Alcuni trial di confronto tra ecografia intravascolare (IVUS) e angiografia hanno mostrato la superiorità dell’IVUS come guida alle procedure di PCI, soprattutto in quelle complesse. Tuttavia, tali studi non confrontavano l’IVUS con i dati forniti dalla angiografia coronarica quantitativa (QCA). Il recente GUIDE-DES trial…
L’efficacia e sicurezza della terapia anticoagulante con anticoagulanti diretti (DOAC) nei pazienti anziani fragili in fibrillazione atriale (AF), non è nota. Questi pazienti non sono stati inclusi nei trial di confronto con warfarin e non pochi dubbi sorgono nel praticare una terapia anticoagulante per la coesistenza di morbilità, spesso di deficit cognitivi e nell’alto rischio di bleeding e di cadute…
Gli antagonisti recettoriali dei mineralcorticoidi (MRA) rappresentano un caposaldo della terapia dello scompenso cardiaco (HF). Tuttavia, non è noto se questa azione benefica sia esercitata anche nei pazienti scompensati in fibrillazione atriale (AF), nei quali alcuni interventi farmacologici (come i betabloccanti) e non farmacologici (come la resincronizzazione miocardica) appaiono meno efficaci che in assenza di questa aritmia…
L’editoriale si riferisce a un articolo apparso sulla stessa rivista[1]Pham HN, Holmstrom L, Chugh H, et al. Dynamic electrocardiogram changes are a novel risk marker for sudden cardiac death. Eur Heart J 2024;45:809–19. https://doi.org/10.1093/eurheartj/ehad770 nel quale il gruppo del Cedars-Sinai Medical Center, Los Angeles, guidato da Harpriya Chugh, propone una valutazione “dinamica” di uno score predittivo di morte cardiaca improvvisa (Electrical Risk Score – ERS -)[2]Aro AL, Reinier K, Rusinaru C, et al. Electrical risk score beyond the left ventricular ejection fraction: prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the … Continua a leggere basata sull’analisi di almeno due elettrocardiogrammi ottenuti nello stesso paziente a distanza di tempo (mediamente in quella casistica 4-6 anni). In particolare le variazioni riscontrate in due parametri, la durata del QT corretto (nella Figura QTc) e del tempo picco/fine dell’onda T (nella Figura TpTe), forniscono informazioni prognostiche analoghe a quelle offerte dall’ERS. Gli autori, dell’editoriale, osservano come l’importanza delle anomalie della ripolarizzazione ventricolare sia da tempo riconosciuta come cruciale nell’aritmogenesi della morte improvvisa e come lo studio presente vada in quella stessa direzione. Altri parametri, quali l’onda T alternante (TWA nella Figura) e l’eterogeneità delle onde T (TWH nella Figura), sono state proposte quali misure quantificabili della dispersione della ripolarizzazione ventricolare. Anche l’analisi spettrale in bassa frequenza, denominate “Periodic Repolarization Dynamics” (PRD nella Figura) permette l’’identificazione di pazienti elettricamente vulnerabili, soprattutto in relazione ad attivazione simpatica secondaria a ischemia miocardica. Tuttavia, queste valutazioni sono “statiche”, eseguite su un solo elettrocardiogramma, mentre la novità dello studio del gruppo di Los Angeles consiste in una valutazione temporale dinamica. Il primo approccio di questo tipo risale addirittura al 1978, quando Schwartz e Wolf[3]Schwartz PJ, Wolf S. QT interval prolongation as predictor of sudden death in patients with myocardial infarction. Circulation 1978;57:1074–7. https://doi.org/10.1161/01.CIR. 57.6.1074. pubblicarono un’esperienza relativa a 55 pazienti con infarto miocardico e 55 controlli sani “matchati” per età, sesso, occupazione, etnia, peso e altezza. Veniva registrato un ECG ogni 2 mesi per 7 anni: 28 pazienti del primo gruppo ebbero una morte improvvisa: nel 36% di essi vi era un QT>450 msec (contro l’8% dei controlli) ma, soprattutto, fu osservata una significativa maggiore variabilità di QT tra i pazienti deceduti rispetto ai sopravvissuti (vedi Tabella da ref. 3). Bibliografia[+] Bibliografia ↑1 Pham HN, Holmstrom L, Chugh H, et al. Dynamic electrocardiogram changes are a novel risk marker for sudden cardiac death. Eur Heart J 2024;45:809–19. https://doi.org/10.1093/eurheartj/ehad770 ↑2 Aro AL, Reinier K, Rusinaru C, et al. Electrical risk score beyond the left ventricular ejection fraction: prediction of sudden cardiac death in the Oregon Sudden Unexpected Death Study and the Atherosclerosis Risk in Communities Study. Eur Heart J 2017;38:3017–25. https://doi.org/10.1093/eurheartj/ ehx331. ↑3 Schwartz PJ, Wolf S. QT interval prolongation as predictor of sudden death in patients with myocardial infarction. Circulation 1978;57:1074–7. https://doi.org/10.1161/01.CIR. 57.6.1074.
