete revascularization (IR) following percutaneous coronary intervention (PCI) has never been investigated.To investigate the relationship between different thresholds of post-PCI cardiac troponin (cTn) elevation and revascularization completeness in determining long-term clinical outcomes.Patients were stratified in tertiles according to preprocedural SYNTAX score (SS) (low: 0-6; medium:6-11; high:11) and residual SS (low: 0-4; medium:4-8; high:8). IR was defined by a rSS value4. Three thresholds of myocardial injury were pre-specified: 5×, 35× and 70× 99th percentile upper reference limit (URL) increase of baseline cTn. Primary outcome was a composite of major adverse cardiac events (MACE) at two years of follow-up.1061 patients undergoing PCI for stable coronary artery disease were enrolled. IR occurred in 249 (23.4 %) and major myocardial injury in 540 (50.9 %). Patients belonging to the highest tertile of SS showed an increased risk of experiencing IR and periprocedural myocardial injury. Two-year follow-up was available in 869. At multi-variate Cox's regression analysis, patients undergoing IR + cTn35 × URL and IR + cTn70 × URL showed an increased risk of MACE [HR 2.30 (1.19-4.41) and HR 3.20 (1.38-7.41); respectively].Periprocedural myocardial injury is critically associated with MACE at two-year follow-up in patient treated with PCI who achieve IR. Despite conflicting evidence exists regarding the influence of periprocedural myocardial injury on clinical outcomes, patients undergoing IR seem to represent a high-risk subgroup.

Evidence assessing potential diurnal variations of platelet reactivity in patients on clopidogrel treated with elective percutaneous coronary intervention (PCI) for chronic coronary syndrome (CCS) are currently lacking. We prospectively enrolled 15 patients affected by stable coronary artery disease (CAD) previously treated with elective PCI and on clopidogrel for at least 8 days (administered at 8 a.m.). A significant heterogeneity in diurnal levels of ADP-dependent platelet aggregation was found (p = 0.0004), with a peak of platelet reactivity occurring at the 6 a.m. assessment, which resulted significantly increased compared to the afternoon (6 p.m.) evaluation (255 ± 66 vs 184 ± 67, p = 0.002). In addition, at the early-morning evaluation a considerably high proportion of patients with high platelet reactivity (53.3%) were observed. In conclusion, clopidogrel-induced platelet inhibition in patients with CCS after elective PCI follows a circadian rhythm, thus suggesting that a consistent and durable antiplatelet inhibition is often failed with standard clopidogrel administration at morning.

Percutaneous coronary intervention (PCI) is frequently complicated by type 4a myocardial infarction (MI), which is associated with an increased risk of mortality. We assessed the usefulness of the angiography-derived hemodynamic index (ADDED), which is based on the extent of myocardium at risk and on the anatomical lesion severity, in predicting type 4a MI in patients with chronic coronary syndrome (CCS) undergoing PCI. We enrolled 442 patients treated with single-vessel PCI. The ADDED index was calculated as the ratio of the Duke Jeopardy Score to the minimum lumen diameter assessed with quantitative angiography analysis. Type 4a MI was defined according to the 4th Universal Definition of MI. The overall population was divided into tertiles of ADDED index. Type 4a MI occurred in 5 patients (3.3%) in the ADDED-low tertile, 8 (5.5%) in the ADDED-mid tertile, and 26 (17.7%) in the ADDED-high tertile (p 0.0001). At ROC curve analysis, the ADDED index could significantly discriminate between patients with and without type 4a MI (area under the curve 0.745). At multivariate analysis, an ADDED index value 5.25 was the strongest independent predictor type 4a MI. Our results support the role of the ADDED index as a predictor of type 4a MI in patients with CCS treated with elective PCI of a single vessel. Whether a selective use of additional preventive measures in patients considered at high risk based on ADDED index values may improve peri-procedural and long-term outcomes remains to be tested in dedicated investigations.

Patients suffering from atrial fibrillation (AF) and severe aortic stenosis thus undergoing transcatheter aortic valve implantation (TAVI) have a worse prognosis than those in sinus rhythm. One of the reasons of this is related to the augmented bleeding risk associated with oral anticoagulation (OAC). Left atrial appendage occlusion (LAAO) represents a therapeutic choice to avoid this drug intake and to reduce this kind of adverse outcome. So, a combined procedure of TAVI and LAAO could be an option for TAVI candidates with AF to omit the need for OAC. The clinical case concerns an 85-year-old man with hypertension and dyslipidemia with a history of recent syncope and permanent atrial fibrillation in therapy with antithrombotic drug. Brain MRI performed during hospitalization showed numerous hemosiderin deposits with microhemorrhagic foci thus contraindicating oral anticoagulation. Severe aortic stenosis has also been found to the transthoracic echocardiogram with a mean gradient of 35 mmHg and confirmed by transesophageal echocardiogram with a planimetric area of 0.8 sq.cm. Furthermore, given the finding of significative left circumflex artery disease, after Heart Team discussion and the execution of CT scan that demonstrated the feasibility of transcatheter approach, it was decided to perform in a single session percutaneous coronary intervention (PCI) plus TAVI plus left atrial appendage closure (LAAO). This kind of approach allowed a quick recovery to the patient after a short period of hospitalization. After six months from interventional procedure his NYHA (New York Heart Association Functional Classification) status improved abutting on I/II class. As described above, it can be deduced that combined approach (TAVI+LAAO) is feasible for certain kind of patients thus avoiding surgical approach and long hospitalization. Furthermore, multimodality imaging is of critical importance to plan a complex procedure and an accurate step-by-step pre-procedural strategical planning is the key for procedural success.

