Background Inflammation plays a pivotal role in coronary artery disease (CAD). The anti‐inflammatory drug colchicine seems to reduce ischemic events in patients with CAD. So far there is equipoise ...about its safety and impact on mortality. Methods and Results To evaluate the utility of colchicine in patients with acute and chronic CAD, we performed a systematic review and meta‐analysis. MEDLINE, EMBASE, Cochrane CENTRAL and conference abstracts were searched from January 1975 to October 2020. Randomized trials assessing colchicine compared with placebo/standard therapy in patients with CAD were included. Data were combined using random‐effects models. The reliability of the available data was tested using trial sequential analyses . Of 3108 citations, 13 randomized trials (n=13 125) were included. Colchicine versus placebo/standard therapy in patients with CAD reduced risk of myocardial infarction (odds ratio OR 0.64; 95% CI, 0.46–0.90; P =0.01; I 2 41%) and stroke/transient ischemic attack (OR 0.50; 95% CI, 0.31–0.81; P =0.005; I 2 0%). But treatment with colchicine compared with placebo/standard therapy had no influence on all‐cause and cardiovascular mortality (OR 0.96; 95% CI, 0.65–1.41; P =0.83; I 2 24%; and OR 0.82; 95% CI, 0.55–1.22; P =0.45; I 2 0%, respectively). Colchicine increased the risk for gastrointestinal side effects ( P <0.001). According to trial sequential analyses, there is only sufficient evidence for a myocardial infarction risk reduction with colchicine. Conclusions Among patients with CAD, colchicine reduces the risk of myocardial infarction and stroke, but has a higher rate of gastrointestinal upset with no influence on all‐cause mortality.
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.
•Inflammation plays a key role in the development coronary artery disease (CAD).•The ancient drug colchicine targets inflammation through multiple pathways.•Recent trials indicated that colchicine ...reduces the risk for ischemic events in CAD.•Albeit colchicine is safe, it may be underused for secondary prevention in CAD.•More data is needed to define the optimal duration of colchicine therapy in CAD.
Inflammation plays a central role in coronary artery disease (CAD), and recent data have shown that anti-inflammatory drugs have the potential to reduce ischemic events in CAD patients. Colchicine is an ancient anti-inflammatory drug that targets neutrophil and inflammasome activities. It has been prescribed for decades for different rheumatological conditions. Given the important role of inflammation in the development of cardiovascular disease, there has been considerable interest in studying colchicine's potential to limit the progression of atherosclerosis among afflicted patients. In fact, there is a growing body of randomized data suggesting that use of low-dose colchicine reduces the risk of ischemic events in patients with CAD, particularly repeated revascularizations, new myocardial infarctions and strokes. This review article summarizes background information—including possible side effects and contraindications—as well as the current evidence backing up the use of colchicine in patients with established CAD.
Treatment of in-stent restenosis (ISR) is challenging and treatment failure rate remains high. Correction of stent under-expansion and neointimal compression using the twin-layer OPN™ highly ...non-compliant balloon (NCB) at high pressure (>30 atm) may lead to increased luminal gain and thus better clinical outcomes. We evaluated periprocedural safety and clinical long-term outcomes after ISR treatment using the OPN™ NCB in a real-world population.
From an ongoing registry, consecutive ISR patients treated with the OPN™ NCB at a tertiary cardiology center in Switzerland were analyzed. We evaluated procedural efficacy, periprocedural complications, target lesion/vessel failure (TLF/TVF), and major adverse cardiovascular events (MACE).
Totally, 208 ISR lesions were treated in 188 patients (mean age 68 ± 13 years, 78 % males). Most lesions were moderately to heavily calcified (89 %), the majority (70.2 %) had complex lesion characteristics (AHA Type B2/C lesions) and 50.5 % were non-focal ISR lesions. After ISR treatment using high pressure pre- and post-dilatation (mean pressure 33 ± 6 atm) with the OPN™ NCB device, the rate of major complications was low (0.96 % coronary perforation, 4 % major dissections, 1.9 % no-reflow and 0.5 % acute vessel closure). At 1-year follow-up, MACE occurred in 19.7 %; 15.4 % patients had TVF; MI and stent thrombosis was found in 5.9 % and 2.1 % of all patients, respectively; and 5 patients died.
