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The determinants and prognostic value of recurrent myocardial infarction (MI) in a contemporary cohort of ST-segment elevation MI patients treated with primary percutaneous coronary intervention (PPCI) and stenting are currently unknown. We investigated the predictors and prognostic impact of recurrent MI on subsequent clinical outcome in 1,700 ST-segment elevation MI patients treated with PPCI and stenting between January 1, 2003, and July 31, 2008. Two hundred forty patients had a recurrent MI during a median follow-up of 4 years and 7 months (Kaplan Meier estimate 21.2%). By multivariable analysis, recurrent MI was associated with a higher risk of subsequent cardiac mortality (hazard ratio [HR] 6.86, 95% confidence interval [CI] 4.24 to 8.72), noncardiac mortality (HR 2.02, 95% CI 1.10 to 3.69), stroke (HR 3.68, 95% CI 2.02 to 6.72), and Global Use of Strategies to Open Occluded Coronary Arteries criteria severe or moderate bleeding (HR 3.17, 95% CI 1.79 to 5.60). Early recurrent MI (within 1 day of the initial PPCI) was associated with higher unadjusted cardiac mortality rates (64.4%) compared with recurrent MIs occurring ≥1 day after PPCI. However, after multivariable adjustment, late recurrent MI (occurring >1 year after PPCI) was associated with the highest risk of subsequent cardiac mortality (HR 7.98, 95% CI 5.05 to 12.6). The risk of cardiac death was irrespective of the presence of persistent ST-segment elevation during the recurrent MI. In conclusion, recurrent MI after PPCI remains a relatively common complication in contemporary practice and confers a significantly increased risk of death, stroke, and bleeding.

Intravascular lithotripsy (IVL) has emerged as a viable treatment option for calcified coronary lesions. This study aimed to identify clinical and procedural factors associated with major adverse cardiovascular events (MACE) following IVL. This retrospective analysis included 583 patients (72.9 ± 9 years, 74% male) treated with IVL for 612 lesions from the multicenter BENELUX-IVL registry (May 2019-December 2024). Kaplan–Meier analysis was performed to evaluate survival probability. Binary logistic regression analysis was performed to identify predictors of MACE, including cardiac death, nonfatal myocardial infarction (MI) or clinically driven target vessel revascularization (TVR) at 1-year follow-up. Patients presented with acute coronary syndrome in 246 cases (42%), while a variety of target lesions was treated, including in-stent lesions (n = 185, 30%), aorta-ostial lesions (n = 148=24%), bifurcation lesions (n = 135, 22%) and chronic total occlusions (CTOs)(n = 45, 7%). MACE occurred in 44 patients (11%) at 1-year and in 53 patients (18%) at 2-years follow-up. Occurrence of procedural complications (p <0.001), CTOs (p = 0.020), in-stent lesions (p = 0.044), post-IVL plaque modification (p = 0.003) and greater postprocedural residual diameter stenosis on fluoroscopy (p = 0.006) were associated with the occurrence of MACE, while MI in the medical history (p = 0.001) was negatively associated with MACE. Following treatment with IVL in a real-world registry, clinical outcomes up to 2-years follow-up were favorable. Procedural complications, CTOs, in-stent lesions, performance of post-IVL plaque modification and greater postprocedural residual diameter stenosis on fluoroscopy were independent risk factors for experiencing MACE at 1-year follow-up. In contrast, a history of MI was associated with a lower risk of MACE.

Chronic kidney disease (CKD) is a prevalent comorbidity in patients undergoing percutaneous coronary intervention (PCI), yet its impact on outcomes following intravascular lithotripsy (IVL) remains insufficiently studied. This study evaluated procedural and long-term outcomes of IVL-assisted PCI in patients with renal insufficiency compared to those with normal renal function. From the BENELUX-IVL registry (May 2019–September 2024), 558 patients were included in a retrospective multicenter analysis. Renal insufficiency was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m² using the CKD-EPI formula. The primary endpoint was major adverse cardiovascular events (MACE) at one and two years of follow-up. Secondary endpoints included procedural, device, and technical success, as well as all-cause mortality. Multivariable logistic regression was used to identify independent predictors of mortality. A total of 586 lesions were treated in 558 patients: 190 (32.4%) with renal insufficiency and 396 (67.6%) with normal renal function. One-year MACE occurred in 14 (13.3%) versus 28 (10.9%) patients (p = 0.80), and between year one and two in 4 (5.6%) versus 5 (2.8%) patients (p = 0.46). Procedural success was similar between groups (88.6% versus 88.7%; p = 0.97). All-cause mortality was higher in the renal insufficiency group (n = 32, 18.2% versus n = 44, 11.5%; p = 0.03). On multivariable analysis, eGFR was independently associated with mortality (OR 0.98; 95% CI 0.97–1.00; p = 0.020). In conclusion, IVL-assisted PCI resulted in similar procedural and MACE outcomes regardless of renal function, although mortality was significantly higher in patients with renal insufficiency.

