Beta-blockers are a crucial part of post-myocardial infarction (MI) pharmacological therapy. Recent studies have raised questions about their efficacy in patients without reduced left ventricular ejection fraction (LVEF). This study aims to assess adherence to beta-blockers after discharge for ST-segment elevation myocardial infarction (STEMI) and the impact of adherence on outcomes based on LVEF at discharge. The retrospective registry FAST-STEMI evaluated real-world adherence to main cardiovascular drugs in STEMI patients between 2012 and 2017 by comparing purchased tablets to expected ones at one year through pharmacy registries. Optimal adherence was defined ≥80%. Primary outcomes included all-cause and cardiovascular death, while secondary outcomes were myocardial infarction, major/minor bleeding events, and ischemic stroke The study included 4688 patients discharged on beta-blockers. Mean age was 64 ± 12.3 years, 76% were male, and mean LVEF was 49.2 ± 8.8%. Mean adherence at one year was 87.1%. Optimal adherence was associated with lower all-cause (adjHR 0.62, 95%CI 0.41-0.92, p 0.02) and cardiovascular mortality (adjHR 0.55, 95%CI 0.26-0.98, p 0.043). In LVEF ≤40% patients, optimal adherence was linked to reduced all-cause and cardiovascular mortality but this was not found either in patients with preserved or mildly reduced LVEF. Predictors of cardiovascular mortality included older age, chronic kidney disease, male gender, and atrial fibrillation. Optimal adherence to beta-blocker therapy in all-comers STEMI patients reduced all-cause and cardiovascular mortality at 1 year; once stratified by LVEF, this effect is confirmed only in patients with reduced LVEF (< 40%) at hospital discharge.
Abstract Introduction The expanding indications for transcatheter aortic valve implatation (TAVI) to younger, lower-risk patients, entails assessing not only the short-term clinical outcomes but also the long-term considerations for future interventions. The prevalence of coronary artery disease (CAD) in TAVI patients is relevant, and the optimal timing of percutaneous coronary intervention (PCI) remains a question. Methods We conducted a systematic literature review and meta analysis including 20 eligible studies involving 1660 patients who underwent coronary angiography after TAVI. The primary endpoint was the incidence of successful selective coronary re-access. Secondary endpoints included semi-selective and non-selective access rates. The analysis was stratified by balloon-expandable (BEVs) and self-expandable valve (SEVs) types. Results Successful coronary access after TAVI was feasible in the majority of patients, with a higher success rate observed for the left main (LM) compared to the right coronary artery (RCA). BEVs demonstrated the highest success rates in coronary ostia cannulation, achieving nearly 100% success for both LM and RCA. Among SEVs, the Acurate Neo and Evolut R/PRO showed superior success rates in selective coronary access (68% and 77% for LM; 57% and 72% for RCA, respectively) compared to the CoreValve (46% for LM and 49% for RCA). Notably, the majority of coronary angiograms were performed due to acute coronary syndrome, primarily non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA). Conclusions Selective coronary engagement after TAVI is generally achievable, with BEVs demonstrating superior success rates compared to SEVs. Among SEVs, the Acurate NEO showed better outcomes than the other types.
