Binita Shah

BACKGROUND: Clinical practice guidelines recommend the use of clopidogrel among patients with chronic coronary syndrome undergoing percutaneous coronary intervention. The frequency of high-potency P2Y12 inhibitors, such as ticagrelor or prasugrel, in this setting is not well known. METHODS: Using the National Cardiovascular Data Registry CathPCI registry, we analyzed patients with chronic coronary syndrome undergoing percutaneous coronary intervention from April 2018 to June 2024, excluding those discharged on oral anticoagulants. Temporal trends in high-potency P2Y12 inhibitor prescription were examined. A mixed-effects multivariable logistic regression model with a random intercept for hospital was used to identify patient-, procedural-, and institutional-level factors associated with high-potency P2Y12 inhibitor prescription while accounting for within-hospital clustering. Between-hospital variation was quantified using the median odds ratio. RESULTS: Among 783 977 patients across 1815 hospitals, 35% were prescribed a high-potency P2Y12 inhibitor at discharge. The use of high-potency P2Y12 inhibitors declined from 35% in 2018 to 31% in 2024 ( P -trend=0.019), driven by a reduction in ticagrelor (from 29% to 23%, P -trend P -trend=0.10). Male sex, prior myocardial infarction, and markers of procedural complexity (high-complexity/type C lesions, left main coronary artery, proximal left anterior descending artery, or use of mechanical circulatory support) were associated with higher odds of high-potency P2Y12 inhibitor prescription. In contrast, older age (≥75 years), prior stroke/transient ischemic attack, prior coronary artery bypass graft, severe renal dysfunction, and chronic total occlusion were associated with lower odds. University hospitals had lower odds of prescribing high-potency P2Y12 inhibitors, with considerable variability in prescription patterns among institutions (median odds ratio, 2.59). CONCLUSIONS: Nearly one-third of chronic coronary syndrome patients undergoing percutaneous coronary intervention were discharged on high-potency P2Y12 inhibitors, with decreasing trends over time. Practice patterns reflected perceived ischemic versus bleeding risk and significant institutional variation, underscoring opportunities for quality improvement and guideline alignment.

BACKGROUND: Randomized trials comparing radial and femoral access report access site crossover rates of 3% to 9% for radial access and 1% to 3% for femoral access. However, contemporary real-world crossover rates are not well characterized. The aim was to evaluate contemporary trends and predictors of vascular access site crossover during percutaneous coronary intervention (PCI). METHODS: We analyzed index PCI procedures recorded in the National Cardiovascular Data Registry CathPCI (Catheterization and Percutaneous Coronary Intervention) Registry from 2018 to 2024. Access site crossover was identified using documented access data, with radial-to-femoral crossover inferred when the final successful access site was femoral. Temporal trends and clinical predictors of crossover were examined. Operator experience was assessed using cumulative total and radial PCI volumes from 2011 to 2024 as captured in CathPCI Registry versions 4 and 5. RESULTS: Among 3 861 790 index PCIs, 192 902 (5.0%) involved access site crossover, with a modest increase over time. Radial-to-femoral crossover accounted for 81.2% of crossover events. Factors independently associated with crossover included older age, female sex, higher body mass index, and peripheral vascular disease. Operators with the lowest total PCI volume and the lowest radial PCI volume experienced the highest crossover rates. Notably, operators with low radial PCI volume demonstrated a substantial decline in radial-to-femoral crossover over the study period. CONCLUSIONS: In contemporary clinical practice, access site crossover rates are consistent with those reported in randomized trials. Although crossover occurs more frequently among lower-volume operators, rates decline with increasing operator experience, supporting the presence of a radial access learning curve and improvement in procedural performance over time.

BACKGROUND: Myocardial infarction with nonobstructive coronary arteries (MINOCA) accounts for 6% to 15% of acute coronary syndromes and disproportionately affects women. Although coronary culprit lesions are present in 45% of patients with MINOCA, multivessel optical coherence tomography (OCT) is infrequently performed. We evaluated whether interventional cardiologists can identify coronary arteries with culprit lesions using invasive coronary angiography in women with MINOCA. METHODS: Women with MINOCA who had a coronary culprit lesion identified by multivessel OCT were included. A core laboratory confirmed and localized OCT-defined culprit lesions using angiographic coregistration. Two interventional cardiologists blinded to OCT findings independently reviewed invasive coronary angiography, before and after review of ECG and transthoracic echocardiography, to identify the culprit artery. RESULTS: Among 64 women with MINOCA (median age 64 years; 97% non-ST-segment elevation MI), OCT-defined culprit lesions were most frequently located in the left anterior descending (50.8%) or right coronary (35.4%) arteries. At least 1 interventional cardiologist identified the culprit artery in 54.7% of patients (95% CI, 42.6%–66.3%); both identified it in 28.1% (95% CI, 18.6%–40.1%). The addition of ECG and transthoracic echocardiography data did not improve accuracy ( P =0.40 and P =0.97). Culprit arteries were identified by at least 1 cardiologist in 87.5% of plaque rupture cases. Only 11% of circumflex lesions were identified. CONCLUSIONS: Interventional cardiologists could not reliably identify culprit arteries using coronary angiography in women with MINOCA, even after ECG and transthoracic echocardiography review. Our findings suggest that invasive angiography alone should not guide vessel selection for intracoronary imaging and support multivessel imaging when evaluating MINOCA. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02905357.