Background Contrast-Induced Acute Kidney Injury (CI-AKI) is a complication of patients undergoing percutaneous coronary intervention (PCI) associated with high morbidity and mortality and higher incidence is in patients with type II diabetes mellitus. Recently several randomized controlled trials have shown a clear benefit of new anti-diabetic drugs (GLP-1 analogues, DPP-4 inhibitors and SGLT-2 inhibitors) in the prevention of kidney damage but no study has evaluated their possible role in the prevention of CI-AKI in patients undergoing percutaneous coronary intervention. Methods The study enrolled 408 patients undergoing PCI and divided them into three groups: 136 with type 2 diabetes mellitus treated with new-antidiabetic drugs, 136 with type 2 diabetes mellitus treated with standard-antidiabetic therapy, and 136 non-diabetic patients. Patients were evaluated for serum creatinine (measured at the time of hospitalization, 24-hour and 48-hour post-PCI), glomerular filtration rate (eGFR) estimated using the Cockcroft-Gault equation before and after the procedure, and markers of myocardial damage at the admission and 24 hours after PCI. CI-AKI was defined as an increase in serum creatinine levels ≥ 0.3 mg / dL (26.5 μmol / L) or greater than 25% of the base value, occurred 24-48 hours after administration of the contrast medium. Results It was observed a significant increase in delta creatinine between pre and post PCI in the group treated with standard-antidiabetic therapy (0.91 ± 0.22 mg / dL vs 0.94 ± 0.23 mg / dL, p= 0.008), but not in the group treated with new-antidiabetic drugs that showed a delta creatinine close to zero (1.01 ± 0.33 mg / dL vs 1.01 ± 0.35 mg / dL, p = 0.945), similar to that observed in non-diabetic patients (1.01 ± 0.30 mg / dL vs 0.99 ± 0.31 mg / dL, p = 0.020). The patients treated with SGLT-2 inhibitors presented pre-PCI mean creatinine levels significantly lower (0.83 ± 0.16 mg / dL) than those treated with DPP-4 inhibitors (1.04 ± 0.34 mg / dL) and GLP-1 analogues (1.05 ± 0.39 mg / dL), (p for trend = 0.009). However, the creatinine delta between the pharmacological classes was similar (p = 0.881). The incidence of CI-AKI, defined as an increase ​​of serum creatinine 24-48 hours after contrast medium administration ≥ 25%, was 9.6% in patients treated with standard-antidiabetic therapy, 4.4% in patients treated with new-antidiabetic drugs and 3.7% in non-diabetic patients (p for trend = 0.080). The incidence of CI-AKI, defined as an increase of serum creatinine 24-48 hours after contrast medium administration ≥0.3 mg / dL, was 5.1% in the standard-antidiabetic therapy group, 3.8% in the new-antidiabetic drugs group and 2.9% in the non-diabetic patients (p for trend = 0.911). Conclusions The study demonstrated in diabetic patients undergoing PCI and in treatment with new anti-diabetic drugs (GLP-1 analogues, DPP-4 inhibitors, SGLT-2 inhibitors) a reduced incidence of CI-AKI compared to diabetic patients in treatment with traditional antidiabetic drugs (metformin, sulfonylureas, thiazolidinediones, insulin) and a similar incidence of CI-AKI compared to non-diabetic patients. The results of this study underline a possible protective role of new anti-diabetic drugs for the prevention of CI-AKI.

Percutaneous closure of a patent forame ovale (PFO) is indicated in selected patients with a confirmed cryptogenic stroke, transient ischemic attack (TIA), or systemic embolism and an estimated high probability of a casual role of the PFO as assessed by clinical, anatomical and imaging features. This procedure is usually undertaken from the femoral vein. In this case, the patient was affected by vena cava agenesis with a compensatory enlargement of azygos vein. We performed the percutaneous closure of the PFO using a 9F jugular vein access. We advanced a straight guide trough the foramen with a Multipurpose 6F catheter supported by a Destino Oscor 8F. Then we changed the straight guide with an Amplatz Super-Stiff 0.035" guide in the left ventricle, on which a Mullins 9F trans-septal catheter was advanced. Finally we delivered an Amplatzer Multifenestrated Septal Occluder "Cribriform" 25/25 mm. In our case, it was impossible to perform the PFO closure procedure using the classic femoral vein access due to the inferior vena cava agenesis. Performing PFO closure using the right internal jugular venous approach was technically challenging but safe and it is possible using standard equipment normally present in the Catheterization Laboratory. In rare cases of an indication for PFO closure and lack of access through the femoral veins, alternative techniques using on the shelf materials help in overcoming the challenging anatomies. The use of steerable catheter is critical for engaging the foramen ovale with unfavourable angulation. The procedure with nitinol double disk devices is safe and effective.

