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La muerte súbita y los síndromes coronarios agudos son, frecuentemente, manifestaciones iniciales de la cardiopatía isquémica. Estudios post mórtem han indicado que la composición de las placas ateromatosas es un factor determinante para la predisposición de las lesiones coronarias a la rotura y el subsiguiente evento clínico. La mayor parte de estos eventos está relacionada con la rotura de placas ateromatosas situadas en lesiones hemodinámicamente no significativas. La detección de estas placas no obstructivas, pero ricas en lípidos, podría tener un gran impacto en la prevención del infarto y la muerte súbita. Actualmente, hay diversas técnicas intravasculares capaces de evaluar distintos determinantes de vulnerabilidad coronaria localmente, tales como el tamaño del core lipídico, el grosor y la inflamación de la cápsula fibrosa y el remodelamiento positivo. Mediante la conducción de estudios prospectivos, estas nuevas modalidades poseen el potencial para proveer in vivo información acerca de la fisiopatología de la historia natural de la aterosclerosis coronaria. Sudden cardiac death or unheralded acute coronary syndromes are common initial manifestations of coronary atherosclerosis and most such events occur at sites of non-flow limiting coronary atherosclerosis. Autopsy data suggests that plaque composition is a key determinant of the propensity of atherosclerotic lesions to provoke clinical events. Most of these events are related to plaque rupture and subsequent thrombotic occlusion at the site of non-flow limiting atherosclerotic lesions in epicardial coronary arteries. Detection of these non-obstructive, lipid rich, high-risk plaques may have an important impact on the prevention of acute myocardial infarction and sudden death. Currently, there are several intravascular tools capable of locally evaluating determinants of plaque vulnerability such as the size of the lipid core, thickness of the fibrous cap, inflammation within the cap and positive remodeling. These new modalities have the potential to provide insights into the pathophysiology of the natural history of coronary plaque by means of prospective studies.

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To investigate if recent technical and procedural developments in percutaneous coronary intervention (PCI) significantly influence outcomes in appropriately selected patients with three-vessel (3VD) coronary artery disease.The SYNTAX II study is a multicenter, all-comers, open-label, single arm study that investigated the impact of a contemporary PCI strategy on clinical outcomes in patients with 3VD in 22 centres from four European countries. The SYNTAX-II strategy includes: heart team decision-making utilizing the SYNTAX Score II (a clinical tool combining anatomical and clinical factors), coronary physiology guided revascularisation, implantation of thin strut bioresorbable-polymer drug-eluting stents, intravascular ultrasound (IVUS) guided stent implantation, contemporary chronic total occlusion revascularisation techniques and guideline-directed medical therapy. The rate of major adverse cardiac and cerebrovascular events (MACCE [composite of all-cause death, cerebrovascular event, any myocardial infarction and any revascularisation]) at one year was compared to a predefined PCI cohort from the original SYNTAX-I trial selected on the basis of equipoise 4-year mortality between CABG and PCI. As an exploratory endpoint, comparisons were made with the historical CABG cohort of the original SYNTAX-I trial. Overall 708 patients were screened and discussed within the heart team; 454 patients were deemed appropriate to undergo PCI. At one year, the SYNTAX-II strategy was superior to the equipoise-derived SYNTAX-I PCI cohort (MACCE SYNTAX-II 10.6% vs. SYNTAX-I 17.4%; HR 0.58, 95% CI 0.39-0.85, P = 0.006). This difference was driven by a significant reduction in the incidence of MI (HR 0.27, 95% CI 0.11-0.70, P = 0.007) and revascularisation (HR 0.57, 95% CI 0.37-0.9, P = 0.015). Rates of all-cause death (HR 0.69, 95% CI 0.27-1.73, P = 0.43) and stroke (HR 0.69, 95% CI 0.10-4.89, P = 0.71) were similar. The rate of definite stent thrombosis was significantly lower in SYNTAX-II (HR 0.26, 95% CI 0.07-0.97, P = 0.045).At one year, clinical outcomes with the SYNTAX-II strategy were associated with improved clinical results compared to the PCI performed in comparable patients from the original SYNTAX-I trial. Longer term follow-up is awaited and a randomized clinical trial with contemporary CABG is warranted.NCT02015832.

