Christian Hamm

Suspected myocardial infarction in patients with acute chest pain at rest is one of the most common diagnostic categories leading to emergency hospital admission and emergency department overcrowding worldwide. Efforts are being made to improve the efficiency of currently used triage and diagnostic work-up strategies. Despite major advances in recent years with the use of high-sensitivity cardiac troponin, challenges still exist regarding how to accurately and rapidly rule out or rule in myocardial infarction, as current strategies are relatively slow due to the need for serial troponin measurements. The 2023 European Society of Cardiology (ESC) guidelines recommend a 0 h/1 h or a 0 h/2 h high-sensitivity troponin diagnostic algorithm, instead of the previously suggested 0 h/3 h diagnostic protocol, to reduce the time required to discharge patients with suspected acute coronary syndrome/myocardial infarction. The ESC endorsed algorithms are not without difficulty, and alternative ways of improving triaging have been proposed, particularly a dual biomarker rule-out strategy involving the combined measurement of copeptin and troponin. Supporters of the dual biomarker strategy argue that a timely optimized algorithm can potentially allow the safe rule-out of myocardial infarction earlier than currently used strategies. In the present Great Debate article, two expert teams discuss the ‘pros’ and ‘cons’ of implementing single vs dual biomarker strategies for the rule-in and rule-out of myocardial infarction, under the moot topic ‘A dual biomarker strategy improves the triage of patients with suspected acute coronary syndrome’. They address in detail many of the controversial issues currently affecting everyday clinical practice and provide insightful comments on how to best triage patients presenting with suspected acute myocardial infarction.

Aims: The aim of the present study was to investigate the inhibition of classically activated macrophages in myocardial infarction (MI) under the influence of the chemokine (C‐C motif) receptor 2 (CCR2) antagonist propagermanium (PPG). Methods and Results: Mice (C57BL/6; n = 121) were subjected to occlusion of the left anterior descending artery and were randomized to the following groups: (a) MI with daily oral administration of 0.9% sodium chloride (“MI”), (b) MI with oral administration of 8 mg/kg PPG (“MI + PPG”), and (c) sham‐operated mice served as control. Mice were euthanized 2, 5, 10, or 21 days after MI for isolation of total RNA, protein, and immunofluorescence measurements. Flow cytometry was performed to investigate peripheral blood leucocytes. Scar size and cardiac function were determined by MRI on Day 7 after surgery and by trichrome staining on Day 21. PPG administration led to a significantly improved ejection fraction (MI + PPG: 38.5 % ± 3.4 % vs. MI: 23.8 % ± 3.0 % ; p < 0.05) after MI. MRI also revealed improved wall thickness (34.7 % ± 3.2 % vs. 21.8 % ± 2.9 % ; p < 0.05) associated with a diminished akinetic area (13.8 % ± 4.0 % vs. 37.3 % ± 5.6 % ; p < 0.01). Trichrome staining confirmed less collagen scar formation in the PPG‐treated group (12.7 % ± 1.4 % vs. 21.9 % ± 3.9 % ; p < 0.05). Flow cytometry showed fewer peripheral blood monocytes in MI + PPG than in MI 2 days after treatment (4.0 % ± 0.7 % vs. 12.7 % ± 1.2 % of total leucocytes; p < 0.05). Immunostaining and western blotting using activation type‐specific markers CCR2 and MRC1 demonstrated that the number of alternatively activated macrophages within the infarct zone increased, whereas the overall number was reduced after PPG treatment. PPG led to increased expression of VEGF‐ α and VEGF‐ β in THP‐1 cells in vitro and increased capillary density in vivo 2 days after MI (MI‐PPG: 1071 ± 81/mm ² vs. MI: 648 ± 79/mm ² ( p < 0.05)). Conclusion: Our results suggest that altering the activation type and distribution of invading macrophages in favor of alternative activation improves cardiac remodeling and function following MI.

