Antiplatelet efficacy of ticagrelor versus clopidogrel in Mediterranean patients with diabetes mellitus and chronic coronary syndromes: A crossover pharmacodynamic investigation

IntroductionPatients with diabetes mellitus (DM) have augmented platelet reactivity and diminished responsiveness to clopidogrel. Ticagrelor, a more potent P2Y(12) inhibitor, is clinically superior to clopidogrel in acute coronary syndromes, although its role in chronic coronary syndromes (CCS) is still the subject of debate. The aim of this investigation was to compare the pharmacodynamic effectiveness of ticagrelor and clopidogrel in Mediterranean DM patients with CCS.Materials and methodsIn this prospective, randomized, crossover study, patients (n = 20) were randomized (1:1) to receive, on top of aspirin therapy, either ticagrelor 180 mg loading dose (LD)/90 mg maintenance dose (MD) b.i.d. or clopidogrel 600 mg LD/75 mg MD o.d. for 1 week in a crossover fashion with a 2-4 week washout period between regimens. Platelet function measurements were performed at 4 timepoints in each period (baseline, 2 h and 24 h after LD, and 1 week), including light transmission aggregometry (LTA, primary endpoint), VASP assay, Multiplate and VerifyNow P2Y(12).ResultsThe ticagrelor LD achieved greater platelet inhibitory effect than clopidogrel LD, assessed with LTA (20 mu M ADP as agonist), at 2 h (34.9 & PLUSMN; 3.9% vs. 63.6 & PLUSMN; 3.9%; p < 0.001) and 24 h (39.4 & PLUSMN; 3.5% vs. 52.3 & PLUSMN; 3.8%; p = 0.014). After 1 week of therapy, platelet reactivity was again significantly inferior with ticagrelor compared to clopidogrel (30.7 & PLUSMN; 3.0% vs. 54.3 +/- 3.0%; p < 0.001). The results were consistent with the other platelet function assays employed.ConclusionIn Mediterranean patients with DM and CCS, ticagrelor provides a more potent antiplatelet effect than clopidogrel after the LD and during the maintenance phase of therapy

Management of Conduction Disturbances Associated With Transcatheter Aortic Valve Replacement: JACC Scientific Expert Panel.

Despite major improvements in transcatheter aortic valve replacement (TAVR) periprocedural complications in recent years, the occurrence of conduction disturbances has not decreased over time and remains the most frequent complication of the procedure. Additionally, there has been an important lack of consensus on the management of these complications, which has indeed translated into a high degree of uncertainty regarding the most appropriate treatment of a large proportion of such patients along with major differences between centers and studies in pacemaker rates post-TAVR. There is therefore an urgent need for a uniform strategy regarding the management of conduction disturbances after TAVR. The present expert consensus scientific panel document has been formulated by a multidisciplinary group of interventional cardiologists, electrophysiologists, and cardiac surgeons as an initial attempt to provide a guide for the management of conduction disturbances after TAVR based on the best available data and group expertise

Treatment of Slow‐Flow After Primary Percutaneous Coronary Intervention With Flow‐Mediated Hyperemia: The Randomized RAIN‐FLOW Study

Background ST‐segment–elevation myocardial infarction complicated with no reflow after primary percutaneous coronary intervention is associated with adverse outcomes. Although several hyperemic drugs have been shown to improve the Thrombolysis in Myocardial Infarction flow, optimal treatment of no reflow remains unsettled. Saline infusion at 20 mL/min via a dedicated microcatheter causes (flow‐mediated) hyperemia. The objective is to compare the efficacy of pharmacologic versus flow‐mediated hyperemia in patients with ST‐segment–elevation myocardial infarction complicated with no reflow. Methods and Results In the RAIN‐FLOW (Treatment of Slow‐Flow After Primary Percutaneous Coronary Intervention With Flow‐Mediated Hyperemia) study, 67 patients with ST‐segment–elevation myocardial infarction and no reflow were randomized to receive either pharmacologic‐mediated hyperemia with intracoronary adenosine or nitroprusside (n=30) versus flow‐mediated hyperemia (n=37). The angiographic corrected Thrombolysis in Myocardial Infarction frame count and the minimal microcirculatory resistance, as assessed with intracoronary pressure‐thermistor wire, dedicated microcatheter, and thermodilution techniques, were compared after study interventions. Both Thrombolysis in Myocardial Infarction frame count(40.2±23.1 versus 39.2±20.7; P=0.858) and minimal microcirculatory resistance (753.6±661.5 versus 993.3±740.8 Wood units; P=0.174) were similar between groups. Thrombolysis in Myocardial Infarction 3 flow was observed in 26.7% versus 27.0% (P=0.899). Flow‐mediated hyperemia showed 2 different thermodilution patterns during saline infusion indicative of the severity of the no reflow phenomenon. In‐hospital death and nonfatal heart failure were observed in 10.4% and 26.9%, respectively. Conclusions Both treatments showed similar (and limited) efficacy restoring coronary flow. Flow‐mediated hyperemia with thermodilution pattern assessment allowed the simultaneous characterization of the no reflow degree and response to hyperemia. No reflow was associated with a high rate of adverse outcomes. Further research is warranted to prevent and to treat no reflow in patients with ST‐segment–elevation myocardial infarction. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT04685941

