Background Diabetes mellitus (DM) has been associated with coronary microvascular dysfunction (CMD) in previous non-invasive studies. However, invasive studies have shown conflicting results. Methods To evaluate the prevalence and predictors of CMD in diabetic patients, invasive coronary physiology data of patients with fractional flow reserve (FFR) > 0.80 on the target vessel were analyzed from the BELmicro registry. Coronary flow reserve (CFR) < 2.5 and index of microcirculatory resistance (IMR) ≥ 25 were considered abnormal. Results Out of 402 patients, 72 had DM. Diabetic patients were older [69(61, 75) vs 64(58, 73), p = 0.02] and had higher rates of hypertension (73 % vs 56 %, p = 0.009) and dyslipidemia (89 % vs 64 %, p < 0.001) compared to non-diabetics. No differences were found between diabetic and non-diabetic patients in FFR [0.92(0.89, 0.94) vs 0.91(0.88, 0.94), p = 0.8] and CFR [3.0(2.1, 4.4) vs 2.8(2.0, 4.1), p = 0.4]. IMR was slightly lower in diabetics [16(9, 24) vs 18(12, 27), p = 0.04], but the rate of abnormal IMR was comparable to non-diabetics (23 % vs 31 %, p = 0.2). Prevalence of CMD was similar between diabetics and non-diabetics (46 % vs 48 %, p = 0.8). Rates of CMD were comparable between patients with longstanding DM (≥10 years) and recent diagnosis (52 % vs 35 %, p = 0.2). No association was found between glycated hemoglobin levels and CFR and IMR. Female sex was the only independent predictor of CMD in diabetics (OR: 2.71, 95 % CI: 1.02, 7.50, p = 0.049). Conclusions No differences in prevalence of CMD were found between diabetic and non-diabetic patients. Longstanding diabetes, glycemic control and concomitant cardiovascular risk factors were not associated with CMD in diabetic patients.

CTOs are frequently encountered in patients undergoing invasive coronary angiography. Even though technical progress in CTO-PCI and enhanced skills of dedicated operators have led to substantial procedural improvement, the success of the intervention is still lower than in non-CTO PCI. Moreover, the scores developed to appraise lesion complexity and predict procedural outcomes have shown suboptimal discriminatory performance when applied to unselected cohorts. Accordingly, we sought to develop a machine learning (ML)-based model integrating clinical and angiographic characteristics to predict procedural success of chronic total occlusion (CTO)-percutaneous coronary intervention(PCI). Different ML-models were trained on a European multicenter cohort of 8904 patients undergoing attempted CTO-PCI according to the hybrid algorithm (randomly divided into a training set [75%] and a test set [25%]). Sixteen clinical and 16 angiographic variables routinely assessed were used to inform the models; procedural volume of each center was also considered together with 3 angiographic complexity scores (namely, J-CTO, PROGRESS-CTO and RECHARGE scores). The area under the curve (AUC) of the receiver operating characteristic curve was employed, as metric score. The performance of the model was also compared with that of 3 existing complexity scores. The best selected ML-model (Light Gradient Boosting Machine [LightGBM]) for procedural success prediction showed an AUC of 0.82 and 0.73 in the training and test set, respectively. The accuracy of the ML-based model outperformed those of the conventional scores (J-CTO AUC 0.66, PROGRESS-CTO AUC 0.62, RECHARGE AUC 0.64, p-value <0.01 for all the pairwise comparisons). In conclusion, the implementation of a ML-based model to predict procedural success in CTO-PCIs showed good prediction accuracy, thus potentially providing new elements for a tailored management. Prospective validation studies should be conducted in real-world settings, integrating ML-based model into operator decision-making processes in order to validate this new approach.

