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Patients with ST-segment elevation MI and multivessel coronary disease who had undergone successful culprit-lesion PCI were assigned to a strategy of either PCI of all other suitable stenoses or no further revascularization. At 3 years, the risk of cardiovascular death or new MI was lower with complete revascularization.

Spontaneous coronary artery dissection (SCAD) is a cause of about 4% of acute coronary syndrome. The pathophysiology of SCAD is not yet fully understood. Loeys-Dietz syndrome is a connective tissue disorder characterized by aortic aneurysms, arterial tortuosity, and aortic dissections. It is caused by mutations in the genes affecting the transforming growth factor β pathway. We describe a family with a SMAD3 gene mutation and Loeys-Dietz syndrome presenting with recurrent SCAD episodes.

Patients with STEMI were assigned to primary PCI with or without thrombectomy. At 180 days, there was no significant between-group difference in the primary outcome of death or cardiovascular events. Patients in the thrombectomy group had a higher rate of stroke at 30 days. Primary percutaneous coronary intervention (PCI), when available, is the most effective method of achieving reperfusion in patients with ST-segment elevation myocardial infarction (STEMI). 1 However, a major limitation of primary PCI is the possibility of distal embolization of thrombus and failure to restore flow at the microvascular level. Measures of microvascular tissue reperfusion, such as the degree of ST-segment resolution or angiographic myocardial blush grade, have been shown to predict the rate of death after primary PCI. 2 , 3 Removal of the thrombus by manual thrombectomy before stent deployment has the potential of reducing distal embolization and improving microvascular perfusion. Small, randomized . . .

BackgroundComposite outcomes in cardiovascular trials often group events of unequal clinical importance, and conventional analyses may obscure treatment trade-offs. Generalised pairwise comparisons (GPC), expressed as a win ratio (WR), allow for hierarchical ranking of events and incorporation of recurrent outcomes, providing a potentially more intuitive assessment of benefit–risk.MethodsIn a prespecified exploratory analysis of the 2×2 factorial, randomised CLEAR (Colchicine and Spironolactone in Patients with Myocardial Infarction) trial (7062 patients within 72 hours of acute myocardial infarction (MI) and percutaneous coronary intervention), we applied both time-to-first and recurrent-event GPC to reassess low-dose colchicine (0.5 mg daily) and spironolactone (25 mg daily) versus placebo. For the colchicine comparison, the hierarchical benefit–risk outcome included all-cause death, stroke, recurrent MI, unplanned ischaemia-driven revascularisation, serious infection or diarrhoea. For the spironolactone comparison, the outcome included all-cause death, stroke, MI, new or worsening heart failure, significant ventricular arrhythmia, hyperkalaemia or gynaecomastia/gynaecodynia. GPC results were compared with Cox, logistic and Andersen-Gill models.ResultsFor colchicine, the time-to-first event GPC showed a 12% lower proportional win rate compared with placebo (WR 0.88, 95% CI 0.79 to 0.98; win difference –2.10%, 95% CI –3.84 to –0.37), driven largely by excess diarrhoea. For spironolactone, patients experienced a 14% lower win rate (WR 0.86, 95% CI 0.75 to 0.99; win difference –1.46%, 95% CI –2.84% to –0.08%), largely attributable to gynaecomastia and hyperkalaemia. Conventional statistical approaches yielded concordant results. Across both interventions, higher-order efficacy outcomes (death, MI, stroke, heart failure) showed no benefit.ConclusionsIn patients with post-MI, both low-dose colchicine and spironolactone demonstrated disadvantageous benefit–risk profiles, reinforcing that neither agent should be used routinely. This prespecified application of GPC provided results consistent with traditional methods but offered a clinically intuitive framework for interpreting composite outcomes.

Radiotherapy can affect the electronic components of a cardiac implantable electronic device (CIED) resulting in malfunction and/or damage. We sought to assess the incidence, predictors, and clinical impact of CIED dysfunction (CIED-D) after radiotherapy for cancer treatment. Clinical characteristics, cancer, different types of CIEDs, and radiation dose were evaluated. The investigation identified 230 patients, mean age 78 ± 8 years and 70% were men. A total of 199 patients had pacemakers (59% dual chamber), 21 (9%) cardioverter-defibrillators, and 10 (4%) resynchronizators or defibrillators. The left pectoral (n = 192, 83%) was the most common CIED location. Sixteen patients (7%) experienced 18 events of CIED-D after radiotherapy. Reset to backup pacing mode was the most common encountered dysfunction, and only 1 (6%) patient of those with CIED-D experienced symptoms of atrioventricular dyssynchrony. Those who had CIED-D tended to have a shorter device age at the time of radiotherapy compared to those who did not (2.5 ± 1.5 vs 3.8 ± 3.4 years, p = 0.09). The total dose prescribed to the tumor was significantly greater among those who had CIED-D (66 ± 30 vs 42 ± 23 Gy, p <0.0001). Multivariate logistic regression analysis identified the total dose prescribed to the tumor as the only independent predictor for CIED-D (odds ratio 1.19 for each increase in 5 Gy, 95% confidence interval 1.08 to 1.31, p = 0.0005). In conclusion, in this large population of patients with CIEDs undergoing radiotherapy for cancer treatment, the occurrence of newly diagnosed CIED-D was 7%, and the reset to backup pacing mode was the most common encountered dysfunction. The total dose prescribed to the tumor was a predictor of CIED-D. Importantly, although the unpredictability of CIEDs under radiotherapy is still an issue, none of our patients experienced significant symptoms, life-threatening arrhythmias, or conduction disorders.

