bluuebunny/crossref_metadata_2025_split huggingface dataset:
Clinical profile and predictors of positivity of acetylcholine test in patients with angina and no obstructive coronary artery disease. Results of a multi-center mediterranean registry
Authors: Grigorian L , Gutierrez E , Oteo J.F , Abdul-Jawad O , Amat Santos I , Gutierrez Barrios A , Fernandez Cisnal A , Jimenez Mazuecos J , Roa J , Vazquez M.E , Sanz R , Diez-Delhoyo F , Rivera A , Elizaga J , Fernandez-Aviles F 
Published: November 2020

Abstract

Background
Coronary endothelial dysfunction and vasospasm are potential causes of ischemia in no obstructive coronary disease (INOCA) and are now known to be associated with an increased risk of major cardiovascular events (MACE) and impaired quality of life. The recent guidelines recommend the use of intracoronary acetylcholine to unravel the underlying pathophysiology of INOCA, by identifying those with endothelial dysfunction, and to guide future treatment in these patients.

Objective
To evaluate the clinical profile and prevalence of endothelial dysfunction in patients with INOCA, and to identify the predictors of positivity of the acetylcholine test.

Methods
A total of 358 patients with INOCA were prospectively enrolled in a multicenter observational study. Coronary angiography and acetylcholine test were performed according to clinical indications in all included patients. Patients were followed-up for 1-year for MACE and clinical reevaluation of symptoms.

Results
Patients' mean age was 60.6±13.5 y.o. and 58.7% were females, with no previous history of coronary heart disease in 76% of cases. Regarding clinical presentation, 56.9% had angina at rest, 59.9% exertional angina, and 29.5% dyspnea. In 39% the EKG was abnormal, and in 10.9% there was a troponin rise.
Coronary endothelial dysfunction –defined as a vasoconstriction over 30%– was observed in 129 (36%) patients, and severe vasoconstriction (&gt;70%) in 75 (21%). Of positive cases, 47 (36%) focal vasoconstriction, and 90 (70%) diffuse. On follow-up, patients with a positive Ach test were treated differently, with a lower prescription of betablockers (12% vs. 24%, p=0.01) and a higher use of vasodilators (47% vs. 28.5%, p=0.001). Guidelines-recommended optimal treatment was prescribed to 39.2% of patients with a positive acetylcholine test. Patients with positive acetylcholine test were more prone to having worsening angina (25.6% vs. 12.8%, p&lt;0.01) and minimal exertion angina (40% vs. 26.7%, p=0.03) on follow-up. Multivariable regression analysis showed that acetylcholine test positivity was predicted by the presence of diabetes (OR 1.7, p=0.04), exertional angina (OR 1.2, p=0.04), coronary atherosclerosis (OR 1.8, p=0.02) and coronary milking (OR 2.6, p=0.04).

Conclusions
Endothelial dysfunction detected by acetylcholine test was present in one third of patients with INOCA and was associated with more severe and worsening symptoms. Although Ach test positivity influenced the pharmacological treatment at discharge, a large room for optimization still remained.

Funding Acknowledgement
Type of funding source: None
Circadian variations in pathogenesis of ST-segment elevation myocardial infarction
Authors: Araki M , Yonetsu T , Kurihara O , Nakajima A , Lee H , Soeda T , Minami Y , Yan B.P , Adriaenssens T , Boeder N.F , Nef H.M , Kim C.J , Crea F , Kakuta T , Jang I.K 
Published: November 2020

Abstract

Background
Previous studies have reported a circadian variation in the onset of ST-segment elevation myocardial infarction (STEMI). However, underlying mechanisms for the circadian variation have not been fully elucidated.

Purpose
We investigated the relationship between onset of STEMI and the underlying pathology using optical coherence tomography (OCT).

Methods
Patients presenting with STEMI were selected from an international, multi-center, longitudinal registry study, which included patients who underwent OCT imaging of the culprit lesion at 11 institutions in 6 countries. Onset of MI was estimated using the time of OCT imaging. Patients were divided into 4 groups based on the estimated time of onset (00:00–05:59, 06:00–11:59, 12:00–17:59, or 18:00–23:59). Underlying pathologies of MI (plaque rupture, plaque erosion, and calcified plaque) were compared among the 4 groups.

