*Correspondence: Ignacio Barriuso E-mail: barriusobarrado@gmail.com Available online: 23-01-2023 Arch Cardiol Mex. 2023;93(3):366-368 www.archivoscardiologia.com Date of reception: 23-02-2022 Date of acceptance: 26-07-2022 DOI: 10.24875/ACM.22000070 A 74-year-old woman without previous medical history except for the left bundle branch block was admitted for evaluation of recurrent syncopes. During admission, she experienced a sustained self-limited monomorphic ventricular tachycardia together with new syncope. Initial echocardiography displayed moderate biventricular systolic dysfunction. Cardiac magnetic resonance imaging (CMRI) confirmed these findings (Fig. 1) and revealed patchy subepicardial areas of late gadolinium enhancement within the left ventricular inferolateral and apical segments (red arrow) and an aneurysm was found in the right ventricular apex, containing a rounded thrombus (blue arrow) which persisted 10 days after intravenous anticoagulation therapy. Due to the clinical suspicion of biventricular arrhythmogenic cardiomyopathy with sustained ventricular arrhythmias, cardioverter-defibrillator (ICD) implantation was decided. Subcutaneous approach, initially preferred due to persistent thrombus, was finally dismissed due to predicted high risk of inappropriate therapies in the screening test. Finally, a transvenous ICD was implanted with defibrillation electrode located in the posterior interventricular vein and left bundle branch pacing (Fig. 2) with a significant reduction of paced QRS duration (Fig. 3) and partial recovery of biventricular function during the follow-up. Subsequently, a genetic study was performed confirming a pathogenic variant in the DSG2 gene, which not only explained the phenotype but also allowed familiar cascade screening (Fig. 4).

BACKGROUND:MicroRNAs (miRNAs) are noncoding RNAs involved in post-transcriptional genetic regulation with a proposed role in intercellular communication. miRNAs are considered promising biomarkers in ischemic heart disease. Invasive physiological evaluation allows a precise assessment of each affected coronary compartment. Although some studies have associated the expression of circulating miRNAs with invasive physiological indexes, their global relationship with coronary compartments has not been assessed. Here, we will evaluate circulating miRNAs profiles according to the coronary pattern of the vascular compartment affectation. STUDY AND DESIGN:This is an investigator-initiated, multicentre, descriptive study to be conducted at three centres in Spain (NCT05374694). The study will include one hundred consecutive patients older than 18 years with chest pain of presumed coronary cause undergoing invasive physiological evaluation, including fractional flow reserve (FFR) and index of microvascular resistance (IMR). Patients will be initially classified into four groups, according to FFR and IMR: macrovascular and microvascular affectation (FFR≤0.80 / IMR≥25), isolated macrovascular affectation (FFR≤0.80 / IMR<25), isolated microvascular affectation (FFR>0.80 / IMR ≥25) and normal coronary indexes (FFR>0.80 / IMR<25). Patients with isolated microvascular affectation or normal indexes will also undergo the acetylcholine test and may be reclassified as a fifth group in the presence of spasm. A panel of miRNAs previously associated with molecular mechanisms linked to chronic coronary syndrome will be analysed using RT-qPCR. CONCLUSIONS:The results of this study will identify miRNA profiles associated with patterns of coronary affectation and will contribute to a better understanding of the mechanistic pathways of coronary pathology.

Introduction Distal radial access for coronary procedures decreases hemostasis time, prevents radial occlusion, and improves patient comfort compared to conventional transradial access. Initially described for left distal radial access (lDRA), the right distal radial access (rDRA) is feasible. However, there are no comparative studies to date. This study aimed to evaluate the impact of the access site on vascular access and procedural performance. Methods From August 2020 to October 2021, coronary procedures performed through distal radial access were prospectively recorded. After propensity score matching, the rDRA and lDRA were compared. The primary endpoint was the proportion of approach success. The secondary endpoints included access time, coronary procedural success, radial spasm, exposition to ionizing radiation, patient comfort, and vascular access-related complications. Results From a total of 385 procedures in 382 patients, after a propensity score matching, 182 procedures were compared between the rDRA and lDRA. There were no differences in the baseline characteristics between the groups. Compared to the lDRA, the rDRA presented similar approach success (96.7% vs. 96.7%, p=1.0), less access time (39 (25–60) sec vs. 50 (29–90) sec, p=0.018), comparable coronary procedural success after sheath placement (100% vs. 100%, p=1.000), and not statistically significant radial spasm (2.19% vs. 6.59%, p=0.148). No differences in dose-area product (32 (20–56.2) Gy.m2 vs. 32.3 (19.4–46.3) Gy.m2; p=0.472) and fluoroscopy time (4.4 (2.5–9.1) min vs. 4.3 (2.4–7.5) min, p=0.251) were detected between the groups. No vascular access-related complications were observed in any group. Conclusions The rDRA, compared to the lDRA, had the same proportion of approach success and procedural performance, with a slight reduction in access time for patients undergoing coronary procedures.

