BACKGROUND Management of myocardial infarction (MI) in a patient with gastrointestinal (GI) bleeding presents a clinical challenge with competing ischemic and bleeding risks. Distinction of type 1 MI from type 2 MI is particularly important when planning antiplatelet therapy. CASE REPORT A 90-year-old man presented with MI, severe acute-on-chronic anemia, and active GI bleeding. The etiology of his MI was unclear in the setting of severe coronary artery disease, although type 2 MI was favored when his chest pain resolved with blood transfusions. After treatment of his bleeding angiodysplasias, dual antiplatelet therapy (DAPT) was attempted but discontinued due to recurrent bleeding. Ischemic heart disease was managed conservatively with antiplatelet monotherapy, which was subsequently withheld after shared decision making with the patient. At the 3-month follow-up, his symptoms were controlled with optimized antianginal therapy, although he required rehospitalization for recurrent GI bleeding that was treated endoscopically. CONCLUSIONS This case highlights the nuances of treating acute ischemic heart disease and the complexity of decision making regarding DAPT in patients with high GI bleeding risk. The risks and benefits of DAPT should be continually assessed in patients who exhibit bleeding or have a risk of bleeding onset. If antiplatelet monotherapy is considered due to GI bleeding, P2Y12 inhibitors such as clopidogrel are preferable. The outcome of the present case supports individualized treatment and may have broader implications for older patients with coexisting GI bleeding and coronary artery disease.

BACKGROUND:Spontaneous coronary artery dissection (SCAD) and atherosclerosis may appear similar on coronary imaging. CASE SUMMARY:A 62-year-old woman with fibromuscular dysplasia, dyslipidemia, and diabetes presented with chest discomfort. Coronary computed tomography angiography suggested left anterior descending artery (LAD) SCAD, and invasive coronary angiography (ICA) showed possible type 3 SCAD. Intracoronary imaging (ICI) was not performed, and she was treated medically. DISCUSSION:Recurrent chest pain prompted repeat imaging. Follow-up computed tomography angiography suggested persistent LAD SCAD. Repeat ICA revealed high-grade proximal LAD and first diagonal stenoses, confirmed as atherosclerosis on ICI. Percutaneous coronary intervention with 2 drug-eluting stents relieved symptoms. At 5 months, recurrent symptoms from severe LAD stenosis proximal to the stents were treated with drug-eluting stents, and ICA at 8 months showed in-stent restenosis, managed by balloon angioplasty. TAKE-HOME MESSAGES:ICI is essential when type 3 SCAD is suspected and angiography is indeterminate. Stent-edge disease and in-stent restenosis highlight important causes of recurrent symptoms after percutaneous coronary intervention.

Acute coronary syndromes (ACS) in women differ from those in men, with age-specific variations in etiology, presentation, and outcomes. Women face distinct risk factors, from autoimmune conditions to pregnancy-associated complications, to microvascular dysfunction. Missed and delayed diagnosis and treatment, and underrepresentation in clinical research compound these risks. This review outlines the evolving mechanisms of ACS in women and calls for tailored, evidence-based strategies to improve diagnosis, prevention, and care.

BACKGROUND:Protruding coronary ostial stents can be prohibitive for repeat percutaneous coronary interventions (PCI). METHODS:We retrospectively included 6 consecutive patients who underwent the EXPOSE (extraction of protruding ostial stents with En Snare) technique to previous ostial stents to facilitate subsequent PCI. The indication in all cases was revascularization of the target vessel with failed guide intubation of the stented lumen. The protruding stents had been implanted 5 days to 9 years before extraction. The procedure included a 7-F × 45-cm transfemoral sheath, 7-F guide catheter, and 12- to 20-mm En Snare device. RESULTS:Procedural success was achieved in all patients, and complete stent extraction was achieved in 1 patient. All patients underwent successful PCI; 1 case of acute vessel closure immediately postextraction was rescued promptly with PCI. CONCLUSIONS:Snare extraction of previously implanted, protruding ostial stents is feasible to enable PCI after failure of guide intubation.

