Adjunctive Low Dose Alteplase During Primary PCI Fails to Imrpove Microvascular Obstruction in STEMI Patients Results of the T-Time trial presented at the American Heart Association (AHA) 2018 Scientific Sessions

A multi-center randomized, double blind, placebo-controlled, parallel group clinical trial has shown that among patients with acute ST-elevation myocardial infarction (STEMI) presenting within 6 hours of symptoms, adjunctive low-dose intracoronary alteplase given after reperfusion via primary percutaneous intervention does not reduce microvascular obstruction. Continue reading

Use of Dynamic Myocardial Imaging in the Evaluation of Heart Failure With Preserved Ejection Fraction Provides Prognostic Value

A study published in JACC: Cardiovascular Imaging has shown that both left ventricular systolic and diastolic reserves contribute to risk prediction in Heart Failure With Preserved Ejection Fraction (HFpEF). Therefore, the inclusion of the exertional assessment of left ventricular function to diagnostic algorithms may improve the prognostication process in this disease condition. Continue reading

2018: Cardiology News at A Glance Most important trials published in 2018

COAPT trial

This prospective, multicenter, open-label, randomized trial aimed to assess the use of transcatheter mitral valve repair in heart failure (HF) patients with mitral regurgitation due to left ventricular dysfunction. A total of 614 patients were randomized to either receiving guideline-directed medical therapy (GDMT) alone or GDMT in addition to transcatheter mitral-valve repair. The primary efficacy endpoint was all hospitalizations due to heart failure at 24 months of follow-up, while the primary safety endpoint was freedom from device-related complications at 12 months of follow-up. The study showed that the device group had a lower risk of hospitalization for HF (HR 0.53, 95% CI 0.4-0.7) and all-cause mortality (HR 0.62, 95% CI 0.46-0.82) at 24 months. Moreover, the rate of freedom from device complications at 12 months was 96.6% which exceeded the prespecified safety threshold. Continue reading

Deciphering the Underpinnings of MINOCA (MI with Non-Obstructive Coronary Arteries) Results from the optical coherence tomography study

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.


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).

Unrecognized Myocardial Infarctions Have a 10-Year Mortality Rate Comparable to Clinically-Recognized Infarctions Results form the ICELAND MI study

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

Benefit of Abdominal Aortic Aneurysm Screening In Question Swedish Registry Based Cohort Study

Screening for abdominal aortic aneurysm (AAA) does not contribute to a significant reduction in mortality, according to a registry study that has been recently published in The Lancet.

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Stress Echo Is Losing Its Prognostic Value in Asymptomatic Aortic Stenosis

Neither increase in mean pressure gradient (MPG) nor systolic pulmonary artery pressure (SPAP) at peak exercise predicts outcomes in patients with asymptomatic aortic stenosis (AS) according to a study published in JACC Cardiovascular Imaging.

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CTA Verified High Risk Coronary Plaque Predicts ACS ICONIC TRIAL

Coronary computed tomography angiography (CTA)-guided vulnerable plaque characteristics have predictive value for future acute coronary syndrome (ACS) in high-risk patients according to Incident COronary EveNts Identified by Computed Tomography (ICONIC) trial which is published in the  Journal of  the American College of Cardiology.

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Cardiac MRI Improves Long-Term Risk Stratification After STEMI

Cardiac magnetic resonance (CMR) imaging provides useful prognostic information in revascularized ST-segment elevation (STEMI) patients, according to a recent study published in June 2018, in the Journal of the American College of Cardiology.

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Prior Silent MI Is Associated with Worse Outcomes in Patients with AMI

A recent observational longitudinal study published in the Journal of American College of Cardiology showed that previous silent myocardial infarction (MI) was found in 8.2% of patients presenting with first acute myocardial infarction (AMI). Previous silent MI was detected by late gadolinium enhancement- cardiac magnetic resonance (LGE-CMR). Continue reading

High Sensitivity Troponin I and Stable Coronary Artery Disease

A recent study published in the Journal of American College of Cardiology found an association between elevated concentrations of high sensitivity troponin I (hsTnI) with increasing prevalence of coronary artery disease (CAD) in stable patients, who were suspected of coronary artery disease and underwent non-emergent coronary computed tomography angiography (CTA).

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2018 Imaging for Plaque Characterization

Sean Madden, Jason Bottiglieri and Dr. Jeff Popma Discuss:

2018 Imaging for Plaque Characterization Sean Madden, Jason Bottiglieri and Dr. Jeff Popma Discuss:

Should Patients with Acute Chest Pain Undergo Noninvasive Testing After the Clinical Diagnosis is Made?

The use of noninvasive cardiac tests such as coronary computed tomographic angiography (CCTA) or stress testing for patients presenting to the emergency department with chest pain is not associated with a better clinical outcome when compared to the conventional method for diagnosing acute coronary syndrome, according to a recent study published in the Journal of American Medical Association. Continue reading

Is Sodium Bicarbonate or N-Acetyl-Cysteine Effective in Preventing Contrast-Induced Nephropathy?

In a recent study published in the New England Journal of Medicine, it was found that amongst patients undergoing angiography, sodium bicarbonate is not better than sodium chloride  and neither is acetylcysteine better than oral placebo in the prevention of a composite outcome of death, need for dialysis, or persistent kidney injury. The treatment was also ineffective in reducing the risk of contrast-associated acute kidney injury.

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Incorporating Non-Invasive Fractional Flow Reserve into Clinical Practice Dr. Jeffrey Popma and Dr. Campbell Rogers Discuss

Incorporating Non-Invasive Fractional Flow Reserve into Clinical Practice

Dr. Jeffrey Popma and Dr. Campbell Rogers Discuss

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Can CTCA-derived Plaque Characteristics Predict MACE?

A systematic review and meta-analysis recently published in the journal, Circulation, showed a strong association between computed tomographic coronary angiography (CTCA) defined high risk plaque (HRP) features and major adverse cardiovascular events (MACE) in patients with suspected coronary artery disease (CAD). Continue reading

Instantaneous wave-free ratio vs fractional flow reserve guided Intervention Dr. Matthias Götberg and Dr. Serge Korjian Discuss: IFR-SWEDEHEART

iFR and FFR decision-making for physiological guided coronary revascularization Dr. Justin E. Davies and Dr. Serge Korjian Discuss: DEFINE-FLAIR