E. Shaw

Clinical utility of optical coherence tomography (OCT) in the optimisation of Absorb bioresorbable vascular scaffold deployment during percutaneous coronary intervention.

AIMS The Absorb everolimus-eluting bioresorbable vascular scaffold (BVS) represents an important advance in percutaneous coronary intervention (PCI) technology. With increasing use of BVS, it is important to understand its expansion characteristics to ensure optimal scaffold deployment. Optical coherence tomography (OCT) has been shown to improve detection of intraprocedural complications compared with conventional intravascular imaging modalities. This study aimed to determine whether or not OCT, post successful angiographic BVS implantation, influenced decision making with regard to the need for further scaffold optimisation. METHODS AND RESULTS Consecutive patients undergoing OCT-guided BVS implantation from August 2012 to March 2013 were reviewed to determine if further intervention was required to optimise BVS implantation, based on OCT performed after what was deemed to be an optimal angiographic result. Nineteen patients with 29 scaffolds were analysed. Mean age was 53.7, with 84% male. There was a range of lesion types with 12 (63%) type A and seven (37%) type B or C. Of 29 scaffolds analysed, 28% required further intervention after OCT review, three (37.5%) due to scaffold malapposition and five (62.5%) due to scaffold underexpansion. CONCLUSIONS Despite achieving angiographic success in all BVS implantations, further optimisation was required in over a quarter of patients on the basis of OCT findings.

The effect of coronary artery plaque composition, morphology and burden on Absorb bioresorbable vascular scaffold expansion and eccentricity — A detailed analysis with optical coherence tomography

AIMS Suboptimal stent expansion correlates with adverse cardiac events. There is limited information regarding Absorb bioresorbable vascular scaffold (BVS) expansion characteristics. Optical coherence tomography (OCT) allows for high-resolution assessment of plaque morphology, composition and assessment of BVS expansion. This study evaluates coronary plaque composition, morphology and burden and their effect on Absorb BVS expansion using OCT. METHODS AND RESULTS Two thousand three hundred and thirty four frames totalling 462.6 mm of BVS from twenty OCT-guided BVS implantations were examined. 200 μm longitudinal cross-sections of each BVS were analysed for lumen contours and plaque characteristics. The relationship between each plaque characteristic and scaffold expansion index (SEI) or scaffold eccentricity index (SEC) was analysed by repeated measures ANOVA. Forty-four fibrous and 265 calcific plaques were identified. Lower SEI was significantly (p<0.001) associated with greater calcific plaque (CP) area (mean SEI 78.9% vs. 80.0%), thickness (78.5% vs. 80.4%) and lower CP depth (78.3% vs. 80.2%). Lower SEC was significantly (p<0.001) associated with greater fibrous plaque (FP) area (0.84 vs. 0.85), thickness (0.83 vs. 0.86), arc angle (0.84 vs. 0.85), greater CP area (0.83 vs. 0.86), CP thickness (0.83 vs. 0.86), CP angle (0.84 vs. 0.85) and lower CP depth (0.84 vs. 0.85). Greater FP area was associated with greater SEI (81.0% vs. 80.0%, p<0.001), even after adjustment for target vessel size. Greater FP angle (80.7% vs 78.3%, p<0.001) and quadrants occupied were also associated (80.0% vs 78.5%, p<0.002) with greater SEI. CONCLUSION BVS expansion and eccentricity are significantly impacted by plaque composition, morphology and burden.

Therapy for Triggered Acute Risk Prevention: A Study of Feasibility

BACKGROUND Heavy physical exertion, emotional stress, heavy meals and respiratory infection transiently increase the risk of myocardial infarction, sudden death and stroke, however it remains uncertain how to use this information for disease prevention. AIMS We determined the feasibility of taking targeted medication for the hazard duration of a triggering activity to reduce risk. METHODS After a run-in training period over 1 month, 17 healthy subjects recorded for 1 month all episodes of physical and emotional stress, heavy meal and respiratory infection. For each episode, they were instructed to take either aspirin 100mg and propranolol 10mg (for physical exertion and emotional stress) or aspirin 100mg alone (for respiratory infection and heavy meal) and record adherence with taking medication. Subjects performed exertion while wearing a heart rate monitor, once during the run-in period, and once 30 min after taking propranolol and aspirin. RESULTS Based on study diary subjects reliably documented triggers with 94% adherence. Designated medication was also reliably taken, with 88% adherence. Propranolol taken prior to exertion resulted in a lower peak heart rate (128+/-38 versus 149+/-21, p<0.01) compared to similar exercise during the run-in period. Over two-thirds (71%) of subjects considered that it was feasible to continue taking medication in this manner. CONCLUSIONS The study indicates that potential triggers of acute cardiovascular disease can be reliably identified, and it is feasible and acceptable to take targeted medication at the time of these triggers. These findings encourage further investigation of the potential role of this therapeutic strategy.

