Heart failure (HF) is a complex clinical syndrome with a huge social burden in terms of cost, morbidity, and mortality. Brain natriuretic peptide (BNP) appears to be the gold standard in supporting ...the daily clinical management of patients with HF. Novel biomarkers may supplement BNP to improve the understanding of this complex disease process and, possibly, to personalize care for the different phenotypes, in order to ameliorate prognosis. In this review, we will examine some of the most promising novel biomarkers in HF. Inflammation plays a pivotal role in the genesis and progression of HF and, therefore, several candidate molecules have been investigated in recent years for diagnosis, prognosis, and therapy monitoring. Noncoding RNAs are attractive as biomarkers and their potential clinical applications may be feasible in the era of personalized medicine. Given the complex pathophysiology of HF, it is reasonable to expect that the future of biomarkers lies in the application of precision medicine, through wider testing panels and “omics” technologies, to further improve HF care delivery.
Coronary microvascular dysfunction (CMD) is related to a broad variety of clinical scenarios in which cardiac microvasculature is morphologically and functionally affected, and it is associated with ...impaired responses to vasoactive stimuli. Although the prevalence of CMD involves about half of all patients with chronic coronary syndromes and more than 20% of those with acute coronary syndrome, the diagnosis of CMD is often missed, leading to the underestimation of its clinical importance. The established and validated techniques for the measurement of coronary microvascular function are invasive and expensive. An ideal method to assess endothelial dysfunction should be accurate, non-invasive, cost-effective and accessible. There are varieties of biomarkers available, potentially involved in microvascular disease, but none have been extensively validated in this heterogeneous clinical population. The investigation of potential biomarkers linked to microvascular dysfunction might improve the assessment of the diagnosis, risk stratification, disease progression and therapy response. This review article offers an update about traditional and novel potential biomarkers linked to CMD.
Coronavirus disease 2019 (COVID-19) is a pandemic disease that is causing a public health emergency. Characteristics and clinical significance of myocardial injury remain unclear.
This retrospective ...single-center study analyzed 189 patients who received a COVID-19 diagnosis out of all 758 subjects with a high sensitive troponin I (Hs-TnI) measurement within the first 24 h of admission at the Policlinico A.Gemelli (Rome, Italy) between February 20th 2020 to April 09th 2020.
The prevalence of myocardial injury in our COVID-19 population is of 16%. The patients with cardiac injury were older, had a greater number of cardiovascular comorbidities and higher values of acute phase and inflammatory markers and leucocytes. They required more frequently hospitalization in Intensive Care Unit (10 32.3% vs 18 11.4%; p = .003) and the mortality rate was significantly higher (17 54.8% vs. 15 9.5%, p < .001). Among patients in ICU, the subjects with myocardial injury showed an increase need of endotracheal intubation (8 out of 9 88% vs 7 out of 1937%, p = .042). Multivariate analyses showed that hs-TnI can significantly predict the degree of COVID-19 disease, the intubation need and in-hospital mortality.
In this study we demonstrate that hs-Tn can significantly predict disease severity, intubation need and in-hospital death. Therefore, it may be reasonable to use Hs-Tn as a clinical tool in COVID-19 patients in order to triage them into different risk groups and can play a pivotal role in the detection of subjects at high risk of cardiac impairment during both the early and recovery stage.
•Prevalence of myocardial injury in COVID-19 population is about 16%.•Patients with myocardial injury were older and with more cardiovascular comorbidities.•Multivariate analyses showed that high-sensitive troponin can predict the degree of COVID-19, intubation need and mortality.•High-sensitive troponin (hs-Tn) can be a clinical tool in COVID-19 patients to triage them into distinct risk groups.•Hs-Tn can play a pivotal role in the detection of subjects at high risk of both short- and long-term cardiac impairment.
The FORZA trial (FFR or OCT Guidance to Revascularize Intermediate Coronary Stenosis Using Angioplasty) prospectively compared the use of fractional flow reserve (FFR) or optical coherence tomography ...(OCT) for treatment decisions and percutaneous coronary intervention (PCI) optimization in patients with angiographically intermediate coronary lesions. Murray law-based quantitative-flow-ratio (μQFR) is a novel noninvasive method for the computation of FFR. In the present study, we evaluated the clinical impact of μQFR, FFR, or OCT guidance in FORZA trial lesions at 3-year follow-up.
