Abstract Purpose of Review Artificial intelligence (AI) applications in (interventional) cardiology continue to emerge. This review summarizes the current state and future perspectives of AI for automated imaging analysis in invasive coronary angiography (ICA). Recent Findings Recently, 12 studies on AI for automated imaging analysis In ICA have been published. In these studies, machine learning (ML) models have been developed for frame selection, segmentation, lesion assessment, and functional assessment of coronary flow. These ML models have been developed on monocenter datasets (in range 31–14,509 patients) and showed moderate to good performance. However, only three ML models were externally validated. Summary Given the current pace of AI developments for the analysis of ICA, less-invasive, objective, and automated diagnosis of CAD can be expected in the near future. Further research on this technology in the catheterization laboratory may assist and improve treatment allocation, risk stratification, and cath lab logistics by integrating ICA analysis with other clinical characteristics.
The predictors of TIMI flow <3 after PCI in patients with acute myocardial infarction have not been examined in a contemporary, large-scale multicentre prospective study.The HORIZONS-AMI trial randomised 3,602 patients with STEMI undergoing primary PCI to bivalirudin (n=1,800) vs. unfractionated heparin plus a glycoprotein IIb/IIIa inhibitor (n=1,802). A total of 3,845 treated lesions (3,362 vessels) were analysed by the core lab; 2,942 vessels (87.5%) and 2,758 patients (87.1%) had final TIMI 3 flow, while 407 (12.9%) had TIMI flow <3. The independent predictors of TIMI flow <3 were age (OR 1.23 per 10-year increase; 95% CI: 1.12 to 1.35; p<0.0001), anterior MI (OR 1.65; 95% CI: 1.33 to 2.05; p<0.0001), baseline TIMI flow grade 0/1 (OR 2.79; 95% CI: 2.14 to 3.62; p<0.0001), and lesion length (OR 1.05 per 10 mm increase; 95% CI: 1.02 to 1.09; p=0.005). The three-year mortality of patients in whom final TIMI 3 flow was achieved was significantly lower than that of patients in whom TIMI 3 flow was not achieved (5.5% vs. 10.5%; p<0.0001).In this large-scale, randomised trial, failure to restore normal TIMI flow after primary PCI in STEMI occurred in 12.9% of patients, and was associated with patient-related factors (age), anatomical factors (anterior MI location), and angiographic factors (baseline TIMI 0/1 flow and lesion length). Failure to achieve TIMI 3 flow continues to be a powerful predictor of mortality after primary PCI in the contemporary era.http://www.clinicaltrials.gov. Unique identifier: NCT00433966.
The COVID-19 pandemic has led to an overburdened healthcare system. While an increased rate of ACS is expected due to the pro-thrombotic state of COVID patients, observed ACS incidence and admission rates were paradoxically decreased during the (first wave of the) pandemic. In this narrative review, we will discuss potential reasons for this decrease in ACS incidence. Furthermore, we will discuss ACS management during the COVID-19 pandemic, and we will discuss outcomes in ACS.A reluctance to seek medical contact (in order not to further overburden the health system or due to fear of being infected with COVID-19 while in hospital) and unavailability of medical services seem to be important factors. This may have led to an increased symptom onset to first medical contact time and an increased rate of out-of-hospital cardiac arrests. A trend towards less invasive management was observed (less invasive coronary angiography in NSTEMI patients and more "fibrinolysis-first" in STEMI patients), although a large variation was observed with some centers having a relative increase in early invasive management. Patients with ACS and concomitant COVID-19 infection have worse outcomes compared to ACS patients without COVID-19 infection. All of the above led to worse clinical outcomes in patients presenting with ACS during the COVID-19 pandemic. Interestingly, staffing and hospital bed shortages led to experimentation with very early discharge (24 h after primary PCI) in low-risk STEMI patients which had a very good prognosis and resulted in significant shorter hospital duration.During the COVID-19 pandemic, ACS incidence and admission rates were decreased, symptom onset to first medical contact time prolonged, and out-of-hospital rates increased. A trend towards less invasive management was observed. Patients presenting with ACS during the COVID-19 pandemic had a worse outcome. On the other hand, experimental very early discharge in low-risk patients may relieve the healthcare system. Such initiatives, and strategies to lower the reluctance of patients with ACS symptoms to seek medical help, are vital to improve prognosis in ACS patients in future pandemics.
