Acetylcholine Use in Modern Cardiac Catheterization Laboratories: A Systematic Review

Background: The use of acetylcholine for the diagnosis of vasospastic angina is recommended by international guidelines. However, its intracoronary use is still off-label due to the absence of safety studies. We aimed to perform a systematic review of the literature to identify adverse events related to the intracoronary administration of acetylcholine for vasoreactivity testing to fill this gap. Methods and results: We conducted a systematic review of observational studies and randomized controlled trials dealing with the intracoronary administration of acetylcholine. Articles were searched in MEDLINE (PubMed) using the MeSH strategy. Three independent reviewers determined whether the studies met the inclusion and exclusion criteria. A total of 434 articles were selected. Data concerning clinical characteristics, study population, acetylcholine dosage, and adverse effects were retrieved from the articles. Overall, 71,566 patients were included, of which only 382 (0.5%) developed one adverse event, and there were no fatal events reported (0%). Conclusions: Intracoronary administration of acetylcholine in the setting of coronary spasm provocation testing is safe and plays a central role in the evaluation of coronary vasomotion disorders, making it worthy of becoming a part of clinical practice in all cardiac catheterization laboratories

The impact of sex and physical performance on long-term mortality in older patients with myocardial infarction

Background: Sex influences outcome of patients with acute coronary syndrome (ACS). If there is a relationship between sex and physical performance is unknown. Methods: The analysis is based on older (≥70 years) ACS patients included in the FRASER, HULK, and LONGEVO SCA prospective studies. Physical performance was assessed by Short Physical Performance Battery (SPPB). The primary outcome was all-cause mortality. Results: The study included 1388 patients, and 441 (32%) were women. At presentation, women were older and more compromised than men. After a median follow-up of 998 [730-1168] days, all-cause death occurred in 334 (24.1%) patients. At univariate analysis, female sex was related to increased risk of death. After adjustments for confounding factors, female sex was no longer associated with mortality. Women showed poor physical performance compared with men (p < 0.001). SPPB values emerged as an independent predictor of death. Including clinical features and SPPB in the multivariable model, we observed a paradigm shift in the prognostic role of female sex that becomes a protective factor (HR 0.73, 95% CI 0.56-0.96). Sex and physical performance showed a significant interaction (p = 0.03). For lower SPPB values (poor physical performance), sex-related changes in mortality were not recorded, while in patients with higher SPPB values (preserved physical performance), female sex was associated with better survival. Conclusions: Two key findings emerged from the present real-life cohort of older ACS patients: (i) physical performance strongly influences long-term mortality; (ii) women with preserved physical performance have a better outcome compared to me

Impact of trans-stent gradient on outcome after PCI: results from a HAWKEYE substudy

To test whether quantitative flow ratio (QFR)-based trans-stent gradient (TSG) is associated with adverse clinical events at follow-up. A post-hoc analysis of the multi-center HAWKEYE study was performed. Vessels post-PCI were divided into four groups (G) as follows: G1: QFR &gt;= 0.90 TSG = 0 (n = 412, 54.8%); G2: QFR &gt;= 0.90, TSG &gt; 0 (n = 216, 28.7%); G3: QFR &lt; 0.90, TSG = 0 (n = 37, 4.9%); G4: QFR &lt; 0.90, TSG &gt; 0 (n = 86, 11.4%). Cox proportional hazards regression model was used to analyze the effect of baseline and prognostic variables. The final reduced model was obtained by backward stepwise variable selection. Receiver operating characteristic (ROC) was plotted and area under the curve (AUC) was calculated and reported. Overall, 449 (59.8%) vessels had a TSG = 0 whereas (40.2%) had TSG &gt; 0. Ten (2.2%) vessel-oriented composite endpoint (VOCE) occurred in vessels with TSG = 0, compared with 43 (14%) in vessels with TSG &gt; 0 (p &lt; 0.01). ROC analysis showed an AUC of 0.74 (95% CI: 0.67 to 0.80; p &lt; 0.001). TSG &gt; 0 was an independent predictor of the VOCE (HR 2.95 [95% CI 1.77-4.91]). The combination of higher TSG and lower final QFR (G4) showed the worst long-term outcome while low TSG and high QFR showed the best outcome (G1) while either high TSG or low QFR (G2, G3) showed intermediate and comparable outcomes. Higher trans-stent gradient was an independent predictor of adverse events and identified a subgroup of patients at higher risk for poor outcomes even when vessel QFR was optimal (&gt; 0.90)