Chronic total occlusions (CTOs) are frequent in patients with previous coronary artery bypass graft (CABG) surgery. Percutaneous coronary intervention (PCI) is the usual revascularization strategy. Whether or not the presence of a graft on a CTO vessel and post-PCI graft patency impacts outcomes after CTO-PCI is unknown. We sought to evaluate the impact of post-PCI graft patency on the durability of CTO-PCI. In total, 259 patients with previous CABG who underwent CTO-PCI in 12 international centers in 2019 to 2023 were categorized into "grafted" and "ungrafted" groups based on the presence of graft on a CTO vessel. The grafted group was subdivided into "graft-occluded" and "graft-patent" groups, depending on graft patency. The primary end points were (1) technical success rate, (2) target vessel failure, and (3) CTO failure rates at 1 year. CTO failure was defined as target vessel revascularization and/or significant in-stent restenosis. A total of 199 patients (77%) were in the grafted group. Grafted CTOs showed higher complexity and lower technical success rates (70% vs 80%, p = 0.004) than nongrafted CTOs. Of the grafted CTOs, 140 (70%) were in the grafted-occluded group and 59 (30%) were in the grafted-patent group. The technical success was lower in the former group (65% vs 81%, p = 0.022). An occluded graft was an independent predictor of technical failure (odds ratio 2.04, 95% confidence interval 1.03 to 4.76, p = 0.049) and persistent post-PCI graft patency was a strong independent predictor of CTO failure at 1 year (hazard ratio 5.6, 95% confidence interval 1.2 to 27.5, log-rank p = 0.033). In conclusion, in patients with previous CABG who underwent CTO-PCI, post-PCI graft patency was a significant predictor of CTO failure.

BACKGROUND:The "Minimalistic Hybrid Approach" (MHA) has been proposed to reduce the invasiveness of chronic total occlusion (CTO) percutaneous coronary intervention (PCI).AIMS:This study aims to assess whether MHA may also reduce the utilization of PCI resources (devices, radiations, and contrast) by comparing it with other conventional algorithms.METHODS:We aimed to assess the impact of MHA on device, radiation, and contrast usage during CTO-PCI analyzing data from the Belgian Working Group on CTO (BWG-CTO) registry. Patients were divided, depending on the algorithm used, into two groups: Conventional versus Minimalistic. Primary objectives were procedure performance measures such as device usage (microcatheters and guidewires), radiological parameters, and contrast use. At 1-year follow-up, patients were evaluated for target vessel failure (TVF), defined as a composite of cardiac death, new myocardial infarction, and target vessel revascularization.RESULTS:Overall, we analyzed 821 CTO-PCIs (Conventional n = 650, Minimalistic n = 171). The Minimalistic group demonstrated higher complexity of CTO lesions. After adjusting for propensity score, the Minimalistic group had a significantly lower number of microcatheters used (1.49 ± 0.85 vs. 1.24 ± 0.64, p = 0.026), while the number of guidewires was comparable (4.80 ± 3.29 vs. 4.35 ± 2.94, p = 0.30). Both groups had similar rates of success and procedural complications, as well as comparable procedural and fluoroscopic times and contrast volume used. At the 1-year follow-up, both groups showed comparable rates of TVF (hazard ratio: 0.57; 95% confidence interval: 0.24-1.34, p = 0.195).CONCLUSION:The MHA may slightly reduce the number of dedicated devices used during CTO-PCI, without adversely affecting the procedural success or long-term outcome.

Coronary function testing (CFT) plays a pivotal role in the diagnosis of coronary vascular dysfunction and in providing patients with tailored therapy. The Belgian registry on coronary function testing (BELmicro registry) is a prospective, observational, multicenter registry including 14 centers in Belgium. All patients undergoing clinically indicated CFT were included in the registry. Baseline characteristics, CFT data, and clinical outcomes were collected. The aims of the current analysis were to describe the baseline characteristics of a real-world population of patients undergoing CFT, to evaluate the prevalence of coronary vascular dysfunction and to assess the safety of CFT in daily clinical practice. Between October 2021 and September 2023, 449 patients were enrolled. The mean age was 65 ± 10 years, and 47.4% of patients were male. Fifty-nine percent of patients had hypertension, 18.7% diabetes, 69.5% hypercholesterolemia, and 40.1% smoking habit. Angina and non-obstructive coronary arteries (ANOCA) were identified in 85.1% of patients. Microvascular physiology assessment was performed in 95.5% of patients, vasoreactivity test in 28.5%, and both in 24.0%. CMD was diagnosed in 23.4% of ANOCA patients, epicardial vasospasm in 26.3%, and microvascular spasm in 14.9%. Rates of major complications were 0.7% for microvascular physiology assessment and 0% for vasoreactivity test. In conclusion, participants in the BELmicro registry represented a real-world population of patients, characterized by a high burden of cardiovascular risk factors. Both CMD and coronary vasospasm were frequent in ANOCA patients. Performing CFT in daily clinical practice was feasible with a low rate of complications.