1.Mejia-Renteria H, Travieso A, Matias-Guiu JA, Yus M, Espejo-Paeres C, Finocchiaro F, et al. Coronary microvascular dysfunction is associated with impaired cognitive function: the cerebral-coronary connection study (C3 study). Eur Heart J 2023;44:113–25. Coronary microcirculatory dysfunction is frequent in patients with coronary artery disease and correlates with cerebral small vessel disease, abnormal cerebral flow haemodynamics, and significant cognitive impairment. These findings support the hypothesis that microvascular dysfunction in the heart and the brain are part of a single pathological process affecting microcirculation in patients with coronary artery disease. https://pubmed.ncbi.nlm.nih.gov/36337036/ 2. Boerhout CKM, Lee JM, de Waard GA, Mejia-Renteria H, Lee SH, Jung JH, et al. Microvascular resistance reserve: diagnostic and prognostic performance in the ILIAS registry. Eur Heart J 2023; 44:2862–9. Microvascular resistance reserve seems a robust indicator of the microvascular vasodilator reserve capacity. Moreover, in line with its theoretical background, this study suggests a diagnostic advantage of microvascular resistance reserve over other indices of vasodilatory capacity in patients with hemodynamically significant epicardial coronary artery disease. https://academic.oup.com/eurheartj/article/44/30/2862/7205678 3. Dong F, Yin L, Sisakian H, Hakobyan T, Jeong LS, Joshi H, et al. Takotsubo syndrome is a coronary microvascular disease: experimental evidence. Eur Heart J 2023;44:2244–53. Abnormalities in flow regulation between the LV apex and base cause Takotsubo syndrome. When perfusion is normalized between the two regions, normal ventricular function is restored. https://academic.oup.com/eurheartj/article/44/24/2244/7160508 4. Perera D, Clayton T, O’Kane PD, Weerackody R, Ryan M, Morgan HP, et al. Percutaneous revascularization for ischemic left ventricular dysfunction. N Engl J Med 2022;387:1351–60. Among patients with severe ischemic left ventricular systolic dysfunction who received optimal medical therapy, revascularization by PCI did not result in a lower incidence of death from any cause or hospitalization for heart failure. https://www.nejm.org/doi/10.1056/NEJMoa2206606 5. Persson J, Yan J, Angeras O, Venetsanos D, Jeppsson A, Sjögren I, et al. PCI or CABG for left main coronary artery disease: the SWEDEHEART registry. Eur Heart J 2023;44: 2833–42. In this non-randomized study, coronary artery bypass grafting in patients with left main coronary artery disease was associated with lower mortality and fewer major adverse cardiovascular and cerebrovascular events compared to PCI after multivariable adjustment for known and unknown confounders. https://academic.oup.com/eurheartj/article/44/30/2833/7191997 6. Rajkumar CA, Foley MJ, Ahmed-Jushuf F, Nowbar AN, Simader FA, Davies JR, et al. A placebo-controlled trial of percutaneous coronary intervention for stable angina. N Engl J Med 2023;389:2319–30. Among patients with stable angina who were receiving little or no antianginal medication and had objective evidence of ischemia, PCI resulted in a lower angina symptom score than a placebo procedure, indicating a better health status with respect to angina. https://www.nejm.org/doi/10.1056/NEJMoa2310610 7. Christensen DM, Schjerning AM, Smedegaard L, Charlot MG, Ravn PB, Ruwald AC, et al. Long-term mortality, cardiovascular events, and bleeding in stable patients 1 year after myocardial infarction: a Danish nationwide study. Eur Heart J 2023;44:488–98. For patients who were event-free 1 year after myocardial infarction, the long-term risks of mortality, cardiovascular events, and bleeding decreased significantly, along with an improved use of guideline-recommended treatments between 2000 and 2017. In the most recent period, 1 year after myocardial infarction, the risk of additional events was lower than previously reported. https://pubmed.ncbi.nlm.nih.gov/36433809/ 8. Stahli BE, Varbella F, Linke A, Schwarz B, Felix SB, Seiffert M, et al. Timing of complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med 2023;389: 1368–79. Among patients in hemodynamically stable condition with STEMI and multivessel coronary artery disease, immediate multivessel PCI was noninferior to staged multivessel PCI with respect to the risk of death from any cause, nonfatal myocardial infarction, stroke, unplanned ischemia-driven revascularization, or hospitalization for heart failure at 1 year. https://www.nejm.org/doi/10.1056/NEJMoa2307823 9. Kang J, Rizas KD, Park KW, Chung J, van den Broek W, Claassens DMF, et al. Dual antiplatelet therapy de-escalation in acute coronary syndrome: an individual patient meta-analysis. Eur Heart J 2023; 44:1360–70. In this individual patient data metaanalysis, dual antiplatelet therapy-based de-escalation was associated with both decreased ischaemic and bleeding endpoints. Reduction in bleeding endpoints was more prominent for the unguided than the guided de-escalation strategy. https://academic.oup.com/eurheartj/article/44/15/1360/7072382 10. Pareek M, Kragholm KH, Kristensen AMD, Vaduganathan M, Pallisgaard JL, Byrne C, et al. Serial troponin-T and long-term outcomes in suspected acute coronary syndrome. Eur Heart J 2023;44:502–12. Individuals with suspected acute coronary syndrome and two consecutively elevated high-sensitivity troponin-T concentrations consistently had the highest risk of death. Mortality was very low in subjects with two normal high-sensitivity troponin-T concentrations, irrespective of changes between measurements. https://academic.oup.com/eurheartj/article/44/6/502/6775308