Background Volumetric intravascular ultrasound (IVUS) assessment provides complementary information on atherosclerotic plaques. The volumes can be calculated by applying Simpson's rule to cross-sectional area data of multiple IVUS images, acquired with a fixed sample spacing, which is the distance (along the vessel's axis) between two images. Objective To evaluate the effect of different sample spacings on the results of volumetric IVUS measurements. Methods A stepwise electrocardiographically gated IVUS image-acquisition and automated three-dimensional analysis approach was applied to 26 patients. Twentyeight coronary segments with mild-to-moderate coronary atherosclerosis were examined. Volumetric measurements of five images per mm (i.e. sample spacing 0.2 mm), representing a complete scanning of the coronary segment, were considered the optimal standard, against which volumetric measurements of three, one, and one-half images per mm (i.e. larger sample spacings) were compared. Results The lumen, total vessel, and plaque volumes obtained with five images per mm were 183.3 ± 2.8, 350.6 ± 141.6, and 167.3 ± 89.2 mm3. There was an excellent correlation (r = 0.99, P< 0.001) between these data and volumetric measurements with larger sample spacings. The volumetric measurements with larger sample spacings differed on average only by a little (< 0.7%) from the optimal standard measurements. However, a relatively small, but significant, increase in SD of these differences was associated with the wider sample spacings <3.6%, P<0.05). Conclusions The width of the sample spacing has a relatively small but significant impact on the variability of volumetric intravascular ultrasound measurements. This should be considered when designing future volumetric studies. The electrocardiographically gated acquisition of five IVUS images per mm axial length during a stepwise transducer pull-back is an ideal approach, particularly when addressing with IVUS volumetric changes that are assumed small, such as those expected in studies of the progression and regression of atherosclerosis.

Due to the recent emergence of adjunctive techniques such as cardiopulmonary bypass support, left main angioplasty may become more routinely applied in the near future. In order to choose the best possible therapy, a precise risk assessment will be desirable. Twenty‐two left main angioplasties were thus reviewed and patients were divided in two groups according to a risk score adapted from a previously published jeopardy score. Group I included patients with a risk score ≤ 6 and group II patients with a risk score &gt; 6. A cutoff criterion of six points was chosen because it represents the maximal amount of myocardium put at jeopardy from a single coronary stenosis. The success rate of the procedure was 77% and was similar in both groups. Of the 12 patients in group I, two patients underwent in‐hospital bypass surgery and one of them died. Among the ten patients of group II, one sustained a myocardial infarction, three underwent acute surgery, and one patient died postoperatively. After a mean follow‐up of 41 months, the total mortality rate was 17% in group I and 30% in group II. The long‐term event‐free survival rate was 75% in group I and 10% in group II (P = 0.004). The risk score was found to be a potentially important predictor of sustained success (long‐term success: 4.4 ± 2.9 vs no long‐term success: 8.3 ± 3.4; P = 0.01), although sophisticated statistical analysis was limited by the small number of patients. Thus, in patients with a low risk score, angioplasty seems to be an appropriate treatment while it appears that surgery should remain the standard therapy for patients with a calculated high risk score. However, the clinical significance of this new risk score remains to be determined with more elaborate statistical analysis applied to a larger number of patients.

Hemodynamic assessment of untreated nonculprit lesions was not studied in the PROSPECT study (Providing Regional Observations to Study Predictors of Events in the Coronary Tree). We developed a virtual intravascular ultrasound-derived lesion-specific fractional flow reserve (lesion-specific IVUS-FFR) algorithm to assess individual lesion-level FFR. We sought to investigate the relation between lesion-specific IVUS-FFR and major adverse cardiovascular events (MACE) arising from untreated nonculprit lesions in the PROSPECT study.In PROSPECT, 697 patients with acute coronary syndromes underwent 3-vessel grayscale and virtual histology-IVUS to correlate untreated nonculprit plaque morphology with 3-year nonculprit related MACE (composite of cardiac death, cardiac arrest, myocardial infarction, or rehospitalization due to unstable or progressive angina). Lesion-specific IVUS-FFR was calculated from volumetric IVUS lumen area measurements at 0.4 mm intervals by applying a mathematical circulation model using basic fluid dynamics equations.Lesion-specific IVUS-FFR was analyzable in 3227 nonculprit lesions in 660 patients among whom 54 nonculprit MACE events (3 myocardial infarctions) occurred at median 3.4-year follow-up. By receiver-operating characteristic analysis, the best cutoff value of lesion-specific IVUS-FFR to predict nonculprit MACE was ≤0.95. After adjusting for patient and lesion characteristics, lesion-specific IVUS-FFR (hazard ratio, 4.83 [95% CI, 2.20-10.61]; P<0.001) was an independent predictor of 3-year nonculprit MACE, in addition to minimum lumen area≤4.0 mm2, plaque burden ≥70%, and virtual histology thin-cap fibroatheroma.Minor reductions in lesion-specific IVUS-FFR were independently associated with future nonculprit MACE arising from untreated angiographically mild stenoses along with previously established high-risk lesion morphological characteristics.URL: https://www.gov; Unique identifier: NCT00180466.