Introduction Aortic valve calcification (AVC) represents a negative prognostic factor in patients undergoing transcatheter aortic valve implantation (TAVI). Recent randomized clinical trials comparing commercially available self-expanding (SE) supra-annular and balloon-expandable (BE) devices with second-generation SE intra-annular devices demonstrated the clinical non-inferiority of the latter in terms of procedural success. However, no current data are available in vivo regarding the potential impact of AVC on SE intra-annular device performance and clinical outcomes. Purpose to evaluate the potential impact of different AVC patterns on SE intra-annular device performance in a consecutive cohort of patients undergoing TAVI. Methods this is an observational, non-randomized, prospective, single-center study preliminarily enrolling 53 consecutive patients who underwent TAVI with a SE intra-annular device (Portico - Abbott Structural Heart, St Paul, MN, USA) between 2019 and 2022 at our department. All patients underwent transthoracic echocardiography, contrast-enhanced multidetector row computed tomography (MDCT) with volumetric calcium score and coronary angiography before TAVI. Patients with bicuspid aortic valve and previous surgical aortic valve replacement eligible for valve-in-valve TAVI were excluded. AVC and left ventricle outflow tract (LVOT) calcification (up to 15 mm below the basal annular plane) were quantified in the contrast images by using a Hounsfield unit threshold of 850. Results Patients undergoing post-TAVI pacemaker implantation (19% of the overall study population) had higher AVC levels compared with those that did not show this complication (all three cusps AVA calcium score 270.6±409.6 vs 158.1±137.1, p=0.146; p=0.048, p=0.181 and p=0.346 for left cusp- LCC, right cusp – RCC- and non-coronary cusp-NCC, respectively). Severe LVOT calcification was also associated with a higher incidence of AV conduction abnormalities (37.9±44.5 vs 13.4±39.0 of patients without AV defects, p=0.045). Moreover, post-procedural moderate/severe aortic regurgitation occurred more frequently in patients with LCC calcification (183.7±87.0 vs 64.2±99.6, p=0.018) and RCC calcification (188.7±149.5 vs 58.7±120.8, p=0.019) rather than those with NCC or LVOT calcification. Conclusion(s) preliminary results of our observational registry highlight the potential impact of AVC patterns on the occurrence of aortic regurgitation and pacemaker implantation after a SE intra-annular device. A larger sample size is needed to better understand the impact of calcium patterns on each single outcome in order to identify patients at higher risk and to early manage these complications, improving long-term outcomes.

Il diabete mellito aumenta tra 2 e 4 volte il rischio di complicanze cardiovascolari maggiori e richiede, pertanto, strategie precoci e aggressive di prevenzione cardiovascolare primaria che dovrebbero comprendere, oltre all’educazione a uno stile di vita sano, l’uso delle statine e di farmaci ipoglicemizzanti con effetti cardioprotettivi. Nell’ambito della prevenzione cardiovascolare primaria assistiamo da anni al dibattito sull’efficacia e la sicurezza dell’aspirina a basse dosi. Nonostante le evidenze non del tutto incoraggianti questo farmaco viene ampiamente prescritto ai soggetti diabetici, spesso in maniera impropria. Lo scopo di questo articolo e quello di fornire una rassegna critica delle evidenze e delle raccomandazioni sull’uso dell’aspirina in prevenzione cardiovascolare primaria nei diabetici e di proporre un approccio ragionato alla prescrizione di questo farmaco.

The Mehran score is the most widely accepted tool for predicting contrast-induced acute kidney injury (CI-AKI), a major complication of percutaneous coronary intervention (PCI). Similarly, abnormal fasting pre-procedural glycemia (FPG) represents a modifiable risk factor for CI-AKI, but it is not included in current risk models for CI-AKI prediction. We sought to analyze whether adding FPG to the Mehran score improves its ability to predict CI-AKI following PCI. We analyzed 671 consecutive patients undergoing PCI (age 69 [63,75] years, 23% females), regardless of their diabetic status, to derive a revised Mehran score obtained by including FPG in the original Mehran score (Derivation Cohort). The new risk model (GlyMehr) was externally validated in 673 consecutive patients (Validation Cohort) (age 69 [62,76] years, 21% females). In the Derivation Cohort, both FPG and the original Mehran score predicted CI-AKI (AUC 0.703 and 0.673, respectively). The GlyMehr score showed a better predictive ability when compared with the Mehran score both in the Derivation Cohort (AUC 0.749, 95%CI 0.662 to 0.836; p = 0.0016) and the Validation Cohort (AUC 0.848, 95%CI, 0.792 to 0.903; p = 0.0008). In the overall population (n = 1344), the GlyMehr score confirmed its independent and incremental predictive ability regardless of diabetic status (p ≤0.0034) or unstable/stable coronary syndromes (p ≤0.0272). In conclusion, adding FPG to the Mehran score significantly enhances our ability to predict CI-AKI. The GlyMehr score may contribute to improve the clinical management of patients undergoing PCI by identifying those at high risk of CI-AKI and potentially detecting modifiable risk factors.

Coronary artery disease (CAD) remains one of the most important causes of morbidity and mortality worldwide, and revascularization through percutaneous coronary interventions (PCI) significantly improves survival. In this setting, poor glycaemic control, regardless of diabetes, has been associated with increased incidence of peri-procedural and long-term complications and worse prognosis. Novel antidiabetic agents have represented a paradigm shift in managing patients with diabetes and cardiovascular diseases. However, limited data are reported so far in patients undergoing coronary stenting. This review intends to provide an overview of the biological mechanisms underlying hyperglycaemia-induced vascular damage and the contrasting actions of new antidiabetic drugs. We summarize existing evidence on the effects of these drugs in the setting of PCI, addressing pre-clinical and clinical studies and drug-drug interactions with antiplatelet agents, thus highlighting new opportunities for optimal long-term management of these patients.

Contrast-induced acute kidney injury (CI-AKI) is a serious complication in patients undergoing diagnostic or therapeutic procedures that require contrast use and negatively affects the long-term outcomes. Patients with type 2 diabetes mellitus (DM), particularly those who have already developed diabetic nephropathy (DN), are more susceptible to contrast-induced renal damage. Indeed, contrast media amplify some pathological molecular and cellular pathways already in place in the DN setting. In recent years, sodium-glucose cotransporter-2 inhibitors (SGLT2i) have triggered a paradigm shift in managing patients with type 2 DM, reducing cardiovascular and renal adverse events, and slowing DN development. Some evidence also suggests favorable effects of SGLT2i on acute kidney injury despite the initial alarm; however, little data exist regarding CI-AKI. The present review provides an updated overview of the most recent experimental and clinical studies investigating the beneficial effects of SGLT2i on chronic and acute renal injury, focusing on their potential role in the development of CI-AKI. Thus, we aimed to expand the clinicians' understanding by underscoring new opportunities to prevent this complication in the setting of DM, where effective preventive strategies are still lacking.