μQFR was assessed at baseline and, in the case of a decision to intervene, after (FFR- or OCT-guided) PCI. The baseline μQFR was considered the final μQFR for deferred lesions, and post-PCI μQFR value was taken as final for stented lesions. The primary end point was target vessel failure (TVF; cardiac death, target-vessel-related myocardial infarction, and target-vessel-revascularization) at a 3-year follow-up.
A total of 419 vessels (199 OCT-guided and 220 FFR-guided) were included in the FORZA trial. μQFR was evaluated in 256 deferred lesions and 159 treated lesions (98 OCT-guided PCI and 61 FFR-guided PCI). In treated lesions, post-PCI μQFR was higher in OCT-group compared with FFR-group (median, 0.93 versus 0.91;
=0.023), and the post-PCI μQFR improvement was greater in FFR-group (0.14 versus 0.08;
<0.0001). At 3-year follow-up, OCT- and FFR-guided treatment decisions resulted in comparable TVF rate (6.7% versus 7.9%;
=0.617). Final μQFR was the only predictor of TVF. μQFR ≤0.89 was associated with 3× increase in TVF (11.6% versus 3.7%;
=0.004). PCI was a predictor of higher final μQFR (odds ratio, 0.22 95% CI, 0.14-0.34;
<0.001).
In vessels with angiographically intermediate coronary lesions, OCT-guided PCI resulted in comparable clinical outcomes as FFR-guided PCI. μQFR estimated at the end of diagnostic or interventional procedure predicted 3-year TVF.
URL: https://www.clinicaltrials.gov; Unique identifier: NCT01824030.
Routine thrombus aspiration (TA) does not improve clinical outcomes in patients with ST-segment-elevation myocardial infarction (STEMI), although data from meta-analyses suggest that patients with ...high thrombus burden may benefit from it. The impact of TA on left ventricular (LV) functional recovery and remodeling after STEMI remains controversial. We aimed to pool data from randomized controlled trials (RCTs) on the impact of TA on LV function and remodeling after primary percutaneous coronary intervention (pPCI).
PubMed and CENTRAL databases were scanned for eligible studies. Primary outcome measures were: LV ejection fraction (LVEF), LV end diastolic volume (LVEDV), LV end systolic volume (LVESV) and wall motion score index (WMSI). A primary pre-specified subgroup analysis was performed comparing manual TA with mechanical TA.
A total of 28 studies enrolling 4990 patients were included. WMSI was lower in TA group than in control (mean difference MD -0.11, 95% confidence interval CI -0.19 to -0.03). A greater LVEF (MD 1.91, 95% CI 0.76 to 3) and a smaller LVESV (MD -6.19, 95% CI -8.7 to -3.6) were observed in manual TA group compared to control. Meta regressions including patients with left anterior descending artery (LAD) involvement showed an association between TA use and the reduction of both LVEDV and LVESV (z = -2.13, p = 0.03; z = -3.7, p < 0.01) and the improvement in myocardial salvage index (z = 2.04, p = 0.04).
TA is associated with improved LV function. TA technique, total ischemic time and LAD involvement appears to influence TA benefit on post-infarction LV remodeling.
Abstract
Rational
The occurrence of stent thrombosis (ST) is a rare event, but it remains one of the most catastrophic complications following percutaneous coronary intervention (PCI). Coronary ...angiography has limited value in differentiating the causative factors responsible for ST.
Technical resolutions
We report a case of a 78-year-old male, hypertensive and dyslipidemic who underwent PCI with stenting of the mid left anterior descending artery (LAD) due to chronic coronary syndrome (CCD) two years before. He was admitted to our emergency department for syncopal episode occurred at rest followed by chest pain radiating to the left arm and to the neck. At the time of admission, his electrocardiogram showed diffuse ST-segment elevation in V2-V6 and DI-aVL, therefore patient was urgently sent to the cath lab. Coronary angiography showed LAD occlusion at the proximal edge of the previously implanted stent with TIMI flow grade 0 and TIMI thrombus grade 5. Multiple thrombus aspiration passes were performed with distal flow restoration, followed by intracoronary abciximab administration. After additional thrombus aspiration passes, ST-segment resolution was observed and chest pain improved significantly. OCT imaging of mid-to-proximal LAD was then performed to better characterize the cause of thrombosis. OCT revealed in stent-thrombosis with mixed thrombus (6 mm length, arc >270°) associated with major stent malapposition (maximum malapposition distance: 1.3 mm) at the proximal edge of the previous implanted stent, without evidence of neoatherosclerosis and/or residual disease with unstable features at the stent edges. Additional thrombus aspiration was performed, further reducing the thrombotic burden. As te patient was hemodynamically stable and asymptomatic, with TIMI flow grade 3 at coronary angiography, we decided to start dual antiplatelet therapy (ASA+ticagrelor) plus continuous heparin i.v. infusion, and to defer PCI, planning a control coronary angiography after 72 hours. After 72 hours, OCT revealed almost complete thrombus resolution, and guided PCI with a 4.0/8 mm everolimus-eluting stent in overlap with the previously implanted stent, postdilated with a 4.5 semi-compliant balloon at 18 atm. Revascularization was completed with an OCT-guided PCI of the proximal left circumflex during the same procedure.