Results
Among 648 patients, plaque rupture was diagnosed in 386 patients (59.6%), plaque erosion in 197 patients (30.4%), and calcified plaque in 65 patients (10.0%). A marked circadian variation was detected in the incidence of plaque rupture with a peak at 9:00, whereas it was not evident in plaque erosion or calcified plaque. The probability of plaque rupture increased in the periods of 06:00–11:59 (odds ratio: 2.13, 95% confidence interval: 1.30 to 3.49, p=0.002) and 12:00–17:59 (odds ratio: 2.10, 95% confidence interval: 1.23 to 3.58, p=0.005), compared to the period of 00:00–05:59. This circadian pattern was observed only during weekdays (p=0.013) and it was not evident during the weekend (p=0.742).

Conclusions
Plaque rupture occurred most frequently in the morning and the circadian variation was evident only during the weekdays. Acute MI caused by plaque rupture may be related to catecholamine surge.

Funding Acknowledgement
Type of funding source: None
Comparison of iFR and FFR for coronary physiology evaluation in patients with severe aortic stenosis
Authors: Kleczynski P , Dziewierz A , Rzeszutko L , Dudek D , Legutko J 
Published: November 2020

Abstract

Background
Reliable coronary physiology assessment with pressure derived indexes in patients with aortic stenosis (AS) rises problems due to its complex nature. Recent data suggest that fractional flow reserve (FFR) may underestimate intermediate coronary stenosis in a presence of AS whereas instantaneous wave-free ratio (iFR) values may remain similar after treatment of AS. Furthermore, both indices has not been validated yet in AS.

Aim
We aimed to find a thresholds for coronary ischemia in the setting of aortic

Material and methods
The functional significance of 416 coronary lesions was investigated with iFR and FFR measurements in 221 AS patients. The iFR-FFR diagnostic agreement has been tested using the cut-off value for iFR of 0.89.

Results
Mean value of %DS was 58.6±13.4%, FFR was 0.85±0.07 and iFR – 0.90±0.04. FFR ≤0.80 was measured in 26.0% of interrogated vessels, iFR ≤0.89 – in 33.2%. The correlation between iFR and FFR was good (r=0.83, p&lt;0.001) and with good agreement between iFR and FFR (mean difference −0.0059, 95% CI −0.056–0.062). The AUC at ROC curve analysis for iFR ≤0.89 was 0,997 (0,986 to 1,000, p&lt;0.001) for FFR. According to ROC analysis, the best FFR cut-off in predicting iFR ≤0.89 was ≤0.82 (J=0.96). The diagnostic accuracy for identifying iFR ≤0.89 was 97.7% for FFR.

Conclusion
In the presence of AS, FFR had good agreement with iFR values. However, FFR threshold for predicting iFR below 0.89 may be different from a standard threshold and that should be taken into account while assessing coronary physiology in the setting of AS.

Funding Acknowledgement
Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Science Center
Comparison of fractional flow reserve and instantaneous wave-free ratio for the hemodynamic assessment of jailed side branches in bifurcation stenting
Authors: Altstidl J.M , Marwan M , Troebs M , Achenbach S , Gaede L 
Published: November 2020

Abstract

Background
Provisional side-branch stenting strategy is one of the preferred strategies for treatment of bifurcation lesions. Whereas using fraction flow reserve (FFR) for the physiologic assessment of jailed side branches is well studied, the reliability of resting indices such as instantaneous wave free ratio (iFR) is unknown.

Methods
Consecutive patients with provisional stenting of a bifurcation and a jailed side branch were enrolled in this study. FFR and iFR were measured and, after assuring absence of baseline shift and drift, both measurements were repeated after 3 minutes. Hyperemia was induced by intra-coronary adenosine with a dose of 48μg for the right coronary artery and 96μg for the left coronary artery. Cut-off for the assumed functional significance of a stenosis was 0.80 for FFR and 0.89 for iFR. The decision to treat the side branch was left to the interventionalist's discretion.

