Platelet inhibition induced by P2Y₁₂ receptor antagonists in patients with ST-elevation myocardial infarction (STEMI) can be affected by concomitant use of opioids. The aim of this trial was to examine the effect of intravenous (iv) acetaminophen compared with iv fentanyl on P2Y₁₂ receptor inhibition in patients with STEMI. The Opioids aNd crushed Ticagrelor In Myocardial infarction Evaluation (ON-TIME 3) trial randomized 195 STEMI patients who were scheduled to undergo primary percutaneous coronary intervention (PCI) and were pre-treated with crushed ticagrelor to iv acetaminophen (N = 98) or iv fentanyl (N = 97) in the ambulance. The primary endpoint, consisting of the level of platelet reactivity units (PRU) measured immediately after primary PCI, was not significantly different between the study arms [median PRU 104 (IQR 37–215) vs. 175 (63–228), P = 0.18]. However, systemic levels of ticagrelor were significantly higher in the acetaminophen arm at the start of primary PCI [151 ng/mL (32–509) vs. 60 ng/mL (13–206), P = 0.007], immediately after primary PCI [326 ng/mL (94–791) vs. 115 ng/mL (38–326), P = 0.002], and at 1 h after primary PCI [488 ng/mL (281–974) vs. 372 ng/mL (95–635), P = 0.002]. Acetaminophen resulted in the same extent of pain relief when compared with fentanyl [reduction of 3 points on 10-step-pain scale before primary PCI (IQR 1–5)] in both study arms (P = 0.67) and immediately after PCI [reduction of 5 points (3–7); P = 0.96]. The iv acetaminophen in comparison with iv fentanyl was not associated with significantly lower platelet reactivity in STEMI patients but resulted in significantly higher ticagrelor plasma levels and was effective in pain relief.

Background: There is uncertainty whether multivessel (MV-PCI) or culprit-only percutaneous coronary intervention (CO-PCI) should be the treatment of choice in patients with non-ST segment elevation acute coronary syndrome (NSTE-ACS) and multivessel disease (MVD). Aims: To evaluate clinical characteristics and outcomes in these patients undergoing MV-PCI or CO-PCI at the index procedure. Methods: Data were retrieved from the nationwide Netherlands Heart Registration. All NSTE-ACS patients with MVD undergoing PCI between 1 January 2017 and 1 October 2019 were grouped into a MV-PCI or CO-PCI group. The primary endpoint was all-cause mortality at long-term follow-up (median 756 days (593–996)). Secondary endpoints were reinterventions, urgent CABG, myocardial infarction (MI) < 30 days, target vessel revascularisation (TVR) and mortality at 1 year. Propensity score matching analyses were performed. Results: In total, 10,507 NSTE-ACS patients with MVD were included into the MV-PCI (N = 4235) and CO-PCI group (N = 6272). Analysing crude data, mortality rates at long-term follow-up (10.7% vs. 10.2%; p = 0.383), mortality at 1 year (6.0% vs. 5.6%; p = 0.412) and MI <30 days (0.8% vs. 0.9%; p = 0.513) were similar between both groups. Reinterventions (11.1% vs. 20.0%; p < 0.001), urgent CABG (0.1% vs. 0.4%; p = 0.001) and TVR (5.2% vs. 6.7%; p = 0.003) occurred less often in the MV-PCI group. Survival analysis after multiple imputation and propensity score matching showed similar mortality rates at long-term follow-up (log-rank p = 0.289), but a significant reduction for reinterventions in the MV-PCI group (log-rank p < 0.001). Conclusion: NSTE-ACS patients with MVD undergoing MV-PCI have similar mortality rates at long-term follow-up compared to CO-PCI. However, improved event-free survival in terms of fewer coronary reinterventions was observed.

