imaging (MRI) in patients with acute chest pain, raised cardiac troponin, and angiographically normal coronary arteries.A diagnosis of myocarditis and cardiomyopathy was made in 50 and 3.4% of cases, respectively.Somewhat unexpectedly, only 11.6% of the population showed myocardial infarction, although it is conceivable that, among patients with a normal MRI scan, myocardial ischaemia might have caused a small increase in circulating troponin.The authors, however, do not provide any detail on the underlying cause of myocardial damage in patients with myocardial infarction and in those without delayed enhancement at MRI. Was any additional test performed to identify non-obstructive coronary atherosclerosis, vasospasm, or microcirculatory dysfunction?Because therapeutic measures vary between these conditions, their discrimination is extremely important.Indeed, the authors should have qualified more concisely the definition of 'unobstructed coronary artery'.Did the coronary arteries appear homogenously smooth at angiography, or rather, did they present an irregular contour, pointing to potentially instable atherosclerotic plaques?Pathophysiology cannot be inferred, though, from coronary 'lumenography' alone, and additional indicators must be sought with other imaging modalities.Combined positron emission tomography/ computed tomography, for example, could become the gold standard for this analysis, 2 notwithstanding its drawbacks due to cost, radiation exposure, and lack of general availability.MRI, on the other hand, is not as limiting.However, in patients with ischaemic heart disease and normal coronary arteries, delayed enhancement MRI alone provides insufficient information on the pathogenesis of myocardial damage and, by extension, is hardly able to guide therapy.In conclusion, myocardial ischaemia needs always to be qualified in its underlying pathophysiology, especially considering that the absence of obstructive coronary atherosclerosis does not necessarily entail a benign long-term prognosis.
Studies focusing on short- and mid-term follow up support the beneficial role of sirolimus-eluting stents (SES) in the treatment of in-stent restenosis (ISR), yet no long-term safety and/or efficacy data are available.Patients with ISR following bare-metal stenting (BMS) and treated with SES were prospectively studied. Baseline, procedural, and in-hospital data were appraised. The primary endpoint was the rate of major cardiovascular events (MACE) at long-term follow up (>9 months). Secondary endpoints were the individual contributors to MACE.A total of 180 SES were implanted to treat 138 consecutive patients. Procedural success was achieved in all patients without in-hospital death, acute stent thrombosis, stroke, or urgent coronary artery bypass. During follow up, MACE occurred in 5.8% of patients at 6 months, 14.3% at 12 months, and 25% at 24 months. Specifically, all-cause mortality was 1.7% at 6 months, 3.5% at 12 months, and 4.8% at 24 months, for a total of 5 deaths. Target vessel revascularization occurred at 6, 12, and 24 months in 4.2%, 11.2%, and 15.9% of patients, respectively, while target lesion revascularization (TLR) alone accounted for 3.4% at 6 months, 9.6% at 12 months, and 11% at 24 months. Three case of myocardial infarction occurred during follow up (2.2%), without any surgical revascularization or stent thrombosis.Treatment of ISR with SES appears safe and effective, even if a 10% annual rate of MACE can be expected, with a sizable portion of these due to apparently nontarget lesion events.
