Fragile hearts:Unveiling the crucial layers of frailty in elderly patients undergoing percutaneous coronary interventions

Wang and Liu's systematic review of frailty among elderly patients undergoing percutaneous coronary intervention(PCI)revealed that patients with frailty have significantly higher risks of all-cause and in-hospital death,major undesirable cardiovascular events,and major haemorrhage.Frailty is associated with adverse events,prolonged hospital stays,increased complications,and elevated mortality risk due to diminished physiological reserves.Integrating frailty into risk assessment tools is crucial,and gait speed has emerged as a key predictor of frailty.Recognizing the impact of frailty leads to personalized and informed decisionmaking,and frailty assessments should be performed.This holistic approach can inform tailored interventions,thereby optimizing outcomes for this vulnerable population undergoing PCI.

Predictors of Complications after Sheath Removal Post Transfemoral Percutaneous Coronary Interventions

Background: Complications post percutaneous coronary interventions (PCI) are more threatening than it was previously thought so that necessary measures should be taken to minimize those risks. Objective: To identify the risk factors related to patient and procedure which could be used as predictors of complications after sheath removal post PCI. Methods: The study used a prospective non-experimental correlational descriptive. Design: The sample was chosen conveniently from three different hospitals and included 118 patients who were subjected to PCI. Results: Three models were used to predict complications. In the first model, none of the baseline variables were predictive of complications. In the second model, the only type of procedure (diagnostic, stent or balloon) was predictive of complications. In the third model, compression time was found to be a risk factor and a predictor of complications after sheath removal. Conclusion: Nurses and medical professionals are in a vital position to prevent, detect and manage PCI complications at the earliest possible opportunity. It is a must to assess and categorize patients in accordance with their risk level to develop post PCI and post sheath removal complications, in order to plan management strategies to decrease the health costs and the suffering.

Coronary interventions in patients with bleeding and bleeding tendency

In general, percutaneous coronary intervention (PCI)is contra-indicated in patients with bleeding and those that are easy to bleed because during PCI the patients need full anticoagulation to counter any thrombotic formation caused by introduction and manipulation of devices in the vascular system.……

Outcomes after percutaneous coronary interventions in patients with chronic kidney disease

Introduction Chronic kidney disease (CKD) is a significant contributor to cardiovascular morbidity and mortality.Patients with CKD are known to have a greater prevalence of cardiovascular disease than the general population,1 and patients with concurrent CKD and coronary artery disease (CAD) have greater mortality than patients without CKD.2-4 The rate of cardiovascular mortality is approximately 50%,five to 10 times higher than the general population.

How to duplicate the procedural success of coronary interventions by the radial approach:tips and tricks in the selection and manipulations of guides

In this issue of the Journal of Geriatric Cardiology;Jing et al. showed off their near perfect results of percutaneous coronary interventions (PCI) through transfemoral approach (TFA) and transradial approach (TRA) in the elderly Chinese patients. All patients were older.than 60years of age, with an average of 67.……

Stent visualization methods to guide percutaneous coronary interventions and assess long-term patency

Evaluation of acute percutaneous coronary intervention(PCI)results and longterm follow-up remains challenging with ongoing stent designs.Several imaging tools have been developed to assess native vessel atherosclerosis and stent expansion,improving overall PCI results and reducing adverse cardiac events.Quantitative coronary analysis has played a crucial role in quantifying the extent of coronary artery disease and stent results.Digital stent enhancement methods have been well validated and improved stent strut visualization.Intravascular imaging remains the gold standard in PCI guidance but adds costs and time to the procedure.With a recent shift towards non-invasive imaging assessment and coronary computed tomography angiography imaging have shown promising results.We hereby review novel stent visualization techniques used to guide PCI and assess stent patency in the modern PCI era.

