F. Schiele

European Society of Cardiology, acute cardiovascular care association, SCAD study group: a position paper on spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) has long been recognized as a cause of acute coronary syndromes (ACS). Initially considered very rare and associated primarily with pregnancy and the peripartum period, the use of higher sensitivity Troponin assays and early angiography in ACS, coupled with greater awareness of the condition, has led to increased diagnosis, and it is now understood that SCAD represents a significant cause of ACS in predominantly young to middle-aged women, with most cases occurring outside the context of recent pregnancy.1,2 Although there are no randomized controlled trials in SCAD, knowledge has further advanced in the last 5-years as a result of an international research effort primarily focused on building and studying national SCAD registries.3–19 These studies have demonstrated, not only that SCAD is a distinct pathophysiological entity, but that there are key differences in management and outcomes compared to ACS of atherosclerotic aetiology. This position paper aims to set-out current knowledge on SCAD for the benefit of practicing clinicians caring for patients with this condition. It presents the consensus on contemporary management and areas of controversy and uncertainty, which remain a focus of ongoing research. The information is provided to support clinical care providers but is not intended to replace individualized decision-making by clinicians and other health care professionals.

Outcomes after extracorporeal membrane oxygenation for the treatment of high-risk pulmonary embolism: a multicentre series of 52 cases

Aims The role of extracorporeal membrane oxygenation (ECMO) remains ill defined in pulmonary embolism (PE). We investigated outcomes in patients with high-risk PE undergoing ECMO according to initial therapeutic strategy. Methods and results From 01 January 2014 to 31 December 2015, 180 patients from 13 Departments in nine centres with high-risk PE were retrospectively included. Among those undergoing ECMO, we compared characteristics and outcomes according to adjunctive treatment strategy (systemic thrombolysis, surgical embolectomy, or no reperfusion therapy). Primary outcome was all-cause 30-day mortality. Secondary outcome was 90-day major bleeding. One hundred and twenty-eight patients were treated without ECMO; 52 (mean age 47.6 years) underwent ECMO. Overall 30-day mortality was 48.3% [95% confidence interval (CI) 41-56] (87/180); 43% (95% CI 34-52) (55/128) in those treated without ECMO vs. 61.5% (95% CI 52-78) (32/52) in those with ECMO (P = 0.008). In patients undergoing ECMO, 30-day mortality was 76.5% (95% CI 57-97) (13/17) for ECMO + fibrinolysis, 29.4% (95% CI 51-89) (5/17) for ECMO + surgical embolectomy, and 77.7% (95% CI 59-97) (14/18) for ECMO alone (P = 0.004). Among patients with ECMO, 20 (38.5%, 95% CI 25-52) had a major bleeding event in-hospital; without significant difference across groups. Conclusion In patients with high-risk PE, those with ECMO have a more severe presentation and worse prognosis. Extracorporeal membrane oxygenation in patients with failed fibrinolysis and in those with no reperfusion seems to be associated with particularly unfavourable prognosis compared with ECMO performed in addition to surgical embolectomy. Our findings suggest that ECMO does not appear justified as a stand-alone treatment strategy in PE patients, but shows promise as a complement to surgical embolectomy.

Incidence, Predictors, and Impact on Six-Month Mortality of Three Different Definitions of Contrast-Induced Acute Kidney Injury After Coronary Angiography

We assessed incidence, predictors, and impact on 6-month mortality of contrast-induced acute kidney injury (CI-AKI) after coronary angiography with or without percutaneous coronary intervention in patients with acute coronary syndrome (ACS), according to 3 different CI-AKI definitions. Serum creatinine (sCr) was assessed at baseline and 48 to 72 hours after procedure to classify patients into 3 CI-AKI groups: Group 1: increase in sCR ≥25% over baseline but absolute increase <0.5 mg/dl; Group 2: absolute increase ≥0.5 mg/dl; Group 3: absolute increase ≥0.3 mg/dl or ≥50% over baseline. The association between CI-AKI and all-cause 6-month mortality was assessed using multivariate Cox regression. Among 1,002 patients included, median age was 68 [57 to 79] years. The sample had the following characteristics: 70% men, 25% diabetics, 22% had a history of myocardial infarction, 21% had baseline estimated glomerular filtration rate (as calculated by the Modification of Diet in Renal Disease)  <60 ml/min/1.72 m2, 34% had ST-segment elevation myocardial infarction, 61% underwent percutaneous coronary intervention, and 43% had multivessel disease. Based on changes in sCr, 89 patients (8.9%) were classified in Group 1; 69 (6.9%) in Group 2; and 157 (15.7%) in Group 3, whereas sCr did not increase >25% in the remaining 844 (84.2%). CI-AKI was significantly associated with 6-month all-cause mortality using the definitions for Group 2 (hazard ratio 3.1, 95% confidence interval [CI] 1.5 to 6.6, p = 0.002) and Group 3 (hazard ratio 2.03, 95% CI 1.03 to 4.0, p = 0.04), but not Group 1. In conclusion, based on the definition used for CI-AKI, CI-AKI is observed in 6% to 15.7% of patients. An increase of 25% over baseline sCr does not identify high-risk patients. CI-AKI defined as an increase in sCr >0.3 mg/dl identifies 15.7% of the population at 2-fold higher risk of mortality.

