In a report in this issue of the JACC: Cardiovascular Interventions, Dr. John A Dodson and his colleagues from the New York University School of Medicine reported that frail patients had lower use of cardiac catheterization and higher risk of major bleeding (when catheterization was performed) as compared to non-frail patients, thereby drawing attention to clinical strategies to avoid bleeding imperative in this population. Continue reading →

A study published in JACC Cardiovascular Interventions has shown that among patients with chronic kidney disease (CKD) undergoing percutaneous coronary intervention (PCI), there was no benefit of IV sodium bicarbonate over IV sodium chloride or of acetylcysteine over placebo for the prevention of contrast-associated acute kidney injury (CAAKI) or intermediate-term adverse outcomes. Continue reading →

A randomized clinical trial that was conducted by Paul M Ridker et al. and published in NEJM showed that there was no meaningful association between low dose methotrexate (MTX) administration and a decrease in cardiovascular events. Additionally, MTX usage was associated with adverse effects. Continue reading →

Canakinumab (an IL-B inhibitor) is associated with decreased heart failure (HF) hospitalizations and the composite of heart failure hospitalization and heart-failure related mortality in patients with a history of myocardial infarction (MI) and elevated high-sensitivity C-reactive protein (hsCRP), according to a new study published in Circulation. Continue reading →

In an original cohort study by Hammadah et al recently published in Annals of Internal Medicine, it has been found that very low high-sensitivity cardiac troponin(hs-cTn) levels can be used in the exclusion of inducible myocardial ischemia in patients with stable coronary artery disease (CAD).  Moreover, it identifies people with CAD who have a lower risk of ischemia during stress testing and adverse cardiovascular events. Continue reading →

 A study by Bhatt et al. published online in the New England Journal of Medicine, accompanied by a detailed supplement, was presented at AHA 2018 in Chicago, Illinois. The study demonstrated that among patients with elevated triglyceride levels despite the use of statins, the risk of ischemic events, including cardiovascular death, was significantly reduced among those who received 2 g of icosapent ethyl twice daily as compared with patients who received placebo. Continue reading →

A prospective cohort study that was conducted by Mohamed Farag et al. in European Heart Journal demonstrated that evaluating endogenous fibrinolysis in patients with acute coronary syndrome may help physicians identify high-risk patients developing recurrent cardiovascular events, especially among those treated with dual antiplatelet therapy (DAT) after primary percutaneous coronary intervention (PPCI). Continue reading →

A recent study published in the European Heart Journal showed that a high percentage of patients undergoing percutaneous coronary intervention (PCI) had persistently high residual inflammatory risk (RIR). Moreover, high RIR was associated with increased all-cause mortality and myocardial infarction (MI) risk at 1 year of follow-up. Continue reading →

A new prospective observational study of 38 patients suffering from myocardial infarction with non-obstructive coronary artery disease (MINOCA) with the use of optical coherence tomography (OCT) and complementary cardiac magnetic resonance imaging (CMR) shows plaque disruption and thrombus account for one-fourth and one-fifth of MINOCA, respectively. Both plaque disruption and thrombosis were repeatedly found in coronary vessels supplying the infarct-related territory as confirmed by CMR. This is the first prospective study that successfully employed the use of OCT along with complementary CMR for studying the basic mechanisms leading to MINOCA suggesting that OCT may aid in deciphering the basic underpinnings of this not so rare type of myocardial infarction (MI).

MINOCA is increasingly being seen in clinical practice. Prior studies have served as a major effort to understand the pathophysiology of this presentation, which may aid in effective secondary prevention in this patient population. Several questions exist due to the heterogeneous nature of patients who suffer from MINOCA. Given this background, Opolski (Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland) and colleagues prospectively enrolled 38 patients (mean age 62 years; 55% women) with MI but <50 % stenosis on angiography (maximal diameter stenosis of 35%) in order to identify the mechanisms that lead to MINOCA. On OCT, nine patients (24%) showed signs of plaque disruption and seven (18%) had evidence of coronary thrombus. A per-lesion analysis of CMR results further demonstrated that, compared with non-infarct-related arteries, infarct-related arteries displayed more plaque disruption (40% vs 6%; P = 0.02), thrombus (50% vs 4%; P = 0.014), and thin-cap fibroatheroma (70% vs 30%; P = 0.03). Moreover, the investigators found that subjects with plaque disruption albeit non-significant tended to have numerically higher rates of ischemic late gadolinium contrast enhancement (LGE) on CMR than subjects without plaque disruption (50% vs. 13%, respectively; p = 0.053).

Utilization of OCT

Optical coherence tomography (OCT) is a high-resolution (10 to 15 mm) intracoronary imaging modality that employs the use of coherent light waves for precise assessment of the integrity of the atheromatous fibrous cap. This allows for visualizing plaques and thrombosis that may be otherwise missed on conventional angiography. In this study, the investigators aimed to perform OCT imaging in at least the coronary vessel that was suspected to be the culprit vessel (based on electrocardiography [EKG], echocardiography, and angiography).

