Ticagrelor versus clopidogrel in patients with ST-elevation myocardial infarction: postdischarge mild bleeding and its clinical impacts No abstract available

Scoring balloon predilation before bioresorbable vascular scaffold implantation in patients with in-stent restenosis: the RIBS VI ‘scoring’ study Background Currently drug-eluting stents (DESs) and drug-eluting balloons are recommended in patients with in-stent restenosis (ISR). However, the efficacy of bioresorbable vascular scaffolds (BVS) after scoring balloon (SCB) predilation in these patients is unknown. Methods RIBS VI (NCT02672878) and RIBS VI ‘Scoring’ (NCT03069066) are prospective multicentre studies assessing the value of BVS in patients with ISR. Inclusion and exclusion criteria were identical in both studies. Results of conventional BVS implantation (112 patients) were compared with those obtained with systematic SCB therapy before BVS (108 patients). Angiographic follow-up was scheduled for all patients. Results On late angiography (93% of eligible patients) the in-segment minimal lumen diameter (primary end-point) (1.88 ± 0.5 vs. 1.90 ± 0.4 mm, P = 0.81), % diameter stenosis (28 ± 17 vs. 29 ± 15%), late lumen loss (0.23 ± 0.4 vs. 0.22 ± 0.4 mm) and binary restenosis rate (8.5 vs. 9.3%) were similar in the conventional BVS and SCB + BVS groups, respectively. At 1-year follow-up (100% of patients) target lesion revascularization (TLR) requirement (9.8 vs. 11.1%) was similar with the two strategies. Freedom from cardiac death, myocardial infarction and TLR was 88% and 87%, respectively. Results remained unchanged after adjusting for potential baseline confounders and were consistent in 10 prespecified subgroups. Conclusion This study suggests that results of conventional BVS implantation in patients with ISR are not improved by systematic predilation with SCB. ClinicalTrials.gov ID: NCT02672878 (RIBS VI) and NCT03069066 (RIBS VI ‘Scoring’). * Fernando Alfonso and Javier Cuesta contributed equally to the writing of this article. Received 23 March 2020 Accepted 4 April 2020 Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.coronary-artery.com. Correspondence to Fernando Alfonso, MD, Departamento de Cardiología, Hospital Universitario de La Princesa, Instituto Investigación Sanitaria, Instituto Princesa (IIS-IP), CIBER-CV, Universidad Autónoma de Madrid, c/ Diego de León 62, Madrid 28006, Madrid, Spain, E-mail: falf@hotmail.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Effect of intervention timing on one-year mortality in elderly non–ST-segment elevation myocardial infarction patients Background The best timing for early invasive therapy in non–ST-segment elevation myocardial infarction (NSTEMI) patients remains controversial. We sought to determine the optimal timing of early catheterization in order to improve long-term outcomes in elderly (>65  years old) patients with NSTEMI. Methods Using data from the CRUSADE registry linked to Medicare claims, we evaluated the association of early catheterization within the first 24  h or earlier time cut-points of NSTEMI presentation with long-term mortality among older Medicare beneficiaries. Results Of 15  575 NSTEMI patients from 398 CRUSADE hospitals (2003–2006), 3880 (24.9%) received early (≤12  h) catheterization. Compared with those undergoing later catheterization, patients treated early were younger and had less comorbid illness. Relative to those treated later, patients receiving early catheterization had similar 1-year all-cause mortality (11.8% vs 11.9%, P  =  0.90). Using on- vs off-hour presentation as an instrumental variable, balancing potential measured and unmeasured confounders, early and later catheterization patients had nonsignificant differences in 1-year mortality (+5.6% [−11.5%, +22.7%]). Similar results were observed in clinically relevant subgroups, such as age (< or ≥75  years), gender, diabetes status, Global Registry of Acute Coronary Events score (< or ≥140), presence of heart failure, and sensitivity analyses of alternative definitions of early catheterization (≤6 and ≤24  h). Conclusions Among older NSTEMI patients, we found that <24  h or earlier (neither <6 nor 12  h) of catheterization timing were not significantly associated with differences in long-term mortality. * Ben He and Eric D. Peterson contributed equally to the writing of this article. Received 5 March 2020 Accepted 24 May 2020 Correspondence to Ben He, MD, PhD, Department of Cardiology, Shanghai Chest Hospital, West Huai Hai Road, No. 241, Shanghai, China, Tel: +86 21 22200000; fax: +86 21 22200001; e-mail: heben241@126.