For ISR treatment, using the super non-compliant OPN™ balloon at very high pressures is safe. Moreover, its use might lead to a low rate of TLF/TVF during long-term follow-up, but this requires further evaluation in dedicated comparative trials.
•The OPN™ – a twin-layer, highly non-compliant balloon (NCB) – allows application of pressures >30 atm.•This ultra-high pressure balloon device has been shown to be effective in native coronary lesions.•This is the first study systematically assessing the utility and safety of the OPN™ in in-stent restenosis (ISR).•Albeit using pressures >30 atm with OPN™ devices, few complications occurred in our complex ISR cohort.•Moreover, we observed clinical outcomes comparable or lower than previous seen in ISR studies.
Abstract
Objectives
It is uncertain, if omitting post-dilatation and stent oversizing (stent optimization) is safe and may decrease the risk for distal thrombus embolization (DTE) in STEMI patients ...with large thrombus burden (LTB).
Background
In patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (pPCI) with stenting, (DTE) and flow deterioration are common and increase infarct size leading to worse outcomes.
Methods
From a prospective registry, 74 consecutive STEMI patients with LTB undergoing pPCI with stenting and intentionally deferred stent optimization were analyzed. Imaging data and outcomes up to 2 years follow-up were analyzed.
Results
Overall, 74 patients (18% females) underwent deferred stent optimization. Direct stenting was performed in 13 (18%) patients. No major complications occurred during pPCI. Staged stent optimization was performed after a median of 4 (interquartile range (IQR) 3; 7) days. On optical coherence tomography, under-expansion and residual thrombus were present in 59 (80%) and 27 (36%) cases, respectively. During deferred stent optimization, we encountered no case of flow deterioration (slow or no-reflow) or side branch occlusion. Minimal lumen area (mm
2
) and stent expansion (%) were corrected from 4.87±1.86mm to 6.82±2.36mm (
p
<0.05) and from 69±18% to 91±12% (
p
<0.001), respectively. During follow-up, 1 patient (1.4%) required target lesion revascularization and 1 (1.4%) patient succumbed from cardiovascular death.
Conclusions
Among STEMI patients with LTB, deferring stent optimization in the setting of pPCI appears safe and potentially mitigates the risk of DTE. The impact of this approach on infarct size and clinical outcomes warrants further investigation in a dedicated trial.
During the Coronavirus Disease 2019 worldwide pandemic, patients with heart failure are a high-risk group with potential higher mortality if infected. Although lockdown represents a solution to ...prevent viral spreading, it endangers regular follow-up visits and precludes direct medical assessment in order to detect heart failure progression and optimize treatment. Furthermore, lifestyle changes during quarantine may trigger heart failure decompensations. During the pandemic, a paradoxical reduction of heart failure hospitalization rates was observed, supposedly caused by patient reluctance to visit emergency departments and hospitals. This may result in an increased patient mortality and/or in more complicated heart failure admissions in the future. In this scenario, different telemedicine strategies can be implemented to ensure continuity of care to patients with heart failure. Patients at home can be monitored through dedicated apps, telephone calls, or devices. Virtual visits and forward triage screen the patients with signs or symptoms of decompensated heart failure. In-hospital care may benefit from remote communication platforms. After discharge, patients may undergo remote follow-up or telerehabilitation to prevent early readmissions. This review provides a comprehensive appraisal of the many possible applications of telemedicine for patients with heart failure during Coronavirus disease 2019 and elucidates practical limitations and challenges regarding specific telemedicine modalities.
The adoption of optical coherence tomography (OCT) in percutaneous coronary intervention (PCI) is limited by need for real-time image interpretation expertise. Artificial intelligence (AI)-assisted ...Ultreon™ 2.0 software could address this barrier. We used eye tracking to understand how these software changes impact viewing efficiency and accuracy.
Eighteen interventional cardiologists and fellows at McMaster University, Canada, were included in the study and categorized as experienced or inexperienced based on lifetime OCT use. They were tasked with reviewing OCT images from both Ultreon™ 2.0 and AptiVue™ software platforms while their eye movements were recorded. Key metrics, such as time to first fixation on the area of interest, total task time, dwell time (time spent on the area of interest as a proportion of total task time), and interpretation accuracy, were evaluated using a mixed multivariate model.