Background The burden and pathophysiologic mechanisms of myocardial infarction (MI) in younger patients remain understudied. Prior studies have been limited by selected cohorts and lack of awareness of nonatherothrombotic causes. Objectives We sought to determine the incidence and outcomes of MI according to a unique pathophysiologic mechanism in a large community cohort aged ≤65 years, and to evaluate sex-differences in etiology Methods We identified all residents of Olmsted County, Minnesota, USA, age ≤65 years who experienced an event associated with a cardiac troponin T >99th percentile of upper reference range (≥0.01 ng/mL) from January 2003 to March 2018. Records and imaging were individually scrutinized. Patients classified as MI were assigned to 1 of 6 adjudicated pathophysiologic mechanisms: atherothrombosis, spontaneous coronary artery dissection (SCAD), embolism, vasospasm, myocardial infarction with nonobstructed coronary arteries not meeting another category (MINOCA-U), and supply/demand mismatch secondary myocardial infarction. We determined incidence and long-term all-cause and cardiovascular mortality for each group. Results There were 4,116 myocardial injury events in 2,780 patients (36% women) over 15 years. Excluding periprocedural MI, 1,474 events were classified as index MI, of which 68% were caused by atherothrombosis. The population incidence of MI was much lower in women, particularly in MI caused by atherothrombosis (48 vs 137 per 100,000 person years and 23 vs 105 per 100,000 person-years). Incidence of SCAD was much higher in women (3.2 vs 0.9 per 100,000 person-years) with 55% of cases misclassified as MINOCA or atherothrombosis at index presentation. Women with atherothrombosis were similar in age to men (55 ± 8 years vs 54 ± 8 years), with similar disease extent at angiography but greater burden of risk factors. Proportionately, nonatherothrombotic causes comprised the majority of MI in women (atherothrombosis 47% vs 75%, secondary myocardial infarction [SSDM] 34% vs 19%, SCAD 11% vs 0.7%, embolism 2% vs 2%, vasospasm 3% vs 1%, MINOCA-U 3% vs 2%). The 5-year all-cause mortality was highest after SSDM (SSDM 33%, atherothrombosis 8%, embolism 8%, SCAD 0%) with low cardiovascular mortality in all groups. Conclusions This community-based study demonstrates nonatherothrombotic causes comprise an important burden of acute MI in persons age ≤65 years, particularly women. These cause-specific findings have implications for individualized management and risk stratification and provide epidemiologic benchmarking for future studies.

Objective To test the feasibility and safety of genotype guidance in the selection of P2Y12 monotherapy within 1 week of percutaneous coronary interventions (PCIs) among patients with high bleeding risk (HBR). Patient and Methods The study was a single-center, open-label, pilot trial. Patients (n=100) with HBR (as defined by an academic research consortium) after successful PCI received dual antiplatelet therapy with clopidogrel and aspirin. Following availability of cytochrome P450 2C19 (CYP2C19) genotype results (mean, 2.9 days), aspirin was discontinued. Normal, rapid, or ultrarapid CYP2C19 metabolizers continued clopidogrel monotherapy for 90 days whereas loss-of-function allele carriers switched to prasugrel or ticagrelor monotherapy. The primary safety endpoints were a composite of post-dismissal cardiac death/spontaneous myocardial infarction less than 30 days or stent thrombosis <90 days of discharge. The subjects also underwent post-dismissal assessment for BARC (Bleeding Academic Research Consortium) type 3 or 5 bleeding, all-cause death, any MI, and/or repeat revascularization up to 90 days. Results There were 98 patients with complete data (median age, 76.5 years, 36% women; 49% acute coronary syndrome). Sixty-nine (70.4%) were normal, rapid, or ultrarapid metabolizers and continued clopidogrel monotherapy, and 29 (29.6%) were intermediate CYP2C19 metabolizers and received monotherapy with prasugrel (n=21) or ticagrelor (n=8). The mean duration of dual antiplatelet therapy was 5.1 days. During 90-day follow-up, no patient died, there was one possible stent thrombosis, and three patients on clopidogrel had Bleeding Academic Research Consortium type 3 bleeding events. Conclusion Genotype-guided P2Y12 inhibitor monotherapy within a week of PCI is feasible and likely safe in patients with HBR (CHAMP [Clopidogrel With High Bleeding Risk and Adverse Events With Monotherapy in Patients Undergoing Percutaneous Coronary Interventions]; NCT05223335).