Safety and efficacy of dual antiplatelet therapy after percutaneous coronary interventions in patients with end-stage liver disease

The prevalence of coronary artery disease(CAD)increases in patients with endstage liver disease,with part of them receiving the percutaneous coronary intervention(PCI)as a treatment option.Dual antiplatelet therapy(DAPT),a standard of care after PCI,could result in catastrophic consequences in this population.Before PCI and the start of DAPT,it is recommended to assess patient bleeding risk.Based on novel findings,liver cirrhosis does not necessarily lead to a significant increase in bleeding complications.Furthermore,conventional methods,such as the international normalized ratio,might not be appropriate in assessing individual bleeding risk.The highest bleeding risk among cirrhotic patients has a subgroup with severe thrombocytopenia(<50×10^(9)/L)and elevated portal pressure.Therefore,every effort should be made to maintain thrombocyte count above>50×10^(9)/L and prevent variceal bleeding.There is no solid evidence for DAPT in patients with cirrhosis.However,randomized trials investigating short(one month)DAPT duration after PCI with new drug-eluting stents(DES)in a high bleeding risk patient population can be implemented in patients with cirrhosis.Based on retrospective studies(with older stents and protocols),PCI and DAPT appear to be safe but with a higher risk of bleeding complications with longer DAPT usage.Finally,novel methods in assessing CAD severity should be performed to avoid unnecessary PCI and potential risks associated with DAPT.When indicated,PCI should be performed over radial artery using contemporary DES.Complementary medical therapy,such as proton pump inhibitors and beta-blockers,should be prescribed for lower bleeding risk patients.Novel approaches,such as thromboelastography and“preventive”upper endoscopies in PCI circumstances,warn clinical confirmation.

Jailing polymer jacketed guide-wires during bifurcation coronary interventions is associated with procedural myocardial infarction

AIM To study the relationship of jailed polymer jacketed guide wires(PGW) with procedural myocardial infarction(PMI) after bifurcation coronary interventions.METHODS Consecutive bifurcation interventions performed from January 2010 to October 2014 were included in the study. Chart review was performed to obtain demographic, clinical and procedural data. PMI was defined as Creatine Kinase MB > 3 × upper reference limit of normal. Multivariate logistic regression was used to ascertain relationship of PGW use with PMI.RESULTS Two hundred and ninety-three patients(age 63.5 ± 12.3 years; 33.8% diabetic) were included in the study. Eighty point two percent(n = 235) were true bifurcation lesions use of PGW was associated with PMI on univariate analysis(OR = 4.1; P = 0.002). This association remained significant after adjusting for other possible risk factors(OR = 3.5; P = 0.02).CONCLUSION Our results suggest that PGW use for side branch protection may be associated with PMI. Randomized studies are needed to validate these findings.

Long-term outcomes of high-risk percutaneous coronary interventions under extracorporeal membrane oxygenation support:An observational study

BACKGROUND Venoarterial extracorporeal membrane oxygenation(VA-ECMO)offers hemodynamic support for patients undergoing high-risk percutaneous coronary interventions(PCIs).However,long-term outcomes associated with VA-ECMO have not previously been studied.AIM To explore long-term outcomes in high-risk cases undergoing PCI supported by VA-ECMO.METHODS In the present observational cohort study,61 patients who received VA-ECMOsupported high-risk PCI between April 2012 and January 2020 at the Sixth Medical Center of Chinese People’s Liberation Army General Hospital were enrolled.The endpoint characteristics such as all-cause mortality,repeated cardiovascular diseases,and cardiac death were examined.RESULTS Among 61 patients,three failed stent implantation due to chronic total occlusions with severely calcified lesions.One patient showed VA-ECMO intolerance because of high left ventricular afterload.PCI was successfully performed in 57 patients(93.4%).The in-hospital mortality was 23.0%,and the overall survival was 45.9%,with a median follow-up period of 38.6(8.6-62.1)mo.CONCLUSION VA-ECMO can be used as a support in patients undergoing high-risk PCI as it is associated with favorable long-term patient survival.

Advances in Periprocedural Anticoagulation for Percutaneous Coronary Interventions

Percutaneous coronary intervention (PCI) is commonly used in the surgical treatment of patients with various types of cardiac diseases. Some patients require long-term anticoagulation in the presence of deep vein thrombosis, atrial fibrillation and mechanical heart valves, and inappropriate anticoagulation during the perioperative period may lead to bleeding events or thrombotic events. In this paper, the importance of anticoagulation in the practical application of percutaneous coronary intervention (PCI) is first introduced, and then the various drug regimens used in the perioperative anticoagulation of percutaneous coronary intervention are explored in detail in the light of current research advances, with a view to providing guidance for clinical practice.