Abstract Background The impact of beta-blocker therapy on cardiovascular outcomes after ST-elevation acute myocardial infarction (STEMI) is debated. Adherence to beta-blockers after acute myocardial infarction and effect on long term cardiovascular outcomes are also fields with significant knowledge gaps. Purpose To identify predictors of lower compliance to beta-blocker therapy and estimate its impact on cardiovascular outcomes and mortality during the first year of follow-up after the index event. Methods We evaluated real-world adherence to the most common cardiovascular drugs by comparing the number of tablets bought in pharmacies to the expected number of tablets needed at 1 year and at the final follow-up. A total of 6043 patients with STEMI were enrolled in the FAST-STEMI registry from 2012 to 2017 and followed up for 4.7±1.6 years. 299 patients with intraprocedural and intrahospital deaths were excluded. The main outcomes evaluated were all-cause death, cardiovascular death, myocardial infarction, major and minor bleeding events, and ischemic stroke. The best compliance cut-off was found by ROC curve analysis with Youden index; Kaplan Meier and Cox proportional hazard models were performed to evaluate cumulative event rates of mortality at follow-up. Predictors of lower adherence were evaluated in univariate and multivariate analyses with logistic regression. Results A total of 4992 patients with beta-blockers prescription at discharge were enrolled: mean age was 64±12.3 years old, 76% were male, mean ejection fraction was 49±8.8%. Mean adherence to beta-blockers was 95,8% (IQR 82.2-100). After univariate and multivariate analyses, age over 75 years old (OR 0.76, 95%CI 0.63-0.91) and previous coronary artery disease (OR 0.62, 95%CI 0.44-0.87) resulted as predictors of lower compliance, whereas concomitant ACEi/ARB prescription at discharge was a predictor of good adherence (OR 1.23, 95%CI 1.04-1.46). Adherence to beta-blockers higher than 65.68% (identified as best cut-off at Youden’s analysis) was related to a lower cardiovascular (0.65% vs 1.49%, p 0.009) and all-cause mortality (1.98% vs 4.48%, p <0.001). At multivariate analysis, adherence to beta-blockers was significantly associated with lower cardiovascular mortality (HR 0.40, 95%CI 0.20-0.81, p 0.01) as well as EF >50% (HR 0.30, 95%CI 0.14-0.63, p 0.002), while age over 75 years old (HR 4.72, 95%CI 2.23-9.98, p <0.001) and history of atrial fibrillation (HR 2.63, 95%CI 1.02-6.80, p 0.04) were associated with a higher risk of cardiovascular death. Finally, optimal adherence to beta-blockers did not reduce the number of myocardial infarctions, strokes, or bleeding events. Conclusions In our large real-world registry, optimal adherence to beta-blockers after STEMI was associated with a reduction in both cardiovascular and all-cause mortality. Older age and previous coronary artery disease resulted as predictors of poor compliance to beta-blocker therapy.Kaplan Meier on all-cause and CV deathMultivariate analysis on CV death
Abstract Aims Data on Glycoprotein IIb/IIIa inhibitors (GPI) use in real world ACS patients following the introduction of potent P2Y12 inhibitors and newer generation stents are scant. Here, we aimed to assess the utilization, effectiveness, and safety of GPI in a large prospective cohort of contemporary ACS patients. Methods SPUM-ACS is a prospective, multicentre study in which ACS patients between 2009 and 2017 were recruited. The primary endpoint of the present study was major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction (MI) and non-fatal stroke at one year. Any bleeding events, BARC 3-5 bleeding, and net adverse cardiovascular events (NACE) comprised the secondary endpoints. Results A total of 4395 ACS patients were included in the analysis. GPI-treated patients had more total coronary artery occlusion (56% vs 35%, p<0.001) and thrombus (60% vs 35%, p<0.001) at angiography. Among the propensity score matched (PSM) population (1992 patients equally split into two groups), GPI-treated patients showed lower MACE risk (PSM adjusted HR 0.70, 95% CI 0.49-0.99) but a higher risk of any (PSM adj HR 1.46, 95% CI 1.06-1.99) and major bleedings (PSM adj HR 1.73, 95% CI 1.09-2.76), resulting in a neutral effect on NACE (PSM adj HR 0.87, 95% CI 0.65-1.17). These results remained consistent across all subgroups. When including only patients treated with potent P2Y12, the incidence of MACE was not different between the two groups, (log rank p=0.50 and PSM adjusted HR 0.94, 95% CI 0.60-1.48). In the PSM population, GPI use (HR 0.76, 95% CI 0.59-0.99, p=0.04), TIMI 3 at the end of the procedure (HR 0.16, 95% CI 0.08-0.30, p<0.001) and potent P2Y12 inhibitor use (HR 0.70, 95% CI 0.49-0.99, p=0.04) were protective independent predictors of MACE at follow-up, while oral anticoagulation at discharge (4.48, 95% CI 2.10-9.52, p<0.001), multivessel disease (HR 1.95, 95% CI 1.09-3.48, p=0.02) and KILLIP class ≥ 2 at admission (HR 1.98, 95% CI 0.99-3.95, p=0.05) were adverse independent predictors. Conclusion In ACS patients undergoing PCI and broadly treated with potent P2Y12 inhibitors, GPI use reduced the risk of MACE at 1 year, while increasing the risk of major bleedings, with a neutral effect on NACE. The routine use of these pharmacological agents should be discouraged, while in selected patients GPI use should be considered following personalized balancing between ischaemic and bleeding risk.Events in PSM populationEvents in PSM population
Spontaneous coronary artery dissection (SCAD) is an increasingly diagnosed cause of myocardial infarction. Although different SCAD angiographic classifications exist, their clinical impact remains unknown.