Results
37 jailed side branches in 36 patients (age 68.4±8.2; male 81% (n=29)) were consecutively enrolled in the study. The main vessel was the left main in 3% (n=1), the left anterior descending (LAD) in 65% (n=24), the diagonal branch (D1) in 3% (n=1), the left circumflex artery (LCX) in 24% (n=9) and the right coronary artery (RCA) in 5% (n=2). The Medina classification revealed true bifurcation stenosis defined as Medina 1–1-1 prior to treatment in 35% (n=13).
FFR showed 35% (n=13) of the stenosis to be functionally significant with a high reproducibility of the results (r=0.986). FFR showed a low correlation with angiographic assessment (r=−0.477). iFR indicated hemodynamic relevance in 38% of lesions (n=14) with a high reproducibility (r=0.967) and also correlated poorly with angiographic assessment (r=−0.271). iFR was found to closely correlate with FFR in jailed side branches (r=0.720, Figure 1A). Bland-Altman analysis showed iFR and FFR agreed with a mean difference between FFR and iFR of −0.054±0.146. In 81% (n=30) FFR and iFR showed the same results regarding functional significance. In 8% (n=3) FFR was ≤0.80 and iFR &gt;0.89, in 11% (n=4) FFR was &gt;0.80 and iFR was ≤0.89 (Figure 1B).
Side branch treatment was performed in 32% (n=12). All of these lesions showed functional significance in FFR or iFR. Stent implantation was performed in 8% (n=3), balloon angioplasty in 19% (n=7) and balloon angioplasty with a drug-eluting balloon in 5% (n=2).

Conclusions
The results of this study confirm the poor correlation of angiographic and functional assessment of coronary artery stenoses. Our data show close agreement of iFR and FFR in stent-jailed side branches. Therefore, iFR can be considered as a reliable technique for guidance of provisional side branch stenting.
Figure 1

Funding Acknowledgement
Type of funding source: None
Predictors of intra-procedural stent thrombosis (IPST) during percutaneous coronary intervention (PCI): a pooled data analysis
Authors: Aggarwal A , Jain A , Beriwal N 
Published: November 2020

Abstract

Background
Among all PCI related intraprocedural thrombotic events, IPST is rare but associated with worst outcomes.

Purpose
We conducted this study to identify specific patient and procedural characteristics that are associated with higher incidence of IPST.

Methods
Data on patient and procedural characteristics from all the studies comparing IPST without IPST was pooled for the purpose of analysis.

Results
5 studies with a total of 21251 patients were included. IPST occurred in 170 patients (0.8%). History of a prior PCI (assumed to be on dual or single anti-platelet agent)was associated with decrease in IPST. IPST occurred more in smokers, patients with abnormal cardiac enzymes at presentation, presentation with STEMI. Incidence of IPST was significantly higher in interventions involving left main artery or bifurcation or with bare metal stent placement. A low pre-TIMI flow of 0 or 1, baseline thrombus, not using upstream GpIIb inhibitors also significantly increased incidence of IPST.

Conclusion
Further studies are needed to validate above described patient and procedural risk factors. Using upstream GpIIb inhibitors in this specific high-risk population may help in prevention.

Funding Acknowledgement
Type of funding source: None
Baseline hemoglobin and bleeding risk in patients with myocardial infarction treated with PCI
Authors: Kanic V , Kompara G , Naji F.H 
Published: November 2020

Abstract

Background
Bleeding is one of the major complications of the modern treatment of myocardial infarction (MI). The data on admission hemoglobin (aHb) and bleeding in patients with MI who underwent percutaneous intervention (PCI) are scarce.

Purpose
We aimed to investigate the association between the graded aHb level and hospital bleeding in patients with MI who underwent PCI.

Methods
A single-center retrospective study was performed at our university, a tertiary referral hospital with a 24/7 PCI service. We analyzed 7315 MI patients. The patients were treated according to the published guidelines for the management of MI. The PCI strategy and concomitant medication were left to the discretion of the operator and the attending physician. The groups, stratified at 10g/L intervals according to the Hb level on admission, were compared. The criteria of the Bleeding Academic Research Consortium (BARC) 3a bleeding (an aHb drop of 30–50 g/L or any transfusion) were used. Data were analyzed using descriptive statistics. The interval with the most patients (130–139 g/L) was used as the reference group. The aHb value was used not only as a categorical variable but also as a continuous variable.

Results
The rates of bleeding were significantly higher in the groups with lower baseline aHb compared to the groups with higher aHb levels (p&lt;0.0001). A nonlinear inverse relationship was observed between the aHb and bleeding (Figure 1). Higher values of aHb were associated with a lower risk of bleeding (adjusted OR 0.76; 95% CI 0.72 to 0.81; p&lt;0.0001). We observed that there was an ∼7.5-fold and an ∼2-fold lower odds of bleeding in the lowest aHb level groups (&lt;100g/L and 100–109 g/L) compared to the reference group, respectively (adjusted OR 7.54; 95% CI 5.38 to 10.56; p&lt;0.0001 and 2.01; 95% CI 1.38 to 2.92) after adjustment for potential confounders. Patients with aHb levels equal to or greater than 110 g/L had a similar bleeding risk to the reference group.