Tailoring antiplatelet therapy in older patients with coronary artery disease

AbstractThe older population represents a unique subset of patients due to a higher rate of comorbidities and risk factors, which can lead to a higher rate of ischemic and bleeding events. As a result, older adults are mainly underrepresented or excluded from randomized trials. Although the advancement in the percutaneous coronary intervention field with the development of new technologies, techniques, and potent antiplatelet therapy led to a reduction of ischemic risk, there is still a concern regarding bleeding hazards. Apart from the global utilization of less invasive trans-radial approach and proton pump inhibitors to reduce bleeding risk, proper tailoring of antiplatelet therapy in the older person is imperative. So far, several antiplatelet drugs have been introduced in different clinical scenarios, with dual antiplatelet therapy (combination of acetylsalicylic acid and P2Y12 inhibitor) recommended after percutaneous coronary intervention. The decision on the choice of antiplatelet drug and the DAPT duration is challenging and should be based on the relationship between ischemia and bleeding with the purpose of reducing ischemic events but not at the expense of increased bleeding complications. This is particularly important in the older population, where the evidence is obscure. The main objective of this review is to summarize the available evidence on contemporary antiplatelet therapy and different approaches of de-escalation strategies in older patients after percutaneous coronary intervention

The role of physiology in the contemporary management of coronary artery disease

Coronary physiology assessment, including epicardial and microvascular investigations, is a fundamental tool in the contemporary management of patients with coronary artery disease. Coronary revascularisation guided by functional evaluation has demonstrated superiority over angiography-only-guided treatment. In patients with chronic coronary syndrome, revascularisation did not demonstrate prognostic advantage in terms of mortality over optimal medical therapy (OMT). However, revascularisation of coronary stenosis, which induces myocardial ischaemia, has demonstrated better outcome than OMT alone. Pressure wire (PW) or angiography-based longitudinal coronary physiology provides a point-by-point analysis of the vessel to detect the atherosclerotic pattern of coronary disease. A careful evaluation of this disease pattern allows clinicians to choose the appropriate management strategy.Patients with diffuse disease showed a twofold risk of residual angina after percutaneous coronary intervention (PCI) than those with focal disease. Therefore, OMT alone or coronary artery bypass graft might be considered over PCI. In addition, the post-PCI physiological assessment aims to optimise the result revealing residual myocardial ischaemia. Improvement in post-PCI PW or angiography-based functional indices has been associated with better quality of life and reduced risk of cardiac events and residual angina. Therefore, the information obtained from coronary physiology allows for an optimised treatment strategy, which ultimately leads to improve patient's prognosis and quality of life. This review provides an overview of the latest available evidence in the literature regarding the use of functional assessment of epicardial coronary stenosis in different settings in the contemporary patient-tailored management of coronary disease

Reading 2023 ESC ACS guidelines between the lines: Gaps in evidence in women

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Safety and efficacy of new-generation coronary bioresorbable scaffolds: a systematic review

Introduction: The concept of bioresorbable scaffolds (BRS) born with the aim to reduce the rate of late and very late cardiac events related to drug-eluting stents. However, first-generation BRS failed to prove their short-term safety and efficacy. Based on data derived from early investigations, new-generation BRS have been developed and tested in preliminary studies. The present review's focus is to summarize the mechanical characteristics of these new scaffolds and the clinical evidence of their safety and efficacy. Evidence acquisition: This systematic review was performed following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). PUBMED, Google Scholar, and Biomed central databases were analyzed. Only papers published in English and in peer-reviewed journals were selected to summarize current evidence about new generation BRS, with CE mark approval. Overall, 23 studies were included. Evidence synthesis: Data obtained from selected studies assessing the safety and efficacy of new generation BRS are encouraging. This is thanks to the progressive development of scaffolds with a different backbone structure and struts thickness that guarantee higher radial strength, flexibility, and resistance to fracture. These characteristics led to low rates of major adverse cardiac events and device-oriented composite endpoint at follow-up. Conclusions: New-generation BRS have a good safety profile in stable patients with simple lesions, supported by a meticulous implantation technique. The first studies were performed on a small population with short-term follow-up, therefore new randomized clinical trials and registries are needed to expand the preliminary findings

Differences in treatment and clinical outcomes in patients aged ≥75 years compared with those aged ≤74 years following acute coronary syndromes: a prospective multicentre study

Objective This study describes the differences in treatment and clinical outcomes in patients aged ≥75 years compared with those aged ≤74 years presenting with acute coronary syndrome (ACS) and undergoing invasive management.Methods A large-scale cohort study of patients with ST-elevation/non-ST-elevation myocardial infarction (MI)/unstable angina underwent coronary angiography (January 2015–December 2019). Patients were classified as older (≥75 years) and younger (≤74 years). Regression analysis was used to yield adjusted risks of mortality for older versus younger patients (adjusted for history of heart failure, hypercholesterolaemia, peripheral vascular disease, chronic obstructive pulmonary disease, ischaemic heart disease, presence of ST-elevation MI on presenting ECG, female sex and cardiogenic shock at presentation).Results In total, 11 763 patients were diagnosed with ACS, of which 39% were aged ≥75 years. Percutaneous coronary intervention was performed in fewer older patients than younger patients (81.2% vs 86.2%, p&lt;0.001). At discharge, older patients were prescribed less secondary-prevention medications than younger patients. Median follow-up was 4.57 years. Older patients had a greater risk of in-hospital mortality than younger patients (adjusted OR (aOR) 2.12, 95% CI 1.62 to 2.78, p&lt;0.001). Older patients diagnosed with ST-elevation MI had greater adjusted odds of dying in-hospital (aOR 2.47, 95% CI 1.79 to 3.41, p&lt;0.001). Older age was not an independent prognostic factor of mortality at 1 year (adjusted HR (aHR) 0.95, 95% CI 0.82 to 1.09, p=0.460) and at longer term (aHR 0.98, 95% CI 0.87 to 1.10, p=0.684).Conclusions Older patients are discharged with less secondary prevention. Patients aged ≥75 years are more likely to die in-hospital than younger patients