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.
Introduction: Among different coronary stents implanted in High Bleeding Risk (HBR) patients with an indication for short antiplatelet therapy, no comparisons in terms of efficacy have been provided. Methods: A Network Meta Analysis was performed including all Randomized Controlled Trials comparing different coronary stents evaluated in HBR patients. Major Adverse Cardiovascular Events (MACEs) as defined by each included trial were the primary end point, whereas TLR (target lesion revascularization), TVR (target vessel revascularization), stent thrombosis and total and major (BARC3-5) bleedings were the secondary ones. Results: A total of 4 studies (ONYX ONE, LEADERS FREE, SENIOR and HBR in BIO-RESORT) including 6637 patients were analyzed with different kind of stents and DAPT length (1 or 6 months) on 12 months follow-up. About one third of these patients were defined HBR due to indication for oral anticoagulation. All Drug Eluting Stents (DESs) reduced risk of MACE compared to Bare Metal Stents (BMSs) when followed by a 1-month DAPT. At SUCRA analysis, Orsiro was the device with the highest probability of performing best. Rates of TLR and TVR were significantly lower when using Resolute Onyx, Synergy and BioFreedom stents in comparison to BMS when followed by 1-month DAPT, with Synergy ranking best. Synergy also showed a significantly lower number of stent thrombosis compared to BMS (RR 0.28, 95%CI 0.06-0.93), while Orsiro and Resolute Integrity showed the highest probability of performing best. Conclusion: In HBRs patients, all DESs were superior to BMSs in terms of efficacy and safety. Among DESs, Orsiro was the one with the highest ranking in terms of MACE, mainly driven by a reduced incidence of repeated revascularization and stent thrombosis
The cardiac autonomic nervous system (CANS) plays a pivotal role in cardiac homeostasis as well as in cardiac pathology. The first level of cardiac autonomic control, the intrinsic cardiac nervous system (ICNS), is located within the epicardial fat pads and is physically organized in ganglionated plexi (GPs). The ICNS system does not only contain parasympathetic cardiac efferent neurons, as long believed, but also afferent neurons and local circuit neurons. Thanks to its high degree of connectivity, combined with neuronal plasticity and memory capacity, the ICNS allows for a beat-to-beat control of all cardiac functions and responses as well as integration with extracardiac and higher centers for longer-term cardiovascular reflexes. The present review provides a detailed overview of the current knowledge of the bidirectional connection between the ICNS and the most studied cardiac pathologies/conditions (myocardial infarction, heart failure, arrhythmias and heart transplant) and the potential therapeutic implications. Indeed, GP modulation with efferent activity inhibition, differently achieved, has been studied for atrial fibrillation and functional bradyarrhythmias, while GP modulation with efferent activity stimulation has been evaluated for myocardial infarction, heart failure and ventricular arrhythmias. Electrical therapy has the unique potential to allow for both kinds of ICNS modulation while preserving the anatomical integrity of the system.
Data on glycoprotein IIb/IIIa inhibitor (GPI) use in real-world acute coronary syndrome (ACS) patients following the introduction of potent P2Y12 inhibitors and newer-generation stents are scant. Here, we aimed to assess the utilization, effectiveness, and safety of GPI in a large prospective multicentre cohort of contemporary ACS patients.
