Nathaniel R. Smilowitz

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.

Introduction: Mechanisms underlying coronary microvascular dysfunction (CMD), a known cause of ischemia with nonobstructive coronary arteries (INOCA), are not well understood. Methods: In a prospective cohort study, we investigated the whole-blood transcriptome of 28 female patients with INOCA who underwent clinically indicated invasive coronary angiography to identify pathways relevant to the pathophysiology of CMD. Results: In this study, four protein-coding genes related to cell signaling and metabolism were differentially expressed and 47 transcriptomic pathways related to cell signaling, metabolism, inflammation, and sex hormone signaling were primarily upregulated with greater CMD. Conclusion: Our findings support the hypothesis that inflammation leads to maladaptive microvascular remodeling and fibrosis, contributing to the pathogenesis of CMD.

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.

Patients with peripheral artery disease undergoing lower extremity revascularization remain at high risk for cardiovascular events despite intervention. This retrospective analysis of 289 participants examined the relationship between pre-procedural bleeding history and post-procedural outcomes using a modified International Society on Thrombosis and Haemostasis bleeding assessment tool. After median 18-month follow-up, participants with significant bleeding history experienced lower risk of major adverse cardiovascular events (18.4% versus 30.6%, p = 0.034) and mortality (13.6% versus 24.2%, p = 0.047). An inverse exposure-outcome relationship was observed between bleeding severity and outcomes. Bleeding history may identify patients at lower risk for thrombotic complications.

BACKGROUND: Although guidelines recommend invasive management for non–ST-segment–elevation myocardial infarction (NSTEMI), there is considerable variability in the application of these recommendations across different hospitals, reflecting a lack of standardized clinical pathways and highlighting ongoing uncertainty in real-world practice. We sought to describe site-level variability in the use and timing of invasive angiography for NSTEMI and its association with in-hospital outcomes. METHODS: Using National Cardiovascular Data Registry Chest Pain-MI registry data (2019–2024), the rates and timing of invasive coronary angiography, if any, were characterized among patients with NSTEMI. Hierarchical logistic regression models were created to describe hospital-level variability in management using median odds ratios, adjusted for patient and site characteristics. Inverse probability weighting was used to estimate the association between treatment strategy and in-hospital outcomes. RESULTS: We included 287 275 patients with type-1 NSTEMI from 541 hospitals (age, 67.6±13.3 years; 36.4% women). Invasive coronary angiography was performed in 87.1%, of whom 56.9% within 24 hours. Among those treated invasively, 66.1% received percutaneous coronary intervention. Older patients with more comorbidities were paradoxically more likely to receive conservative management or delayed intervention (>24 hours). Site-level variability for invasive strategy (versus conservative) was large (median odds ratio, 2.85 (95% CI, 2.64–3.10]), as was early invasive treatment (median odds ratio, 1.67 [95% CI, 1.62–1.74]), particularly on weekends/holidays (median odds ratio, 1.89 [95% CI, 1.81–1.98]). The use of any invasive strategy was associated with lower in-hospital mortality versus conservative management (weighted odds ratio, 0.36 [95% CI, 0.31–0.42]). This finding was consistent across all baseline risk categories ( P _interaction <0.001). CONCLUSIONS: Patients with type-1 NSTEMI and higher-risk clinical profiles were not consistently prioritized to undergo early invasive management with substantial variability across hospitals. Invasive management was associated with lower in-hospital mortality compared with conservative treatment. Future randomized studies in the modern percutaneous coronary intervention era are needed to confirm our findings and identify which patients benefit most and when intervention should occur.