Evaluation of CRUSADE and ACUITY-HORIZONS Scores for Predicting Long-term Out-of-Hospital Bleeding after Percutaneous Coronary Interventions

Background：There is scanty evidence concerning the ability of Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the ACC/AHA Guidelines （CRUSADE） and Acute Catheterization and Urgent Intervention Triage Strategy and Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction （ACUITY-HORIZONS） scores to predict out-of-hospital bleeding risk after percutaneous coronary interventions （PCIs） with drug-eluting stents （DES） in patients receiving dual antiplatelet therapy.We aimed to assess and compare the long-term prognostic value of these scores regarding out-of-hospital bleeding risk in such patients.Methods：We performed a prospective observational study of 10,724 patients undergoing PCI between January and December 2013 in Fuwai Hospital,China.All patients were followed up for 2 years and evaluated through the Fuwai Hospital Follow-up Center.Major bleeding was defined as Types 2,3,and 5 according to Bleeding Academic Research Consortium Definition criteria.Results：During a 2-year follow-up,245 of 9782 patients （2.5%） had major bleeding （MB）.CRUSADE （21.00 [12.00,29.75] vs.18.00 [11.00,26.00],P 〈 0.001） and ACUITY-HORIZONS （9.00 [3.00,14.00] vs.6.00 [3.00,12.00],P 〈 0.001） risk scores were both significantly higher in the MB than non-MB groups.Both scores showed a moderate predictive value for MB in the whole study cohort （area under the receiver-operating characteristics curve [AUROC],0.565;95% confidence interval [CI],0.529-0.601,P =0.001;AUROC,0.566;95% CI,0.529-0.603,P 〈 0.001,respectively） and in the acute coronary syndrome （ACS） subgroup （AUROC：0.579,95% CI：0.531-）.627,P =0.001;AUROC,0.591;95% CI,0.544-0.638,P 〈 0.001,respectively）.However,neither score was a significant predictor in the non-ACS subgroup （P 〉 0.05）.The value of CRUSADE and ACUITY-HORIZONS scores did not differ significantly （P 〉 0.05） in the whole cohort,ACS subgroup,or non-ACS subgroup.Conclusions：CRUSADE and ACUITY-HORIZONS scores showed statistically significant but relatively limited long-term prognostic value for out-of-hospital MB after PCI with DES in a cohort of Chinese patients.The value of CRUSADE and ACUITY-HORIZONS scores did not differ significantly （P 〉 0.05） in the whole cohort,ACS subgroup,or non-ACS subgroup.

Platelet function monitoring guided antiplatelet therapy in patients receiving high-risk coronary interventions

Background Large-scale clinical trials have shown that routine monitoring of the platelet function in patients after percutanous coronary intervention （PCI） is not necessary. However, it is still unclear whether patients received high-risk PCI would benefit from a therapy which is guided by a selective platelet function monitoring. This explanatory study sought to assess the benefit of a therapy guided by platelet function monitoring for these patients. Methods Acute coronary syndrome （ACS） patients （n=384） who received high-risk, complex PCI were randomized into two groups. PCI in the two types of lesions described below was defined as high-risk, complex PCI： lesions that could result in severe clinical outcomes if stent thrombosis occurred or lesions at high risk for stent thrombosis. The patients in the conventionally treated group received standard dual antiplatelet therapy. The patients in the platelet function monitoring guided group received an antiplated therapy guided by a modified thromboelastography （TEG） platelet mapping： If inhibition of platelet aggregation （IPA） induced by arachidonic acid （AA） was less than 50% the aspirin dosage was raised to 200 mg/d; if IPA induced by adenosine diphosphate （ADP） was less than 30% the clopidogrel dosage was raised to 150 mg/d, for three months. The primary efficacy endpoint was a composite of myocardial infarction, emergency target vessel revascularization （eTVR）, stent thrombosis, and death in six months. Results This study included 384 patients; 191 and 193 in the conventionally treated group and platelet function monitoring guided group, respectively. No significant differences were observed in the baseline clinical characteristics and interventional data between the two groups. In the platelet function monitoring guided group, the mean IPA induced by AA and ADP were （69.2＋24.5）% （range, 4.8% to 100.0%） and （51.4＋29.8）% （range, 0.2% to 100.0%）, respectively. The AA- induced IPA of forty-three （22.2%） patients was less than 50% and the ADP-induced IPA of fifty-seven （29.5%） patients was less than 30%; therefore, their drug dosages were adjusted. The TEG was rechecked one to four weeks after PCI, and the results indicated that the IPAs had significantly improved （P 〈0.01）. However, no significant differences were found in the rates of the primary efficacy endpoint. Rates in the conventionally treated group and platelet function monitoring guided group were 4.7% and 5.2%, respectively （hazard ratio： 1.13; P=0.79）. Conclusion An antiplatelet therapy guided by TEG monitored platelet function could not improve clinical efficacy even in ACS patients treated with high-risk complex PCI.

