Coronary microcirculation and peripheral endothelial function evaluation after acute ST elevation myocardial infarction treated with primary angioplasty

ABSTRACT: Introduction: Despite achieving normal epicardial coronary artery flow after primary percutaneous coronary intervention (P-PCI), a significant proportion of patients with acute ST elevation myocardial infarction has a poorer outcome because of microvascular coronary damage and/or dysfunction. Endothelial dysfunction may play a role in this microvascular coronary damage after STEMI, and its evaluation by peripheral arterial tonometry may be useful to predict the extent of microvascular coronary damage and the extent of myocardial infarction. Objectives: To evaluate the relation of early peripheral endothelial dysfunction, as measured by the reactive hyperemia index (RHI, obtained by peripheral arterial tonometry) and the index of microcirculatory resistance (IMR) immediately after P-PCI and to access the relation between RHI and IMR values and: 1) the extent of myocardial infarct evaluated by contrast enhanced cardiac magnetic resonance (ceCMR) and troponin release; 2) the extent of microvascular obstruction (MVO), evaluated by ceCMR and by other available indirect indicators; 3) late (3 months) left ventricular remodelling, measured by echocardiography. Methods: Observational, prospective cohort study. Patients with a first STEMI successfully treated with P-PCI, hemodynamically stable and without contra-indications for adenosine administration were included. After successful P-PCI, IMR was determined, using a pressure-wire. RHI was evaluated acutely and after 24 hours, using EndoPAT; endothelial dysfunction was defined as RHI24 had significantly worse ST resolution and angiographic indicators of microvascular dysfunction. IMR also correlated with infarct mass (r=0.70, p24 had significantly higher peak (p=0.013) and AUC (p=0.003) TnI. LVEF improved significantly only in patients with IMR24, a resolução do ST foi significativamente menor e os indicadores angiográficos de reperfusão foram significativamente piores. O IRM também se correlacionou com a massa de enfarte (r=0,70, p24 tiveram valores significativamente mais elevados de TnI máxima (p=0,013) e ASC de TnI (p=0,003). A FEVE melhorou de forma significativa apenas nos doentes com IMR<24 (p=0,01). Os preditores independentes do IRH foram a idade, a glicemia na admissão e a HbA1c na admissão. Conclusões: Não parece ser possível avaliar de forma fidedigna o IHR na fase aguda do EAMcST após ICP-P. O IHR medido 24h após a ICP-P é mensurável de forma adequada e prevê a dimensão do enfarte e da OMV, confirmando a disfunção endotelial como um mecanismo importante na disfunção microvascular em doentes com EAMcST. O IRM correlaciona-se fortemente com a OMV e permite prever a dimensão do enfarte e o risco de remodelagem ventricular esquerda

A position paper of the Portuguese Society of Cardiology

Copyright © 2023 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.Global warming is a result of the increased emission of greenhouse gases. This climate change consequence threatens society, biodiversity, food and resource availability. The consequences in health involve the increased risk of cardiovascular (CV) disease and cardiovascular mortality. In this position paper we summarize the data from the main studies that assessed the risks of temperature increase or heat waves in CV events (CV mortality, myocardial infarction, heart failure, stroke, and CV hospitalizations), as well as the data concerning air pollution as an enhancer of temperature-related CV risks. The data currently supports that global warming/heat waves (extreme temperatures) are cardiovascular threats. Achieving the neutrality in the emissions to prevent global warming is essential and it is likely to have an effect in the global health, including the cardiovascular health. Simultaneously, urgent step is required to adapt the society and individual to this new climate context potentially harmful for the cardiovascular health. Multidisciplinary teams should plan and intervene in heat-related healthcare and advocate for environmental health policy change.proofepub_ahead_of_prin

Adoption and patterns of use of invasive physiological assessment of coronary artery disease in a large cohort of 40 821 real-world procedures over a 12-year period