Abstract Aims Whether patients with spontaneous coronary artery dissection (SCAD) should undergo an initial conservative management or immediate revascularization through percutaneous coronary intervention (PCI) remains debated. To investigate the frequency and predictors of choosing a strategy of immediate PCI for SCAD, and to compare the clinical outcomes of immediate PCI patients with those undergoing an initial strategy of medical management. Methods and results 369 patients enrolled in the multicentre international DIssezioni Spontanee COronariche (DISCO) registry between January 2009 and December 2020 were included. The primary endpoint was major adverse cardiovascular events (MACE), a composite of cardiac death, non-fatal myocardial infarction (MI) and any PCI. 240 (65%) patients underwent initial medical management, whereas 129 (35%) had immediate PCI. PCI patients presented more frequently with ST segment-elevation myocardial infarction (STEMI) (68.2% vs. 35%, P < 0.001) and had higher frequency of proximal coronary segment SCAD (31.8% vs. 6.7%, P < 0.001), Thrombolysis in Myocardial infarction (TIMI) flow grade 0–1 (54.3% vs. 20.4%, P < 0.001) and multivessel SCAD (18.6% vs. 9.2%, P = 0.015), as well as a more severe diameter stenosis [99% (100–90) vs. 90% (99–75), P < 0.001]. At multivariate logistic regression, STEMI at presentation (vs. NSTE-ACS, OR: 3.30 95% CI: 1.56–7.12, P = 0.002), proximal coronary segment involvement (OR: 5.43, 95% CI: 1.98–16.45, P = 0.002), TIMI flow grade 0–1 and 2 (respectively, vs. grade 3: OR: 3.22 95% CI: 1.08–9.96, P = 0.038; and OR: 3.98; 95% CI: 1.38–11.80, P = 0.009) and diameter stenosis (per 5% increase, OR: 1.13; 95% CI: 1.01–1.28, P = 0.037) were predictors of immediate PCI, whereas the angiographic subtype 2B predicted a conservative approach (OR: 0.25; 95% CI: 0.07–0.83, P = 0.026). The frequency of in-hospital major adverse cardiac events did not differ between medically and PCI-treated patients. At 2-year follow-up, there were no differences with respect to the composite of MACE (11.7% vs. 13.9%, P = 0.47) and the individual components of cardiovascular death (0.4% vs. 0.7%, P = 0.65), non-fatal MI (8.3% vs. 9.3%, P = 0.92), and any PCI (8.7% vs. 12.4%, P = 0.23). Conclusions The choice between an immediate medical or PCI management of SCAD is mostly driven by clinical presentation and procedural aspects. In the DISCO cohort, the primary treatment approach was not associated with the risk of short-to-midterm adverse events.
Background: Patients with acute myocardial infarction (AMI) who undergo endotracheal intubation (ETI) are at high risk for mortality, but the outcome of those patients submitted to primary angioplasty (PCI) has not yet clearly reported.Methods: We collected data about all consecutive patients with AMI within 12 hours who underwent primary PCI and analyzed clinical and procedural characteristics as well as in-hospital mortality of ETI compared to no-ETI patients.Results: From September 2001 to June 2010, 1251 patients underwent primary PCI and 99 (7.9%) of them underwent ETI.ETI patients were more likely to be hypertensive (76.8% vs 67.8%, p=0.003), diabetic 43.4% vs 17.9%, p<0.0001), resuscitated by cardiac arrest (68.7% vs 0.7%, p<0.0001), to present with cardiogenic shock (CS) (61.6% % vs 8.1%, p<0.0001), with a lower left ventricular ejection fraction (LVEF) (38.9±9.4% vs 48.9±9.2%,p<0.0001) and to be treated with intra-aortic balloon counterpulsation (IABP) (60.1% vs 15.4%, p<0.0001).The in-hospital mortality was higher in ETI patients (37.4% vs 4.3%, p<0.0001) and they were more likely to undergo stent thrombosis (3% vs 0.34%, p=0.006).After using the propensity score modelling.Considering the risk profile, ETI was associated to higher in hospital mortality in the patients at higher risk (39.8% vs 18.5%, p=0.003).Moreover, ETI was one of the most powerful predictors of in-hospital mortality at multivariate analysis (OR 37.04, 95% CI 6.0-228.45,p=0.0001).Conclusions: ETI was found to be an independent predictor of mortality in high-risk AMI patients undergoing primary angioplasty.The implications for current clinical care remained undefined.
We report the case of a 55-year-old man who underwent coronary angiography in 2004 for early angina following anterior ST-elevation myocardial infarction. Angiography disclosed a critical stenosis in the proximal left anterior descending artery and significant stenoses in the right coronary artery and first obtuse marginal branch, treated with two paclitaxel-eluting stents and a sirolimus-eluting stent, respectively. After completion of a six-month thienopyridine course and while still being on lifelong aspirin, in 2007 he was readmitted for lateral ST-elevation myocardial infarction: angiography revealed stent thrombosis beginning at the proximal edge of the sirolimus-eluting stent implanted in the first obtuse marginal branch. Intravascular ultrasound was performed after thrombectomy but before balloon dilation showing suboptimal stent expansion and a thrombus partially adhering to the sirolimus-eluting stent. The procedure was then successfully completed with the implantation of another sirolimus-eluting stent. This clinical vignette suggests that suboptimal drug-eluting stent deployment may be associated with stent thrombosis well after the traditional time frame of subacute thrombosis.