Airway inflammation is characteristic of asthma. Distal inflammation may be particularly important.To calculate alveolar nitric oxide (NO) concentration (C(alv)) and bronchial flux NO (J(NO)) in children.We measured C(alv) and J(NO) from the fractional exhaled NO (FeNO(50)) measured at multiple exhalation flow rates in 132 children (aged 4-18 yr) with known atopic status, medication, and asthma control.Of participants, 85% (112/132) completed all measurements. In 20 of 112, the result did not fit the linear model. Thus, J(NO) and C(alv) were assessed in 92 (70%) subjects. The median (range) values of asthmatic (n = 52), normal (n = 20), and nonasthmatic atopic (n = 20) children were as follows: FeNO(50): 28.1 (4.3-190), 10.35 (3.3-29), 21.8 (8.7-69) ppb, respectively; J(NO): 1,230 (204-9,236), 480 (196-1,913), 1,225 (486-4,119) pl/s, respectively; C(alv): 2.22 (0.44-6.63), 1.63 (0.44-3), 1.21 (0.03-2.85) ppb, respectively. A reproducibility study in 18 other children gave intraclass correlation coefficients (single measures) of 0.99 (J(NO)) and 0.81 (C(alv)). J(NO) and C(alv) were higher in children with asthma than normal children (p = 0.0004 and p = 0.0002, respectively). Children with poorly controlled asthma (n = 27) had higher FeNO(50) measurements than children with good symptom control (n = 25): C(alv): mean (+/- SD), 3.17 +/- 1.62 versus 2.26 +/- 1.30 ppb, p = 0.03; J(NO): mean (+/- SD), 2,634 +/- 2,255 versus 1,193 +/- 1,294 pl/s, p = 0.007, respectively.Measurement of J(NO) and C(alv) is feasible in 70% of school-age children. FeNO(50) and J(NO) give the same information (r = 0.97, p < 0.0001), C(alv) is higher in asthmatic children than in normal children and is affected by asthma control, but not by atopy. C(alv) may possibly reflect alveolar inflammation in asthma.

Background: Visual angiographic assessment of left main (LM) bifurcation lesions is fraught with major limitations. Bifurcation‐dedicated quantitative coronary angiography (Bif‐QCA) assessment provides higher accuracy than standard QCA in bifurcation lesions. Fractal laws (e.g., Finet’s and Murray’s laws) can enhance the accuracy of reference diameter calculation when applied to angiography‐derived algorithms and may serve as a surrogate for pressure‐based assessment. Aims: To investigate the correlation between Bif‐QCA, Finet’s law derived Bif‐QCA (Finet‐QCA) and pressure–wire functional assessment for LM bifurcation stenosis. Methods: Using instantaneous wave‐free ratio (iFR) as a reference standard (≤ 0.89), we compared the value of Bif‐QCA and Finet‐QCA (diameter stenosis ≥ 50%). Moreover, the differences in MEDINA classification according to site‐reported visual assessment vs Bif‐QCA or Finet‐QCA were investigated. Results: Eighty‐four patients were included in the analysis, of which 72 (85.7%) presented an abnormal iFR. Bif‐QCA derived %DS was moderately correlated with iFR values; however, implementing Finet’s law in the correlation resulted weak. Site‐reported MEDINA (visual assessment) resulted in significant higher rate of 1,1,1 and lower rate of 1,0,0 patterns compared to Bif‐QCA MEDINA (9.5% vs. 1.2%, p &lt; 0.001 and 33.3% vs. 46.4%, p &lt; 0.001, respectively) and to Finet‐QCA MEDINA (9.5% vs. 2.4%, p &lt; 0.001 and 33.3% vs. 40%, p &lt; 0.001, respectively). Conclusions: The present study suggested that LM MEDINA bifurcation pattern should be based on QCA analysis rather than visual assessment, both in the context of clinical practice and clinical studies. Compared to conventional Bif‐QCA, the implementation of fractal laws (Finet‐QCA) did not appear to improve the determination of the reference diameters of the LM shaft.

Although most clinical trials of coronary stents have measured nominally identical safety and effectiveness end points, differences in definitions and timing of assessment have created confusion in interpretation.The Academic Research Consortium is an informal collaboration between academic research organizations in the United States and Europe. Two meetings, in Washington, DC, in January 2006 and in Dublin, Ireland, in June 2006, sponsored by the Academic Research Consortium and including representatives of the US Food and Drug Administration and all device manufacturers who were working with the Food and Drug Administration on drug-eluting stent clinical trial programs, were focused on consensus end point definitions for drug-eluting stent evaluations. The effort was pursued with the objective to establish consistency among end point definitions and provide consensus recommendations. On the basis of considerations from historical legacy to key pathophysiological mechanisms and relevance to clinical interpretability, criteria for assessment of death, myocardial infarction, repeat revascularization, and stent thrombosis were developed. The broadly based consensus end point definitions in this document may be usefully applied or recognized for regulatory and clinical trial purposes.Although consensus criteria will inevitably include certain arbitrary features, consensus criteria for clinical end points provide consistency across studies that can facilitate the evaluation of safety and effectiveness of these devices.