BACKGROUND: Racial and ethnic disparities exist in postacute myocardial infarction (AMI) care. High-potency P2Y12 inhibitors use among patients with AMI who undergo percutaneous coronary intervention (PCI) carries a class I indication in the guidelines. This study aims to examine racial and ethnic differences in high-potency P2Y12 inhibitor prescription on discharge among patients with AMI undergoing PCI. METHODS: Using data from the NCDR Cath PCI registry, we identified consecutive patients with AMI who underwent PCI from April 2018 to June 2023. Likelihood of high-potency P2Y12 inhibitor prescription on discharge was assessed using logistic regression models adjusted for social deprivation index and other patient- and procedure-related variables. RESULTS: Among 1 662 387 patients hospitalized with AMI and who underwent PCI, 165 579 (9.9%) were Black, 58 595 (3.5%) were Asian, and 1 302 576 (78.3%) were of White race, while 135 637 (8.1%) were of Hispanic ethnicity. At discharge 876 078 (52.7%) were prescribed a high-potency P2Y12 inhibitor. Compared with White patients, Black patients were less likely (adjusted odds ratio, 0.93 [95% CI, 0.92–0.94]), while Asians were more likely (adjusted odds ratio, 1.08 [1.07–1.10]) to have a high-potency P2Y12 inhibitor discharge prescription. Compared with non-Hispanics, Hispanic patients were less likely to have a high-potency P2Y12 inhibitor discharge prescription (adjusted odds ratio, 0.95 [95% CI, 0.93–0.96). CONCLUSIONS: In a contemporary national registry of hospitalized patients with AMI who underwent PCI, Black and Hispanic patients were less likely to be discharged on a high-potency P2Y12 inhibitor irrespective of socioeconomic status. These findings highlight an opportunity to achieve equity in guideline-directed AMI pharmacotherapies to improve outcomes.

BACKGROUND: Myeloproliferative neoplasms (MPN) are a group of chronic leukemias that are associated with pulmonary hypertension (PH), which has been associated with increased risk adverse outcomes. The echocardiographic characterization of PH in MPN has not been reported, and the prognostic significance of PH among patients with MPN remains unclear. METHODS: This was a multicenter, retrospective cohort study of patients with MPN with ≥1 echocardiogram from 2010 to 2023. The echocardiographic probability of PH was determined according to the guidelines. The outcomes were hematologic progression and major adverse cardiovascular events. Exploratory analysis included outcomes among patients with right heart catheterization after the first echocardiogram, with PH defined as mean pulmonary artery pressure of >20 mm Hg. Multivariable Fine-Gray competing risk regression was used to estimate the subhazard ratio of hematologic progression and major adverse cardiovascular events. RESULTS: Five hundred fifty-five patients were included and 237 (42.7%) had an intermediate or high probability of PH on echocardiography. Over a median follow-up period of 51.2 months (interquartile range, 29.5–79.8), it was observed that echocardiographic probability of PH was associated with increased risk of hematologic progression (adjusted subhazard ratio, 1.92 [95% CI, 1.09–3.39]) and major adverse cardiovascular events (adjusted subhazard ratio, 1.66 [95% CI, 1.04–2.66]) but not all-cause death (adjusted hazard ratio, 1.51 [95% CI, 0.98–2.32]). Among patients with right heart catheterization (n=61), PH was present in 51 (83.6%) patients and was associated with a higher risk of hematologic progression (29.4% versus 0%; P =0.048). CONCLUSIONS: Among patients with MPN, echocardiographic probability of PH was associated with an increased risk of hematologic progression. Prospective studies are needed to assess the optimal use of echocardiography on MPN-specific prognostication.

BACKGROUND: Myocardial injury detected after percutaneous coronary intervention (PCI) is associated with increased mortality. Predictors of post-PCI myocardial injury are not well established. The long-term prognostic relevance of post-PCI myocardial injury remains uncertain. METHODS: Consecutive adults aged ≥18 years with stable ischemic heart disease who underwent elective PCI at NYU Langone Health between 2011 and 2020 were included in a retrospective, observational study. Patients with acute myocardial infarction or creatinine kinase myocardial band (CKMB) or troponin concentrations >99% of the upper reference limit before PCI were excluded. All patients had routine measurement of CKMB concentrations at 1 and 3 hours post-PCI. Post-PCI myocardial injury was defined as a peak CKMB concentration >99% upper reference limit. Linear regression models were used to identify clinical factors associated with post-PCI myocardial injury. Cox proportional hazard models were generated to evaluate relationships between post-PCI myocardial injury and all-cause mortality at long-term follow-up. RESULTS: Among 10 807 patients undergoing elective PCI, the median age was 67 years (interquartile range, 15.6), and 24.9% were of female sex. Post-PCI myocardial injury occurred in 1813 (16.8%) patients. Myocardial injury was less common among female than male patients (14.1% versus 17.7%, P P <0.001). After adjustment for demographics and clinical covariates, post-PCI myocardial injury was associated with an excess hazard for long-term mortality (hazard ratio, 1.46 [95% CI, 1.20–1.78]). CONCLUSIONS: Myocardial injury defined by elevated CKMB early after PCI is common and associated with all-cause, long-term mortality. More complex coronary anatomy is predictive of post-PCI myocardial injury.