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Safety and efficacy of intracoronary thrombolytic therapy via a new infusion catheter in patients with ST-segment elevation myocardial infarction with large thrombus burden: a pilot study Background A large intracoronary thrombus burden is associated with adverse clinical results. The optimal management of this scenario remains unknown. We aimed to determine the efficacy and safety of a new rapid infusion catheter combined with low-dose intracoronary thrombolysis in patients with ST-segment elevation myocardial infarction (STEMI) with a large thrombus burden. Methods and results This pilot study included 22 patients with STEMI with a large thrombus burden. A large thrombus burden was defined as a definite thrombus with the largest dimension of at least two vessel diameters [thrombolysis in myocardial infarction (TIMI) thrombus grades 4 and 5]. All patients received primary percutaneous coronary intervention guided by the presence of recurrent chest pain or clinical myocardial ischemia evidences. All patients regained myocardial perfusion immediately after the infusion catheter crossed the thrombus. Local fibrinolysis with low-dose recombinant human prourokinase was administered continuously via the infusion catheter for 30 min. Repeat coronary angiography revealed marked thrombus resolution, with an improvement in TIMI flow from 0.14 ± 0.35 at baseline to 2.82 ± 0.40. Only one patient with postlysis thrombus grades 4–5 was observed. No major bleeding events were observed. Conclusions In patients with STEMI presenting with a large thrombus burden, all patients regained myocardial perfusion immediately after the infusion catheter crossed over the thrombus, and low doses of intracoronary thrombolysis could significantly reduce the thrombus burden and improve the coronary flow without major bleeding. * Tao Chen and Qi Wang contributed equally to the writing of this article. Received 22 April 2020 Accepted 25 May 2020 Correspondence to Jun Guo, MD, Department of Cardiovascular, Chinese PLA General Hospital, Beijing 100853, China, Tel: +86 18511296301; fax: +86 010 6818 4552; e-mail: junguodoc@163.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Likelihood of myocardial infarction, revascularization and death following catheterization laboratory activation in patients with vs. without both chest pain and ST elevation Background Emergent cardiac catheterization laboratory activation (CCLA) for patients with suspected ST-elevation myocardial infarction (STEMI) is employed to expedite acute revascularization (AR). The incidence of false-positive CCLA, in which AR is not performed, remains high. The combination of chest pain (CP) and electrocardiographic ST elevation (STE) are the hallmarks of STEMI. However, CCLA is sometimes initiated for patients lacking this combination. The study objective was to quantify the difference in likelihood of AR and mortality in patients with vs. without both CP and STE. Methods Retrospective analysis of 1621 consecutive patients for whom CCLA was initiated in a six-hospital network. We assessed the likelihood of acute myocardial infarction (AMI), presence of a culprit lesion (CL), performance of AR, and hospital mortality among patients with both CP and STE (+CP/+STE) compared with patients lacking one or both [non(CP/STE)]. Results 87.0% of patients presented with CP, 82.4% with STE, and 73.7% with both. Among +CP/+STE patients, AMI was confirmed in 90.4%, a CL in 88.9%, and AR performed in 83.1%. The corresponding values among non(CP/STE) patients were 35.8, 31.9, and 28.1%, respectively (P < 0.0001 for each). Nevertheless, mortality among non(CP/STE) patients was three-fold higher than in +CP/+STE patients (13.3% vs. 4.5%; P < 0.0001), with non-coronary deaths 24-fold more likely. Conclusion Patients lacking the combination of CP and STE have a markedly lower likelihood of AMI and AR than +CP/+STE patients, but significantly higher mortality. Protocols aimed at rapid, focused evaluation of non(CP/STE) patients prior to CCLA are needed. Received 20 April 2020 Accepted 26 May 2020 Correspondence to Peter Puleo, MD, St. Luke’s University Hospital, 801 Ostrum St. PPH2, Bethlehem, PA 18015, USA, Tel: +484 375 5836; fax: +484 526 4010; e-mail: ppuleo@ptd.net This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CC-BY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Elevated