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome that primarily affects young women. Although intravascular imaging, particularly optical coherence tomography (OCT), provides high-resolution visualization of intramural hematoma and dissection planes, its routine use in SCAD is not recommended. This is mainly due to the risk of false lumen propagation from high-pressure injection of a flushing medium, typically viscous contrast medium, to exclude intraluminal blood and enable OCT luminal visualization. We present a case series of 3 patients with SCAD who underwent flush-free OCT image acquisition, allowing for the identification of intramural hematoma without the need for high-pressure contrast injection. In all cases, findings were confirmed through conventional contrast OCT image acquisition. Our novel approach minimizes procedural risks associated with high-pressure contrast injection while preserving the diagnostic benefits of OCT. These findings suggest that the flush-free OCT technique is feasible and can be a safer initial intravascular modality in patients with suspected SCAD.

Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of acute coronary syndrome that primarily affects young women. Although intravascular imaging, particularly optical coherence tomography (OCT), provides high-resolution visualization of intramural hematoma and dissection planes, its routine use in SCAD is not recommended. This is mainly due to the risk of false lumen propagation from high-pressure injection of a flushing medium, typically viscous contrast medium, to exclude intraluminal blood and enable OCT luminal visualization. We present a case series of 3 patients with SCAD who underwent flush-free OCT image acquisition, allowing for the identification of intramural hematoma without the need for high-pressure contrast injection. In all cases, findings were confirmed through conventional contrast OCT image acquisition. Our novel approach minimizes procedural risks associated with high-pressure contrast injection while preserving the diagnostic benefits of OCT. These findings suggest that the flush-free OCT technique is feasible and can be a safer initial intravascular modality in patients with suspected SCAD.

CYP2C19 loss of function (LOF) carriers undergoing percutaneous coronary intervention (PCI) have an increased risk of ischemic events when treated with clopidogrel. PCI patients in TAILOR-PCI were randomized to clopidogrel or genotype-guided (GG) therapy in which LOF carriers received ticagrelor and non-carriers clopidogrel. Direct medical costs associated with a GG approach have not been described before. TAILOR-PCI participants for whom direct medical costs were available for the duration from the date of PCI to one-year post PCI were included. Primary cost estimates were obtained from the Mayo Clinic Cost Data Warehouse. There were no differences in direct medical costs between the GG and clopidogrel groups (mean $20,682 versus $19,747, p = 0.11) however total costs were greater in the GG group (mean $21,245 versus $19,891, p = 0.02) which was primarily driven by ticagrelor costs. In conclusion the increased expense of a GG strategy post PCI as compared to clopidogrel for all is primarily driven by the cost of ticagrelor.