Physicians exhibited improved viewing efficiency with Ultreon™ 2.0, characterized by reduced time to first fixation (Ultreon™ 0.9 s vs. AptiVue™ 1.6 s,
= 0.007), reduced total task time (Ultreon™ 10.2 s vs. AptiVue™ 12.6 s,
= 0.006), and increased dwell time in the area of interest (Ultreon™ 58% vs. AptiVue™ 41%,
< 0.001). These effects were similar for experienced and inexperienced physicians. Accuracy of OCT image interpretation was preserved in both groups, with experienced physicians outperforming inexperienced physicians.
Our study demonstrated that AI-enabled Ultreon™ 2.0 software can streamline the image interpretation process and improve viewing efficiency for both inexperienced and experienced physicians. Enhanced viewing efficiency implies reduced cognitive load potentially reducing the barriers for OCT adoption in PCI decision-making.
Treatment of ST represents a challenge. The presence of large amounts of thrombus combined with stent optimization increase the risk of distal embolization. A two‐step strategy of stent implantation ...and deferred stent optimization might be appropriated. We hereby present three clinical cases of ST successfully treated with a two‐step approach.
In patients with stent thrombosis, clinicians should consider a strategy of initial low pressure balloon dilatation ± thrombectomy with new stent implantation at nominal pressure followed by staged (3‐5 days) intravascular imaging‐guided optimization. This may reduce the risk of no‐reflow and maximize myocardial salvage.
The magnesium-based sirolimus-eluting bioresorbable scaffold (Mg-BRS) Magmaris™ showed promising clinical outcomes, including low rates of both the target lesion failure (TLF) and scaffold thrombosis ...(ScT), in selected study patients. However, insights regarding long-term outcomes (>2 years) in all-comer populations remain scarce.
We analyzed data from a single-center registry, including patients with acute coronary syndrome (ACS) and chronic coronary syndrome (CCS), who had undergone percutaneous coronary intervention (PCI) using the Mg-BRS. The primary outcome comprised the device-oriented composite endpoint (DoCE) representing a hierarchical composite of cardiac death, ScT, target vessel myocardial infarction (TV-MI), and clinically driven target lesion revascularization (TLR) up to 5 years.
In total, 84 patients mean age 62 ± 11 years and 63 (75%) men were treated with the Mg-BRS devices between June 2016 and March 2017. Overall, 101 lesions had successfully been treated with the Mg-BRS devices using 1.2 ± 0.4 devices per lesion. Pre- and postdilatation using dedicated devices had been performed in 101 (100%) and 98 (97%) of all the cases, respectively. After a median follow-up time of 62 (61-64) months, 14 (18%) patients had experienced DoCEs, whereas ScT was encountered in 4 (4.9%) patients early ScTs (<30 days) in three cases and two fatal cases. In 4 (29%) of DoCE cases, optical coherence tomography confirmed the Mg-BRS collapse and uncontrolled dismantling.
In contradiction to earlier studies, we encountered a relatively high rate of DoCEs in an all-comer cohort treated with the Mg-BRS. We even observed scaffold collapse and uncontrolled dismantling. This implicates that this metal-based BRS requires further investigation and may only be used in highly selected cases.
Graphical Abstract
Central illustration. Design principles and hemodynamic effects of the Impella™ device. AOP, Aortic pressue; EDP, Enddiastolic pressure; EDV, Enddiastolic volume.
Cardiogenic shock ...(CS) remains a leading cause of hospital death. However, the use of mechanical circulatory support has fundamentally changed CS management over the last decade and is rapidly increasing. In contrast to extracorporeal membrane oxygenation as well as counterpulsation with an intraaortic balloon pump, ventricular unloading by the Impella™ device actively reduces ventricular volume as well as pressure and augments systemic blood flow at the same time. By improving myocardial oxygen supply and enhancing systemic circulation, the Impella device potentially protects myocardium, facilitates ventricular recovery and may interrupt the shock spiral. So far, the evidence supporting the use of Impella™ in CS patients derives mostly from observational studies, and there is a need for adequate randomized trials. However, the Impella™ device appears a promising technology for management of CS patients. But a profound understanding of the device, its physiologic impact and clinical application are all important when evaluating CS patients for percutaneous circulatory support. This review provides a comprehensive overview of the percutaneous assist device Impella™. Moreover, it highlights in depth the rationale for ventricular unloading in CS and describes practical aspects to optimize care for patients requiring hemodynamic support.
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