Characteristics and risk factors of cerebrovascular accidents after percutaneous coronary interventions in patients with history of stroke

Background Percutaneous coronary intervention （PCI） is a well-established method for managing coronary diseases. However, the increasing use of PCI has led to an increased incidence of acute cerebrovascular accidents （CVA） related to PCI. In this study, we investigated the characteristics and risk factors of CVA after PCI in patients with known stroke history. Methods Between January 1, 2005 and March 1, 2009, 621 patients with a history of stroke underwent a total of 665 PCI procedures and were included in this retrospective study. Demographic and clinical characteristics, previous medications, procedures, neurologic deficits, location of lesion and in-hospital clinical outcomes of patients who developed a CVA after the cardiac catheterization laboratory visit and before discharge were reviewed. Results Acute CVA was diagnosed in 53 （8.5%） patients during the operation or the perioperative period. Seventeen patients suffered from transient ischemic attack, thirty-four patients suffered from cerebral infarction and two patients suffered from cerebral hemorrhage. The risk factors for CVA after PCI in stroke patients were： admission with an acute coronary syndrome, use of an intra-aortic balloon pump, urgent or emergency procedures, diabetes mellitus, and poor left ventricular systolic function, arterial fibrillation, previous myocardial infarction, dyslipidemia, tobacco use, and no/irregular use of anti-platelet medications. Conclusions The incidence of CVA during and after PCI in patients with history of stroke is much higher than that in patients without history of stroke. Patients with atrial fibrillation, previous myocardial infarction, diabetes mellitus, dyslipidemia, tobacco use, and no or irregular use of anti-platelet medications were at higher risk for recurrent stroke. This study showed a strong association between acute coronary svndromes and in-hospital stroke after PCI.

Unloading and successful treatment with bioresorbable stents during percutaneous coronary intervention:A case report

BACKGROUND With the development of percutaneous coronary intervention(PCI),the number of interventional procedures without implantation,such as bioresorbable stents(BRS)and drug-coated balloons,has increased annually.Metal drug-eluting stent unloading is one of the most common clinical complications.Comparatively,BRS detachment is more concealed and harmful,but has yet to be reported in clinical research.In this study,we report a case of BRS unloading and successful rescue.This is a case of a 59-year-old male with the following medical history:“Type 2 diabetes mellitus”for 2 years,maintained with metformin extended-release tablets,1 g PO BID;“hypertension”for 20 years,with long-term use of metoprolol sustained-release tablets,47.5 mg PO QD;“hyperlipidemia”for 20 years,without regular medication.He was admitted to the emergency department of our hospital due to intermittent chest pain lasting 18 hours,on February 20,2022 at 15:35.Electrocardiogram results showed sinus rhythm,ST-segment elevation in leads I and avL,and poor R-wave progression in leads V1–3.High-sensitivity troponin I level was 4.59 ng/mL,indicating an acute high lateral wall myocardial infarction.The patient’s family requested treatment with BRS,without implanta-tion.During PCI,the BRS became unloaded but was successfully rescued.The patient was followed up for 2 years;he had no episodes of angina pectoris and was in generally good condition.CONCLUSION We describe a case of a 59-year-old male experienced BRS unloading and successful rescue.By analyzing images,the causes of BRS unloading and the treatment plan are discussed to provide insights for BRS release operations.We discuss preventive measures for BRS unloading.