Triggering of acute coronary occlusion by episodes of anger

Aims: The aim of this study was to report the association between episodes of anger and acute myocardial infarction (MI) in patients with angiographically confirmed coronary occlusion. Methods and results: 313 participants with acute coronary occlusion (Thrombolysis In Myocardial Infarction 0 or 1 at emergency angiography) reported frequency of anger episodes in the 48 h prior to MI. In primary analysis, anger exposures within 2 h and 2–4 h prior to symptom onset were compared with subjects’ own usual yearly exposure to anger using case-crossover methodology. Anger level ≥5 (on an anger scale of 1–7) was reported by seven (2.2%) participants within 2 h of MI. Compared with usual frequency, the relative risk of onset of MI symptoms occurring within 2 h of anger level ≥5 (defined as very angry) was 8.5 (95% confidence interval 4.1–17.6). Anger level <5 was not associated with onset of MI symptoms. Compared with 24–26 h pre MI, anxiety scores >75th percentile on State–Trait Personality Inventory were associated with a relative risk of 2.0 (95% confidence interval 1.1–3.8) and in those above the 90th percentile, the relative risk of MI symptom onset was 9.5 (95% confidence interval 2.2–40.8). Conclusion: Findings confirm that episodes of intense anger, defined as being ‘very angry, body tense, clenching fists or teeth’ (within 2 h) are associated with increased relative risk for acute coronary occlusion. Additionally, increased anxiety was associated with coronary occlusion. Further study, including the role of potential modifiers, may provide insight into prevention of MI during acute emotional episodes.

Therapy for Triggered Acute Risk Prevention in Subjects at Increased Cardiovascular Risk

Heavy physical exertion, emotional stress, heavy meals, and respiratory infection transiently increase the risk of myocardial infarction, sudden cardiac death, and stroke; however, it remains uncertain how to use this information for disease prevention. We determined whether it was feasible for those with either risk factors for cardiovascular disease (CVD) or known CVD to take targeted medication for the hazard duration of the triggering activity to reduce their risk. After a run-in of 1 month, 20 subjects (12 women and 8 men) aged 68.6 years (range 58 to 83) recorded for 2 months all episodes of physical and emotional stress, heavy meal consumption, and respiratory infection. For each episode, the subjects were instructed to take either aspirin 100 mg and propranolol 10 mg (for physical exertion and emotional stress) or aspirin 100 mg alone (for respiratory infection and heavy meal consumption) and to record their adherence. Adherence with taking the appropriate medication was 86% according to the diary entries, with 15 of 20 subjects (75%) achieving ≥80% adherence. Propranolol taken before exertion reduced the peak heart rate compared with similar exercise during the run-in period (118 ± 21 vs 132 ± 16 beats/min, p = 0.016). Most subjects (85%) reported that it was feasible to continue taking the medication in this manner. In conclusion, it is feasible for those with increased CVD risk to identify potential triggers of acute CVD and to take targeted therapy at the time of these triggers.

Routine aspiration thrombectomy improves the diagnosis and management of embolic myocardial infarction

Assess the effect of aspiration thrombectomy on diagnosis and management of embolic acute myocardial infarction.

Comparison of two dimensional quantitative coronary angiography (2D-QCA) with optical coherence tomography (OCT) in the assessment of coronary artery lesion dimensions

Objectives There is limited data on how well 2D-QCA and OCT agree with each other for measurement of coronary artery lumen dimensions. We aimed to assess the agreement between the two modalities. Methods Patients undergoing OCT for assessment of coronary artery lesions were reviewed. Minimum luminal diameter (MLD), proximal reference diameter and distal reference diameter were measured for each lesion prior to stenting. Results OCT was performed in 64 patients and 40 lesions were suitable for analysis. There was a good correlation for proximal and distal reference diameters (r = 0.86, p < 0.0001 and r = 0.92, p < 0.0001 respectively). There was good agreement on Bland–Altman analysis; the proximal and distal reference diameters measured by QCA were on average 0.09 mm (95% CI, − 0.52 to 0.53 mm) and 0.1 mm (95% CI, − 0.59 to 0.6 mm) smaller than OCT respectively. There was a satisfactory correlation (r = 0.63, p = < 0.0001) between QCA and OCT for MLD. However, the MLD by QCA was 0.49 mm (95% CI, − 1.57 to 0.59 mm) smaller than OCT, suggesting a poor agreement for MLD. Conclusions There is a good correlation and agreement between QCA and OCT for measurement of proximal and distal reference diameters. However, the MLD was underestimated by QCA.

Late gadolinium enhancement does occur in Tako-tsubo cardiomyopathy — a quantitative cardiac magnetic resonance and speckle tracking strain study

Background Late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) has been recommended to distinguish Tako-tsubo cardiomyopathy (TTC) from either acute myocardial infarction or myocarditis. Method 44 consecutive patients with confirmed Mayo Clinic criteria for TTC underwent CMR imaging at 1.5 Tesla during the acute phase. 10 patients who had CMRI to exclude scar related ventricular tachycardia, and had negative studies, were used as negative controls. LGE was quantitated at two signal intensity thresholds (CircleCVi software) at > 2 and > 5 standard-deviations (SD) above reference myocardium, and compared to biomarkers. Findings Mean door-to-CMR time was 57 hours. 18 patients (41%) had LGE > 2 SD localized to the area of abnormal wall motion, representing 28.9 ± 11.2% LV mass. In 16 of these 18 patients (89%) LGE signal intensity was > 5 SD above normal myocardium, representing 12.1 ± 10% LV mass. LGE signal intensity was significantly greater in TTC than in matched controls (p < 0.05) but lower than in STEMI patients (p < 0.05). Mean troponin was significantly higher in LGE positive patients (2.5 ± 1.8 vs 4.4 ± 6.9, p = 0.001). Mean ejection fraction (EF) by CMR was 45% ± 8.7 in LGE-negative, and 40% ± 7.1 in LGE-positive patients (p = 0.37). Recovery of segmental function was confirmed at follow-up, mean EF was 59% in both groups. Conclusion LGE was present in 41% of cases of TTC, 89% of which had intense enhancement > 5 SD above normal myocardium. Presence of LGE was associated with worse myocardial injury in the acute setting, with no difference in recovery of function.