In patients with ST-segment elevation myocardial infarction (STEMI), prehospital tirofiban significantly improved myocardial reperfusion. However, its impact on the rate of disrupted myocardial infarction (MI), particularly in the context of high-sensitivity cardiac troponin (hs-cTn) assays, is still unclear. The On-TIME 2 (Ongoing Tirofiban In Myocardial infarction Evaluation 2) trial randomly assigned STEMI patients to prehospital tirofiban or placebo before transportation to a percutaneous coronary intervention (PCI) centre. In this post hoc analysis, we evaluated STEMI patients that underwent primary PCI and had measured hs-cTn levels. Troponin T levels were collected at 18–24 and 72–96 h after PCI. Disrupted MI was defined as peak hs-cTn T levels ≤ 10 times the upper limit of normal (≤140 ng/L). Out of 786 STEMI patients, 47 (6%) had a disrupted MI. Disrupted MI occurred in 31 of 386 patients (8.0%) in the tirofiban arm and in 16 of 400 patients (4.0%) in the placebo arm (P = 0.026). After multivariate adjustment, prehospital tirofiban remained independently associated with disrupted MI (odds ratio 2.03; 95% confidence interval 1.10–3.87; P = 0.027). None of the patients with disrupted MI died during the 1-year follow-up, compared with a mortality rate of 2.6% among those without disrupted MI. Among STEMI patients undergoing primary PCI, the use of prehospital tirofiban was independently associated with a higher rate of disrupted MI. These results, highlighting a potential benefit, underscore the need for future research focusing on innovative pre-treatment approaches that may increase the rate of disrupted MI.

Heart failure results in abnormal loading conditions in the heart and lungs. These altered haemodynamics induce functional and structural changes in the cardiopulmonary system. Heart catheterization plays a major role in diagnosis and treatment of heart failure, for example, in diagnosing heart failure with preserved ejection fraction or pulmonary hypertension. Whereas in-depth haemodynamic evaluation using a right heart catheter is used to establish the correct diagnosis and monitor treatment responses, left heart catheterization and coronary and structural interventions provide direct treatment approaches. Invasive haemodynamic evaluation is indicated when clinical assessment and imaging do not sufficiently explain the aetiology of heart failure. Standardized data acquisition and good procedural technique are key to achieving high diagnostic quality. Equally essential is a thorough understanding of haemodynamics for correct interpretation of pressure curves. Physicians must be adequately trained in obtaining high-quality haemodynamic measurements in order to provide an accurate diagnosis and effective treatment recommendations for the best possible patient care.

Aims: The goal of this case series was to evaluate the feasibility, safety, and advantages of a wire-based approach for the live visualization of coronary arteries (CAs) in an electroanatomic mapping (EAM) system and to assess its diagnostic information.Methods and results: For this single-centre case series, we included procedures in which close proximity of a possible ablation site to any epicardial vessel was suspected. An uncoated-tip guidewire was introduced into the relevant CAs after exclusion of critical CA stenosis by coronary angiography. By connecting this wire to the EAM system using a clip and pin connection, mapping and live visualization of the wire tip is possible, as well as the assessment of the local electrograms within the respective CAs. Procedural wire insertion and intracoronary mapping was performed by EP specialists and was assisted to judge the relevance of CA disease by an interventional cardiologist. A total of nine procedures in nine patients were included in this case series, four ventricular tachycardia ablation procedures and five procedures for the ablation of premature ventricular contractions. The left CAs were mapped in eight cases and the right CA was mapped in one case. In two cases, epicardial mapping was combined with visualization of the right or left CAs. There were no complications attributed to coronary wiring and mapping in this case.Conclusion: We demonstrated the feasibility and safety of CA visualization and integration in an EAM. The live visualization of the CAs added valuable information without the need for preprocedural planning or the purchase of separate software. Electroanatomic visualization was achieved intraprocedurally in a safe and straightforward manner, adding critical diagnostic information without excessive costs or risks.

Background: In recent years, transcatheter aortic valve replacement (TAVR) techniques and technology have continuously improved. Data regarding the impact of these advancements on outcomes in large real-world settings are still limited. The aim of this study was to investigate temporal trends and assess contemporary outcomes after TAVR with Evolut PRO/PRO+ supra-annular self-expanding valves. Methods: This study included patients enrolled in the multicenter NEOPRO (A Multicenter Comparison of Acurate NEO Versus Evolut PRO Transcatheter Heart Valves) and NEOPRO-2 (A Multicenter Comparison of ACURATE NEO2 Versus Evolut PRO/PRO+ Transcatheter Heart Valves 2) registries who underwent transfemoral TAVR with Evolut PRO/PRO+. Procedural dates (August 2017 through November 2021) were stratified in quartiles (Q) and used to investigate temporal trends in TAVR outcomes. Predischarge, 30-day Valve Academic Research Consortium-3 defined, and 1-year outcomes were evaluated. Results: In total, 1616 patients from 28 centers were included. Over time, patients had lower Society of Thoracic Surgeon-Predicted Risk of Mortality score (Q1–4, 4.1% [2.8–6.3%], 3.7% [2.6–5.3%], 3.3% [2.4–4.9%], 2.9% [2.2–4.3%]; P P =0.038). Overall Valve Academic Research Consortium-3 technical success was 94.1%, with 30-day and 1-year all-cause mortality of 2.4% and 10%, respectively. Throughout the study period, procedures were associated with higher rates of 30-day device success (Q1–4, 81.2%, 82.2%, 82.0%, 88.0%; Cochran-Armitage P =0.023) and early safety (Q1–4, 66.8%, 67.5%, 74.0%, 77.6%; Cochran-Armitage P P =0.023) and residual mild or greater paravalvular leaks (Q1–4, 50.4%, 42.1%, 36.5%, 35.8%; Cochran-Armitage P <0.001). Conclusions: TAVR with Evolut PRO/PRO+ self-expanding valve is safe and effective. Despite the treatment of heavier calcified anatomies, procedural outcomes are improving over time with less need for pacemaker implantation and less significant paravalvular leaks.