High platelet reactivity (HPR) on clopidogrel and chronic kidney disease (CKD) are recognized as potent risk factors for adverse outcomes in patients suffering coronary artery disease (CAD) and undergoing percutaneous coronary intervention (PCI). However, conclusive evidence regarding their reciprocal interaction and the consequent impact on clinical events is still lacking.We performed a metaanalysis with the aim to evaluate the prevalence of HPR in patients with and without CKD and the incidence of major adverse cardiovascular events (MACE) according to the renal and platelet function status in current literature (co-primary endpoints). Secondary endpoints were myocardial infarction (MI), all-cause death, and definite/probable stent thrombosis (ST).We searched on PubMed, EMBASE, and Cochrane Library studies investigating CKD and HPR on clopidogrel in patients suffering CAD who underwent PCI and their related outcomes. Overall, 13 studies including 22.464 patients were selected. Odds ratios (ORs) and 95% confidence intervals (CI) were calculated using a random-effects model with the Mantel-Haenszel method.Patients with CKD presented significantly higher odds of HPR compared with those without CKD (OR 1.51 [95% CI: 1.29, 1.76]). In patients without CKD, HPR was associated with increased odds of MACE (OR 1.31 [95% CI: 1.01, 1.72]), MI (OR 1.48 [95% CI: 1.17, 1.86]) and definite/probable ST (OR 2.45 [95% CI: 1.08, 5.60]). In patients with CKD, HPR was associated with higher odds of both MACE (OR 1.61 [95% CI: 1.14, 2.27]) and MI (OR 1.69 [95% CI: 1.11, 2.59]), compared to those without HPR.Our analysis shows that HPR on clopidogrel is more frequent in patients with CKD treated with PCI. Patients with HPR are exposed to a high risk of MACE after PCI, regardless of the renal function status.

Aims Percutaneous coronary intervention (PCI) is frequently complicated by type 4a myocardial infarction (MI). We assessed the usefulness of the angiography-derived haemodynamic index (ADDED) index in predicting type 4a MI in patients with chronic coronary syndrome (CCS) undergoing PCI. Methods and results We enrolled 442 patients treated with single-vessel PCI. The ADDED index was calculated as the ratio of the Duke Jeopardy Score (DJS) to the minimum lumen diameter (MLD) assessed with quantitative angiography analysis (QCA). Patients in the higher ADDED tertile presented higher occurrence of type 4a MI (17.7%, P 5.25 was the strongest independent predictor type 4a MI. Conclusions Our results support the role of the ADDED index as a predictor of type 4a MI in patients with CCS treated with elective PCI.

Aims The potential diurnal variations of platelet reactivity in patients on clopidogrel treated with elective percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) are currently unknown. Methods and results We prospectively enrolled 15 patients with stable CAD treated PCI and on clopidogrel therapy for at least eight days. All patients received their maintenance 75-mg clopidogrel dose at 8 AM. Platelet reactivity was assessed with the Verifynow P2Y12 assay at three different time points (10 AM, 6 PM, and 6 AM). Platelet reactivity is expressed as P2Y12 reaction units (PRU) and PRU thresholds ≥208 and ≥240 were used to define high platelet reactivity (HPR). A significant heterogeneity in diurnal levels of platelet reactivity was found (P = 0.0004), with a peak occurring at the 6 AM assessment. In addition, at the 6 AM evaluation patients showed the highest prevalence of HPR (53.3% of patients with PRU ≥240, 66.7% of patients with PRU ≥208). Conclusions Platelet reactivity in patients with stable CAD treated with PCI and taking clopidogrel in the morning follows a circadian rhythm, thus suggesting that platelet inhibition may not be constant and sufficient throughout the day. Whether an evening or a bis in die administration of clopidogrel may result in a constant and more reliable antiplatelet inhibition, should be investigated in dedicated studies.

Aims High platelet reactivity (HPR) on clopidogrel and chronic kidney disease (CKD) are recognized as potent risk factors for adverse outcomes in patients suffering coronary artery disease (CAD) and undergoing percutaneous coronary intervention (PCI). However, conclusive evidence regarding their reciprocal interaction and the consequent impact on clinical events is still lacking. We performed a meta-analysis with the aim to evaluate the prevalence of HPR in patients with and without CKD and the incidence of major adverse cardiovascular events (MACE) according to the renal and platelet function status in current literature (co-primary endpoints). Secondary endpoints were myocardial infarction (MI), all cause death and definite/probable stent thrombosis (ST). Methods and results We searched on PubMed, EMBASE, and Cochrane Library studies investigating CKD and HPR on clopidogrel in patients suffering CAD who underwent PCI and their related outcomes. Overall, 13 studies including 22.464 patients were selected. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random-effects model with the Mantel–Haenszel method. Patients with CKD presented significantly higher odds of HPR compared with those without CKD [OR: 1.51 (95% CI: 1.29–1.76)]. In patients without CKD, HPR was associated with increased odds of MACE [OR: 1.31 (95% CI: 1.01–1.72)], MI [OR: 1.48 (95% CI: 1.17–1.86)] and definite/probable ST [OR: 2.45 (95% CI: 1.08–5.60)]. In patients with CKD, HPR was associated with higher odds of both MACE [OR: 1.61 (95% CI: 1.14–2.27)] and MI [OR: 1.69 (95% CI: 1.11–2.59)], compared to those without HPR. Conclusions Our analysis shows that HPR on clopidogrel is more frequent in patients with CKD treated with PCI. Patients with HPR are exposed to a high risk of MACE after PCI, regardless of the renal function status.

