No abstract

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Background: Women and the elderly with ST-elevation myocardial infarction (STEMI) experience longer treatment delays despite prehospital STEMI diagnosis and catheterization laboratory activation systems. It is not known what role specific STEMI referral systems might play in mediating this gap in care. We therefore examined sexand age-based differences in STEMI treatment delay (TD) in different STEMI activation systems. Methods: This observational comparative effectiveness study comprised 3 retrospective STEMI cohorts: a traditional hospital-based R ESUM ECJC Open 3 (2021) 723e732

This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

No abstract

Antithrombotic management of STEMI patients with apical dysfunction, but without demonstrable thrombus, is controversial. Triple antithrombotic therapy (TATT, defined as the addition of oral anticoagulation to dual antiplatelet therapy, or DAPT) may be associated with increased bleeding, while DAPT alone may not adequately protect against cardio-embolic events. We undertook a dual-center study of anterior STEMI patients treated with primary PCI (pPCI) from 2013 to 2015 and presenting presumed new apical dysfunction. The Centre hospitalier de l’Université de Montréal (CHUM) uses a strategy of selective TATT, whereas the Centre hospitalier universitaire de Sherbrooke (CHUS) has favored ticagrelor-based DAPT for all patients since 2013. The primary composite outcome consisted of death, MI, stroke, revascularization, and BARC 3 to 5 bleeding up to 4-months follow-up. We identified 177 cases (69 CHUM; 108 CHUS). Baseline characteristics were similar and procedural success was high (97%). There was no difference in post-procedure LVEF (39 ± 9% vs 37 ± 9%) or the extent of apical dysfunction. The primary composite outcome occurred in 27% with the selective TATT strategy compared to 19% with ticagrelor-DAPT (p = 0.342). Thus, this retrospective dual-center analysis does not support a strategy of conventional TATT over ticagrelor-based DAPT for patients with apical dysfunction following anterior STEMI treated with pPCI. A pragmatic randomized trial is needed to provide a definitive answer to this clinical conundrum.

Partial anomaly of the pulmonary venous return is a rare congenital condition treated with surgical redirection of the blood flow through the creation of a conduit to the left atrium. We report the case of a stenotic pulmonary vein to left atrium conduit successfully treated with the implantation of a drug-eluting stent. Pulmonary vein or conduit stenosis is generally treated with balloon dilation or bare-metal stent but is often met with underwhelming outcomes. Given the successful outcome of the case presented, drug-eluting stents may represent an attractive treatment option in suitable anatomies.

Fernandez-Portales J. Limitation to the utilization of the new antiplatelet agents in acute coronary syndromes related with patient's characteristics. Rev Esp Cardiol 2015;68:448-50. 5. Wittfeldt A, Emanuelsson H, Brandrup-Wognsen G, et al. Ticagrelor enhances adenosine-induced coronary vasodilatory responses in humans. J Am Coll Cardiol 2013;61:723-7. REPLY: Lights and Shadows of Antiplatelet Therapy in Primary Percutaneous Coronary Intervention We thank Lozano et al. for their thoughtful comments on our ETAMI (Early Thienopyridine Treatment to Improve Primary PCI in Patients With Acute Myocardial Infarction) trial (1) and fully agree with their statement that in antithrombotic therapy, there should always be a balance between efficacy and safety. Our study has investigated the very acute phase of primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) in which a faster onset of action of a platelet inhibition effect is desirable to reduce ischemic complications of the procedure. In the recently published ATLANTIC (A 30 Day Study to Evaluate Efficacy and Safety of Pre-hospital vs. In-hospital Initiation of Ticagrelor Therapy in STEMI Patients Planned for Percutaneous Coronary Intervention) trial, a very early initiation of ticagrelor in the pre-hospital phase leading to clinical relevant difference in platelet inhibition 1 h after PCI was associated with a reduction in stent thrombosis compared with the same loading dose started on average 31 min later in the hospital (2). In addition, there are several reports linking inadequate platelet inhibition at the time of PCI to ischemic complications, underscoring the importance of an effective platelet periprocedural inhibition during primary PCI (3). In the TRITON (Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition With Prasugrel) trial, patients with STEMI have especially benefited from prasugrel compared with clopidogrel without an increase in bleeding complications (4). These results were confirmed by recent reports from real-life experience of registries. Bleeding complications in TRITON accumulated over time but were not statistically different between clopidogrel and prasugrel in the primary PCI group at 30 days as well as at 15 months (4). The net clinical benefit was clearly in favor of prasugrel. The statement about a differential effect of prasugrel between secondary and primary PCI in STEMI is not correct, and this reference indicated no statistical heterogeneity between the 2 groups (4).This has been now well evaluated, and there is no significant interaction for the primary and secondary endpoints and a consistent effect of prasugrel across all types of PCI performed in STEMI patients (5). The numerical differences are related to the difficulties in measuring periprocedural MI in primary PCI versus secondary PCI and not related to the efficacy of prasugrel (5). The statement about contraindications against prasugrel majorly relates to patients with prior stroke, which is pr...