Evaluation of Myocardial Injury on CMR

In this study, myocardial edema was evaluated as an area of high T2 signal intensity on a segmental basis (Left ventricle segments were defined by American Heart Association 17-segment model). The presence and pattern of late gadolinium enhancement (LGE) were determined for each segment and divided into subendocardial, subepicardial, midwall, or transmural. LGE in the subendocardial and transmural distributions were considered ischemic. Correlation between the coronary artery distribution and myocardial segments with LGE of ischemic origin served as a source of identification of infarct-related artery.

Limitations

The study has its limitations since it was a small, single-center, and observational study. In addition, loss of eligible patients due to logistical problems and withdrawals of informed consent gives rise to selection bias. Furthermore, the investigators failed to perform 3-vessel OCT imaging in all patients, which could have resulted in a lower proportion of patients with plaque disruption and/or thrombus (specifically owing to a lower rate of OCT in the right coronary artery).

A study published in Circulation showed that the evaluation of chest pain in emergency departments with higher chest pain volume had lower rates of death or hospitalization for patients with acute coronary syndrome after discharge. The primary investigator, Dr. Dennis T. Ko and his colleagues also found that past a certain volume threshold, a rise in volume was not associated with any reduction in outcomes. Continue reading →

The use of Proton Pump Inhibitors (PPIs) for prophylaxis against gastrointestinal (GI) bleeding due to stress ulceration in critically ill patients admitted to the Intensive Care Unit (ICU) was not associated with improved mortality rate or fewer clinically important events, according to a new study published in the New England Journal of Medicine. Continue reading →

According to a new study published in the Journal of American Medical Association, unrecognized myocardial infarction (UMI) detected by cardiac magnetic resonance (CMR) was associated with equivalent all-cause mortality as compared to recognized myocardial infarction (RMI) at 10 years of follow-up. Individuals with UMI also had a higher risk of nonfatal MI, heart failure, and death than those without any evidence of MI. Continue reading →

In an article published in the Journal of the American College of Cardiology, authored by Caroline Sindet-Pederson, MSc, and colleagues in the Department of Cardiology at Copenhagen University Hospital Herlev and Gentofte in Hellerup, Denmark, evaluating a real-world population of AF patients with MI and/or after PCI, the use of direct oral anticoagulants (DOAC) as compared to VKA reduced the risk of bleeding in patients also taking dual antiplatelet therapy (DAPT). Continue reading →

In patients with acute myocardial infarction (MI) and a left ventricular ejection fraction (LVEF) equal or less than 35%, the use of wearable cardioverter defibrillator early after the MI did not lead to significant lowering of death from arrhythmia or from any cause, according to a new study published in the New England Journal of Medicine. Continue reading →

For angina patients without obstructive coronary artery disease (CAD), adjunctive testing of coronary vascular function during coronary angiography followed by medical therapy targeted to the findings improved angina outcomes, according to the CorMicA trial. In the study published in the Journal of the American College of Cardiology, a tiered approach for assessment for microvascular and/or vasospastic angina among patients with stable angina and no evidence of significant epicardial disease was deemed superior to usual care. Continue reading →

The outcomes of percutaneous coronary intervention (PCI) in nonagenarians is an understudied topic. A recent observational study published in the Journal of American College of Cardiology  has looked into the time-dependent PCI trends and outcomes in 70,000 nonagenarians from 2003 to 2014 using data from the National Inpatient Sample, which is the largest longitudinal hospital inpatient database in the United States. Continue reading →

Researchers have confirmed that the extent of residual angiographic disease calculated using the residual SYNTAX score (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) or RSS has no association with ischemic events occurring subsequently in patients presenting with ACS. The study, published in JACC, reinforces the concept that functionally complete revascularization is applicable even in ACS patients. Continue reading →

 In a randomized multi-center clinical trial that enrolled more than 700 patients with multi-vessel coronary artery disease and acute myocardial infarction (MI) with cardiogenic shock, it was shown that percutaneous coronary intervention (PCI) of the culprit lesion only (with the option of staged revascularization of nonculprit lesions) was associated with better clinical outcomes compared to immediate multi-vessel PCI. It was found that at 30 days, there was a 9.5% absolute reduction in the rate of the primary endpoint of death or renal replacement therapy in patients randomized to culprit-lesion only revascularization. Previously DANAMI-3-PRIMULTI, PRAMI, and CvLPRIT trials have suggested that there may be a benefit to complete revascularization but those studies did not enroll patients with hemodynamic instability or cardiogenic shock. Consequently, this led to the inclusion of immediate multi-vessel PCI in the 2015 ACC/AHA/SCAI STEMI guidelines as a Class II-b recommendation (can be considered). Continue reading →

A new single-center study has shown that the catheterization laboratory (CCL) activation in response to a prehospital ECG interpreted as ST-segment elevation myocardial infarction (STEMI) can be frequently canceled which represents an economic burden and affects the patient satisfaction negatively. Continue reading →

Adverse change in employment after myocardial infarction (MI) is associated with a lower quality of life, increased depression and more difficulty affording medications according to a study that has been published in the June issue of Circulation Cardiovascular Quality and Outcomes .

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