Diabetes mellitus (DM) is associated with increased coronary calcification and adverse outcomes after percutaneous coronary intervention (PCI), yet the performance of intravascular lithotripsy (IVL) in this high-risk population remains insufficiently defined. This study, conducted within the all-comers BENELUX-IVL registry, evaluated the safety and efficacy of IVL-assisted PCI in patients with and without DM. The primary endpoint was major adverse cardiovascular events (MACE) at 1 and 2 years, defined as cardiovascular death, nonfatal myocardial infarction, or clinically driven target vessel revascularization. Secondary endpoints included procedural outcomes, complications, and all-cause mortality. A total of 574 patients were included, of whom 193 (33.6%) had DM and 381 (66.4%) did not. Procedural (87.0% vs 89.5%; p = 0.381) and device success (95.3% vs 97.9%; p = 0.087) were similar between groups. Post-PCI minimum lumen diameter (2.80 ± 0.59 vs 2.95 ± 0.70 mm; p = 0.027) and area (6.0 [4.80 to 7.75] vs 6.6 [4.98 to 8.90] mm²; p = 0.045) were smaller in patients with DM. Thirty-day MACE was higher among diabetics (3.1% vs 0.3%; p = 0.007), whereas 1- and 2-year MACE and mortality rates were comparable. Diabetes was not independently associated with mortality (adjusted OR 1.51; p = 0.17). In conclusion, IVL-assisted PCI is safe and effective in diabetic patients, with long-term outcomes comparable to those without diabetes, although the higher early MACE risk, particularly in type 1 DM, warrants careful procedural planning and follow-up.

Acute coronary syndrome mostly arises from rupture or erosion of a vulnerable plaque. Vulnerable plaques typically appear as lipid-rich plaques with a thin cap, called thin-cap fibroatheromas. Various intracoronary imaging techniques can be used to detect vulnerable plaques, such as intravascular ultrasound (IVUS), optical coherence tomography (OCT) and near-infrared spectroscopy (NIRS), each visualizing different high-risk plaque characteristics. IVUS and its post-processing techniques, such as virtual histology IVUS, can primarily be used to identify calcified and soft plaques, while OCT is also able to quantitatively measure the cap thickness. The addition of NIRS allows the exact measurement of lipid content in the plaque. Non-invasive imaging techniques to identify vulnerable plaques, such as computed tomography, are less often used but are evolving and may be of additional diagnostic use, especially when prophylactic treatments for vulnerable plaques are further established. Pharmacological treatment with lipid-lowering or anti-inflammatory medication leads to plaque stabilization and reduction of cardiovascular events. Moreover, the implantation of a stent or scaffold for the local treatment of vulnerable plaques has been found to be safe and to stabilize high-risk plaque features. The use of drug-coated balloons to treat vulnerable plaques is the subject of ongoing research. Future studies should focus on non-invasive imaging techniques to adequately identify vulnerable plaques and further randomized clinical studies are necessary to find the most appropriate treatment strategy for vulnerable plaques.

ObjectivesGlobal left ventricular (LV) function is routinely used to assess cardiac function; however, myocardial strain is able to identify more subtle dysfunction. We aimed to determine the recovery and prognostic value of featuring tracking (FT) cardiovascular magnetic resonance (CMR) strain in ST-segment elevation myocardial infarction (STEMI) patients with a concurrent chronic total occlusion (CTO).MethodsIn the randomized EXPLORE trial, there was no significant difference in global LV function after percutaneous coronary intervention (PCI) of the CTO, compared with no-CTO PCI, post-STEMI. In the current study, we included 200 of the 302 EXPLORE patients with a baseline CMR, of which 180 also had 4-month follow-up (serial) CMR. Global longitudinal strain (GLS) was calculated from 3 long-axis views. Global circumferential strain (GCS) and segmental strain were calculated from 3 short-axis views (basal, mid, and apical).ResultsGlobal strain significantly improved at 4 months (GLS ∆ − 1.8 ± 4.3%, p < 0.001; GCS ∆ − 1.7 ± 4.7%, p < 0.001); however, there was no treatment effect of CTO-PCI on strain recovery. GLS was a significant predictor for 4 months of LV ejection fraction (p = 0.006), incremental to other CMR parameters including infarct size. For mortality, infarct size remained the strongest predictor. On regional level, segmental strain independently predicted recovery in the dysfunctional segments (p < 0.001).ConclusionsGlobal and segmental myocardial strains significantly improved over time, with no effect of CTO-PCI. Global strain was associated with outcome and segmental strain was an independent predictor for regional LV recovery in the dysfunctional CTO territory. Further research is needed to determine the additional prognostic value of strain beyond routine CMR parameters.Key Points• In STEMI patients with a concurrent CTO, strain significantly improves over time, regardless of CTO-PCI.• Global strain is an independent predictor for functional recovery, incremental to infarct size, LVEF, and clinical parameters.• Segmental strain was able to predict the recovery of wall thickening, incremental to transmural extent of infarction.

