Juan F. Iglesias

Temporal trends in the treatment and outcomes of elderly patients with acute coronary syndrome

AIMS To determine whether treatment and outcomes of older acute coronary syndrome (ACS) patients changed over time. METHODS AND RESULTS We analysed the use of guideline-recommended therapies and in-hospital outcomes of 13 662 ACS patients ≥70 years enrolled in the prospective Acute Myocardial Infarction in Switzerland (AMIS) cohort between 2001 and 2012 according to 4-year periods (2001-2004, 2005-2008, and 2009-2012). Between first and last 4-year period, percutaneous coronary intervention (PCI) use increased from 43.8 to 69.6% of older ACS patients ( ITALIC! P < 0.001). Use of guideline-recommended drugs as well increased. At the same time, in-hospital mortality of the overall population decreased from 11.6% in the first to 10.0% in the last 4-year period ( ITALIC! P = 0.020), and in-hospital major adverse cardiac and cerebrovascular events from 14.4 to 11.3% ( ITALIC! P < 0.001). Percutaneous coronary intervention was used in increasingly older and co-morbid patients over time (mean age of patients treated with PCI 76.2 years in 2001-2004 and 78.1 years in 2009-2012, ITALIC! P < 0.001; Charlson score ≥2 was found for 27.6% of patients treated with PCI in 2001-2004 and for 32.1% in 2009-2012, ITALIC! P = 0.003). Percutaneous coronary intervention use was associated with similar odds ratios (ORs) of in-hospital mortality over time (adjusted OR 0.29, 95% confidence interval, CI, 0.22-0.40, in 2001-2004; and, adjusted OR 0.26, 95% CI 0.20-0.35, in 2009-2012). CONCLUSION Use of guideline-recommended therapies for ACS increased and in-hospital outcomes improved over the observed 12-year period. Though PCI was used in increasingly older and co-morbid patients, PCI use was associated with similar ORs of in-hospital mortality over time. This study suggests that increasing use of guideline-recommended therapies was appropriate. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01305785.

Stepwise Evaluation of Unexplained Syncope in a Large Ambulatory Population

Background: Up to 60% of syncopal episodes remain unexplained. We report the results of a standardized, stepwise evaluation of patients referred to an ambulatory clinic for unexplained syncope.

First prospective multicenter experience with the 7 French Glidesheath slender for complex transradial coronary interventions

To assess the feasibility and safety of the 7 French (Fr) Glidesheath Slender for complex transradial (TR) percutaneous coronary interventions (PCI).

Dual antiplatelet therapy for secondary prevention of coronary artery disease

Dual antiplatelet therapy (DAPT) combining aspirin and a P2Y12 receptor inhibitor has been consistently shown to reduce recurrent major adverse cardiovascular events (MACE) in patients with acute coronary syndrome (ACS) or undergoing percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) compared with aspirin monotherapy, but at the expense of an increased risk of major bleeding. Nevertheless, the optimal duration of DAPT for secondary prevention of CAD remains uncertain, owing to the conflicting results of several large randomised trials. Among patients with stable CAD undergoing PCI with drug-eluting stents (DES), shorter durations of DAPT (3–6 months) were shown non-inferior to 12 or 24 months duration with respect to MACE, but reduced the rates of major bleeding. Contrariwise, prolonged DAPT durations (18–48 months) reduced the incidence of myocardial infarction and stent thrombosis, but at a cost of an increased risk of major bleeding and all-cause mortality. Until more evidence becomes available, the choice of optimal DAPT regimen and duration for patients with CAD requires a tailored approach based on the patient clinical presentation, baseline risk profile and management strategy. Future studies are however needed to identify patients who may derive benefit from shortened or extended DAPT courses for secondary prevention of CAD based on their individual ischaemic and bleeding risk. Based on limited evidence, 12 months duration of DAPT is currently recommended in patients with ACS irrespective of their management strategy, but large ongoing randomised trials are currently assessing the efficacy and safety of a short-term DAPT strategy (3–6 months) for patients with ACS undergoing PCI with newer generation DES. Finally, several ongoing, large-scale, randomised trials are challenging the current concept of DAPT by investigating P2Y12 receptor inhibitors as single antiplatelet therapy and may potentially shift the paradigm of antiplatelet therapy after PCI in the near future. This article provides a contemporary state-of-the-art review of the current evidence on DAPT for secondary prevention of patients with CAD and its future perspectives.