Background: The percutaneous treatment of calcified coronary lesions remains challenging and is associated with worse clinical outcomes. In addition, coronary artery calcification is associated with more frequent peri-procedural myocardial infarction. Study design and objectives: The ShOckwave ballooN or Atherectomy with Rotablation in calcified coronary artery lesions (SONAR) study is an investigator-initiated, prospective, randomized, international, multicenter, open label trial (NCT05208749) comparing a lesion preparation strategy with either shockwave intravascular lithotripsy (IVL) or rotational atherectomy (RA) before drug-eluting stent implantation in 170 patients with moderate to severe calcified coronary lesions. The primary endpoint is difference in the rate of peri-procedural myocardial infarction. Key secondary endpoints include rate of peri-procedural microvascular dysfunction, peri-procedural myocardial injury, descriptive study of IMR measurements in calcified lesions, technical and procedural success, interaction between OCT calcium score and primary endpoint, 30-day and 1-year major adverse clinical events. Conclusions: The SONAR trial is the first randomized controlled trial comparing the incidence of peri-procedural myocardial infarction between 2 contemporary calcium modification strategies (Shockwave IVL and RA) in patients with calcified coronary artery lesions. Furthermore, for the first time, the incidence of peri-procedural microvascular dysfunction after Shockwave IVL and RA will be evaluated and compared.

Background Balloon uncrossable coronary lesions are lesions that cannot be crossed with a conventional balloon. Multiple balloons have been designed to overcome this problem. The Blimp balloon has a very low scoring profile (0.6 mm) with a very high rated burst pressure (30 atmospheres). We aimed to evaluate the efficacy of this balloon compared to customary low-profile balloons. Methods We conducted a multicenter, prospective, randomised, controlled trial in which 126 patients with an uncrossable lesion were randomly (1:1 randomization) assigned to treatment first with the Blimp balloon or low-profile balloon. The primary endpoint was the success of crossing the lesion after initial failure with a microcatheter (group A) or with a conventional balloon (group B). Results Overall, the first attempt of Blimp was successful in 29 out of 61 cases (48%) while the LP balloon immediately crossed in 30 out 67 cases (45%; p = 0.761). Using a low-profile balloon in the BLIMP group after failure of the Blimp balloon increased the success to 64% (39 out of 61 cases). Using the Blimp balloon in the low-profile first group after failure of the low-profile balloon increased the success to 60% (40 out of 67 cases). After the placement of a guide catheter extension, the overall successful lesion crossing in the BLIMP group was 80% (49 out of 61 cases) compared to 76% (51 out of 67 cases) in the LP Balloon group (p = 0.327). Conclusions The Blimp balloon catheter showed no superiority to customary low-profile balloons in uncrossable lesions. It can however be complementary in treating uncrossable lesions.

The present study aims to assess the clinical and hemodynamic impact of percutaneous edge-to-edge mitral valve repair with MitraClip in patients with atrial functional mitral regurgitation (A-FMR) compared with ventricular functional mitral regurgitation (V-FMR). Mitral regurgitation (MR) grade, functional status (New York Heart Association class), and major adverse cardiac events (MACE; all-cause mortality or hospitalization for heart failure) were evaluated in 52 patients with A-FMR and in 307 patients with V-FMR. In 56 patients, hemodynamic assessment during exercise echocardiography was performed before and 6 months after intervention. MR reduction after MitraClip implantation was noninferior in A-FMR compared with V-FMR (MR grade <= 2 at 6 months in 94% vs 82%, respectively, p <0.001 for noninferiority) and was associated with improvement of func-tional status (New York Heart Association class <= 2 at 6 months in 90% vs 80%, respec-tively, p = 0.2). Hemodynamic assessment revealed that cardiac output at 6 months was higher in A-FMR at rest (5.1 +/- 1.5 L/min vs 3.8 +/- 1.5 L/min, p = 0.002) and during peak exercise (7.9 +/- 2.4 L/min vs 6.1 +/- 2.1 L/min, p = 0.02). In addition, the reduction in systolic pulmonary artery pressure at rest was more pronounced in A-FMR: Delta SPAP -13.1 +/- 15.1 mm Hg versus -2.2 +/- 13.3 mm Hg (p = 0.03). MACE rate at follow-up was significantly lower in A-FMR versus V-FMR, with an adjusted odds ratio of 0.46 (95% confidence inter -val 0.24 to 0.88), which was caused by a reduction in hospitalization for heart failure. In con-clusion, percutaneous edge-to-edge mitral valve repair with MitraClip is at least as effective in A-FMR as in V-FMR in reducing MR. However, the hemodynamic improvement and reduction of MACE were significantly better in A-FMR. (C) 2021 Elsevier Inc. All rights reserved.