troponin levels in patients with atrial tachyarrhythmias Objective Data regarding the significance of elevated troponin in the setting of atrial tachyarrhythmia remain inconclusive. In the present study, we aimed to explore the discriminative ability of troponin for obstructive coronary artery disease (CAD) among patients with atrial tachyarrhythmias. Methods We retrospectively identified patients with atrial tachyarrhythmias and elevated serum troponin levels, who underwent invasive coronary angiography during the same admission. The prevalence of obstructive CAD among these patients was compared to that of historically matched patients who underwent coronary angiography due to suspected non-ST elevation myocardial infarction and had no arrhythmias. Results Overall 318 patients with suspected non-ST elevation myocardial infarction were analyzed (n = 159 with atrial tachyarrhythmias and n = 159 without arrhythmias). Obstructive CAD was detected in 39% of patients with an arrhythmia compared to 85.5% in the control group (P < 0.001). A multivariable analysis demonstrated that parameters associated with obstructive CAD among patient with atrial tachyarrhythmias and elevated troponin were diabetes mellitus [odds ratio (OR) 2.7, 95% confidence interval (CI) 1.23–5.91, P = 0.013], prior ischemic heart disease (OR 4.48, 95% CI 1.93–10.4, P < 0.001) and troponin level (OR 3.18 for every 1000 ng/L increment, 95% CI 1.85–5.48, P < 0.001). Conclusions Elevated troponin is not a reliable indicator for the presence of underlying obstructive CAD among patients who present with atrial tachyarrhythmias. Risk stratification of these patients should rely on the degree of troponin elevation, and the presence of diabetes mellitus and prior ischemic heart disease. * Dr. Zach Rozenbauma and Dr. Orly Sapir contributed equally to the writing of this article. Received 4 September 2019 Accepted 3 January 2020 Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.coronary-artery.com. Correspondence to Zach Rozenbaum, MD, Department of Cardiology, Tel Aviv Medical Center, 6 Weizman Street, Tel Aviv, Israel, Tel: +972 3 6973395; fax: +972 3 6962334; e-mail: zachroze@gmail.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Temporal trends in management and outcome of patients with acute coronary syndrome according to admission low-density lipoprotein cholesterol levels Background The importance of differences in baseline low-density lipoprotein cholesterol (LDL-C) levels and pretreatment with statins on the temporal improvement in outcome of acute coronary syndrome (ACS) patients has not been studied yet. Methods Patients were divided into two groups according to baseline LDL-C levels: LDL-C <130 mg/dl and LDL-C ≥130 mg/dl. Baseline characteristics, clinical data and outcomes were compared for each LDL-C group between patients enrolled in early (2000–2006), mid (2008–2010) and recent (2013–2016) surveys. Results The study population was comprised of 8343 patients. Patients with LDL-C <130 mg/dl were older and were more commonly pretreated with aspirin and statins compared to patients with LDL-C ≥130 mg/dl. Patients included in recent surveys were more frequently selected for an invasive strategy with coronary angiography and subsequent revascularization, and were more commonly treated with guideline-based medical therapy. For patients with a LDL-C ≥130 mg/dl, the temporal improvements in therapy were associated with lower 1-year mortality rates (7.2, 4.4 and 3.5% for patients in early, mid and late surveys, respectively, P = 0.006). That temporal improvement in outcomes existed only in statin-naïve patients. For patients with LDL-C <130 mg/dl, temporal improvement in treatment was not accompanied by a reduction in 30 day or 1-year mortality rates. Conclusion Treatment of ACS patients has improved over the past decades regardless of LDL-C levels. This improvement was accompanied by lower mortality rates in ACS patients with LDL-C ≥130 mg/dl, but not in patients with LDL-C <130 mg/dl. Received 19 November 2019 Accepted 28 December 2019 Correspondence to Mony Shuvy, MD, Heart Institute, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel, Tel: +972 2 6776564; fax: +972 2 6411028; e-mail: monysh@gmail.com Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Mediation analysis for the relationship between dyslipidemia and coronary artery disease via hypersensitive C-reactive protein in a case-control study Background The