Aims: Complete non-culprit (NC) revascularisation may help reduce recurrent events after non-ST-segment elevation myocardial infarction (NSTEMI), especially if NC lesions would harbour high-risk plaque (HRP) features similar to ST-segment elevation myocardial infarction (STEMI). This study aimed to assess differences in fractional flow reserve (FFR)-negative NC plaque morphology in patients presenting with NSTEMI vs. STEMI and assess the association of HRP morphology and clinical outcome. Methods and results: In the prospective PECTUS-obs study, 438 patients presenting with myocardial infarction (MI) underwent optical coherence tomography (OCT) of all FFR-negative intermediate NC lesions. The primary endpoint was the occurrence of major adverse cardiovascular events (MACE, composite of all-cause mortality, non-fatal MI or unplanned revascularisation) at 2-year follow-up. Four hundred and twenty patients had at least one analysable OCT, including 203 (48.3%) with NSTEMI and 217 (51.7%) with STEMI. The prevalence of HRPs, including thin-cap fibroatheromas, plaque rupture, and thrombus, was comparable between groups. MACE occurred in 29 (14.3%) NSTEMI patients and 16 (7.4%) STEMI patients (Puni-variable = 0.025 and Pmulti-variable = 0.270). Incidence of MACE was numerically higher among patients with HRP, irrespective of the clinical presentation at index (Pinteraction = 0.684). Among HRP criteria, plaque rupture was associated with MACE in both NSTEMI (P < 0.001) and STEMI (P = 0.020). Conclusion: Presence of NC HRP is comparable between NSTEMI and STEMI and leads to numerically higher event rates in both. These results call for additional research on complete revascularisation in NSTEMI and treatment of HRP. Clinical trial registration: NCT03857971

Background: Diabetes is a known risk factor of acute coronary syndrome (ACS). However, diabetes de novo and prediabetes are also common in ACS patients. This study explored the prevalence of prediabetes and diabetes de novo in ACS patients, glucose-mediating therapy at discharge, and compared the prevalence of 30-day major adverse cardiac and cerebrovascular events (MACCE) in patients with prediabetes and diabetes de novo with known diabetes. Methods: ACS patients with measured haemoglobin A1c (HbA1c) from the South-East Netherlands Heart Registry, a prospective, multicentre registry of patients undergoing percutaneous coronary intervention (PCI), were analysed. Patients were stratified into two groups: known diabetes, and prediabetes (HbA1c 39–47 mmol/mol) or diabetes de novo (HbA1c ≥ 48 mmol/mol). Outcomes were analysed at 30 days post-PCI. Results: HbA1c was available in 34.1% of ACS patients (n = 1836), of whom 526 (28.7%) had known diabetes, 619 (33.7%) prediabetes, and 180 (9.8%) diabetes de novo. Compared with patients with known diabetes, patients with prediabetes and diabetes de novo had a significantly higher risk of MACCE (HR = 1.81, 95% CI 1.12–2.93, p = 0.016) after multivariable adjustment. At discharge, 59% of patients with diabetes de novo received no insulin, metformin, nor sodium-glucose co-transporter-2 inhibitor, compared with 16% of patients with known diabetes (p < 0.001). Conclusions: Impaired glucose metabolism without known diabetes was observed in nearly 45% of ACS patients and they demonstrated a significantly higher risk of 30-day MACCE compared with patients with known diabetes. Despite clear guideline recommendations, routine screening for hyperglycaemia and the appropriate initiation of glucose-mediating therapy remain underutilised in clinical practice.

Background/Objectives: Despite progress in secondary prevention, people with chronic coronary syndrome (CCS) still face a residual risk of ischemic events. Antithrombotic therapy reduces this risk and helps stabilize chronic cardiovascular disease. Studies have shown that combining low-dose rivaroxaban with aspirin—an approach called dual-pathway inhibition (DPI)—can lower this risk and reduce major adverse cardiovascular events (MACEs). However, researchers have not yet gathered enough real-world data to confirm the efficacy and safety of this strategy. The DUTCH CCS registry aims to collect real-world data on how effective and safe low-dose rivaroxaban combined with aspirin is for patients with CCS in The Netherlands. The study aims to provide insights into the outcomes, benefits, and risks of DPI in a real-world setting, beyond the scope of controlled clinical trials. Methods: The DUTCH CCS registry operates as a national, multicenter, prospective observational study. It enrolls 1000 patients with CCS who receive rivaroxaban (2.5 mg twice daily) and aspirin (80 mg or 100 mg once daily). The study targets individuals at high ischemic risk due to coronary artery disease (CAD) and follows a single-arm design. Researchers will measure the primary efficacy endpoint by tracking MACEs, clinically driven coronary, peripheral, or carotid revascularization, and stent thrombosis over one year. They will assess the primary safety endpoint by recording major bleeding events at one year. The team will collect data at both 3-month and 1-year follow-ups. Conclusions: As an observational study, this registry is not designed to establish causality. However, it seeks to improve our understanding of how DPI performs in real-world secondary prevention for CCS patients. The results may help update treatment guidelines and inform clinical decisions in everyday practice.