Background To chart the evolution of the CTO-PCI landscape in Belgium and Luxembourg, the Belgian Working Group on Chronic Total Occlusions (BWGCTO) was established in 2016. Methods Between May 2016 and December 2019, patients undergoing a CTO-PCI treatment were prospectively and consecutively enrolled. Twenty-one centres in Belgium and one in Luxembourg participated. Individual operators had mixed levels of expertise in treating CTO lesions. Demographic, angiographic, procedural parameters and incidence of major adverse cardiac and cerebrovascular events (MACCE) were systematically registered. Results Over a four-year enrolment period, 1832 procedures were performed in 1733 patients achieving technical success in 1474 cases (80%), with an in-hospital MACCE rate of 2.3%. Fifty-nine (3%) cases were re-attempt procedures of which 41 (69%) were successful. High-volume centres treated more complex lesions (mean J-CTO score: 2.15 +/- 1.21) as compared to intermediate (mean J-CTO score: 1.72 +/- 1.23;p < 0.001) and low-volume centres (mean J-CTO score: 0.99 +/- 1.21;p = 0.002). Despite this, success rates did not differ between centres (p = 0.461). Overall success rates did not differ over time (p = 0.810). High-volume centres progressively tackled more complex CTOs while keeping success rates stable. In all centres, the most applied strategy was antegrade wire escalation (83%). High-volume centres more often successfully applied antegrade dissection and re-entry and retrograde techniques in lesions with higher complexity. Conclusion With variable experience levels, operators treated CTOs with high success and relatively few complications. Although AWE remains the most used technique, it is paramount for operators to be skilled in all contemporary techniques in order to be successful in more complex CTOs.

Aims The current study assessed the impact of COVID-19-related public containment measures (i.e. lockdown) on the ST elevation myocardial infarction (STEMI) epidemic in Belgium. Methods and results Clinical characteristics, reperfusion therapy modalities, COVID-19 status and in-hospital mortality of consecutive STEMI patients who were admitted to Belgian hospitals for percutaneous coronary intervention (PCI) were recorded during a three-week period starting at the beginning of the lockdown period on 13 March 2020. Similar data were collected for the same time period for 2017-2019. An evaluation of air quality revealed a 32% decrease in ambient NO(2)concentrations during lockdown (19.5 mu g/m(3) versus 13.2 mu g/m(3),p < .001). During the three-week period, there were 188 STEMI patients admitted for PCI during the lockdown versus an average 254 STEMI patients before the lockdown period (incidence rate ratio = 0.74,p = .001). Reperfusion strategy was predominantly primary PCI in both time periods (96% versus 95%). However, there was a significant delay in treatment during the lockdown period, with more late presentations (>12 h after onset of pain) (14% versus 7.6%,p = .04) and with longer door-to-balloon times (median of 45 versus 39 min,p = .02). Although the in-hospital mortality between the two periods was comparable (5.9% versus 6.7%), 5 of the 7 (71%) COVID-19-positive STEMI patients died. Conclusion The present study revealed a 26% reduction in STEMI admissions and a delay in treatment of STEMI patients. Less exposure to external STEMI triggers (such as ambient air pollution) and/or reluctance to seek medical care are possible explanations of this observation.

Aim: Cardiac arrest is a common complication of ST elevation myocardial infarction and is associated with high mortality. We evaluated whether vulnerability to cardiac arrest follows a circadian rhythm and whether it is related to specific patient characteristics. Methods: A total of 24,164 ST elevation myocardial infarction patients who were admitted to 60 Belgian hospitals between 2008-2017 were analysed. The proportion of patients with cardiac arrest before initiation of reperfusion therapy was calculated for different time periods (hour of the day, months, seasons) and related to patient characteristics using stepwise logistic regression analysis. Results: Cardiac arrest occurred in 10.8% of the ST elevation myocardial infarction patients at a median of 65 min (interquartile range 33-138 min) after onset of pain. ST elevation myocardial infarction patients with cardiac arrest showed a biphasic pattern with one peak in the morning and one peak in the late afternoon. Multivariate analysis identified the following independent factors associated with cardiac arrest: cardiogenic shock (odds ratio=28), left bundle branch block (odds ratio=3.7), short (<180 min) ischaemic period (odds ratio=2.2), post-meridiem daytime presentation (odds ratio=1.4), anterior infarction (odds ratio=1.3). Overall in-hospital mortality was 30% for cardiac arrest patients versus 3.7% for non-cardiac arrest patients (p<0.0001). Conclusion: In the present study population, cardiac arrest in ST elevation myocardial infarction showed an atypical circadian rhythm with not only a morning peak but also a second peak in the late afternoon, suggesting that cardiac arrest and ST elevation myocardial infarction triggers are, at least partially, different. In addition, specific patient characteristics, such as short ischaemic period, cardiogenic shock and left bundle branch block, increase the vulnerability to cardiac arrest.