Abstract Objectives To investigate the prevalence, predictors and associations between guideline‐directed medical therapy (GDMT) and clinical outcomes in acute myocardial infarction (AMI) patients undergoing percutaneous coronary intervention (PCI) from eight academic centers in the United States. Background Evidence for GDMT in patients with AMI comes from randomized controlled trials. The use of GDMT in clinical practice is unknown in this setting. Methods PROMETHEUS is a multicenter observational registry comprising 19,914 patients with acute coronary syndrome (ACS) undergoing PCI. Patients with AMI were divided into two groups based on the prescription of GDMT or not (non‐GDMT) at discharge. GDMT was defined according to American College of Cardiology/American Heart Association (ACC/AHA) class I recommendations, specifically, dual antiplatelet therapy, statin and beta‐blocker for all AMI patients, and additional ACEI/ARB in patients with left ventricular ejection fraction (LVEF) less than 40%, hypertension, diabetes mellitus (DM) or chronic kidney disease (CKD). The primary endpoint was major adverse cardiovascular events (MACE) defined as a composite of all‐cause death, MI, stroke or unplanned target vessel revascularization (TVR) at 1 year. Results Out of 4,834 patients with AMI, 3,356 (69.4%) patients were discharged on GDMT. Patients receiving GDMT were more often younger and male. Compared with non‐GDMT patients, GDMT patients had a significantly lower frequency of comorbidities. Predictors of greater GDMT prescription at discharge were ST‐segment elevation myocardial infarction (STEMI), and increased body mass index (BMI), whereas hypertension, prior PCI, anemia and CKD were associated with less GDMT prescription. At 1 year, the use of GDMT was associated with a significantly lower incidence of MACE (13.7% vs. 22.5%; adjusted HR 0.68; 95%CI 0.58–0.80; P < 0.001), death (3.7% vs. 9.4%; adjusted HR 0.61; 95%CI 0.46–0.80; P < 0.001), and unplanned TVR (8.4% vs. 11.3%; adjusted HR 0.76; 95%CI 0.61–0.96; P = 0.020). However, there were no significant differences in the incidence of MI (4.3% vs. 7.0%; adjusted HR 0.75; 95%CI 0.56–1.01; P = 0.056), stroke (1.5% vs. 2.0%; adjusted HR 0.79; 95%CI 0.47–1.34; P = 0.384) between the two groups. Conclusion In a contemporary practice setting in the United States, GDMT was utilized in just over two‐thirds of AMI patients undergoing PCI. Predictors of GDMT prescription at discharge included STEMI, BMI and absence of hypertension, CKD, anemia or prior PCI. Use of GDMT was associated with significantly lower risk of 1‐year MACE and mortality.
Abstract Background Incomplete revascularization (ICR) after percutaneous coronary intervention (PCI) is associated with mortality and morbidity. Aim We sought to investigate whether ICR in the left anterior descending artery (LAD) is worse than ICR of the right coronary artery (RCA) or left circumflex artery (LCX); and whether ICR in patients with a chronic total occlusion (CTO) is worse than in those without. Methods In the RIVER‐PCI trial, 2651 patients with ICR after PCI were randomly assigned to ranolazine or placebo. Angiograms were assessed at an independent core laboratory in 2501 patients (94.3%). The primary endpoint was the composite of ischemia‐driven revascularization or hospitalization. Results A total of 1664 patients (66.5%) had ICR involving the LAD, whereas 837 (33.5%) had ICR limited to the RCA or LCX. At median follow‐up of 643 days, the primary endpoint occurred in 26.9% versus 26.5% of patients (adjusted HR [aHR]: 1.03, 95% confidence interval [CI]: 0.88–1.21). A nonrecanalized CTO was present in 854 patients (34.1%) with ICR after PCI. The primary endpoint occurred in 28.6% versus 25.9% of ICR patients with versus without a CTO (aHR: 1.10, 95% CI: 0.94–1.29). However, patients with a CTO had higher rates of ischemia‐driven hospitalization without revascularization (aHR: 1.27, 95% CI: 1.04–1.56), heart failure hospitalization (aHR: 2.69, 95% CI: 1.61–4.59) and myocardial infarction (aHR: 1.46, 95% CI: 1.11–1.92) compared with those without. Conclusions The 2‐year prognosis was similar in post‐PCI patients with ICR whether the LAD was versus was not involved. ICR patients with a CTO had more frequent hospitalizations for ischemia and myocardial infarctions compared with those without.
