Monica Verdoia

Background: The ankle–brachial index (ABI) has been extensively applied for the diagnosis and risk stratification of vascular disease. However, it can also provide information about the interaction between ventricular function and peripheral vascular compliance, defined as ventricular–arterial coupling (VAC), which has been extensively shown to predict the outcome of patients with heart failure (HF). So far, no study has addressed the use of ABI for the assessment and prognostic stratification of patients with acute decompensated left ventricular systolic dysfunction, which was the aim of our study. Methods: Patients hospitalized with acute HF and reduced left ventricular ejection fraction (EF < 50%) were prospectively included. Echocardiogram and ABI were performed after the resolution of the acute phase, before discharge, and on optimized medical therapy. Abnormal ABI was defined as values ≤0.90 or >1.4. Arterial and ventricular elastance and E_es/E_a (iVAC) were estimated from echocardiographic parameters. The normal range for iVAC was considered [0.5–1.0]. Results: We included 80 patients, of whom 81.3% were males, with a mean age of 67.98 ± 11.3 years. Among them, 57.5% were hypertensive, 32.5% were active smokers, 41.3% were hypercholesterolemic, 20% were diabetic and 11.3% had previous myocardial infarction. The mean ejection fraction was 36.8 ± 9.22%, stroke volume was 46.3 ± 14.3 mL, arterial elastance was (E_a) 2.48 ± 0.87 mmHg/mL and VA coupling was 0.64 ± 0.25. HF etiology was ischemic in 58 (72.5%) of the patients, of whom 31 displayed multivessel disease. Impaired ABI values were observed in 21 (26.3%) of the patients (≤0.90 in 11 patients and >1.4 in 10 patients). A significant non-linear (logistic) relationship was observed between ABI values and VA coupling (β = 1.07, p = 0.007), which became linear for iVAC ≥ 0.5 (β = 0.92, p < 0.001). A similar trend was observed in patients with ischemic (β = 1.06, p < 0.001) and non-ischemic etiology (β = 1.02, p = 0.12). Echocardiographic follow-up was available in 63 patients, as three died before re-assessment. At a median follow-up of 281.5 days, EF recovery was observed in 44 patients, and EF improvement in 76.2%. VA coupling was the only independent predictor of EF recovery (OR [95%CI] = 0.15 [0.03–0.69], p = 0.015 for iVAC < 0.5). Conclusions: Ventricular–arterial coupling can represent a useful tool for the prognostic stratification of patients hospitalized for acute decompensated left ventricular systolic dysfunction, with lower values being associated with worse outcomes. The ankle–brachial index is a widely available parameter displaying a good association with VAC; therefore, it could offer a faster bedside estimation of ventricular–arterial interaction. Future larger-scale studies are certainly needed to confirm our results and implement the use of the ABI in acute HF.

Background: The most appropriate management of glucose-lowering therapies in patients exposed to iodinated contrast media (ICM) is still debated. The recent development of antidiabetic drugs that improve cardiovascular and renal outcomes leads to questions regarding their impact on the risk of contrast-associated acute kidney injury (CA-AKI). The present study aimed to assess the effect of different glucose-lowering therapies on the rate of CA-AKI among patients undergoing coronary angiography and/or angioplasty. Methods: Diabetic patients exposed to ICM for coronary procedures were retrospectively identified and divided according to the strategy for the management of diabetes mellitus. The use of a new antidiabetic drug (NAD) was defined for patients treated with SGLT2-I, DDP4-I or GLP-1 receptor agonists on admission. The primary endpoint was the occurrence of CA-AKI within 72 h after contrast medium exposure. Results: We included 462 patients with diabetes mellitus, 51.5% treated with insulin, 44.4% treated with metformin and 50.9% receiving NAD. Among them, 48 (10.4%) experienced CA-AKI. Patients experiencing acute renal injury were more often treated with calcium channel blockers (p = 0.04) and diuretics (p = 0.004), and less often P2Y12 inhibitors (p = 0.04), and presented lower levels of hemoglobin (p = 0.02). Patients receiving NADs displayed a significantly lower occurrence of CA-AKI (33.3% vs. 53.6%, p = 0.009), mainly for those treated with SGLT2-I. On the contrary, patients treated with sulfonylureas and meglitinides displayed a significant increase in the rate of CA-AKI (10.4% vs. 3.9%, p = 0.05). The results were confirmed via multivariable analysis, with NADs and diuretics emerging as the only independent predictors of CA-AKI (NAD: adjusted OR = 0.42 [0.21–0.81], p = 0.01; diuretics: adjusted OR = 2.22 [1.14–4.35], p = 0.02). The independent predictors of CA-AKI were the use of NADs (adjusted OR = 0.45 [0.24–0.86], p = 0.02) and diuretics (adjusted OR = 2.57 [1.33–4.97], p = 0.005). Conclusions: Among patients with diabetes mellitus undergoing coronary angiographic procedures, the use of diuretics, sulfonylureas and meglitinides is associated with an increased occurrence of CA-AKI, whereas the rate of events was significantly lower among users of new antidiabetic drugs and especially SGLT2-I.