Percutaneous mitral valve repair using MitraClip offers symptomatic benefit and improves rest and exercise hemodynamics in patients with severe functional mitral regurgitation (MR). Recent randomized trials have shown contradictory results regarding the impact of MitraClip on mid-term survival in functional MR. It is unknown whether improved hemodynamics are related to patients" outcome. To assess whether residual MR and altered resting and exercise hemodynamics are predictors of outcome in patients with functional MR treated with MitraClip. Consecutive patients (n = 45, 72 ± 10years, left ventricular ejection fraction (LVEF) 34 ± 9%) with symptomatic severe functional MR were prospectively evaluated by Doppler echocardiography at rest and during symptom-limited exercise on a semi-supine bicycle pre- and 6 months post-MitraClip procedure. LVEF, MR severity, cardiac output (CO), systolic pulmonary artery pressure (SPAP) and a flow-corrected SPAP/CO ratio were assessed at rest and peak exercise. 2-year follow-up clinical data were collected from patient records. During 2-year follow-up post-MitraClip, 15 patients (33%) experienced major cardiac events (hospitalization for heart failure (n = 14) and/or cardiac death (n = 5)). Age, gender, a history of coronary artery disease, diabetes, baseline MR severity and baseline SPAP/CO ratio at rest and during exercise were not related to a worse event-free survival. In contrast, patients with events at 2-year follow up had more often a history of hospitalization for heart failure (73 vs. 37%, p = 0.029), lower baseline LVEF (30 ± 8 vs. 36 ± 10%, p = 0.041), more residual MR at 6 months post-MitraClip (MR jet area/left atrial area 27 ± 14 vs. 15 ± 10%, p = 0.004) and higher SPAP/CO ratios at rest and during exercise 6 months post-MitraClip (13.9 ± 5.3 vs. 9.9 ± 3.4mmHg/L/min, p = 0.007 and 13.6 ± 4.9 vs. 9.4 ± 4.6mmHg/L/min, p = 0.009, respectively). When corrected for baseline LVEF, residual MR 6 months post-MitraClip remained an independent predictor for worse 2-year outcome. Residual MR was moderately correlated to a worse SPAP/CO ratio 6 months post-MitraClip (Pearson Rho 0.518, p < 0.001). In patients with functional MR treated with MitraClip, residual MR at 6-month follow-up is associated with impaired hemodynamics, and is an independent predictor of cardiac events at 2-year follow-up.

"Transcatheter tricuspid valve repair using MitraClip device for significant tricuspid regurgitation: novel treatment for a common problem." Acta Cardiologica, 75(8), pp. 793–794

Recent MitraClip heart failure (HF) trials suggest that baseline left ventricular (LV) remodeling may be critical for patient selection. We, therefore, investigated whether baseline LV remodeling affects safety, efficacy, and clinical outcomes in HF patients with symptomatic secondary mitral regurgitation (MR) undergoing percutaneous mitral valve repair using MitraClip. LV remodeling was assessed by LV end-systolic dimension index (LVESDi) on transthoracic baseline echocardiography. Early and late outcome was reported using Mitral Valve Academic Research Consortium-criteria. A total of 107 consecutive HF patients (73 ± 10 years, 70% male) who underwent MitraClip intervention for secondary MR were studied. The study population was stratified by median LVESDi between nonadvanced (<28 mm/m², n = 49) and advanced LV remodeling (≥28 mm/m², n = 58). Both groups had similar acute procedural success, in hospital bleeding and nonbleeding complications and significant improvement in MR severity and symptoms, sustained up to 36 months (all p >0.05). LVESDi, but not LV end-diastolic diameter index nor LV ejection fraction, independently related to HF hospitalization (hazard ratio 1.11, 95% confidence interval 1.05 to 1.16, p <0.001) and mortality (hazard ratio 1.11, 95% confidence interval 1.06 to 1.17, p <0.001). At 1 and 3 years, survival free of HF hospitalization was higher in patients without versus with advanced LV remodeling (89% vs 66% and 65% vs 37%, p = 0.002) and mortality was lower (9% vs 24% and 36% vs 47%, p = 0.074), respectively. Annual HF hospitalization rate only decreased in the nonadvanced LV remodeling group (-43%, p = 0.025). Advanced LV remodeling, assessed by LVESDi, in HF patients who underwent MitraClip therapy does not influence therapeutic safety nor efficacy, but implies increased HF hospitalization and mortality risk. This parameter may be valuable for MitraClip therapy patient selection.