Coronary artery disease (CAD) affects over 200 million individuals globally, accounting for approximately 9 million deaths annually. Patients living with diabetes mellitus exhibit an up to fourfold increased risk of developing CAD compared to individuals without diabetes. Furthermore, CAD is responsible for 40 to 80 percent of the observed mortality rates among patients with type 2 diabetes. Patients with diabetes typically present with non-specific clinical complaints in the setting of myocardial ischemia, and as such, it is critical to select appropriate diagnostic tests to identify those at risk for major adverse cardiac events (MACEs) and for determining optimal management strategies. Studies indicate that patients with diabetes often exhibit more advanced atherosclerosis, a higher calcified plaque burden, and smaller epicardial vessels. The diagnostic performance of coronary computed tomographic angiography (CCTA) in identifying significant stenosis is well-established, and as such, CCTA has been incorporated into current clinical guidelines. However, the predictive accuracy of obstructive CAD in patients with diabetes has been less extensively characterized. CCTA provides detailed insights into coronary anatomy, plaque burden, epicardial vessel stenosis, high-risk plaque features, and other features associated with a higher incidence of MACEs. Recent evidence supports the efficacy of CCTA in diagnosing CAD and improving patient outcomes, leading to its recommendation as a primary diagnostic tool for stable angina and risk stratification. However, its specific benefits in patients with diabetes require further elucidation. This review examines several key aspects of the utility of CCTA in patients with diabetes: (i) the diagnostic accuracy of CCTA in detecting obstructive CAD, (ii) the effect of CCTA as a first-line test for individualized risk stratification for cardiovascular outcomes, (iii) its role in guiding therapeutic management, and (iv) future perspectives in risk stratification and the role of artificial intelligence.

Graphical Abstract Graphical Abstract Clinical outcomes and treatment adherence during 12 months follow-up. *Second bleeding event in same patient. PCI, percutaneous coronary intervention; TVR, target vessel revascularization.

Background The population is ageing rapidly and the proportion of patients aged ≥ 80 years undergoing primary percutaneous coronary intervention (PCI) is rising, but clinical trials have primarily been performed in younger patients. Methods Patients undergoing primary PCI between 2003 and 2008 were subdivided into 3 groups: < 60, 60-79, and ≥ 80 years. Endpoints at 3-year follow-up included all-cause mortality, recurrent myocardial infarction (reMI), stent thrombosis, target lesion revascularisation (TLR), bleeding (BARC bleeding ≥ 3), stroke, and major adverse cardiovascular events (MACE, a composite of cardiac mortality, reMI, stroke and TLR). Results 2002 patients with ST-segment elevation myocardial infarction (STEMI) were included, 885 (44.2 %) aged < 60, 921 (46.0 %) 60–79, and 196 (9.7 %) ≥ 80 years. Comorbidities such as diabetes mellitus, prior stroke, malignant disease, anaemia, and chronic kidney disease were more prevalent in patients ≥ 80 years. The incidence of both ischaemic and bleeding events strongly increased with age. Age ≥ 80 years was an independent predictor of mortality (HR 2.56, 95 % CI1.69–3.87, p  < 0.001), a borderline non-significant predictor of overall bleeding (HR 1.38, 95 %CI 0.95–2.00, p  = 0.088), and a significant predictor of non-access site bleeding (HR 2.26, 95 %CI 1.46–3.51, p  < 0.001). Conclusion Patients ≥ 80 years experienced high rates of ischaemic and bleeding complications; especially in this high-risk patient group individualised therapy is needed to optimise clinical outcomes.