Background. Despite technological innovations and improvements in stents and devices, sex-related discrepancies are still reported in the outcomes after ST-segment elevation myocardial infarction (STEMI), depending on biological and sex-specific pathophysiological differences, which have not been completely understood. The aim of the present study was to provide real-world data on the prognostic role of sex among patients with STEMI, enclosed into a recent up-to-date international registry. Methods. The ISACS-STEMI COVID-19 is a large-scale retrospective registry, including STEMI patients treated with mechanical reperfusion between 1 March and 30 June, 2019 and 2020. Patients, treated in 109 centers across Europe, Latin America, Southeast Asia, and North Africa, were grouped according to sex. Primary endpoint: In-hospital mortality; secondary endpoints: Time delay, 30-day mortality, and postprocedural Thrombolysis In Myocardial Infarction (TIMI) 3 flow. Results. We included 16,083 patients, 24.3% females (54.3% hospitalized in 2019, 45.7% in 2020). Women with STEMI were older, more often diabetic and hypertensive (p < 0.001), with a higher prevalence of hypercholesterolemia (p = 0.02), longer ischemia time (p = 0.01), ambulance referral (p = 0.03) and cardiogenic shock at presentation (p = 0.05), but less frequently smokers, with a previous cardiovascular event (p < 0.001) or anterior STEMI (p = 0.03) as compared to males. Preprocedural TIMI 0 flow, multivessel disease, need for thrombectomy (p < 0.001 and p = 0.001, respectively), use of Glycoprotein IIbIIIa inhibitors or cangrelor, radial access and implantation of drug-eluting stents (p < 0.001, p < 0.001 and p = 0.001, respectively) were also more common in men. Impaired postprocedural epicardial reperfusion (TIMI flow 0–2) was observed more frequently in females as compared to males (10% vs. 7.2%; adjusted OR [95% CI] = 1.30 [1.13–1.49], p = 0.01). In-hospital mortality was 5.8%, significantly higher among women (8.3% vs. 5%, p < 0.001, adjusted HR [95% CI] = 1.26 [1.06–1.5], p = 0.01). Similar data were observed for 30-day mortality (10.3% vs. 6.2%, p < 0.001, adjusted HR [95% CI] = 1.22 [1.06–1.38], p = 0.007). Conclusions. Among STEMI patients being treated with the most updated standard of care for primary percutaneous coronary intervention, female sex is still associated with higher complexity and impaired prognosis, displaying suboptimal epicardial reperfusion and increased in-hospital and 30-day mortality.

Article: Ankle-Brachial Index in patients with acute myocardial infarction - Minerva Cardiology and Angiology 2025 Jun 05 - Minerva Medica - Journals

Right ventricular myocardial infarction (RVI) is rarely an isolated event; rather, it generally complicates 10% to 50% of cases of acute inferior ST-segment elevation myocardial infarction (STEMI)., Proximal right coronary artery occlusion, impairing right ventricular (RV) branch flow, is most frequently the culprit vessel, although it depends on coronary tree anatomy. Previous studies underlined that RVI is often unrecognized, since RV ischemic dysfunction is generally transient, due to the different composition and higher resistance to hypoxia of the RV wall.