Acute myocardial infarction caused by coronary embolization of a papillary fibroelastoma of the thoracic ascending aorta

Papillary fibroelastomas (PFE) are benign endocardial masses and generally originate from the cardiac valves, while PFE arising from the ascending thoracic aorta are an uncommon clinical finding. We report the case of a 78-year-old female who presented to the emergency department with an acute ST segment elevation myocardial infarction. Urgent coronary angiography showed no significant coronary artery obstructive disease but left ventriculography revealed the presence of a highly mobile mass located in the proximal portion of the ascending thoracic aorta. We postulated that the clinical symptoms were caused by embolization from the aortic mass and surgical excision of the peduncle was performed. Histopathological examination revealed a PFE with thrombotic material. Nowadays, surgical excision of PFE remains, the treatment of choice for symptomatic patients with excellent short- and long-term results but recurrence of PFE following surgical excision has not been reported.

Coronary Subclavian Steal Syndrome and Acute Anterior Myocardial Infarction A New Treatment Dilemma in the Era of Primary Percutaneous Coronary Intervention

Coronary subclavian steal syndrome (CSSS) is an uncommon complication after coronary artery bypass graft (CABG) surgery using the left internal mammary artery (LIMA).1–3 CSSS results from the retrograde blood flow through the LIMA graft in the left subclavian artery (SCA), consecutive to a proximal SCA stenosis or total occlusion. CSSS usually manifests as stable angina pectoris1 but also rarely presents as ST-segment–elevation myocardial infarction secondary to an acute SCA occlusion or plaque rupture.1,2 Anterior ST-segment–elevation myocardial infarction resulting from an acute thrombotic occlusion of the left anterior descending (LAD) artery at the LIMA-to-LAD anastomotic site in a patient with concomitant CSSS may be a challenging problem during primary percutaneous coronary intervention and has not been reported to date. Here, we report on a 62-year-old woman with hypertension, dyslipidemia, and peripheral artery disease who underwent CABG surgery using a LIMA graft to the LAD 12 years earlier (Figure 1 and Movie I in the online-only Data Supplement). The patient presented to the emergency department with de novo exertional chest pain. The 12-lead ECG showed negative T waves in the anterior leads, and her cardiac biomarkers were normal. During admission, the patient developed chest pain at rest associated with paresthesias of the left hand. An ECG showed new anterior ST-segment elevation, and the patient was transferred for primary percutaneous coronary intervention. The left coronary angiogram (Movie II in the online-only Data Supplement) showed a patent LAD with critical …

Aortic valve lesion after coronary angiography

A 56-year-old patient admitted to hospital for the suspicion of an acute coronary syndrome underwent coronary angiography without detection of significant lesions. Seven days later the echocardiography showed acute severe aortic valve insufficiency. Intraoperatively we found a perforated leaflet probably due to lesion during transcatheter procedure.

Interosseous artery collaterals and their support to ulno-palmar arch: A case report and a review of the literature