In-hospital Outcomes of Rotational Atherectomy in ST-Elevation Myocardial Infarction: Results From the Multicentre ROTA-STEMI Network

Although the use of rotational atherectomy (RA) is off-label in the setting of ST-elevation myocardial infarction (STEMI), it can be the only option in severely calcified culprit lesions to achieve procedural success. We sought to investigate the safety and feasibility of RA during primary percutaneous coronary intervention (PPCI).This was a retrospective observational study of patients who underwent RA during PPCI from 12 European centers. The main outcomes were procedural success (defined as successful stent implantation with final TIMI flow 3 and residual stenosis <30%) and in-hospital mortality. A comparison of patients presenting with and without shock was performed.In 104 patients with RA during STEMI the mean age was 72.8±9.1 years, 35% presented with cardiogenic shock. Bailout RA was performed in 76.9% of cases. Mean burr size was 1.42±0.21mm. Procedural success was achieved in 86.5% of cases, with no difference between shocked and non-shocked patients (94.4% vs. 82.4%, p=0.13). In-hospital stent thrombosis occurred in 0.96%, perforation in 1.9% and burr entrapment in 2.9% of cases. In-spite of equally high procedural success, in-hospital mortality was higher in shocked (50%) compared with non-shocked patients (1.5%, p<0.0001).Patients presenting with STEMI, requiring RA, represent a high-risk population, frequently presenting with cardiogenic shock. In this analysis of selected patients, RA was performed as a bailout strategy in the majority, and as such RA seems to be feasible with a high procedural success rate. In the absence of cardiogenic shock, RA-facilitated PCI seems to be associated with low in-hospital mortality

Late Cerebrovascular Events Following Transcatheter Aortic Valve Replacement.

This study sought to determine the incidence, clinical characteristics, associated factors, and outcomes of late cerebrovascular events (LCVEs) (>30 days post-procedure) following transcatheter aortic valve replacement (TAVR). Scarce data exist on LCVEs following TAVR. This was a multicenter study including 3,750 consecutive patients (mean age, 80 ± 8 years; 50.5% of women) who underwent TAVR and survived beyond 30 days. LCVEs were defined according to the Valve Academic Research Consortium 2 (VARC 2) criteria. LCVEs occurred in 192 (5.1%) patients (stroke, 80.2%; transient ischemic attack, 19.8%) after a median follow-up of 2 (1 to 4) years. Late stroke was of ischemic, hemorrhagic, and undetermined origin in 80.5%, 18.8%, and 0.7% of patients, respectively. Older age, previous cerebrovascular disease, higher mean aortic gradient at baseline, the occurrence of stroke during the periprocedural TAVR period, and the lack of anticoagulation (novel oral anticoagulants or vitamin K antagonists) post-TAVR were independent factors associated with late ischemic stroke/transient ischemic attack (p  LCVEs occurred in 5.1% of TAVR recipients after a median follow-up of 2 years. LCVEs were ischemic in most cases, with older age, previous cerebrovascular events, higher mean aortic gradient at baseline, the occurrence during the periprocedural TAVR period, and lack of anticoagulation (but not valve thrombosis/degeneration) determining an increased risk. Late stroke was disabling in most cases and associated with dreadful early and midterm outcomes

In-hospital Outcomes of Rotational Atherectomy in ST-elevation Myocardial Infarction - Results from the Multicenter ROTA-STEMI Network

BACKGROUND: Although the use of rotational atherectomy (RA) is off-label in the setting of ST-elevation myocardial infarction (STEMI), it can be the only option in severely calcified culprit lesions to achieve procedural success. We sought to investigate the safety and feasibility of RA during primary percutaneous coronary intervention (PPCI).METHODS: This was a retrospective observational study of patients who underwent RA during PPCI from 12 European centers. The main outcomes were procedural success (defined as successful stent implantation with final TIMI flow 3 and residual stenosis &lt;30%) and in-hospital mortality. A comparison of patients presenting with and without shock was performed.RESULTS: In 104 patients with RA during STEMI the mean age was 72.8±9.1 years, 35% presented with cardiogenic shock. Bailout RA was performed in 76.9% of cases. Mean burr size was 1.42±0.21mm. Procedural success was achieved in 86.5% of cases, with no difference between shocked and non-shocked patients (94.4% vs. 82.4%, p=0.13). In-hospital stent thrombosis occurred in 0.96%, perforation in 1.9% and burr entrapment in 2.9% of cases. In-spite of equally high procedural success, in-hospital mortality was higher in shocked (50%) compared with non-shocked patients (1.5%, p&lt;0.0001).CONCLUSION: Patients presenting with STEMI, requiring RA, represent a high-risk population, frequently presenting with cardiogenic shock. In this analysis of selected patients, RA was performed as a bailout strategy in the majority, and as such RA seems to be feasible with a high procedural success rate. In the absence of cardiogenic shock, RA-facilitated PCI seems to be associated with low in-hospital mortality.</p