Prognostic value of low heart rates in patients admitted with acute myocardial infarction

INTRODUCTION AND OBJECTIVES: The risk prediction scores adopted in acute coronary syndromes (ACS) use incremental models to estimate mortality for heart rate (HR) above 60 bpm. Nonetheless, previous studies reported a nonlinear relationship between HR and events, suggesting that low HR may have an unrecognized prognostic role. We aimed to assess the prognostic impact of low HR in ACS, defined as admission HR <50 bpm. METHODS: This study analyzed data from the AMIS Plus registry, a cohort of hospitalized patients with ACS between 1999 and 2021. The primary endpoint was in-hospital all-cause mortality, while a composite of all-cause mortality, major cardiac/cerebrovascular events was set as the secondary endpoint. A multilevel statistical method was used to assess the prognostic role of low HR in ACS. RESULTS: The study included 51 001 patients. Crude estimates showed a bimodal distribution of primary and secondary endpoints with peaks at low and high HR. A nonlinear relationship between HR and in-hospital mortality was observed on restricted cubic spline analysis. An HR of 50 to 75 bpm showed lower mortality than HR <50 bpm (OR, 0.67; 95%CI, 0.47-0.99) only after primary multivariable analysis, which was not confirmed after multiple sensitivity analyses. After propensity score matching, progressive fading of the prognostic role of HR <50 bpm was evident. CONCLUSIONS: Low admission HR in ACS is associated with a higher crude rate of adverse events. Nonetheless, after correction for baseline differences, the prognostic role of low HR was not confirmed. Therefore, low HR probably represents a marker of underlying morbidity. These results may be clinically relevant in improving the accuracy of risk scores in ACS

Metal free percutaneous coronary interventions in all-comers: First experience with a novel sirolimus-coated balloon

Background: Limus-eluting stents have become the mainstay for percutaneous coronary intervention (PCI). However, even with the latest generation drug-eluting stent, in-stent restenosis and very late stent thrombosis remain a concern. The Selution SLR™ drug-coated balloon (DCB) is a novel sirolimus-coated balloon that provides a controlled release of the antiproliferative drug. Herein is evaluated its performance in a real-world patient cohort with complex coronary artery lesions. Methods: Patients undergoing PCI using the Selution SLR™ DCB were analyzed from the prospective SIROOP registry. We evaluated procedural success and clinical outcomes, including major adverse cardiovascular event (MACE), cardiac death, target vessel myocardial infarction and target lesion revascularization. Results: From September 2020 to April 2021, we enrolled 78 patients (87 lesions) treated using a “DCB only” strategy. The mean age was 66.7 ± 10.4 years and 28 (36%) presented with an acute coronary syndrome. Almost all lesions were type B2/C 86 (99%) and 49 (63%) had moderate to severe calcifications. Procedural success was 100%. After a median follow-up of 11.2 months (interquartile range: 10.0–12.6), MACE occurred in 5 (6.8%) patients. No acute vessel closure was observed. Conclusions: In complex coronary lesions, a “DCB only” strategy using the Selution SLR™ DCB is not just safe and feasible, but also seems to be associated with a low rate of MACE at 1-year follow-up. Our promising results warrant further evaluation in a dedicated comparative trial

Acute coronary syndrome, antiplatelet therapy, and bleeding: a clinical perspective

Inhibition of platelet function by means of dual antiplatelet therapy (DAPT) is the cornerstone of treatment of acute coronary syndrome (ACS). While preventing ischemic recurrences, inhibition of platelet function is clearly associated with an increased bleeding risk, a feared complication that may lead to significant morbidity and mortality. Since bleeding risk management is intrinsically associated with therapeutic adjustments undertaken during the whole clinical history of patients with acute coronary syndrome, single decisions taken from the very first day to years of follow-up might be decisive. This review aims at providing a clinically oriented, patient-tailored approach in reducing the risk and manage bleeding complications in ACS patients treated with DAPT. The steps in clinical decision making from the day of ACS to follow-up are analyzed. New treatment strategies to enhance the safety of DAPT are also described

Heavy drinking habits are associated with worse in-hospital outcomes in patients with acute coronary syndrome: an insight from the AMIS plus registry

Background: The association between alcohol consumption and the occurrence of coronary heart disease is well described in the literature, while data regarding the impact of regular alcohol consumption on in-hospital outcomes in the setting of acute coronary syndrome (ACS) are lacking. We aimed to evaluate the impact of self-reported alcohol consumption on in-hospital outcomes in patients with ACS. Methods: Data derived from patients enrolled between 2007 and 2019 in the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry were retrospectively analyzed. Patients were stratified based on alcohol drinking pattern. Primary outcome was all-cause in-hospital mortality, while secondary outcomes were set as incidence of major adverse cardiac and cerebrovascular events (MACCEs). Outcome comparisons according to quantity of daily alcohol intake were also performed. Results: Records concerning alcohol consumption were available in 25,707 patients; 5,298 of them (21%) fulfilled the criteria of regular alcohol consumption. Regular drinkers were predominantly male, younger, smokers, more comorbid and with a worse clinical presentation as compared with abstainers/occasional drinkers. Daily alcohol intake was reported in 4,059 (77%) of these patients (regular drinkers). Among them, 2,640 were light drinkers (≤2 drinks/day) and 1,419 heavy drinkers (>2 drinks/day). In-hospital mortality and MACCEs of heavy drinkers were significantly higher compared with those of light drinkers (5.4 vs. 3.3% and 7.0 vs. 4.4%, both p = 0.001). When tested together with Global Registry of Acute Coronary Events risk score parameters, heavy alcohol consumption was independently associated with in-hospital mortality (p = 0.004). Conclusions: Our results support that heavy alcohol consumption is an independent predictor of in-hospital mortality in patients presenting with ACS