Impact of frailty on outcomes of elderly patients undergoing percutaneous coronary intervention: A systematic review and metaanalysis

BACKGROUND Frailty is a common condition in elderly patients who receive percutaneous coronary intervention(PCI).However,how frailty affects clinical outcomes in this group is unclear.AIM To assess the link between frailty and the outcomes,such as in-hospital complic-ations,post-procedural complications,and mortality,in elderly patients post-PCI.METHODS The PubMed/MEDLINE,EMBASE,Cochrane Library,and Web of Science databases were screened for publications up to August 2023.The primary outcomes assessed were in-hospital and all-cause mortality,major adverse cardiovascular events(MACEs),and major bleeding.The Newcastle-Ottawa Scale was used for quality assessment.RESULTS Twenty-one studies with 739693 elderly patients undergoing PCI were included.Frailty was consistently associated with adverse outcomes.Frail patients had significantly higher risks of in-hospital mortality[risk ratio:3.45,95%confidence interval(95%CI):1.90-6.25],all-cause mortality[hazard ratio(HR):2.08,95%CI:1.78-2.43],MACEs(HR:2.92,95%CI:1.85-4.60),and major bleeding(HR:4.60,95%CI:2.89-7.32)compared to non-frail patients.CONCLUSION Frailty is a pivotal determinant in the prediction of risk of mortality,development of MACEs,and major bleeding in elderly individuals undergoing percutaneous coronary intervention.

Fundamentals of percutaneous coronary bifurcation interventions

Coronary bifurcation lesions(CBLs)account for 15%-20%of all percutaneous coronary interventions.The complex nature of these lesions is responsible for poorer procedural,early and late outcomes.This complex lesion subset has received great attention in the interventional cardiac community,and multiple stenting techniques have been developed.Of these,the provisional stenting technique is most often the default strategy;however,the elective double stenting(EDS)technique is preferred in certain subsets of complex CBLs.The double kissing crush technique may be the preferred EDS technique because of its efficacy and safety in comparative trials;however,this technique consists of many steps and requires training.Many new methods have recently been added to the EDS techniques to provide better stent scaffolding and to reduce early and late adverse outcomes.Intravascular imaging is necessary to determine the interventional strategy and postinterventional results.This review discusses the basic concepts,contemporary percutaneous interventional technical approaches,new methods,and controversial treatment issues of CBLs.

Impact of primary percutaneous coronary intervention on ST-segment elevation myocardial infarction patients:A comprehensive analysis

BACKGROUND Myocardial infarction,particularly ST-segment elevation myocardial infarction(STEMI),is a key global mortality cause.Our study investigated predictors of mortality in 96 STEMI patients undergoing primary percutaneous coronary intervention at Erbil Cardiac Center.Multiple factors were identified influencing in-hospital mortality.Significantly,time from symptom onset to hospital arrival emerged as a decisive factor.Consequently,our study hypothesis is:"Reducing time from symptom onset to hospital arrival significantly improves STEMI prognosis."AIM To determine the key factors influencing mortality rates in STEMI patients.METHODS We studied 96 consecutive STEMI patients undergoing primary percutaneous coronary intervention(PPCI)at the Erbil Cardiac Center.Their clinical histories were compiled,and coronary evaluations were performed via angiography on admission.Data included comorbid conditions,onset of cardiogenic shock,complications during PPCI,and more.Post-discharge,one-month follow-up assessments were completed.Statistical significance was set at P<0.05.RESULTS Our results unearthed several significant findings.The in-hospital and 30-d mortality rates among the 96 STEMI patients were 11.2%and 2.3%respectively.On the investigation of independent predictors of in-hospital mortality,we identified atypical presentation,onset of cardiogenic shock,presence of chronic kidney disease,Thrombolysis In Myocardial Infarction grades 0/1/2,triple vessel disease,ventricular tachycardia/ventricular fibrillation,coronary dissection,and the no-reflow phenomenon.Specifically,the recorded average time from symptom onset to hospital arrival amongst patients who did not survive was significantly longer(6.92±3.86 h)compared to those who survived(3.61±1.67 h),P<0.001.These findings underscore the critical role of timely intervention in improving the survival outcomes of STEMI patients.CONCLUSION Our results affirm that early hospital arrival after symptom onset significantly improves survival rates in STEMI patients,highlighting the critical need for prompt intervention.