Funding Information: The authors wish to acknowledge the invaluable contributions of Paulo Leal regarding data acquisition and management, and John Henderson for statistical consultancy. Publisher Copyright: © 2021 Sociedade Portuguesa de CardiologiaIntroduction and Objectives: Use of invasive physiological assessment in patients with coronary artery disease varies widely and is perceived to be low. We aimed to examine adoption rates as well as patterns and determinants of use in an unselected population undergoing invasive coronary angiography over a long time frame. Methods: We retrospectively determined the per-procedure prevalence of physiological assessment in 40 821 coronary cases performed between 2007 and 2018 in two large-volume centers. Adoption was examined according to procedure type and patient- and operator-related variables. Its association with relevant scientific landmarks, such as the release of clinical trial results and practice guidelines, was also assessed. Results: Overall adoption was low, ranging from 0.6% in patients undergoing invasive coronary angiography due to underlying valve disease, to 6% in the setting of stable coronary artery disease (CAD); it was 3.1% in patients sustaining an acute coronary syndrome. Of scientific landmarks, FAME 1, the long-term results of FAME 2 and the 2014 European myocardial revascularization guidelines were associated with changes in practice. Publication of instantaneous wave-free ratio (iFR) trials had no influence on adoption rates, except for a higher proportion of iFR use. In 42.9% of stable CAD patients undergoing percutaneous coronary intervention there was no objective non-invasive evidence of ischemia, nor was physiological assessment performed. Younger operator age (4.5% vs. 4.0% vs. 0.9% for ages 55 years, respectively; p<0.001) and later time of procedure during the day (2.9% between 6 and 8 p.m. vs. 4.4% at other times) were independent correlates of use of invasive physiology. Conclusions: Our study confirms the low use of invasive physiology in routine practice. The availability of resting indices did not increase adoption. Strategies are warranted to promote guideline implementation and to improve patient care and clinical outcomes.publishersversionpublishe

A position paper

Copyright © 2022 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.Air pollution is one of the main environmental risk factors for health and is linked to cardiovascular diseases, which are the leading cause of mortality worldwide. In this position paper, we discuss the main air pollutants and how they can promote the development of cardiovascular disease or cardiovascular events. We also summarise the main evidence supporting the association between air pollution and cardiovascular events, such as coronary events (acute coronary syndromes/myocardial infarction; chronic coronary syndromes), stroke, heart failure and mortality. Some recommendations are made based on these data and the European Society of Cardiology guidelines on cardiovascular disease prevention, acknowledging that it is important to increase awareness and literacy on this topic in Portugal.publishersversionpublishe

PrOgnosis in Pulmonary Embolism (PoPE): 30-Day mortality risk score based on five admission parameters

Introduction and objective: Several scoring systems have been developed for risk stratification in patients with acute pulmonary embolism (PE). The Pulmonary Embolism Severity Index (PESI) and its simplified version (sPESI) are among the most used, however the high number of variables hinder its application. Our aim was to derive an easy-to-perform score based on simple parameters obtained at admission to predict 30-day mortality in acute PE patients. Methods: Retrospective study in 1115 patients with acute PE from two institutions (derivation cohort n=835, validation cohort n=280). The primary endpoint was all-cause mortality at 30 days. Statistically and clinically relevant variables were selected for multivariable Cox regression analysis. We derived and validated a multivariable risk score model and compared to other established scores. Results: The primary endpoint occurred in 207 patients (18.6%). Our model included five variables weighted as follows: modified shock index ≥1.1 (hazard ratio [HR] 2.57, 1.68–3.92, p1,1 (HR 2,57, 1,68-3,92, p<0,001), neoplasia ativa (HR 2,27, 1,45-3,56, p<0,001), alteração do estado de consciência (HR 3,82, 2,50-5,83, p<0,001), concentração de lactato sérica ≥2,50 mmol/L (HR 5,01, 3,25-7,72, p<0,001) e idade ≥80 anos (HR 1,95, 1,26-3,03, p=0,003). O desempenho prognóstico foi superior a outros scores (AUC 0,83 [0,79-0,87] versus 0,72 [0,67-0,79] no PESI e (0,70 [0,62-0,75]) no sPESI, p<0,001) e a sua performance na cohort de validação foi boa (73 eventos em 280 doentes, 26,1%, AUC 0,76, 0,71-0,82, p<0,0001) e superior aos outros scores (p<0,05). Conclusões: O score PoPE (https://tinyurl.com/ybsnka8s) é um instrumento fácil com performance superior para prever mortalidade precoce em doentes admitidos com EP de baixo risco

