Prevalence and long-term outcomes of patients with coronary artery ectasia presenting with acute myocardial infarction

Coronary artery ectasia (CAE) is described in 5% of patients undergoing coronary angiography. Previous studies have shown controversial results regarding the prognostic impact of CAE. The prevalence and prognostic value of CAE in patients with acute myocardial infarction (AMI) remain unknown. In 4788 patients presenting with AMI referred for coronary angiography the presence of CAE (defined as dilation of a coronary segment with a diameter >= 1.5 times of the adjacent normal segment) was confirmed in 174 (3.6%) patients (age 62 + 12 years; 81% male), and was present in the culprit vessel in 79.9%. Multivessel CAE was frequent (67%). CAE patients were more frequently male, had high thrombus burden and were treated more often with thrombectomy and less often was stent implantation. Markis I was the most frequent angiographic phenotype (43%). During a median follow-up of 4 years (1-7), 1243 patients (26%) experienced a major adverse cardiovascular event (MACE): 282 (6%) died from a cardiac cause, 358 (8%) had a myocardial infarction, 945 (20%) underwent coronary revascularization and 58 (1%) presented with a stroke. Patients with CAE showed higher rates of MACE as compared to those without CAE (36.8% versus 25.6%; p <0.001). On multivariable analysis, CAE was associated with MACE (HR 1.597; 95% CI 1.238-2.060; p <0.001) after adjusting for risk factors, type of AMI and number of narrowed coronary arteries. In conclusion, the prevalence of CAE in patients presenting with AMI is relatively low but was independently associated with an increased risk of MACE at follow-up. (c) 2021 The Author(s). Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/) (Am J Cardiol 2021;156:9-15)Cardiolog

Time Course of Ischemic and Bleeding Burden in Elderly Patients&#160;With&#160;Acute Coronary Syndromes Randomized to Low-Dose Prasugrel or Clopidogrel

Background Elderly patients have high ischemic and bleeding rates after acute coronary syndrome; however, the occurrence of these complications over time has never been studied. This study sought to characterize average daily ischemic rates ( ADIRs ) and average daily bleeding rates ( ADBRs ) over 1\ua0year in patients aged >74\ua0years with acute coronary syndrome undergoing percutaneous coronary intervention who were randomized in the Elderly ACS 2 trial, comparing low-dose prasugrel (5\ua0mg daily) with clopidogrel (75\ua0mg daily). Methods and Results ADIRs and ADBRs were calculated as the total number of events, including recurrent events, divided by the number of patient-days of follow-up and assessed within different clinical phases: acute (0-3\ua0days), subacute (4-30\ua0days), and late (31-365\ua0days). Generalized estimating equations were used to test the least squares mean differences for the pairwise comparisons of ADIRs and ADBRs and the pairwise comparison of clopidogrel versus prasugrel effects. Globally, ADIRs were 2.6 times (95% CI, 2.4-2.9) higher than ADBRs . ADIRs were significantly higher in the clopidogrel arm than in the low-dose prasugrel arm in the subacute phase ( Padj<0.001) without a difference in ADBRs ( Padj=0.35). In the late phase, ADIRs remained significantly higher with clopidogrel ( Padj<0.001), whereas ADBRs were significantly higher with low-dose prasugrel ( Padj<0.001). Conclusions Ischemic burden was greater than bleeding burden in all clinical phases of 1-year follow-up of elderly patients with acute coronary syndrome treated with percutaneous coronary intervention. Low-dose prasugrel reduced ischemic events in the subacute and chronic phases compared with clopidogrel, whereas bleeding burden was lower with clopidogrel in the late phase. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01777503

Concomitant use of proton pump inhibitors and dual antiplatelet therapy for cardiovascular outcomes