Aims Severe tricuspid valve regurgitation (TVR) is critically associated with an increased risk of morbidity and mortality, surgical treatment is limited by high perioperative risk. In these patients, transcatheter edge to edge valve repair (TEER) is progressively recognized as an effective treatment strategy. The aim of this work is to report the single centre experience procedural results and clinical outcomes in ‘real-world’ patients suffering TVR treated with the TriClip™ device (Abbott Vascular, Santa Clara, California). Methods From January up to July 2021, we screened 30 patients with severe TR, among which 8 were treated with TEER. All patients underwent cardiac computerized tomography and both transesophageal and transthoracic echocardiography, with the purpose to identify a dedicated grasping strategy. TEER was performed through right common femoral vein access, advancing a 24 F steerable guiding catheter (SGC) in the right atrium. Following, the TriClip delivery system was advanced and positioned over the valve centroid and, once oriented, the clip was opened. Under fluoroscopic and transesophageal monitoring, the clip was advanced in the right ventricle and pulled back to grasp the target leaflets. Following echocardiographic control, the clip was released. Results Procedural success, defined as a significative reduction of the regurgitation’s severity, was achieved in all patients. No procedural or in-hospital adverse events were reported. At 30 days follow-up, all patients were alive and no further hospitalizations occurred. Conclusions In our single centre experience, TEER appeared to be a valid and feasible therapeutic option in patients with severe TVR. Multicentre prospective studies are mostly needed to assess the long terms outcomes of TEER in these patients, with the purpose to introduce in the clinical practice a valid alternative to the highly risk surgical option.

The critical role of the coronary microvascular compartment and its invasive functional assessment has become apparent in light of the significant proportion of patients presenting signs and symptoms of myocardial ischemia, despite the absence of epicardial disease, or after the adequate treatment of it. However, coronary microvascular dysfunction (CMD) represents a diagnostic challenge because of the small dimensions of the coronary microvasculature, which prevents direct angiographic visualization. Several diagnostic tools are now available for the invasive assessment of the coronary microvascular function, which, in association with the physiological indices used to investigate the epicardial department, may provide a comprehensive evaluation of the coronary circulation as a whole. Recent evidence suggests that the physiology-guided management of CMD, although apparently costly and time-consuming, may offer a net clinical benefit in terms of symptom improvement among patients with angina and ischemic heart disease. However, despite the results of several observational studies, the prognostic effect of the physiology-driven management of CMD within this population is currently a matter of debate, and therefore represents an unmet clinical need that urgently deserves further investigation.

We evaluated the predictive power of age, creatinine, and ejection fraction (ACEF) score on mortality at 5-year follow-up in a population of 471 patients with chronic coronary syndrome (CCS) treated with percutaneous coronary intervention (PCI). Patients in the ACEF-High tertile showed the highest incidence of death at 5 years (15.7% vs. 2.6% in ACEF-Low and 4.3% in ACEF-Mid; log rank p0.001). The ACEF score could significantly discriminate between patients who died and those who were still alive at 5 years (AUC 0.741, 95% CI 0.654-0.828), and an ACEF score1.32 was identified as the optimal cutoff point to predict 5-year mortality (sensitivity 74%, specificity 68%). An ACEF score1.32 was an independent predictor of 5-year mortality (HR 5.77, 95% CI 2.70-12.31; p0.001). Our study shows that the ACEF score can predict mortality at 5-year follow-up in patients with CCS treated with PCI.

Background While the superiority of reabsorbable-polymer drug-eluting stents (RP-DES) over bare-metal stents and first-generation durable-polymer (DP)-DES has been largely established, their advantage compared with new-generation DP-DES is still controversial. This study aimed was to compare clinical outcomes of all-comer patients undergoing percutaneous coronary intervention (PCI) with new generation DP-DES or RP-DES implantation. Methods We prospectively enrolled 679 consecutive patients treated with PCI with RP-DES or DP-DES. The primary endpoint was the 1-year incidence of major adverse clinical events (MACE), a composite of death, myocardial infarction (MI), and target vessel revascularization (TVR). Target lesion revascularization (TLR) and definite stent thrombosis were also recorded. Results A total of 439 (64.6%) received RP-DES and 240 (36.4%) received DP-DES. No significant difference in the incidence of MACE (5.9 vs. 4.9%; hazard ratio, 1.23; 95% confidence interval (CI), 0.61-2.49; P = 0.569), death (1.8 vs. 1.7%; hazard ratio, 1.09; 95% CI, 0.33-3.64; P = 0.882), MI (2.3 vs. 2.1%; hazard ratio, 1.05; 95% CI, 0.36-3.08; P = 0.927), TVR (2.3 vs. 1.3%; hazard ratio, 1.70; 95% CI, 0.47-6.20; P = 0.418), TLR (1.4 vs. 0.4%; hazard ratio, 3.06; 95% CI, 0.37-25.40; P = 0.301), and definite stent thrombosis (0.5 vs. 0.4%; hazard ratio, 1.09; 95% CI, 0.10-12.10; P = 0.942) was observed between RP-DES and DP-DES patients at 1-year follow-up. These results were confirmed in a propensity score-matched cohort (n = 134 per group). Conclusion In our registry including a real-world population of all-comer patients undergoing PCI, RP-DES, or durable polymer-DES showed similar efficacy and safety at a 1-year follow-up.