Background Chronic kidney disease (CKD) is an established risk factor for coronary artery disease (CAD), displaying a linear relationship with glomerular filtration rate (GFR). The prognostic role of the different formulas for the estimation of GFR is still debated. Objective To evaluate the impact of GFR calculation in the prediction of angiographically assessed CAD. Methods In consecutive patients undergoing coronary angiography, GFR was assessed at admission with the formulas Cockroft-Gault, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Modification of Diet in Renal Disease Study (MDRD). A 2-sided p-value < 0.05 was considered statistically significant. Results Among 1742 patients, 79.8% displayed CAD. No difference in the mean values of GFR was observed in patients with and without CAD with the three different GFR formulas. We observed a significant association between severe CAD and GFR, by Cockcroft Gault (26.6% vs 35% vs 36.9%, p<0.001), MDRD (27.1% vs 36.9% vs 39%, p<0.001), and CKD-EPI (28.9% vs 39.2% vs 22.2%, p=0.03). In multivariate analysis, only MDRD remained statistically significant (adjusted OR[95%CI]= 1.27[1.01-1.59], p=0.04). In ROC curve analysis, we identified the value of 12.4 ml/min/1.73m^2 as the best predicting value for severe CAD with the MDRD formula. Higher rates of calcifications, restenosis, and chronic occlusion were observed for the Cockroft-Gault and MDRD formulas. Conclusion The present study showed a significant association between the extent of angiographically-defined CAD and GFR, estimated by the MDRD, but not for the Cockroft-Gault and CKD-EPI formulas. MDRD values below 12.4 ml/min/1.73m^2 best predicted more severe CAD.

Background: 20 years ago, drug coated balloon (DCB) angioplasty was introduced into the interventionalist’s toolbox initially to treat in-stent restenosis. Since then, considerable clinical evidence was generated in patients with de novo lesions. Whether drug-eluting stents (DES) or DCB angioplasty are associated with better clinical outcomes for de novo lesion treatment is still a matter of debate. Objective: The objective of this post-hoc analysis was to assess the impact of vessel diameter in a real-world, unselected patient population treated with either paclitaxel-coated balloon (PCB) angioplasty or polymer-free sirolimus-eluting stent (PF-SES) implantation based on patient-level data. Methods: Four all-comers observational studies based on similar protocols were pooled and vessel-diameter matched to study the clinical outcomes following revascularization with either PCB or PF-SES. The primary endpoint in all studies was the accumulated clinically driven target lesion revascularization (TLR) rate at 9–12 months complemented with secondary endpoints such as the rates for major adverse cardiac events (MACE), myocardial infarction (MI) and cardiac death. Results: In the unmatched patient population, 3035 patients received either PCB (1614 patients) or PF-SES (1421 patients). The ‘unmatched’ TLR and MACE rates were low with 2.5% (PCB) vs. 2.0% (PF-SES, p = 0.319) and 4.5% (PCB) vs. 5.0% (PF-SES, p = 0.493), respectively. In the large vessel group (≥ 3 mm), 253 patient pairs were matched with reference diameters of 3.19 ± 0.27 mm (PCB) and 3.18 ± 0.27 mm (PF-SES, p = 0.787), and lesion lengths of 17.5 ± 9.8 mm (PCB) and 17.3 ± 7.1 mm (PF-SES, p = 0.839). The accumulated TLR rates were not significantly different (PCB 2.0% vs. PF-SES 2.8%, p = 0.786). Likewise, MACE rates in this large vessel subgroup were similar (5.6% vs. 6.4%, p = 0.723). In the small vessel group (< 3 mm), 420 patient pairs were matched with reference diameters of 2.49 ± 0.18 mm (PCB) and 2.49 ± 0.18 mm (PF-SES, p = .995), and lesion lengths of 16.0 ± 9.0 mm (PCB) and 16.7 ± 7.1 mm (PF-SES, p = 0.665). The accumulated TLR rates were not significantly different (PCB 1.9% vs. PF-SES 2.2%, p = 0.810). Likewise, MACE rates in the small vessel subgroup were similar (4.4% vs. 5.8%, p = 0.346). Individual clinical event rates were low and not significantly different between patients with small and large vessels. Conclusions: In this real-world experience PCB and PF-SES angioplasty were associated with low clinical event rates. There was no difference in clinical efficacy between PCB and PF-SES in large and small vessel PCI in terms of clinically driven TLR and MACE. Previously reported higher rates for clinical events after DCB angioplasty in large coronary vessels ≥ 3 mm could not be observed. Graphical