A major limitation of primary percutaneous coronary intervention (PPCI) for the treatment of ST-elevation myocardial infarction (STEMI) is impaired microvascular perfusion due to embolization and obstruction of microcirculation with thrombus. Manual thrombectomy has the potential to reduce distal embolization and improve microvascular perfusion. Clinical trials have shown mixed results regarding thrombectomy. The objective of this study is to evaluate the efficacy of routine upfront manual aspiration thrombectomy during PPCI compared with percutaneous coronary intervention alone in patients with STEMI. This is a multicenter, prospective, open, international, randomized trial with blinded assessment of outcomes. Patients with STEMI undergoing PPCI are randomized to upfront routine manual aspiration thrombectomy with the Export catheter (Medtronic CardioVascular, Santa Rosa, CA) or to percutaneous coronary intervention alone. The primary outcome is the composite of cardiovascular death, recurrent myocardial infarction, cardiogenic shock, or new or worsening New York Heart Association class IV heart failure up to 180 days. The trial uses an event-driven design and will recruit 10,700 patients. The TOTAL trial will determine the effect of routine manual aspiration thrombectomy during PPCI on clinically important outcomes.

The duration of red blood cell (RBC) storage may have a negative impact on endothelial nitric oxide bioavailability. We tested the hypothesis that transfused fresh blood will have a more favorable effect on microvascular endothelial function as compared to older standard issue blood. Participants requiring chronic RBC transfusions were enrolled in a crossover design study to receive fresh (<7 days of storage) or standard (up to 42 days of storage) blood on 2 separate visits. Endothelial function was assessed by reactive hyperemia peripheral arterial tonometry that was measured before and after transfusions. For each participant, the difference between endothelial function pretransfusion and posttransfusion was assessed in relation to blood storage time. Twenty-one patients (71 ± 16 years, 52% females) were enrolled. Mean age of fresh blood was 5.5 days (±1.0), and that of standard blood was 24.5 days (±7.9 days). The pretransfusion hemoglobin was 83.1 ± 2.5 g/L; and posttransfusion, 98.9 ± 2.6 g/L. An average of 2 U of packed RBCs was transfused. Microvascular endothelial function decreased more frequently after transfusion of standard blood compared to fresh blood. Standard issue blood transfusion was associated with decrease in reactive hyperemia peripheral arterial tonometry index (−0.25 ± 0.63) compared to fresh blood (+0.03 ± 0.49); P = .026. Transfusions of standard issue blood are associated with less favorable effect on microvascular endothelial function as compared to fresh blood.

The interaction between physicians and industry is complex and essential for improvement of medical care. However, conflict of interests may affect decision process. Our aim was to test if promotional visits by industry representatives affect treatment patterns and the use of various stents during percutaneous coronary interventions. Medical records of 1,145 consecutive patients who underwent percutaneous coronary intervention in an academic institution over 1-year period were retrospectively reviewed and linked to presence or absence of industry representative. We compared use of bare-metal stents, drug-eluting stents (DES), and balloon catheters according to company presence. A total of 1,785 stents were implanted in 1,145 patients; 60.8% were DES. More DES per case were implanted when a representative was present (1.71 ± 0.9 vs 1.60 ± 0.93, P = .023). There was no difference in the utilization of balloons and bare-metal stents between groups. Stent cost per case was higher when a representative was present (Can $1,703.5 ± 1,314.4 vs 1,468.9 ± 1,273.3, P < .001). For all companies marketing DES, there was increase in the use of the company's DES when their sale representative was present with less use of the competitors' stents. Sale representative presence was associated with increased use of the representative company's stents during percutaneous coronary interventions. The effect was more pronounced on use of the company's DES and resulted in higher procedural cost.

Experimental evidence suggests that the inhalational anesthetic sevoflurane has a cardioprotective effect. Our objective was to determine if sedation with sevoflurane will reduce infarct size in patients with acute myocardial infarction (MI) who are treated with primary percutaneous coronary intervention (PCI). We randomized 50 patients presenting with a first acute ST-elevation MI treated by primary PCI within 6 hours from symptom onset to sedation with sevoflurane inhalation or standard sedation (control). Coronary flow at the end of PCI was assessed by corrected Thrombolysis In Myocardial Infarction frame count. Myocardial reperfusion was assessed by ST-segment resolution 60minutes post-PCI. Infarct size was assessed by release of creatinine kinase (CK) and troponin T. There was no difference in the primary end point: troponin T or CK release adjusted to the area at risk, between groups. However, among patients with anterior MI, there was a trend toward lower CK (P = .05) and nonsignificant decrease in troponin (P = .11) levels in the sevoflurane group. Corrected Thrombolysis In Myocardial Infarction frame count was 12.3 ± 1.5 in the sevoflurane group and 15.6 ± 9.1 in the control group (P = .16). There was more ST resolution in patients treated by sevoflurane 80.7% ± 25.8% versus 56.6% ± 35.7% (P = .01). Sevoflurane had no significant adverse effect during administration. Sevoflurane administration during primary PCI did not reduce infarct size. There was a trend toward a reduction in infarct size among patients with anterior MI. Sevoflurane administration was associated with improvement in ST-segment resolution.