Background To this day, there is no data concerning guideline adherence on P2Y12-inhibitors in Austria. Prasugrel and ticagrelor have been shown to be superior to clopidogrel in the treatment of acute coronary syndromes (ACS). However, recent data from European registries showed a reluctant prescription policy with rates of clopidogrel at discharge ranging from 35 to 55%. Methods In this prospective, multi-centre registry we assessed prescription rates of P2Y12-inhibitors in patients with ACS in four Austrian PCI centres. Parameters associated with the use of clopidogrel have been evaluated in multivariate logistic regression. Results Between January and June 2015, 808 patients with ACS undergoing PCI were considered for further analysis. 416 (51.5%) presented with STEMI and 392 (48.5%) with NSTE-ACS. Mean age was 65.7 ± 12.4 and 240 (30.9%) were female. Twenty-eight (3.5%) died during the hospital stay. At discharge, 212 (27.2% of all patients) received clopidogrel, 260 (32.2%) prasugrel and 297 (36.8%) ticagrelor, while 11 (1.4%) did not receive any P2Y12-inhibitor. Of those patients, who were discharged with clopidogrel, 117 (55.2%) had no absolute contraindication against a more potent P2Y12-inhibitor. Diagnosis of NSTE-ACS (p<0.001), COPD (p = 0.049), and age (p<0.001) next to factors contributing to absolute contraindication were positively associated with the use of clopidogrel. Conclusions Despite a high level of care, a considerable number of patients were not treated with the more potent P2Y12-inhibitors. Parameters associated with a presumably higher risk of bleeding and side-effects against the more effective P2Y12 inhibitors were the most prominent factors for the prescription of clopidogrel.

Randomized controlled trials have shown conflicting results regarding the outcome of bivalirudin in primary percutaneous coronary intervention (PPCI). The aim of this study was to evaluate the in-hospital outcomes of patients receiving heparin or bivalirudin in a real-world setting of PPCI: 7,023 consecutive patients enrolled in the Austrian Acute PCI Registry were included between January 2010 and December 2014: Patients were classified according to the peri-interventional anticoagulation regimen receiving heparin (n = 6430) or bivalirudin (n = 593) with or without GpIIb/IIIa inhibitors (GPIs). In-hospital mortality (odds ratio [OR] 1.13, 95% confidence interval [CI] 0.57 to 2.25, p = 0.72), major adverse, cardiovascular events (OR 1.18, 95% CI 0.65 to 2.14, p = 0.59), net adverse clinical events (OR 1.01, 95% CI 0.57 to 1.77, p = 0.99), and Tall non coronary artery bypass graft-related major bleeding (OR 0.41, 95% CI 0.09 to 1.86, p = 0.25) were not significantly different between the groups. However, we detected potential effect modifications of anticoagulants on mortality by GPIs (OR 0.12, 95% CI 0.01 to 1.07, p = 0.06) and access site (OR 0.25,95% CI 0.06 to 1.03, p = 0.06) favoring bivalirudin in femoral access. In conclusion, this large real-world cohort of PPCI, heparin-based anticoagulation showed similar results of short-term mortality compared with bivalirudin. We observed a potential effect modification by additional GPI use and access favoring bivalirudin over heparin in femoral, but not radial, access. (C) 2017 Elsevier Inc. All rights reserved.

OBJECTIVE:Renal denervation (RDN) can cause focal (notches) and global (spasms) changes in renal artery dimensions. We quantified these changes and related them to renal norepinephrin tissue content in animals and to blood pressure (BP) changes in patients.METHODS:We measured renal artery dimensions pre-RDN and post-RDN, utilizing quantitative renal angiography (QRA) in a porcine model and in a retrospective patient cohort, and intravascular ultrasound (IVUS) in a prospective patient cohort. Focal and global measurements were minimum and mean diameter/area/volume with QRA, minimum lumen/vessel/wall area and volume with IVUS. BP was assessed with 24-h ambulatory monitoring, norepinephrin content with liquid chromatography.RESULTS:In 36 pigs treated unilaterally with RDN, norepinephrin content of the treated right kidney was 48.2% of the untreated left kidney. QRA measurements following RDN were associated with norepinephrin content only of the (treated) right kidney. In the human QRA study (n = 43 patients), mean 24-h BP fell by 8/4 and 12/6 mmHg at 1 and 12 months, respectively. More pronounced changes in QRA measurements were associated with a more pronounced BP drop. In multiple regression models, the change in minimum diameter was independently associated with BP changes at 12 months. In the prospective IVUS study (n = 17 patients), a larger decrease in minimum lumen/vessel area and larger increase of wall area/volume were associated with a larger BP drop.CONCLUSION:Focal and global changes in renal arteries following RDN can be quantified, using QRA or IVUS, and may serve as markers of a successful procedure.