Age and functional relevance of coronary stenosis: A post hoc analysis of the ADVISE II trial

Background : The influence of age-dependent changes on fractional flow reserve (FFR) or instantaneous wave-free ratio (iFR) and the response to pharmacological hyperaemia has not been investigated. Aims : We investigated the impact of age on these indices. Methods : This is a post hoc analysis of the ADVISE II trial, including a total of 690 pressure recordings (in 591 patients). Age-dependent correlations with FFR and iFR were calculated and adjusted for stenosis severity. Patients were stratified into three age terciles. The hyperaemic response to adenosine, calculated as the difference between resting and hyperaemic pressure ratios, and the prevalence of FFR-iFR discordance were assessed. Results : Age correlated positively with FFR (r=0.08, 95% CI: 0.01 to 0.15, p=0.015), but not with iFR (r=-0.03, 95% CI: -0.11 to 0.04, p=0.411). The hyperaemic response to adenosine decreased with patient age (0.12±0.07, 0.11±0.06, 0.09±0.05, for the 1st [33-58 years], 2nd [59-69 years] and 3rd [70-94 years] age tertiles, respectively, p0.89 discordance doubled in the first age tercile (14.1% vs 7.1% vs 7.0%, p=0.005). Conclusions : The hyperaemic response of the microcirculation to adenosine administration is age dependent. FFR values increase with patient age, while iFR values remain constant across the age spectrum. These findings contribute to explaining differences observed in functional stenosis classification with hyperaemic and non-hyperaemic coronary indices

Predictive factors of discordance between the instantaneous wave‐free ratio and fractional flow reserve

Objectives: To identify clinical, angiographic and hemodynamic predictors of discordance between instantaneous wave‐free ratio (iFR) and fractional flow reserve (FFR). Background: The iFR was found to be non‐inferior to the gold‐standard FFR for guiding coronary revascularization, although it is discordant with FFR in 20% of cases. A better understanding of the causes of discordance may enhance application of these indices. Methods: Both FFR and iFR were measured in the prospective multicenter CONTRAST study. Clinical, angiographic and hemodynamic variables were compared between patients with concordant values of FFR and iFR (cutoff ≤0.80 and ≤0.89, respectively). Results: Out of the 587 patients included, in 466 patients (79.4%) FFR and iFR agreed: both negative, n = 244 (41.6%), or positive, n = 222 (37.8%). Compared with FFR, iFR was negative discordant (FFR+/iFR‐) in 69 (11.8%) patients and positive discordant (FFR‐/iFR+) in 52 (8.9%) patients. On multivariate regression, stenosis location (left main or proximal left anterior descending) (OR: 3.30[1.68;6.47]), more severe stenosis (OR: 1.77[1.35;2.30]), younger age (OR: 0.93[0.90;0.97]), and slower heart rate (OR: 0.59[0.42;0.75]) were predictors of a negative discordant iFR. Absence of a beta‐blocker (OR: 0.41[0.22;0.78]), older age (OR: 1.04[1.00;1.07]), and less severe stenosis (OR: 0.69[0.53;0.89]) were predictors of a positive discordant iFR. Conclusions: During iFR acquisition, stenosis location, stenosis degree, heart rate, age and use of beta blockers influence concordance with FFR and should be taken into account when interpreting iFR

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P &lt; 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)