Conclusion
We found that a graded decrease in the aHb level is associated with a progressively increased risk of hospital bleeding. Patients with aHbs lower than 110 g/L are particularly prone to bleed. Up to now, no consensus has been reached as to whether interventions aimed at correcting anemia could improve the outcome in these patients. Therefore, preventive measures to minimize additional bleeding (radial access, thinner sheaths, the use of selective GPIIb/IIIa receptor antagonists, proton-pump inhibitors) should be used. Even bare-metal stents may be selected, based on the evaluation of the bleeding/thrombosis risk for each patient. In general, the lower the aHb, the greater the bleeding risk.
Admission Hb and bleeding

Funding Acknowledgement
Type of funding source: None
Diabetic patients treated with novel thin composite-wire strut zotarolimus-eluting stents versus ultrathin strut sirolimus-eluting stents in the BIONYX trial: 2-year results of a prespecified analysis
Authors: Ploumen E , Buiten R.A , Zocca P , Roguin A , Doggen C.J.M , Jessurun G.A.J , Schotborgh C.E , Danse P.W , Benit E , Aminian A , Van Houwelingen K.G , Stoel M.G , Hartmann M , Linssen G.C.M , Von Birgelen C 
Published: November 2020

Abstract

Background/Introduction
The novel thin composite-wire strut zotarolimus-eluting stent (ZES) is a drug-eluting stent that is frequently used for treating patients with obstructive coronary artery disease, but so far no clinical outcome data have been published in patients with diabetes. In all-comer patients, the BIONYX trial (NCT02508714) has established non-inferiority of the ZES versus the ultrathin strut biodegradable-polymer sirolimus-eluting stent (SES) regarding the primary composite endpoint of target vessel failure at 1 year follow-up.

Purpose
To assess in patients with diabetes, the 2-year safety and efficacy of the current generation thin composite-wire strut ZES, compared to the ultrathin strut SES.

Methods
In the international, multicentre BIONYX trial, randomisation was stratified for sex and the presence of diabetes mellitus. We performed a prespecified subgroup analysis of patients with diabetes. The main endpoint target vessel failure was a composite of safety and efficacy, consisting of cardiac death, target vessel-related myocardial infarction or clinically indicated target vessel revascularisation. Secondary endpoints, such as target lesion revascularisation and stent thrombosis were also assessed.

Results
A total of 510/2488 (20.5%) BIONYX trial participants had diabetes, and were therefore included in this analysis. Patients were on average 66.4±10.3 years old, and 28.6% were female. Most participants presented with acute coronary syndromes (65.1%), and 182/510 (35.7%) patients were insulin dependent. Two-year follow up was available in 500 of 510 (98.0%) patients. Target vessel failure occurred in 31/260 (12.2%) patients assigned to ZES versus 26/250 (10.7%) patients assigned to SES (HR 1.14, 95%-CI 0.68–1.92; P-logrank=0.63). Kaplan Meier curves of target vessel failure are displayed in Figure 1. There were no significant between-stent differences in the individual components of this endpoint. Target lesion revascularisation occurred in 15/260 (6.0%) patients treated with ZES versus 9/250 (3.7%) patients treated with SES (HR 1.61, 95%-CI 0.71–3.68; P-logrank=0.25). Definite stent thrombosis was an infrequent event and did not differ significantly between stent-arms (0.4% vs. 1.2%; HR 0.32, 95%-CI 0.03–3.06; P-logrank=0.30).

Conclusion
In patients with diabetes, the novel thin composite-wire strut durable polymer ZES was similarly safe and efficacious as compared to the ultrathin cobalt-chromium strut biodegradable-polymer SES at 2-year follow-up.
Figure1. Target vessel failure at 2 years

Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): The BIONYX trial was equally funded by Biotronik and Medtronic.
A new approach to the treatment of post-catheterization pseudoaneurysms by ultrasound-guided tissue glue injection or ultrasound-guided thrombin injection depending on a late to early velocity index
Authors: Zandecki L , Kurzawski J , Jaroszynska A , Piatek L 
Published: November 2020

Abstract

Background
Ultrasound-guided thrombin injection (UGTI) is often the first-line treatment for iatrogenic post-catheterization pseudoaneurysms (psA). There are reports of the use of biologically-derived tissue glues (TG) instead of sole thrombin especially when UGTI was unsuccessful or in case of psA recurrence. TG are more potent procoagulants and may increase the procedure success rates at the cost of higher risk of complications in case too much substance escape into the patient's circulation during the procedure. TG are also more expensive than thrombin so they are often reserved for selected patients.
We have previously identified a late to early velocity index (LEVI) &lt;0.2 as a predictor of an increased risk of psA recurrence after standard UGTI. In the current paper we report our first experiences when the choice of the first-line treatment method was based on LEVI.