With great interest, we read the carefully performed study by Borlaug et al. [(1)][1] on the beneficial effect of sodium nitrite on invasive exercise hemodynamics in patients with heart failure with preserved ejection fraction. We appreciate their findings and suggest a complementary explanation:

Objective: Procedural characteristics predicting blood pressure (BP) response to renal denervation (RDN) are currently lacking. The changes in renal artery (RA) dimensions induced by RDN have rarely been quantified and never been related to BP. Design and method: We prospectively investigated RAs of 17 patients (7 females, 11 diabetics, mean age 61.9 years) pre and post RDN (Symplicity Flex in 9 pts, Symplicity Spyral in 8 pts) with intravascular ultrasound (IVUS; Atlantis pro, Boston Scientific iLab). IVUS images were analyzed with QCU-CMS research software yielding global measures of RA size (RA vessel volume VV, lumen volume LV, wall volume WV), and measures of most pronounced focal changes (minimum and maximum vessel area VA, lumen area LA and wall thickness WT). Results: Pre RDN, 24 hour BP was 152/88 mmHg, mean number of ablation points was 11.8 (SD 3.8). After 1, 3, 6, and 12 months, 24 hour BP decreased by 11/6, 8/5, 16/8, and 20/9 mmHg, respectively. RDN induced a non-significant decrease in RA VV of 5.6 (SD 9.4) %, a significant decrease of RA LV of 8.9 (SD 10.4)%, and a non-significant increase of RA WV of 6.9 (SD 11.4) %. Max and min LA decreased significantly by 7.3 (SD 9.1) % and 10.5 (13.9) %, respectively, as did min VA by 6.8 (12.2) %. Max WT increased significantly by 14.1 (SD 21.1) 24 hour-based BP changes at 1, 3, 6 and 12 months were significantly and directly related to focal changes in min LA and min VA (r = 0.50–0.72, p-values 0.003–0.05). The change in min WT at 1, 3, and 12 months was significantly and inversely related to the change in systolic BP (r = −0.49, −0.54, −0.72, respectively, p = 0.006–0.05). Changes in global measures of RA size showed only moderate correlations with changes in BP. Conclusions: RDN leads to effects on global and focal RA dimensions (decrease in vessel and lumen size, increase in wall thickness). A higher degree of focal changes, particularly focal vessel narrowing and vessel thickening, may be associated with a better BP response to the procedure.

Diabetes mellitus, cardiovascular disease and heart failure are interacting dynamically. Patients being diagnosed with cardiovascular disease should be screened for diabetes mellitus. Enhanced cardiovascular risk stratification based on biomarkers, symptoms and classical risk factors should be performed in patients with pre-existing diabetes mellitus.

Summary: Thyroid Hormone Action in the Heart and Cardiovascular Effects of Thyroid Disease. Thyroid hormones (TH)

Objective: The concept of arterial aging and its relationship with arterial stiffness has been successfully introduced. However, the distribution of successful and premature aging in the population is currently unknown. Design and method: We acquired brachial waveforms with automated oscillometric devices (Agedio, i.e.m., Stolberg, Germany) in 13 public pharmacies and at 2 public health events from September to December 2015. Aortic pulse wave velocity (aoPWV) was estimated, using age, systolic blood pressure, and waveform characteristics, with the validated ARCSolver algorithm. Using the 50th and the 90th percentile from a previous population study, we defined age-specific cutoff values for separating arterial age and coded results according to a traffic light system. Results: Overall, we included 1281 persons (33.1% male). Mean age was 59.4 years (SD 15.3, range 20–91). Mean systolic blood pressure was 133 mmHg (SD 17), mean diastolic blood pressure 83 mmHg (SD 12). Hypertension had been diagnosed previously in 38% of participants, and 33% were taking antihypertensive drugs. Diabetes had been diagnosed in 7.2%, and cardiac disease in 11.3%. Mean aoPWV was 8.9 m/sec (SD 2.2, range 4.0–15.2). According to the predefined limits, arterial age was in the green range in 20.4%, in the yellow range in 44%, and in the red range in 35.4%. Participants with hypertension (10.1 vs 8.2 m/sec, p < 0.001), diabetes (9.9 vs 8.8 m/sec, p < 0.001), and cardiac disease (10.5 vs 8.7 m/sec, p < 0.001) had higher aoPWVs, as compared to their counterparts, but age was different between the groups. Distribution of arterial age was different between patients with and without hypertension or cardiac diasease and their counterparts (Table). Conclusions: We provide initial data from a screening approach for arterial aging in the population. The automated and user-independent method we used facilitates screening of large populations.