pathological basis of coronary artery disease (CAD) is atherosclerosis which is associated with inflammation and dyslipidemia. However, the involvement of hypersensitive C-reactive protein (hs-CRP) in lipid metabolism and how it affects the pathogenesis of CAD is uncertain. Objective To explore whether the relationship between dyslipidemia and CAD is partly mediated by hs-CRP levels. Methods Three hundred fifteen pairs of randomly sexand age-matched CAD and non-CAD subjects collected from Zhongda Hospital Affiliated to Southeast University were involved in the final analysis. We gathered information about each subjects clinical history as well as their results of detected hs-CRP and lipid levels. Linear regression analysis was used to determine the association between dyslipidemia and hs-CRP levels in which univariate and multivariate logistic regression analyzes were performed to determine the relationship between hs-CRP levels and CAD as well as dyslipidemia and CAD. Mediation analysis was used to evaluate whether hs-CRP levels act as a mediator of the relationship between dyslipidemia and CAD. Results Dyslipidemia and hs-CRP levels were significantly associated with an increased risk of CAD, with β = 0.594 (P = 0.001) and β = 0.016 (P = 0.024), respectively, and there was a correlation between dyslipidemia and hs-CRP levels (β = 3.273, P = 0.004). Mediation analysis results revealed that the correlation between dyslipidemia and CAD was 8.27% mediated by hs-CRP levels with a direct effect of 0.621 and an indirect effect of 0.056. Conclusion Hs-CRP levels played a partial mediation role in the association between dyslipidemia and CAD. Received 19 November 2019 Accepted 19 April 2020 Correspondence to Li-na Wang, PhD, Key Laboratory of Environmental Medicine Engineering, Ministry of Education, Department of Epidemiology & Biostatistics, School of Public Health, Southeast University, 87 Ding Jiaqiao Rd., Nanjing 210009, China, Tel: +86 25 832 72569; fax: +86 25 832 24322; e-mail: lnwang@seu.edu.cn Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.

Concomitant acute myocardial infarction and stress cardiomyopathy No abstract available

Regional variations in cardiovascular risk factors and access to care among US veterans with cardiovascular disease Background It remains unclear whether cardiovascular risk factors and access to healthcare for veterans with cardiovascular disease (CVD) vary among US regions. This study sought to determine the extent of regional variations in cardiovascular risk factors and access to medical care in a cohort of veterans with CVD in the USA. Methods The 2016 Centers for Disease Control Behavioral Risk Factor Surveillance Survey was utilized to identify a cohort of veteran patients with CVD. Participants were classified based on four US regions: (1) Northeast, (2) Midwest, (3) South, and (4) West. We compared demographic data, medical history, and access to care for veterans of each US region. The outcomes of interest included financial barriers to medical care and annual medical checkup. Results Among the 13 835 veterans, 18.3% were from the Northeast, while 23.5, 37.1, and 21.1% were from the Midwest, South, and West, respectively. Veterans of each region differed significantly with respect to demographic characteristics, prior medical history, and access to care. Rates of financial barriers to medical care were similar across the four regions (7.3 vs. 7.1 vs. 8.0 vs. 6.9%, P = 0.203). Veterans from the West had the lowest rates of medical checkup within the past year (91.7 vs. 89.5 vs. 91.4 vs. 86.6%). On multivariate analysis, the Midwest [odds ratio (OR) 0.69; 95% CI, 0.53–0.89] and West (OR 0.53; 95% CI 0.41–0.68) regions were independently associated with lower rates of medical checkup within the past year compared to the Northeast. Conclusions In this observational study involving US veterans with CVD, cardiovascular risk factors and frequency of annual medical checkup differed amongst each US region. Further large-scale studies examining the prevalence of impaired access to care and quality of care in US veterans with CVD are warranted. Received 27 December 2019 Accepted 6 April 2020 Correspondence to Puja B. Parikh, MD, MPH, FACC, FAHA, FSCAI, Department of Medicine, Division of Cardiology, Health Sciences Center, T16-080, Stony Brook, NY 11794-8160, USA, Tel: +631 444 1066; fax +631 444 1054; e-mail: puja.parikh@stonybrookmedicine.edu Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.