Abstract Background Recent randomised trials have shown conflicting results regarding the usefulness of percutaneous mitral valve repair using MitraClip in patients with severe functional mitral regurgitation (FMR). At present, it remains unclear whether patients with FMR and advanced heart failure might benefit from MitraClip therapy. Moreover, it has been shown that left ventricular reverse remodelling (LVRR) post-MitraClip is associated with a favourable outcome. Purpose We sought to assess whether baseline contractile reserve (CR) can predict LVRR and improvement of LV ejection fraction (EF) in FMR patients undergoing MitraClip therapy. Methods Consecutive patients with symptomatic severe FMR referred for MitraClip were recruited in two tertiary centres. All patients were scheduled for a semi-supine bicycle exercise echocardiography before and 6 months after the intervention. Patients who were not able to perform an exercise test and who did not complete 6 month follow up were excluded from further analysis. Baseline CR was obtained by subtracting peak exercise LVEF from LVEF at rest. LVRR was defined as a 10% decrease in LV end systolic volume (ESV) at follow-up. Results 34 patients completed 6 month follow up (61% male, age 71 ± 10 years, LVEF 32 ± 8%). LVRR was observed in 15 patients (44%). We found a trend towards a moderate correlation between baseline CR and relative decrease in LVESV at 6 months (Pearson Rho -0.321, p = 0.064). This correlation became significant in a sub-analysis considering only patients with post-procedural FMR grade ≤2 (n = 27; Pearson Rho -0.444, p = 0.020). In contrast, LVRR was not related to baseline LVEF, LV dimensions or volumes. Furthermore, baseline CR was strongly correlated with an increase of LVEF at 6 months post-MitraClip in these patients (Pearson Rho 0.653, p < 0.001). Conclusion CR predicts LVRR and improvement of LVEF in patients with FMR after successful MitraClip therapy (reduction of FMR towards grade ≤2), in contrast to resting indices of LV dysfunction and dilatation. More studies with outcome data are needed to determine whether CR is a useful parameter to identify patients with FMR who might benefit from MitraClip therapy.

Aims To assess the adherence to established quality indicators (QIs) for ST-elevation myocardial infarction (STEMI) at the hospital-network level and its relation to outcome. Methods and results The data of 7774 STEMI patients admitted to 32 STEMI networks during the period 2014-18 were extracted from the Belgian STEMI database. Five QIs [primary percutaneous coronary intervention use, diagnosis-to-balloon time (DiaTB) <90min, door-to-balloon time (DoTB) <60 min, P2Y12 inhibitor and statin prescription at discharge, and a composite QI score ranging from 0 to 10] were correlated with in-hospital mortality adjusted for differences in baseline risk profile (TIMI risk score). The median composite QI score was 6.5 [interquartile range (IQR) 6-8]. The most important gaps in quality adherence were related to time delays: the recommended DiaTB and DoTB times across the different networks were achieved in 68% (IQR 53-71) and 67% (IQR 50-78), respectively. Quality adherence was better in networks taking care of more high-risk STEMI patients. The median in-hospital mortality among the STEMI networks was 6.4% (IQR 4.1-7.9%). There was a significant independent inverse correlation between the composite QI score and in-hospital mortality (partial correlation coefficient: -0.45, P=0.013). Stepwise regression analysis revealed that among the individual QIs, prolonged DiaTB was the most important independent outcome predictor. Conclusion Among established STEMI networks, the time delay between diagnosis and treatment was the most variable and the most relevant prognostic QI, underscoring the importance of assessing quality of care throughout the whole network.

During the ESC congress in September 2018 in Munich, the new ESC guidelines were presented and are now available on the ESC website. The new guidelines describe the definition of myocardial infarction and covers management recommendations on following cardiovascular items: myocardial revascularisaton, cardiovascular disease during pregnancy and arterial hypertension. The present document gives a summary of these guidelines and highlights the most important recommendations and changes in the management of these diseases. It will help to increase awareness about the new guidelines and may stimulate to consult the full document for specific items. Ultimately, the authors hope that this document will enhance the implementation of new ESC guidelines in daily clinical practice.