INTRODUCTION: The aim of this review is to discuss the consequences of potential pharmacokinetic interactions between proton pump inhibitors (PPIs) and antiplatelet therapy on cardiovascular (CV) outcomes and provide guidance on the management of concomitant use of PPIs in patients on dual antiplatelet therapy (DAPT). EVIDENCE ACQUISITION: DAPT combining aspirin and oral P2Y12 receptor inhibitors increases the risk of gastrointestinal (GI) bleeding, with higher rates of morbidity and mortality in patients undergoing percutaneous coronary intervention (PCI). PPIs are recommended in patients at risk of bleeding to reduce the risk of GI hemorrhage. PPIs can reduce the metabolism of Clopidogrel by competing with CYP450 enzymes, mostly CYP2C19 isoform. The clinical significance of this pharmacological interaction is not uniform in observational studies. The only randomized clinical trial assessing the clinical relevance of clopidogrel-omeprazole interaction showed that the use of omeprazole was associated with a reduction in GI bleeding, without any differences in CV outcomes. EVIDENCE SYNTHESIS: Several systematic reviews and meta-analyses suggest an increased risk of major adverse cardiovascular events (MACE), but not of mortality in patients with concomitant use of PPIs and Clopidogrel. Two metaanalysis studying the interactions between individual PPIs and Clopidogrel failed to demonstrate any strong relationships with adverse CV outcomes. CONCLUSIONS: PPIs should be administered in patients on DAPT at risk for GI bleeding. However the uncertain benefit of PPIs in patients who are not at risk of GI bleeding and the unclear risk in MACE suggest that caution should be used when prescribing PPIs in these patients

De-escalating dual antiplatelet therapy in patients with acute coronary syndromes : the right strategy to harmonize time-dependent ischemic and bleeding risk in elderly patients?

The European Society of Cardiology guidelines for myocardial revascularization state that de-escalation of P2Y12 inhibitor treatment guided by platelet function testing may be considered for acute coronary syndrome (ACS) patients deemed unsuitable for 12-month potent platelet inhibition. De-escalation strategy aim is to harmonize the time-dependency of thrombotic risk, which is high in the first month after ACS, then decreases exponentially, with bleeding risk, which tends to remain more stable after the procedure-related peak. Harmonizing time-dependency of clinical events may be particularly relevant in those at high risk, such as the elderly patients with ACS in whom an individualized antiplatelet therapy may be more appropriate than a 'one-size-fits all' approach. In this review, we outline the current medical evidence on the topic of dual antiplatelet therapy de-escalation. In addition, we include insights from the Elderly ACS 2 study and recently published post-hoc analyses conducted by the authors' consortium, which further expands current knowledge

Transcatheter mitral valve repair with MitraClip in patients with pulmonary hypertension: Hemodynamic and prognostic perspectives

Transcatheter mitral valve repair with MitraClip has emerged as a possible therapeutic option for patients with severe mitral regurgitation (MR) with high risk for surgical valve repair. MitraClip intervention has demonstrated to improve haemodynamics and clinical outcomes in selected patients in observational and randomized studies. Preoperative pulmonary hypertension (PH) is known to affect prognosis in patients undergoing surgical mitral valve intervention. The aim of the present review is to discuss the available literature focused on the haemodynamic and clinical effects of MitraClip in patients with severe MR and PH. © 2021 The Authors. Published by IMR Press

Oral aspirin or low dose of intravenous lysine acetylsalicylate in ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention

AIM: To compare the pharmacodynamic effect of an oral loading dose of 'noncoated' ASA 300 mg vs. an intravenous bolus injection of lysine acetylsalicylate 150 mg in patients with STEMI undergoing pPCI. METHODS: This was a prospective single-center, open label, pharmacodynamic study, including nonconsecutive patients presenting at our catheterization laboratory with STEMI undergoing pPCI and not receiving ASA within the previous 7 days. Pharmacodynamic analyses were performed at five time points: baseline, and 1, 2, 4 and 12 h after the loading dose, and measured as ASA reaction units (ARU) by the Verify Now System. An ARU more than 550 was considered as nonresponsiveness to study drugs. The primary end point was the different rate of patients with ARU more than 550 at 2 h after the loading dose of oral vs. intravenous ASA. Secondary end points included the comparison of ARU more than 550 at the other time points and the comparison of continuous ARU at each time point. RESULTS: The study was planned with a sample size of 68 patients, but it was prematurely stopped due to slow enrollment after the inclusion of 23 patients, 12 randomized to oral ASA and 11 to intravenous lysine acetylsalicylate. At 2 h the rate of patients with ARU more than 550 was numerically but not significantly higher in patients receiving oral ASA as compared with intravenous lysine acetylsalicylate (33 vs. 14.2%; Δ -0.19, 95% confidence interval -0.59-0.21, P = 0.58). The difference over time was NS (P = 0.98), though the prevalence of ARU more than 550 was higher at the other time points. Both routes of administration reduced ARU values over time, though with no overall significant difference between profiles (P overall = 0.48). CONCLUSION: In patients with STEMI undergoing pPCI the rate of nonresponsiveness to ASA was not different comparing an oral 'noncoated' loading dose of ASA with an intravenous bolus injection of lysine acetylsalicylate. However, as patient enrollment was prematurely terminated, this study is underpowered to draw a definite conclusion