Background: The Mehran score is the most widely accepted tool for predicting contrast-induced acute kidney injury (CI-AKI), a major complication of percutaneous coronary intervention (PCI). Similarly, abnormal fasting pre-procedural glycemia (FPG) represents a modifiable risk factor for CI-AKI, but it is not included in current risk models for CI-AKI prediction. We sought to analyze whether adding FPG to the Mehran score improves its ability to predict CI-AKI following PCI.Methods: We analyzed 671 consecutive patients undergoing PCI (age 69 [63,75] years, 23% females), regardless of their diabetic status, to derive a revised Mehran score obtained by including FPG in the original Mehran score (Derivation Cohort). The new risk model (GlyMehr) was externally validated in 673 consecutive patients (Validation Cohort) (age 69 [62,76] years, 21% females). Results: In the Derivation Cohort, both FPG and the original Mehran score predicted CI-AKI (AUC 0.703 and 0.673, respectively). The GlyMehr score showed a better predictive ability when compared with the Mehran score both in the Derivation Cohort (AUC 0.749, 95%CI 0.662-0.836; p=0.0016) and the Validation Cohort (AUC 0.848, 95%CI, 0.792–0.903; p=0.0008). In the overall population (n=1344), the GlyMehr score confirmed its independent and incremental predictive ability regardless of diabetic status (p≤0.0034) or unstable/stable coronary syndromes (p≤0.0272). Conclusions: Adding FPG to the Mehran score significantly enhances our ability to predict CI-AKI. The GlyMehr score may contribute to improve the clinical management of patients undergoing PCI by identifying those at high risk of CI-AKI and potentially detecting modifiable risk factors.

Atherosclerotic cardiovascular (CV) disease represents one of leading cause of mortality and morbidity in Western countries. An increased risk of CV events was identified in patients with peripheral arterial diseases (PADs), which include all arterial diseases, other than coronary arteries and the aorta. In particular, lower extremity artery disease (LEAD) and/or carotid artery disease present growing incidence in general population and a consequent increase in mortality and morbidity. Medical treatment, including antiplatelet therapy, is a cornerstone in management of these patients, even when they are treated with endovascular or surgical procedures. Despite their clinical relevance, data on optimal antiplatelet treatment in this clinical setting are lacking and often derived from clinical trials on coronary artery disease and by subgroups analysis. The purpose of this review is to examine the available data from registries, randomized trials and meta-analysis on antiplatelet treatment in patients with LEAD and carotid stenosis with the aim to provide evidence to support clinical decision making.

No comprehensive data are available on the role of platelet indexes (PI) in the periprocedural risk stratification of patients who underwent percutaneous coronary intervention (PCI). The aim of this study was to investigate the relation of PI to platelet reactivity (PR) and periprocedural myocardial infarction (PMI) in patients receiving PCI. A total of 502 PCI patients had preprocedural measurement of PI and PR, the latter assessed by VerifyNow P2Y12 assay. Study end points were incidence of PMI and high platelet reactivity (HPR) according to tertiles of PI and evaluation of PI in HPR patients. Incidence of PMI in the overall population was 6.6%. Rates of PMI were not different in PI tertiles: platelet count (I: 6.0%, II: 7.1%, III: 6.5%; p = 0.74), mean platelet volume (MPV, I: 6.6%, II: 7.3%, III: 5.8%;p = 0.86), platelet distribution width (I: 7.2%, II: 7.2%, III: 5.8%;p = 0.74), and MPV/P ratio (I: 6.6%, II: 6.0%, III: 7.1%; p = 0.91). The occurrence of PMI was significantly different in PR tertiles (I: 3%, II: 5.4%, III: 11.4%; p = 0.006). Platelet count and MPV/P ratio were significantly different in patients with and without HPR (221.8 ± 58.6 × 103/µL vs207 ± 59.4 × 103/µL, p = 0.008; 51.73 ± 15.17 vs 56.7 ± 18.3, p = 0.002).In conclusion, this study showed no relation between PI and PMI in PCI patients but confirms the association of HPR with increased incidence of PMI; thus, PI seem to be not able to identify patients at higher periprocedural risk, but monitoring PR by a bedside assay remains a useful tool for risk stratification.

The management of antithrombotic therapy in patients undergoing percutaneous coronary intervention (PCI) with an indication for long-term oral anticoagulant therapy (OAT) is still a matter of debate. We aim to evaluate the safety and the efficacy of dual therapy (DT) compared to triple therapy (TT) in this clinical setting.A study level meta-analysis and a review of randomized trials selected using PubMed, Embase, EBSCO, Cochrane database of systematic reviews, Web of Science, and abstract from major cardiology congresses. Six randomized trials with 12,156 patients evaluating the strategy of DT vs. TT in patients treated with PCI with indication for long-term OAT were included.Patients treated with DT demonstrated a 45% relative reduction in the risk of TIMI major bleeding (1.71% vs. 2.99%; OR 0.55, 95% CI 0.41-0.71; P0.0001) and TIMI minor bleeding compared to TT arm (4.67% vs 7.83%, OR 0.55 95% CI 0.39-0.78, P = 0.0007). All-cause mortality was similar in two arms (3.95% vs 3.77%, P = 0.92), as well as cardiovascular mortality (2.21% vs 2.19%, P = 0.97). DT was associated with a borderline increase of ST (1.02% vs 0.67%, P = 0.07). No significant differences were observed in occurrence of MI and stroke.Our findings suggest that DT is safer than TT with regard to occurrence of major bleeding. DT with a direct oral anticoagulant plus clopidogrel at discharge could be effective in most patients, maintaining aspirin in periprocedural phase and as longer "tailored" treatment for patients at higher ischemic risk.

Background Diabetic patients with on-treatment high platelet reactivity (HPR) show an increased risk of thrombotic events. Whether measuring glycated haemoglobin (HbA1c) levels and/or glycaemic variability (GV) may help identifying diabetic patients at higher risk deserving tailored antiplatelet and/or glucose lowering strategies is unknown. We aimed to investigate the relationship between GV, HbA1c levels and platelet reactivity in patients with type 2 diabetes mellitus (DM) undergoing percutaneous coronary intervention (PCI). Methods Platelet reactivity was measured in type 2 DM patients using VerifyNow P2Y12 assay. HPR was defined as P2Y12 Reaction Unit (PRU) > 240. GV was expressed through mean amplitude of glycaemic excursions (MAGE) and coefficient of variance (CV) by using the iPro™ continuous glucose recorder. Results Thirty-five patients (age 70 ± 9 years, 86% male, mean HbA1c 7.2 ± 1.0%) on clopidogrel therapy were enrolled. HbA1c was independently associated with HPR (OR 7.25, 95% CI 1.55–33.86, p = 0.012). Furthermore, when factored into the model, GV indexes provided independent (OR 1.094, 95% CI 1.007–1.188, p Conclusions Glyco-metabolic state significantly correlates with HPR in well-controlled type 2 DM patients on clopidogrel therapy. HbA1c identifies patients at higher thrombotic risk but the highest diagnostic accuracy is achieved by combining GV and HbA1c. Whether individualized antithrombotic and glucose-lowering therapies based on the assessment of these parameters may reduce the incidence of thrombotic events in patients undergoing PCI should be further investigated.