Methods
From May 2017 till January 2020 we included 36 patients with psA. Of them, 10 had LEVI &lt;0.2 and they underwent ultrasound-guided tissue glue injection (UGTGI) and 26 had LEVI &gt;0.2 and underwent UGTI. The injection set (containing human thrombin and fibrinogen) was used for UGTGI. Bovine thrombin was used for UGTI.

Results
The success rate was 100% and no psA recurrence was detected during 2-week follow-up. It was significantly better when compared to the expected recurrence rates based on our previous 15 years of experience (0% vs. 13%, p=0.02). All complications were mild and transient and included clinical symptoms of paraesthesia, numbness, tingling, or pain. Their rates were comparable to the rates we previously reported. No significant differences in other characteristics were observed.

Conclusion
The approach to choose the first-line treatment method for iatrogenic psA based on LEVI is encouraging.
Two examples of LEVI calculations

Funding Acknowledgement
Type of funding source: None
Ischemic burden reduction after chronic total occlusion percutaneous coronary intervention related to patient prognosis
Authors: Schumacher S.P , Stuijfzand W.J , Everaars H , Van Diemen P.A , Bom M.J , De Winter R.W , Kamperman L , Kockx M , Hagen B.S.H , Raijmakers P.G , Van De Ven P.M , Van Rossum A.C , Opolski M.P , Nap A , Knaapen P 
Published: November 2020

Abstract

Background
Chronic total occlusion (CTO) percutaneous coronary intervention (PCI) leads to major reductions in ischemic burden. However, to date, studies investigating if more ischemia reduction after CTO PCI translates into an improved patient prognosis, are lacking.

Purpose
To evaluate if change in absolute myocardial perfusion after CTO PCI is related to patient prognosis.

Methods
Between 2013–2019, 219 prospectively recruited patients with a CTO underwent quantitative [15O]H2O positron emission tomography perfusion imaging before and 3 months after successful CTO PCI in a single high-volume CTO PCI center (175 procedures/year). Changes in perfusion defect size (in myocardial segments) and hyperemic myocardial blood flow (MBF, in mL min–1 g–1) within the CTO territory after PCI were related to the combined endpoint of death or myocardial infarction (MI). Kaplan-Meier curves (log-rank test) and multivariable Cox regression (including covariates age, gender, prior MI, and left ventricular function) were used to analyze unadjusted and risk-adjusted event-free survivals with HR [95% CI].

Results
Out of 213 (97%) patients with a median follow-up of 3.2 [2.1–4.7] years, 22 (10%) patients experienced the composite of death (19, 9%) or MI (5, 2%). Event-free survival was significantly improved in patients with a perfusion defect size reduction of ≥3 segments (N=132, 62%) after CTO PCI compared to &lt;3 segments (p=0.01, risk-adjusted: p=0.02 with HR 0.36 [0.15–0.87]), as well in patients with increase in hyperemic MBF above the median of the population (delta &gt;1.13 mL min–1 g–1) as compared to below the median (p&lt;0.01, risk-adjusted: p=0.01 with HR 0.27 [0.10–0.75]). After PCI, patients with ≥1 segment residual perfusion defect size in the CTO territory at follow-up (N=114, 54%) had a significantly worse event-free survival compared to patients with no residual defect size (p&lt;0.01, risk-adjusted: p=0.01 with HR 4.12 [1.35–12.59]), whereas patients with a residual hyperemic MBF &gt;2.30 mL min–1 g–1 (N=105, 49%) showed a better event-free survival compared to patients with lower residual hyperemic MBF levels (p=0.02, risk-adjusted: p=0.04 with HR 0.33 [0.12–0.95]).

Conclusions
Patients with more ischemic burden reduction and less residual ischemia following CTO PCI showed a major improved survival free of death or MI. A limitation was the low absolute number of events that prohibited more extensive risk-adjustment of the analyses.

Funding Acknowledgement
Type of funding source: None