Resumo Fundamento Os limiares de corte para a “relação do ciclo completo de repouso” (RFR) oscilam em diferentes séries, sugerindo que as características da população podem influenciá-los. Da mesma forma, foram documentados preditores de discordância entre a RFR e a reserva de fluxo fracionado (FFR). O Estudo RECOPA, mostrou que a capacidade diagnóstica está reduzida na “zona cinzenta” da RFR, tornando necessária a realização de FFR para descartar ou confirmar isquemia. Objetivos Determinar os preditores de discordância, integrar as informações que eles fornecem em um índice clínico-fisiológico: a “RFR Ajustada”, e comparar sua concordância com o FFR. Métodos Usando dados do Estudo RECOPA, os preditores de discordância em relação à FFR foram determinados na “zona cinzenta” da RFR (0,86 a 0,92) para construir um índice (“RFR Ajustada”) que pesaria a RFR juntamente com os preditores de discordância e avaliar sua concordância com a FFR. Resultados Foram avaliadas 156 lesões em 141 pacientes. Os preditores de discordância foram: doença renal crônica, cardiopatia isquêmica prévia, lesões não envolvendo a artéria descendente anterior esquerda e síndrome coronariana aguda. Embora limitada, a “RFR Ajustada” melhorou a capacidade diagnóstica em comparação com a RFR na “zona cinzenta” (AUC-RFR = 0,651 versus AUC-“RFR Ajustada” = 0,749), mostrando também uma melhora em todos os índices diagnósticos quando foram estabelecidos limiares de corte otimizados (sensibilidade: 59% a 68%; especificidade: 62% a 75%; acurácia diagnóstica: 60% a 71%; razão de verossimilhança positiva: 1,51 a 2,34; razão de verossimilhança negativa: 0,64 a 0,37). Conclusões Ajustar a RFR integrando as informações fornecidas pelos preditores de discordância para obter a “RFR Ajustada” melhorou a capacidade diagnóstica em nossa população. Mais estudos são necessários para avaliar se os índices clínico-fisiológicos melhoram a capacidade diagnóstica da RFR ou de outros índices coronarianos.

Ischemic cardiovascular diseases have a high incidence and high mortality worldwide. Therapeutic advances in the last decades have reduced cardiovascular mortality, with antithrombotic therapy being the cornerstone of medical treatment. Yet, currently used antithrombotic agents carry an inherent risk of bleeding associated with adverse cardiovascular outcomes and mortality. Advances in understanding the pathophysiology of thrombus formation have led to the discovery of new targets and the development of new anticoagulants and antiplatelet agents aimed at preventing thrombus stabilization and growth while preserving hemostasis. In the following review, we will comment on the key limitation of the currently used antithrombotic regimes in ischemic heart disease and ischemic stroke and provide an in-depth and state-of-the-art overview of the emerging anticoagulant and antiplatelet agents in the pipeline with the potential to improve clinical outcomes.

IMÁGENES EN CARDIOLOGÍAVarón de 79 años al que se le realizó intervencionismo coronario percutáneo (ICP) sobre la arteria descendente anterior media.A pesar de un enfoque agresivo no se consiguió expansión adecuada de la placa calcificada, provocando disección coronaria, por lo que se implantó un stent farmacoactivo (3.0 x 22 mm), con evidencia de infraexpansión (IS) resistente a posdilataciones (Fig. 1A [flecha], B y C).Se mantuvo ingresado en espera del dispositivo de litotricia intracoronaria (LIC), ya que no estaba disponible en ese momento.Tres días después presentó trombosis subaguda del stent (Fig. 1D [asterisco]), requiriendo tromboaspiración y múltiples posdilataciones inefectivas (Fig. 1 E y F).A las 48 h, en un tercer procedimiento guiado por tomografía de coherencia óptica (TCO) se documentó IS sobre una placa calcificada circunferencial (Fig. 2 E-G).Mediante un balón de LIC (3.5 x 12 mm) (Fig. 2B) se consiguió la expansión del stent (Fig. 2 C y D).La TCO mostró fragmentación del calcio (Fig. 2H [asteriscos]), con adecuada expansión y aposición del stent (Fig. 2 F-H).No se documentó disfunción ventricular al alta.La ICP de lesiones calcificadas de novo es compleja, suele recomendarse la imagen intracoronaria para mejor evaluación morfológica y planificación terapéutica, disminuyendo así eventos adversos.La IS incrementa el riesgo de trombosis-reestenosis, de ahí la importancia de su tratamiento, con opciones limitadas.La aterectomía láser presenta problemas logísticos y pocos centros disponen de ella 1-3 .

Background Cutoff thresholds for the “resting full-cycle ratio” (RFR) oscillate in different series, suggesting that population characteristics may influence them. Likewise, predictors of discordance between the RFR and fractional flow reserve (FFR) have been documented. The RECOPA Study showed that diagnostic capacity is reduced in the RFR “grey zone”, requiring the performance of FFR to rule out or confirm ischemia. Objectives To determine predictors of discordance, integrate the information they provide in a clinical-physiological index, the “Adjusted RFR”, and compare its agreement with the FFR. Methods Using data from the RECOPA Study, predictors of discordance with respect to FFR were determined in the RFR “grey zone” (0.86 to 0.92) to construct an index (“Adjusted RFR”) that would weigh RFR together with predictors of discordance and evaluate its agreement with FFR. Results A total of 156 lesions were evaluated in 141 patients. Predictors of discordance were: chronic kidney disease, previous ischemic heart disease, lesions not involving the anterior descending artery, and acute coronary syndrome. Though limited, the “Adjusted RFR” improved the diagnostic capacity compared to the RFR in the “grey zone” (AUC-RFR = 0.651 versus AUC-“Adjusted RFR” = 0.749), also showing an improvement in all diagnostic indices when optimal cutoff thresholds were established (sensitivity: 59% to 68%; specificity: 62% to 75%; diagnostic accuracy: 60% to 71%; positive likelihood ratio: 1.51 to 2.34; negative likelihood ratio: 0.64 to 0.37). Conclusions Adjusting the RFR by integrating the information provided by predictors of discordance to obtain the “Adjusted RFR” improved the diagnostic capacity in our population. Further studies are required to evaluate whether clinical-physiological indices improve the diagnostic capacity of RFR or other coronary indices.