The hybrid strategy allows for a complete myocardial revascularization in patients with multivessel coronary artery disease and a high frailty index. These patients, due to their old age and multi-comorbidities, are evaluated with inadequate tools for their clinical complexity and destined to an incomplete revascularization for increased surgical or procedural risk. Hybrid revascularization enables to use the best techniques resulting from the surgical and percutaneous approach defining a tailored strategy for the patient. In the frail patient, this strategy is associated with favorable outcomes and a lower exposure to periprocedural complications.

To summarize available evidence regarding lipid-lowering interventions for the prevention of cardiovascular disease in patients with diabetes. Statins and non-statin therapies that act through upregulation of LDL receptor expression are associated with similar cardiovascular risk reduction per decrease in LDL cholesterol. In subjects with diabetes, with or without established cardiovascular disease, each 39 mg/dl reduction in LDL cholesterol observed with statins is associated with a 21% relative reduction in the risk of major coronary events at 5 years. Statins remain the first-line lipid-lowering agents for the management of dyslipidemia in individuals with diabetes; however, the addition of non-statin therapies to lower LDL cholesterol, such as ezetimibe and PCSK-9 inhibitors, to maximally tolerated statin therapy is recommended in patients with atherosclerotic cardiovascular disease and baseline LDL cholesterol over 70 mg/dl. Recent data support even lower LDL cholesterol targets (

In-stent restenosis (ISR) is a major cause of failure of percutaneous coronary intervention. The efficacy and safety of drug-coated balloon (DCB) in patients with high-risk clinical features are largely unknown. We enrolled 82 consecutive patients at high risk of bleeding with angiographically significant (diameter stenosis ≥ 50%) ISR of bare metal stent (BMS) or drug-eluting stent (DES), treated with paclitaxel-coated balloon. All patients presented at least one of the following criteria: high bleeding risk, neoplasm, chronic inflammatory disease, and need for noncardiac surgery. Dual antiplatelet therapy was indicated for 4 weeks after the procedure. At angiographic follow-up, overall late lumen loss was 0.24 ± 0.32 mm, with no significant difference between BMS-ISR and DES-ISR (0.25 ± 0.35 vs 0.22 ± 0.30 mm, p = 0.714). The Kaplan-Meier estimate for major adverse clinical events-free survival at 3 years was 81.4% (82.3% in BMS-ISR vs 79.4% in DES-ISR, log-rank p = 0.866). No stent thrombosis has been recorded. In conclusion, the use of paclitaxel-coated balloon seems to be associated with favorable outcomes after percutaneous coronary intervention for BMS-ISR or DES-ISR in patients with high-risk clinical features and could be considered as a reasonable option in the presence of systemic co-morbidities and contraindications to long-term dual antiplatelet therapy.

Objectives This study sought to evaluate whether a strategy with a 600-mg clopidogrel load and a short-term, high-dose atorvastatin reload would improve outcomes in clopidogrel-naive, statin-treated patients undergoing protected carotid stenting. Background Optimal clopidogrel loading dose during carotid stenting has not been investigated; in addition, statin neuroprotection in this setting has not been described. Methods A total of 156 patients were randomized using a 2 × 2 factorial design to receive either a 600-mg (n = 78) or 300-mg (n = 78) clopidogrel load given 6 h before intervention and either a atorvastatin reload (n = 76; 80 mg + 40 mg initiating 12 h before the procedure) or no statin reload (n = 80). The primary endpoint was the 30-day incidence of transient ischemic attack/stroke or new ischemic lesions on cerebral diffusion-weighted magnetic resonance imaging performed at 24 to 48 h. Results Occurrence of the primary outcome measure was significantly lower in the 600-mg clopidogrel arm (18% vs. 35.9% in the 300-mg group; p = 0.019) and in the atorvastatin reload arm (18.4% vs. 35.0% in the no statin reload group; p = 0.031). High-dose clopidogrel also significantly reduced the transient ischemic attack/stroke rate at 30 days (0% vs. 9%, p = 0.02, secondary endpoint), without an increase in bleeding risk. Conclusions In patients undergoing carotid stenting, a strategy using both a 600-mg clopidogrel load and a short-term reload with high-dose atorvastatin protects against early ischemic cerebral events. These results, obtained along with routine mechanical neuroprotection, provide new evidence of the optimization of drug therapy before percutaneous carotid intervention. (Clopidogrel and Atorvastatin Treatment During Carotid Artery Stenting [ARMYDA-9 CAROTID]; NCT01572623 )

Congenital coronary artery fistulas (CAF) are a sizable connection between a large sub-epicardial coronary artery and a great vessel, a cardiac chamber or pulmonary circulation. They are a rare heart defect, usually found incidentally, associated sometimes to other congenital defects. We present three different case report (Case 1: coronary artery steal phenomen, Case 2: two different types of CAF associated to hypertrophic cardiomyopathy; Case 3: CAF between coronary and right ventricle in congestive heart failure) and review of literature discussing the epidemiology, morphology, clinical presentation and complications, diagnosis techniques and treatment possibilities.