Sex Differences in Epidemiology, Morphology, Mechanisms, and Treatment of Mitral Valve Regurgitation

Sex-related disparities have been recognized in incidence, pathological findings, pathophysiological mechanisms, and diagnostic pathways of non-rheumatic mitral regurgitation. Furthermore, access to treatments and outcomes for surgical and interventional therapies among women and men appears to be different. Despite this, current European and US guidelines have identified common diagnostic and therapeutic pathways that do not consider patient sex in decision-making. The aim of this review is to summarize the current evidence on sex-related differences in non-rheumatic mitral regurgitation, particularly regarding incidence, imaging modalities, surgical-derived evidence, and outcomes of transcatheter edge-to-edge repair, with the goal of informing clinicians about sex-specific challenges to consider when making treatment decisions for patients with mitral regurgitation

WorldwIde SurvEy on clinical and anatomical factors driving the choice of transcatheter aortic valve pRostheses

Background: Following the success of the first human transcatheter aortic valve replacement (TAVR) in 2002, multiple transcatheter heart valves (THVs) have become available. However, guidelines or expert consensus on how to optimize THV choice according to patients' anatomical and clinical characteristics is missing. This survey-based study aimed to identify patient-specific characteristics deemed important in the choice of THV type. Methods and results: A web-based survey including 39 questions was completed by 71 experienced TAVR operators from 23 countries with a median TAVR volume of 88 procedures in the year prior to survey completion (IQR 61-180). The survey covered five topics: access, aortic annulus/leaflets, aortic root, left ventricular function and clinical characteristics. Factors with the most impact on THV choice were reported to be a calcified sinotubular junction, valve-in-valve procedure, annular dimension >575 mm2, femoral diameter ≤ 5.0 mm, low coronary ostia, calcification at the annular level and/or protruding into the left ventricular outflow tract, and need for post TAVR PCI. Also, in case of off-label use of THVs to treat bicuspid aortic valve disease and isolated aortic regurgitation, the choice of THV type was reported to be important. Conclusions: This survey-based study identifies key patient characteristics that impact THV selection. As such, we present a guide, based on current practice, of which THV types are best suited to these different patient-specific characteristics. A patient-tailored THV choice is likely to optimize TAVR outcomes

Dual antiplatelet therapy is under-prescribed in patients with surgically treated acute myocardial infarction

OBJECTIVES Despite guideline recommendations, previous reports, coming mainly from outside Europe, showed low rates of prescriptions for dual antiplatelet therapy (DAPT) in patients with acute myocardial infarction (AMI) undergoing surgical revascularization. The present study assesses this issue in the era of potent P2Y12 inhibitors in Switzerland. METHODS All patients with a diagnosis of AMI included in the Acute Myocardial Infarction in Switzerland Plus Registry from January 2014 to December 2019 were screened; 9050 patients undergoing either percutaneous (8727, 96.5%) or surgical (323, 3.5%) revascularization were included in the analysis. RESULTS Surgically treated patients were significantly less likely to receive DAPT at discharge (56.3% vs 96.7%; P < 0.001). Even when discharged with a prescription for DAPT, those patients were significantly less likely to receive a regimen containing a new P2Y12 inhibitor (67/182 [36.8%] vs 6945/8440 [83.2%]; P < 0.001). At multivariate analysis, surgical revascularization was independently associated with a lower likelihood of receiving a prescription for DAPT at discharge (odds ratio 0.03, 95% confidence interval 0.02-0.06). CONCLUSIONS DAPT prescriptions for patients with AMI undergoing surgical revascularization are not in line with current guideline recommendations. Efforts are necessary to clarify the role of DAPT for secondary prevention in these patients and increase the confidence of treating physicians in guideline recommendations. CLINICAL TRIAL REGISTRATION Acute Myocardial Infarction in Switzerland Plus Registry; registration number at ClinicalTrials.gov: NCT01305785

Prevalence of Incidental Findings Suspicious for Transthyretin Cardiac Amyloidosis among Patients Undergoing Bone Scintigraphy: A Systematic Review and a Meta-Analysis

The myocardial uptake of bone-seeking tracers suspicious for transthyretin cardiac amyloidosis (ATTR-CA) can be incidentally detected in patients undergoing bone scintigraphy for noncardiac reasons. We conducted a systematic review and meta-analysis to assess the prevalence of these scintigraphic findings. A comprehensive literature search was performed using two bibliographic databases (PubMed/MEDLINE and Cochrane Library), searching for articles related to the review question. Eligible articles were selected, and relevant data were extracted by two authors. The pooled prevalence of incidental findings suspicious for ATTR-CA among patients undergoing bone scintigraphy was calculated on a per-patient-based analysis using a random-effects model. The pooled measure was provided with 95% confidence interval (95% CI) values. Among 219 records, 11 articles were selected for the systematic review and 10 for the meta-analysis. The pooled prevalence of incidental findings suspicious for ATTR-CA was 1.1% (95% CI: 0.7-1.4%) with heterogeneity due to the characteristics of the included studies, patients, and index tests. These findings are more prevalent in older men. The prevalence of incidental findings of ATTR-CA among patients undergoing bone scintigraphy is low but not negligible. Nuclear medicine physicians should suggest, in the scintigraphic report, further clinical investigations when these findings are detected. Prospective studies are warranted