Beyond Reperfusion Networks in ST-segment Elevation Myocardial Infarction: Assessment of Quality of Care

Reperfusion therapy has long since been firmly established as the treatment of choice in ST-segment elevation myocardial infarction (STEMI), since it dramatically improves outcome when delivered in a timely manner. Several randomized controlled trials (RCTs) have addressed and validated the various means of reperfusion, eg, thrombolysis, prehospital thrombolysis, rescue percutaneous coronary intervention (PCI), and primary PCI (pPCI) compared with standard therapy. RCTs have also shown that pPCI leads to a better outcome than thrombolysis. In addition, data from registries and surveys have also shown that prehospital thrombolysis, if delivered early, particularly in young patients, performs equally as well as pPCI. Based on these tenets, the guidelines strongly recommend reperfusion therapy for any patient with STEMI presenting within 12 hours following symptom onset, unless contraindicated. The strategy recommended in the guidelines looks pretty straightforward. Any patient referred primarily to a PCI-capable hospital should be referred immediately to the catheterization laboratory for reperfusion. The same is true if the patient is transported from any other location, as long as the time from first medical contact to balloon is less than 2 hours, and even less than 90 minutes in the case of presumably massive STEMI. If these time constraints cannot be met, patients should undergo thrombolysis, preferably prehospital thrombolysis, unless contraindicated, and should be transferred immediately to the nearest PCI-capable hospital. This ‘‘drip and ship’’, or pharmacoinvasive strategy, is firmly validated in RCTs. If reperfusion has occurred on arrival at the PCI-capable hospital, then secondary PCI is recommended within 3 to 24 hours; if reperfusion has not occurred, the patient should undergo rescue PCI, also firmly validated in RCTs vs a noninvasive strategy. Despite these recommendations, registries have shown that a lack of reperfusion is still a major issue, with rates varying from a low of 25% to a high of 50%, depending on the country. Rates even vary widely within the same country. This implies that many hurdles still exist along the pathway to reperfusion. Some obstacles are linked to the lack of adequate structures. For example, data from the European Society of Cardiology reporting the reperfusion rate in the member countries show that lowincome countries clearly cannot offer reperfusion therapy– particularly pPCI–to all those who are candidates for reperfusion. It is also clear that within the same country, irrespective of its income, the reperfusion rate may vary considerably from one center to another. Several factors may explain these situations, such as lack of information, difficult logistics in mountainous areas, long distances and transfer times to the nearest hospital, and perilous weather conditions. Human factors may also play a role, as some physicians may not be willing to adhere to regional or national programs for reperfusion, or they may be reluctant to transfer their patients with STEMI because they feel devaluated by the ‘‘loss’’ of the most ‘‘interesting’’ cases. These are some of the obstacles that need to be overcome when considering reperfusion as a national cause. Indeed, many initiatives have been undertaken to improve implementation rates for reperfusion therapy within countries. In Europe, some smaller countries in terms of population and size have succeeded in implementing pPCI in almost all patients with STEMI thanks to nationwide initiatives, raising reperfusion rates to very high levels. Short distances to the nearest PCI-capable hospital, motivation and the implementation of reperfusion networks are key elements to success. This implies that all contributors to the network, namely physicians, paramedics, ambulance services, and emergency mobile services, who may be confronted with STEMI patients, must understand what is at stake; they must agree on a predefined protocol and act accordingly to speed up the process and shorten delays in order to improve the reperfusion rate. In this regard, the current report published in Revista Española de Cardiologı́a on reperfusion in Spain is remarkable. Based on hospital records of the Spanish National Health System involving almost all regions of Spain, the report analyzes in-hospital outcome of STEMI patients over a period of several years after the implementation of reperfusion networks, with a focus on mechanical reperfusion. Cequier et al. report an increase in the overall reperfusion rate, driven by the increase in PCI rate with, in parallel, a reduction in in-hospital mortality. This increase in PCI rates over the 9 years of the survey implies that centers have developed reperfusion pathways, probably due to improved Rev Esp Cardiol. 2017;70(3):140–141

Prognostic impact of thrombus burden as evaluated by OCT in patients with non-ST elevation acute coronary syndromes undergoing PCI

Introduction: We aimed to evaluate the impact of thrombus burden quantified by optical coherence tomography (OCT) on the risk of peri-procedural myocardial infarction (MI) (type IVa) in patients un...