Statin therapy reduces the risk of cardiovascular events in patients with coronary artery disease. Recent in vitro and in vivo studies demonstrated a LDL-independent action of these class of drugs, which appears in modulating endothelial function, inflammation and thrombosis. Periprocedural myocardial infarction and contrast-induced nephropathy after percutaneous coronary intervention (PCI), associated with worse outcome on long-term follow-up, are both complications related to inflammatory pathogenetic mechanisms. Randomized studies demonstrated a beneficial effect of short-term statin pretreatment in reducing periprocedural cardiac marker release in patients undergoing PCI. Statin therapy before elective PCI reduces periprocedural myocardial infarction in patients with stable angina. Furthermore, an acute loading with a high dose of atorvastatin prevents myocardial damage in patients with acute coronary syndromes undergoing early PCI (

PURPOSE OF REVIEW This review discusses the role of statin therapy in patients with acute coronary syndromes. These drugs modulate endothelial function and stabilize atherosclerotic plaque by inhibiting oxidative stress and inflammation and may provide a relevant clinical benefit in unstable patients. RECENT FINDINGS Conflicting data derive from randomized trials about early statin therapy in medically treated patients with acute coronary syndromes. Results of the ARMYDA studies demonstrate a clear benefit of statin pretreatment in patients with both stable and unstable syndromes undergoing percutaneous coronary revascularization. In the ARMYDA RECAPTURE, even an acute reload with high-dose atorvastatin in patients on top of chronic statin use was associated with a significant reduction of 30-day major adverse cardiac events, especially in those patients who presented with acute coronary syndromes. SUMMARY All this evidence strongly supports an 'upstream' administration of high-dose statins in patients with acute coronary syndromes treated with an early invasive strategy.

A large number of randomized trials have established the beneficial effects of statins for primary and secondary prevention of coronary artery disease. Statins may improve endothelial function and stabilize atherosclerotic plaques by inhibiting oxidative stress and inflammation. Pretreatment with statins before elective percutaneous coronary intervention reduces periprocedural myocardial infarction in patients with stable angina or acute coronary syndromes. Moreover, an acute reload of atorvastatin even in the context of chronic statin has been associated with a significant reduction within 30 days of major adverse cardiac events after percutaneous coronary intervention. Patients on statins at the time of percutaneous coronary intervention also had a lower incidence of contrast-induced nephropathy, as compared with those that were statin-naive. Finally, atorvastatin pretreatment may prevent the occurrence of atrial fibrillation in patients undergoing elective cardiac surgery. Overall, this evidence may st...

Statins exert a number of beneficial effects on endothelial function and atherosclerotic plaque, modulating oxidative stress and inflammation, with subsequent, well documented, primary and secondary prevention of coronary artery disease. Periprocedural myocardial infarction and contrast induced nephropathy, after percutaneous coronary intervention (PCI), are associated with a worse outcome on long term follow-up. In the ARMYDA study, pretreatment with statins before elective PCI reduces periprocedural myocardial infarction in patients with stable angina. Moreover, the ARMYDA ACS was the first randomized, prospective trial that demonstrated that an acute loading with a high dose of atorvastatin prevents myocardial damage in patients with unstable syndromes undergoing early (

Over the last few years, the advance in operator’s experience, the improvement in technology and the strong demand from patients for a less-invasive alternative to surgery has made carotid artery stenting (CAS) an equally efficient and safe procedure to carotid endarterectomy for the treatment of carotid artery stenosis [1–3]. The introduction of mechanical cerebral protection systems can be considered the cornerstone in the evolution of CAS; these devices aim to prevent emboli from reaching the brain, and their introduction in the majority of procedures is responsible for better outcomes reported in recent clinical trials and registries. Therefore, guidelines strongly recommend the use of embolic protection devices in all procedures [4]. Despite progress in CAS, periprocedural stroke rate remains significant, and has an important physical, mental and social impact on patients’ lives. Therefore, indication for treatment of asymptomatic patients is one of the most debatable issues in the literature. In particular, incidence of microembolization, during and after CAS, persists despite the use of cerebral protection devices. Diffusion-weighted MRI (DW-MRI) has been shown to be a sensitive tool in identifying new ischemic cerebral lesions that are caused by emboli during CAS. Cerebral ischemic lesions are observed by DW-MRI in 15–78% of patients after CAS, and most of them are not associated with acute neurological symptoms [5–7]. Clinical implication and impact on prognosis of asymptomatic cerebral microembolism is still debated. Recently, a large study analyzing the role of asymptomatic cerebral ischemic lesions after CAS on prognosis in terms of major adverse cardiac and cerebrovascular event (death, stroke and myocardial infarction) demonstrated that a positive DW-MRI after CAS was not an

Poor glycemic control is associated with unfavorable outcome in patients undergoing percutaneous coronary intervention (PCI), irrespective of diabetes mellitus. However a complete assessment of glycemic status may not be fully described by glycated hemoglobin or fasting blood glucose levels, whereas daily glycemic fluctuations may influence cardiovascular risk and have even more deleterious effects than sustained hyperglycemia. Thus, this paper investigated the effectiveness of a continuous glucose monitoring (CGM), registering the mean level of glycemic values but also the extent of glucose excursions during coronary revascularization, in detecting periprocedural outcome such as renal or myocardial damage, assessed by serum creatinine, neutrophil gelatinase-associated lipocalin (NGAL), and troponin I levels. High glycemic variability (GV) has been associated with worse postprocedural creatinine and NGAL variations. Moreover, GV, and predominantly hypoglycemic variations, has been observed to increase in patients with periprocedural myocardial infarction. Thus, our study investigated the usefulness of CGM in the setting of PCI where an optimal glycemic control should be achieved in order to prevent complications and improve outcome.