Clinical implications
Our case demonstrates the utility of OCT in determining thrombus burden and assessing the causes of late stent failure, guiding PCI. In this case, OCT was useful as diagnostic tool to identify the mechanism underlying the very-late ST, and as guidance for treatment. It enabled to exclude neoatherosclerosis and/or unstable plaques at stent edges, leaving us more confident to defer PCI after 72 h of antithrombotic therapy.
Perspectives
The occurrence of ST is rare, but it remains one of the most catastrophic complications following PCI. Coronary angiography has limited value in differentiating the causative factors responsible for ST, while OCT allows to detect and characterize the causes of stent thrombosis (i.e., evaluate thrombus burden, presence of neoatherosclerosis, stent malapposition/underxpansion, uncovred stent struts, significant disease and/or unstable plaques at the stent edges, etc.). A better understanding of the pathophysiological mechanism underlying ST is an important clinical need. The increasing availability of high-resolution intravascular imaging techniques such as OCT provides new opportunities for tailoring treatment strategy and guiding PCI.
Abstract
Aims
Due to its bidimensional nature, angiography is not always sufficient to accurately define coronary lesions, in particular when they are ambiguous or indeterminate. Intracoronary ...imaging, such as intravascular ultrasound or optical coherence tomography (OCT), is often useful in these cases to better characterize the ambiguous angiographic images, to identify the culprit lesion during acute coronary syndrome (ACS) and to guide percutaneous coronary intervention (PCI).
Methods and results
We report a case of a 61-year-old male with multiple cardiovascular risk factors and a previous ST-segment elevation myocardial infarction treated by PCI of the right coronary artery (RCA) about 7 years before, wo was admitted to our emergency department after acute onset chest pain. At the time of admission, his ECG was normal and cardiac troponin was below the upper reference limit of normality with positive molecular SARS-CoV-2 diagnostic test. Echocardiogram disclosed a mild left ventricular dysfunction with inferior wall hypokinesia. Coronary angiography showed a moderate in-stent restenosis at mid RCA and a hazy, undetermined image at the proximal edge of the previously implanted stent. Left coronary artery angiography showed only diffuse atherosclerotic disease without significant stenoses and a myocardial bridge at the mid tract of left anterior descending artery. OCT pullback of RCA to better characterize the undetermined lesions shown by angiography. OCT revealed significant neointima hyperplasia and a focal area of neoatherosclerosis with unstable features (fissure/microthrombi) at mid RCA. Severe stent strut malapposition embedded neointimal hyperplasia was observed at the proximal stent edge, resulting in ‘dual’ lumen appearance. The two lesions were treated with a single 3.5/48 mm everolimus-eluting stent (stent-in-stent), which was post-dilated with a 3.5/20 mm non-compliant balloon (18 atm) in the mid-to-distal segments, and 4.5/15 mm (16 atm) and 5.0/8 mm (14 atm) semi-compliant balloons in the proximal stent segment. Post-PCI OCT imaging confirmed good stent expansion and apposition. Our case demonstrates the utility of OCT in clarifying the aetiology of ambiguous angiographic lesions and as a guide for PCI. Indeed, the ‘hazy’ appearance on the angiograms corresponded to the major stent malapposition covered by neointima disclosed by OCT as a ‘dual-lumen’. Of note, OCT allowed to confirm the correct guidewire position in the ‘true’ lumen preventing a crush of the previously implanted stent. OCT was also useful as a diagnostic modality for the identification and characterization of the mechanism underlying the ACS (neoatherosclerosis instability).
Conclusions
Due to its unprecedented spatial resolution, OCT enables an ‘optical biopsy’ of the coronary artery wall and intrastent tissue. Therefore, OCT imaging should be considered when lesions are ambiguous or indetermined by coronary angiography to guide the diagnosis and treatments of ACS patients. OCT imaging is also useful to guide stenting and to optimize PCI result, and its impact on clinical outcome is under investigation in large randomized clinical trials.
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