Objectives. Early coronary angiography (CAG) has been recommended in selected patients following out -of -hospitalcardiac -arrest (OHCA). We aimed to identify clinical features associated with acute coronary occlusion (ACO) and evaluate the associations between ACO, successful percutaneous coronary intervention (PCI) and outcomes in this population. Methods. We included comatose OHCA patients treated with targeted temperature management (TTM) between December 2005 and September 2016 who underwent early CAG within 24 hours. The co -primary outcomes were all -cause 30 -day mortality and good neurological outcome (modified Rankin Score [mRS] <= 2) at hospital discharge. Results. Among 155 patients (93% shockable arrest rhythm, 55% with ST elevation), 133 (86%) had coronary artery stenosis >= 50% and 65 (42%) had ACO. ST elevation (sensitivity 74%, specificity 59%, OR 4.0, 95% CI 2.0-8.1) and elevated first troponin (sensitivity 88%, specificity 26%, OR 2.5, 95% CI 1.1-6.1) had limited sensitivity and specificity for ACO. Unadjusted 30 -day mortality did not differ significantly by coronary disease severity or ACO. Successful PCI was associated with a lower risk of 30 -day mortality (adjusted HR 0.5, 95% CI 0.2-0.9, P=.03), especially among patients with ACO (adjusted HR 0.4, 95% CI 0.1-0.9, P=0.03). After adjustment, ACO and PCI were not associated with the probability of good neurological outcome. Conclusions. In this select cohort of resuscitated OHCA patients undergoing CAG, unstable coronary disease is highly prevalent and successful PCI was associated with a higher probability of 30 -day survival, especially among those with ACO. Neither ACO nor successful PCI were independently associated with good neurological outcome.

Limited data exist regarding outcomes after coronary angiography (CAG) and percutaneous coronary intervention (PCI) in patients aged ≥90 years admitted to the cardiac intensive care unit (CICU) with acute coronary syndrome (ACS). We studied sequential CICU patients ≥90 years admitted with ACS from 2007 to 2018. Three therapeutic approaches were defined: (1) No CAG; (2) CAG without PCI (CAG/No PCI); and (3) CAG with PCI (CAG/PCI). In-hospital mortality was evaluated using multivariable logistic regression. All-cause 1-year mortality was evaluated using Kaplan-Meier and multivariable Cox proportional hazards analysis. The study included 239 patients with a median age of 92 (range 90 to 100) years (57% females; 45% ST-elevation myocardial infarction; 8% cardiac arrest; 16% shock). The No CAG group had higher Day 1 Sequential Organ Failure Assessment scores, more co-morbidities, worse kidney function, and fewer ST-elevation myocardial infarctions. In-hospital mortality was 20.8% overall and did not differ between the No CAG (n = 103; 21.4%), CAG/No PCI (n = 47; 21.3%), and CAG/PCI (n = 90; 20.0%) groups, before or after adjustment. Overall 1-year mortality was 52.5% and did not differ between groups before or after adjustment. Median survival was 6.9 months overall and 41.2% of hospital survivors died within 1 year of CICU admission. CICU patients aged ≥90 years with ACS have a substantial burden of illness with high in-hospital and 1-year mortality that was not lower in those who underwent CAG or PCI. These results suggest that careful patient selection for invasive coronary procedures is essential in this vulnerable population.

Purpose: Spatio-temporal variability in clinical fluoroscopy and cine angiography images combined with nonlinear image processing prevents the application of traditional image quality measurements in the cardiac catheterization laboratory. We aimed to develop and validate methods to measure human observer impressions of the image quality. Approach: Multi-frame images of the thorax of a euthanized pig were acquired to provide an anatomical background. The detector dose was varied from 6 to 200 nGy (increments 2x), and 0.6 and 1.0 mm focal spots were used. Two coronary stents with/without 0.5 mm separation and a synthetic right coronary artery (RCA) with hemispherical defects were embedded into the background images as test objects. The quantitative observer (n=17) performance was measured using a two-alternating forced-choice test of whether stents were separated and by a count of visible right coronary artery defects. Qualitative impressions of noise, spatial resolution, and overall image quality were measured using a visual analog scale (VAS). A paired t-test and multinomial logistic regression model were used to identify statistically significant factors affecting the observer's impression image quality. Results: The proportion of correct detection of stent separation and the number of reported right coronary artery defects changed significantly with detector dose increment in the 6 to 100 nGy (p<0.05). Although a trend favored the 0.6 versus 1.0 mm focal spot for these quantitative assessments, this was insignificant. Visual analog scale measurements changed significantly with detector dose increments in the range of 24 to 100 nGy and focal spot size (p<0.05). The application of multinomial logistic regression analysis to observer VAS scores demonstrated sensitivity matching of the paired t-test applied to quantitative observer performance measurements. Conclusions: Both quantitative and qualitative measurements of observer impression of the image quality were sensitive to image quality changes associated with changing the detector dose and focal spot size. These findings encourage future work that uses qualitative image quality measurements to assess clinical fluoroscopy and angiography image quality.

