Anna Cantone

Background: Optimal stent expansion is a key determinant of long‐term outcomes after PCI. Intravascular imaging provides the most accurate assessment of stent deployment but remains underused, especially in older patients with MI and multivessel disease. ESV is an angiographic enhancement technology that may help detect gross stent underexpansion when advanced imaging is not feasible. Aims: To evaluate the procedural and clinical impact of enhanced stent visualization (ESV)‐guided percutaneous coronary intervention (PCI) in older patients with myocardial infarction (MI) and multivessel disease. Methods: In this prespecified sub‐study of the FIRE trial, we evaluated the impact of ESV use during PCI in older MI patients. Among 1445 enrolled patients, 331 underwent ESV‐guided PCI and 1114 standard angiography‐guided PCI. Procedural optimization triggered by ESV was defined as additional postdilation, extra stent implantation, or use of intravascular imaging. Minimal lumen diameter (MLD) was assessed before and after ESV‐guided optimization. Clinical outcomes were compared using multivariable and competing‐risk adjusted Cox models. Results: Operator‐driven optimization occurred in 85% of ESV cases, primarily through postdilation (96%). ESV guidance resulted in a significant MLD increase from 2.51 [2.22–2.87] to 2.93 [2.41–3.32] mm ( p < 0.001), yielding an acute luminal gain of 0.42 mm (95% CI 0.37–0.47). At 3 years, the composite primary endpoint (death, MI, stroke, or ischemia‐driven revascularization) was lower in the ESV group (adjusted HR 0.70, 95% CI 0.54–0.91; p = 0.008). Conclusions: In older MI patients with complex multivessel disease, ESV‐guided PCI was associated with greater procedural optimization, improved acute stent expansion, and lower long‐term adverse events. While not a substitute for intracoronary imaging, ESV represents a pragmatic and valuable adjunct to enhance PCI quality in settings where intravascular imaging is seldom performed. Trial Registration: ClinicalTrials.gov identifier NCT03772743.

Background: The number of older patients admitted with myocardial infarction (MI) is increasing, and their clinical profiles range from very fit to frail and functionally impaired. Objectives: To evaluate whether the benefits of complete revascularization are consistent across subpopulations of older MI patients stratified by the Clinical Frailty Scale (CFS). Methods: In the FIRE trial, 1445 patients aged ≥75 years with MI and multivessel disease were randomized to either complete or culprit-only revascularization. Overall, 1010 patients (70%) were stratified according to CFS (scores 1–3 non-frail, 4 pre-frail, 5–9 frail). The primary endpoint was a 3-year composite of death, MI, stroke, or ischemia-driven revascularization. Results: Of the stratified cohort, 523 (52%) were non-frail, 304 (30%) pre-frail, and 183 (18%) frail. Increasing frailty was significantly associated with a higher risk of the primary endpoint (HR 1.62, 95% CI 1.19–2.20; P = .002). Complete revascularization reduced the primary endpoint with no significant interaction between revascularization strategy and CFS category (p for interaction = 0.769). The benefit of complete versus culprit-only revascularization remained consistent across the full range of CFS scores. Similar findings were observed for secondary endpoints, and no significant interaction emerged for safety outcomes. Conclusions: Frailty, as assessed by the CFS, was independently associated with adverse outcomes. Complete revascularization was effective regardless of frailty status and should be considered in all older MI patients with multivessel disease undergoing an invasive strategy. Trial Registration: ClinicalTrials.gov Identifier: NCT03772743.

BACKGROUND: Thresholds to define prognosis with hs-cTnI (high-sensitivity cardiac troponin I) have not been systematically addressed in wild-type transthyretin amyloid cardiomyopathy, in part because of the multiplicity of hs-cTnI assays. The aims of this study were: first, to assess the prognostic performance of hs-cTnI measured with different assays in patients with wild-type transthyretin amyloid cardiomyopathy and, second, to identify assay-specific hs-cTnI thresholds for prognosis that could be integrated into staging systems for risk stratification. METHODS: Observational multicenter study of stable wild-type transthyretin amyloid cardiomyopathy patients from different cohorts using the Abbott Architect Stat hs-cTnI assay and the Beckman Coulter Access hs-cTnI assay (testing cohorts) and the Siemens Centaur XPT hs-cTnI assay (validation cohort). Outcome was all-cause mortality. RESULTS: In the Abbott cohort (n=136; median follow-up 22 [13–41] months; 31 [23%] deaths) and Beckman cohort (n=98; median follow-up 19 [12–28] months; 16 [16%] deaths), natural log-transformed hs-cTnI was an independent predictor of mortality (age- and sex-adjusted hazard ratio, 1.62 [95% CI, 1.11–2.35]; P =0.012 and 2.47 [95% CI, 1.48–4.14]; P 80 ng/L) and NPs (natriuretic peptides; NT-proBNP [N-terminal pro-B-type natriuretic peptide] >3000 ng/L or BNP [B-type natriuretic peptide] >250 ng/L) identified 3 groups with progressively worse prognosis. The staging system (using hs-cTnI >80 ng/L and NT-proBNP>3000 ng/L) was then applied to an independent cohort evaluated with the hs-cTnI Siemens assay (n=345, median follow-up 32 [24-42] months, 119 [34%] deaths). The significant differences between the groups were maintained. CONCLUSIONS: In patients with wild-type transthyretin amyloid cardiomyopathy, hs-cTnI is a strong and independent predictor of mortality. A threshold of hs-cTnI of 80 ng/L for these 3 assays provides effective risk stratification alone and in a staging system with NP.