Coronary artery disease and heart failure:Late-breaking trials presented at American Heart Association scientific session 2023

The late-breaking science presented at the 2023 scientific session of the American Heart Association paves the way for future pragmatic trials and provides meaningful information to guide management strategies in coronary artery disease and heart failure(HF).The dapagliflozin in patient with acute myocardial infarction(DAPA-MI)trial showed that dapagliflozin use among patients with acute MI without a history of diabetes mellitus or chronic HF has better cardiometabolic outcomes compared with placebo,with no difference in cardiovascular outcomes.The MINT trial showed that in patients with acute MI and anemia(Hgb<10 g/dL),a liberal transfusion goal(Hgb≥10 g/dL)was not superior to a restrictive strategy(Hgb 7-8 g/dL)with respect to 30-day all-cause death and recurrent MI.The ORBITA-2 trial showed that among patients with stable angina and coronary stenoses causing ischemia on little or no antianginal therapy,percutaneous coronary intervention results in greater improvements in anginal frequency and exercise times compared with a sham procedure.The ARIES-HM3 trial showed that in patients with advanced HF who received a HeartMate 3 levitated left ventricular assist device and were anticoagulated with a vitamin K antagonist,placebo was noninferior to daily aspirin with respect to the composite endpoint of bleeding and thrombotic events at 1 year.The TEAMMATE trial showed that everolimus with low-dose tacrolimus is safe in children and young adults when given≥6 months after cardiac transplantation.Providing patients being treated for HF with reduced ejection fraction(HFrEF)with specific out-of-pocket(OOP)costs for multiple medication options at the time of the clinical encounter may reduce‘contingency planning’and increase the extent to which patients are taking the medications decided upon.The primary outcome,which was cost-informed decisionmaking,defined as the clinician or patient mentioning costs of HFrEF medication,occurred in 49%of encounters with the checklist only control group compared with 68%of encounters in the OOP cost group.

Challenging situation of coronary artery anomaly associated with ischemia and/or risk of sudden death

Coronary artery anomaly is known as one of the causes of angina pectoris and sudden death and is an important clinical entity that cannot be overlooked.The incidence of coronary artery anomalies is as low as 1%-2%of the general population,even when the various types are combined.Coronary anomalies are practically challenging when the left and right coronary ostium are not found around their normal positions during coronary angiography with a catheter.If there is atherosclerotic stenosis of the coronary artery with an anomaly and percutaneous coronary intervention(PCI)is required,the suitability of the guiding catheter at the entrance and the adequate back up force of the guiding catheter are issues.The level of PCI risk itself should also be considered on a caseby-case basis.In this case,emission computed tomography in the R-1 subtype single coronary artery proved that ischemia occurred in an area where the coronary artery was not visible to the naked eye.Meticulous follow-up would be crucial,because sudden death may occur in single coronary arteries.To prevent atherosclerosis with full efforts is also important,as the authors indicated admirably.

Bioresorbable stent unloading during percutaneous coronary intervention:Early detection and management

In this letter,we comment on a recent case report by Sun et al in the World Journal of Cardiology.The report describes the successful management of a rare complication:The unloading or detachment of a bioresorbable stent(BRS)during percutaneous coronary intervention(PCI)in a male patient.The unloading of BRS was detected via angiography and intravascular ultrasound(IVUS)imaging of the left coronary artery and left anterior descending artery.Although this case is interesting,the authors’report lacked crucial details.Specifically,insufficient information about the type of BRS used,potential causes of BRS unloading,or whether optical coherence tomography(OCT)imaging for coronary arteries was performed before,during,or after PCI.The OCT imaging of coronary arteries before PCI can potentially prevent BRS unloading due to its higher resolution compared to IVUS.In addition,despite detecting myocardial bridging during the PCI,the authors did not provide any details regarding this variation.Here we discuss the various types of BRS,the importance of OCT in PCI,and the clinical relevance of myocardial bridging.