High blood pressure is a major modifiable risk factor for all clinical manifestations of coronary artery disease (CAD). In people without known cardiovascular disease, the lowest systolic (down to 90–114 mmHg) and the lowest diastolic (down to 60–74 mmHg) pressures are associated with the lowest risk for developing CAD. Although diastolic blood pressure is the strongest predictor of CAD in younger and middle-aged people, this relationship becomes inverted and pulse pressure shows the strongest direct relationship with CAD in people above 60 years of age.

The blood pressure (BP) response to renal denervation (RDN) is highly variable. In addition, the changes in renal artery (RA) dimensions induced by RDN have rarely been quantified and never been related to BP changes. We investigated RAs of 16 patients (7 females, 11 diabetics, mean age 62.6 years

Objectives: To compare noninvasive methods to assess pulse wave velocity (PWV) with the invasive gold standard in terms of absolute values, age-related changes, and relationship with subclinical organ damage. Methods: Invasive aortic PWV (aoPWVinv) was measured in 915 patients undergoing cardiac catheterization (mean age 61 years, range 27–87 years). Carotid–femoral PWV (cfPWV) was measured with tonometry, using subtracted distance (cfPWVsub), body height-based estimated distance (cfPWVbh), direct distance × 0.8 (cfPWVdir0.8), and caliper-based distance (cfPWVcalip) for travel distance calculation. Aortic PWV was estimated (aoPWVestim) from single-point radial waveforms, age, and SBP. Results: Invasive and noninvasive transit times were strikingly similar (median values 60.8 versus 61.7 ms). In the entire group, median value of aoPWVinv was 8.3 m/s, of cfPWVsub and cfPWVbh 8.1 m/s, and of aoPWVest 8.5 m/s. CfPWVsub overestimated aoPWVinv in younger patients by 0.7 m/s and underestimated aoPWVinv in older patients by 1.7 m/s, with good agreement from 50 to 70 years of age. AoPWVestim differed from aoPWVinv by no more than 0.4 m/s across all age groups. CfPWVdir0.8, measured in 632 patients, overestimated aoPWVinv by 1.7 m/s in younger patients, with good agreement in middle-aged and older patients. CfPWVcalip, measured in 336 patients, underestimated aoPWVinv in all ages. In 536 patients with preserved systolic function, aoPWVinv and aoPWVestim were superior to cfPWVs in predicting coronary atherosclerosis, renal function impairment, left atrial enlargement, and diastolic dysfunction. Conclusion: CfPWVsub, cfPWVdir0.8, and aoPWVestim are reasonable surrogates for aoPWVinv. AoPWVinv predicts subclinical organ damage better than cfPWVs, and as good as aoPWVestim.

The non-invasive quantification of arterial wave reflection is an increasingly important concept in cardiovascular research. It is commonly based on pulse wave analysis (PWA) of aortic pressure. Alternatively, wave separation analysis (WSA) considering both aortic pressure and flow waveforms can be applied. Necessary estimates of aortic flow can be measured by Doppler ultrasound or provided by mathematical models. However, this approach has not been investigated intensively up to now in subjects developing systolic heart failure characterized by highly reduced ejection fraction (EF). We used non-invasively generated aortic pressure waveforms and Doppler flow measurements to derive wave reflection parameters in 61 patients with highly reduced and 122 patients with normal EF. Additionally we compared these readings with estimates from three different flow models known from literature (triangular, averaged, Windkessel). After correction for confounding factors, all parameters of wave reflection (PWA and WSA) were comparable for patients with reduced and normal EF. Wave separations assessed with the Windkessel based model were similar to those derived from Doppler flow in both groups. The averaged waveform performed poorer in reduced than in normal EF, whereas triangular flow represented a better approximation for reduced EF. Overall, the non-invasive assessment of WSA parameters based on mathematical models compared to ultrasound seems feasible in patients with reduced EF.