Cognitive impairment and outcomes in older adults with non-ST-elevation acute coronary syndrome

Objective This study aimed to explore the prognostic impact of cognitive impairment on the long-term risk of major adverse cardiovascular events (MACEs) in older patients with non-ST-elevation acute coronary syndrome (NSTEACS) undergoing invasive treatment.Methods Patients aged &gt;= 75 years with NSTEACS undergoing an invasive strategy were included in the multicentre prospective study (NCT01933581). Montreal Cognitive Assessment was used to evaluate cognitive status at baseline (scores &gt;= 26 classified as normal, &lt;26 as cognitive impairment). Long-term follow-up data were obtained from electronic patient care records. The primary endpoint was MACE as a composite of all-cause deaths, reinfarction, stroke/transient ischaemic attack, urgent revascularisation and significant bleeding.Results 239 patients with baseline cognitive assessment completed long-term follow-up. Median age was 80.9 years (IQR 78.2-83.9 years) and 62.3% were male. On 5-year follow-up, there was no significant difference in the occurrence of MACE between the cognitively impaired group and the normal cognition group (p=0.155). Cognition status was not associated with MACE (HR 1.37 (95% CI 0.96 to 1.95); p=0.082). However, there was significantly more deaths (p=0.005) in those with cognitive impairment. Kaplan-Meier survival analysis (log-rank p=0.003) and Cox regression analysis (aHR 1.85 (95% CI 1.11 to 3.08); p=0.018) revealed increased risk of all-cause mortality, even after adjusting for frailty and GRACE (Global Registry of Acute Coronary Events) score.Conclusion Cognitive impairment in older patients with NSTEACS undergoing an invasive strategy was associated with long-term all-cause mortality. Routine cognitive screening may aid risk stratification and further studies are needed to identify how this should influence management strategies and individual decision-making in this patient group

[Dual antiplatelet therapy (DAPT) after acute coronary syndrome: short DAPT versus de-escalation]

SCOPO DELLO STUDIO L’obiettivo principale dello studio è stato quello di confrontare mediante una network meta-analysis due strategie terapeutiche emergenti nel trattamento dei pazienti con sindrome coronarica acuta (SCA) sottoposti ad angioplastica percutanea (PCI): la short DAPT (interruzione a 1-6 mesi di uno dei due antiaggreganti) vs la strategia di de-escalation (12 mesi di DAPT con shift ad un certo punto da prasugrel/ticagrelor a clopidogrel o a dose dimezzata di prasugrel/ticagrelor) utilizzando la standard DAPT (12 mesi) come termine di paragone. POPOLAZIONE E CENTRI COINVOLTI Complessivamente sono stati selezionati 29 studi studi (randomizzati o sottoanalisi di studi randomizzati), per un totale di 50 602 pazienti affetti da SCA e sottoposti a PCI. INTERVENTO Nel dettaglio, è stata inizialmente eseguita un’analisi a tre nodi che ha permesso di confrontare le diverse strategie terapeutiche (short DAPT vs de-escalation vs standard DAPT) e successivamente un’analisi a cinque nodi che ha permesso di confrontare più nel dettaglio i vari approcci in base alla strategia scelta per la prosecuzione della terapia (short DAPT con interruzione di aspirina vs short DAPT con interruzione di inibitore di P2Y12 vs de-escalation con shift a clopidogrel vs de-escalation con dose ridotta dell’inibitore del P2Y12 vs standard DAPT). OUTCOME PRINCIPALI Mortalità per tutte le cause, evento composito cardiovascolare netto [Net Adverse Cardiovascular Events (NACE)], evento composito cardiovascolare ischemico [Major Adverse Cardiovascular Events (MACE)] e sanguinamenti. RISULTATI • 50 602 pazienti affetti da SCA e sottoposti a PCI • Arruolati in 29 studi studi randomizzati (globali o sottoanalisi) • Short DAPT vs standad DAPT o de-escalation vs standard DAPT I risultati derivanti sia da analisi indirette sia frequentistiche che Bayesiane hanno dimostrato l’assenza di una differenza significativa in termini di mortalità per tutte le cause tra short DAPT e de-escalation. Tuttavia, la de-escalation è risultata associata ad una riduzione significativa dei NACE (RR 0.87, IC 95% 0.70-0.94) nonostante un aumento dei sanguinamenti maggiori (RR 1.54, IC 95% 1.07-2.21) rispetto alla short DAPT. Nell’analisi a 5 nodi, la short DAPT con interruzione dell’inibitore di P2Y12 è risultato potenzialmente il peggiore dei trattamenti analizzati, e l’unico associato ad un lieve incremento del rischio di MACE