BackgroundAminophylline, an adenosine antagonist, can be used to prevent adenosine-mediated bradyarrhythmias.MethodsRetrospective, observational, descriptive analysis of patients undergoing rotational atherectomy with intravenous (IV) aminophylline pretreatment during a 10-year period (2010-2020). The primary composite outcome was the occurrence of a documented bradyarrhythmia requiring pharmacologic intervention and/or temporary pacemaker (TPM) implantation.ResultsA total of 296 patients received IV aminophylline pretreatment. The primary composite outcome occurred in 1.7% (n = 5) of patients. None of the patients required rescue TPM. Bradyarrhythmias were documented in 2.4% (n = 7) of patients. Pharmacologic interventions, typically with IV atropine, were used in 15% (n = 43) of patients. Per-vessel analyses demonstrated that patients undergoing atherectomy to the circumflex and right coronary arteries were more likely than those undergoing atherectomy to other vessels to have bradyarrhythmias requiring pharmacologic intervention (3.4% vs 0%, P = .01).ConclusionsIn this 10-year single-center experience using IV aminophylline pretreatment to prevent major bradyarrhythmias in patients undergoing coronary atherectomy, none of the patients required rescue TPM implantation. These data demonstrate that coronary atherectomy can be performed safely without prophylactic TPM, with aminophylline pretreatment and selective use of atropine representing an effective noninvasive approach.

BACKGROUND:Genetic-guided P2Y12 inhibitor selection has been proposed to reduce ischemic events by identifying CYP2C19 loss-of-function (LOF) carriers at increased risk with clopidogrel treatment after percutaneous coronary intervention (PCI). A prespecified analysis of TAILOR-PCI (Tailored Antiplatelet Therapy Following PCI) evaluated the effect of genetic-guided P2Y12 inhibitor therapy on cumulative ischemic and bleeding events. OBJECTIVES:Here, the authors detail a prespecified analysis of cumulative endpoints. The primary endpoint was cumulative incidence rate of ischemic events at 12 months. Cumulative incidence of major and minor bleeding was a secondary endpoint. Cox proportional hazards models as adapted by Wei, Lin, and Weissfeld were used to estimate the effect of this strategy on all observed events. METHODS:The TAILOR-PCI trial was a prospective trial including 5,302 post-PCI patients with acute and stable coronary artery disease (CAD) who were randomized to genetic-guided P2Y12 inhibitor or conventional clopidogrel therapy. In the genetic-guided group, LOF carriers were prescribed ticagrelor, whereas noncarriers received clopidogrel. TAILOR-PCI's primary analysis was time to first event in LOF carriers. RESULTS:Among 5,276 patients (median age 62 years; 25% women; 82% acute CAD; 18% stable CAD), 1,849 were LOF carriers (903 genetic-guided; 946 conventional therapy). The cumulative primary endpoint was significantly reduced in the genetic-guided group compared with the conventional therapy (HR: 0.61; 95% CI: 0.41-0.89; P = 0.011) with no significant difference in cumulative incidence of major or minor bleeding (HR: 1.36; 95% CI: 0.67-2.76; P = 0.39). CONCLUSIONS:Among CYP2C19 LOF carriers undergoing PCI, a genetic-guided strategy resulted in a statistically significant reduction in cumulative ischemic events without a significant difference in bleeding. (Tailored Antiplatelet Therapy Following PCI [TAILOR-PCI]; NCT01742117).