Article history: Received 3 June 2015 Accepted 20 June 2015 Available online 27 June 2015 (Glidesheath, Terumo, Somerset, NJ) instead of a brachial access to perform coronary angiography. We also performed a right forearm arteriography (Fig. 1), which demonstrated an efficient collateralization from interosseous anterior branch to distal radial artery. The access site was managed with verapamil 5 mg and heparin 5000 UI. The coronary angiography showed a sub-occlusive restenosis of the RCA treated with a DES. At the end of the procedure, the 6 French ulnar sheath was A 65 year-old woman, with known hypertension, dyslipidemia, and positive family history of coronary artery disease and conservatively treated for an aorto-iliac occlusive disease, was admitted in September 2014 in our institution with angina (CCS 2) and a positive non-invasive test suggests myocardial ischemia in the inferior wall of the left ventricle. Diagnostic suspicion of a right coronary artery (RCA) restenosis indicated an invasive coronary artery assessment. Patient clinical history starts 7 months before with an acute anterior non-ST-segment Elevation Myocardial Infarction. Coronary angiography, performed through a right trans-radial access (TRA) evidenced a sub-occlusive mid-LAD stenosis and a significant stenosis on the RCA. The patient was successfully treated by a PCI on the proximal left anterior descending (LAD)with drug eluting stent (DES) implantation. After a short and uneventful hospitalization, she was discharged. One month later, the patient was readmitted to undergo a stage procedure on the RCA due to ventricular inferior wall ischemia evidence. Arterial pulse evaluation showed a probably iatrogenic right radial arterial occlusion (RAO). Therefore, in the context of the aorto-iliac occlusive disease, a left TRA was chosen. Coronary angiography confirmed the good result of the LAD stenting and the RCA stenosis was treated with PCI and Bare Metal Stent (BMS) implantation. The procedure was uneventful and the patient was discharged the following day. Prior to coronary artery angiography, during September 2014 hospitalization, pulse examination was performed with a bilateral radial artery occlusion evidence. Despite a highly abnormal reverse modified Allen test which would have contraindicated a wrist access, the pulseoxymetry evaluation (right thumb) recorded a C pattern [1] suggesting the presence of an efficient blood flow to ulno-palmar arch. We then

A comparison of an ultrathin-strut biodegradable polymer sirolimus-eluting stent with a durable polymer everolimus-eluting stent for patients with acute ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention: rationale and design of the BIOSTEMI trial

AIMS A novel ultrathin-strut biodegradable polymer sirolimus-eluting stent (BP-SES) (Orsiro; Biotronik, Bülach, Switzerland) was shown to be superior to a thin-strut durable polymer everolimus-eluting stent (DP-EES) (XIENCE Xpedition/Alpine; Abbott Vascular, Santa Clara, CA, USA) with respect to the primary endpoint of target lesion failure (TLF) at 12 months in the pre-specified subgroup of patients with ST-segment elevation myocardial infarction (STEMI) included in the BIOSCIENCE trial. We designed a large-scale, randomised, clinical trial to assess the clinical superiority of ultrathin-strut BP-SES over thin-strut DP-EES among patients with STEMI undergoing primary percutaneous coronary intervention (PPCI). METHODS AND RESULTS BIOSTEMI (NCT02579031) is a prospective, multicentre, randomised, controlled, superiority trial that will randomly assign 1,250 patients with STEMI undergoing PPCI to treatment with BP-SES or DP-EES. The primary endpoint of TLF, a composite of cardiac death, target vessel reinfarction, and clinically indicated target lesion revascularisation within 12 months, will be analysed with Bayesian models applied to the BIOSTEMI data set (n=1,250) using robust historical priors to incorporate historical information from the BIOSCIENCE STEMI subgroup (n=407). CONCLUSIONS The BIOSTEMI trial will determine whether ultrathin-strut BP-SES are superior to thin-strut DP-EES with respect to TLF in patients with STEMI undergoing PPCI.

Subepicardial Hematoma of the Left Ventricle Mimicking Acute Anterior Myocardial Infarction

A 63-year-old male with hypercholesterolemia was admitted to the emergency department complaining of a 12-hour persisting typical central chest pain. He had experienced a blunt chest trauma while practicing judo 6 weeks earlier. On admission, the 12-lead ECG was consistent with acute anterior ST-segment elevation myocardial infarction (STEMI), and the patient received loading doses of aspirin, prasugrel, and unfractioned heparin. The urgent coronary angiogram (CA) showed an occlusion of the mid-left anterior descending (LAD) artery, with retrograde collateralization arising from the first diagonal branch, and absence of significant lesions in the left circumflex and right coronary arteries (Movie I in the online-only Data Supplement). Percutaneous coronary intervention to the LAD was attempted without possibility to access the distal LAD beyond the occlusion site, suggesting a chronic total occlusion (Movie II in the online-only Data Supplement). The procedure was stopped because the patient became symptom free without hemodynamical compromise. The final CA showed persisting occlusion of the mid-LAD and absence of coronary perforation (Movie III in …