Background: Several studies have suggested that proton pump inhibitors (PPIs) may reduce the antiplatelet effects of clopidogrel and/or aspirin, possibly leading to cardiovascular events.Aims: We aimed to investigate the association between PPI and clinical outcomes in patients treated with ticagrelor monotherapy or conventional antiplatelet therapy after percutaneous coronary intervention (PCI).Methods: This is a subanalysis of the randomized GLOBAL LEADERS trial, comparing the experimental antiplatelet arm (23‐month ticagrelor monotherapy following 1‐month dual antiplatelet therapy [DAPT]) with the reference arm (12‐month aspirin monotherapy following 12‐month DAPT) after PCI. Patient‐oriented composite endpoints (POCEs: all‐cause mortality, myocardial infarction, stroke, or repeat revascularization) and its components were assessed stratified by PPI use as a time‐dependent covariate in patients with the experiment or reference antiplatelet arm.Results: Among 15,839 patients, 2115 patients (13.5%) experienced POCE at 2 years. In the reference arm, the use of PPIs was independently associated with POCE (hazard ratio [HR]: 1.27; 95% confidence interval [CI]: 1.12–1.44) and its individual components, whereas it was not in the experimental arm (HR: 1.04; 95% CI: 0.92–1.19; p_interaction = 0.035). During the second‐year follow‐up, patients taking aspirin with PPIs had a significantly higher risk of POCE compared to those on aspirin without PPIs (HR: 1.57; 95% CI: 1.27–1.94), whereas the risk did not differ significantly irrespective of PPI in ticagrelor monotherapy group (HR: 1.03; 95% CI: 0.83–1.28; p_interaction = 0.008).Conclusions: In contrast to conventional antiplatelet strategy, there were no evidence suggesting the interaction between ticagrelor monotherapy and PPIs on increased cardiovascular events, which should be confirmed in further studies.Clinical Trial Registration: URL: https://clinicaltrials.gov

There are disparities in the adherence to guideline-recommended therapies after coronary artery bypass graft (CABG). We therefore sought to evaluate the effect of guideline-adherent medical secondary prevention on 1-year outcome after CABG. Data were taken from the randomized ‘Ticagrelor in CABG’ trial. From April 2013 until April 2017, patients who underwent CABG were included. For the present analysis, we compared patients who were treated with optimal medical secondary prevention with those where 1 or more of the recommended medications were missing. Follow-up data at 12 months were available in 1807 patients. About half (54%) of them were treated with optimal secondary prevention. All-cause mortality [0.5% vs 3.5%, hazard ratio (HR) 0.14 (0.05–0.37), P < 0.01], cardiovascular mortality [0.1% vs 1.7%, HR 0.06 (0.01–0.46), P = 0.007] and major adverse events [6.5% vs 11.5%, HR 0.54 (0.39–0.74), P < 0.01] were significantly lower in the group with optimal secondary prevention. The multivariable model for the primary end point based on binary concordance to guideline recommended therapy identified 3 independent factors: adherence to guideline recommended therapy [HR 0.55 (0.39–0.78), P < 0.001]; normal renal function [HR 0.99 (0.98–0.99), P = 0.040]; and off-pump surgery [HR 2.06 (1.02–4.18), P = 0.045]. Only every second patient receives optimal secondary prevention after CABG. Guideline adherent secondary prevention therapy is associated with lower mid-term mortality and less adverse cardiovascular events after 12 months.