Platelet glycoprotein IIb/IIIa inhibitors (GPIs) have been part of the adjuvant treatment of acute coronary syndrome for years. However, real-life data regarding the efficacy and safety of GPIs under the current indications are lacking in the setting of potent platelet inhibition. The objectives were to assess the efficacy and safety of abciximab versus tirofiban in patients with ST-elevation acute myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PPCI) and pretreated with ticagrelor, and to identify independent predictor factors of efficacy, bleeding and platelet drop. Three hundred sixty-two patients were divided by GPI administered. Clinical, laboratory, angiographic and outcome characteristics were compared. The primary objective was a composite efficacy endpoint (death from any cause, nonfatal myocardial infarction and nonfatal stroke) at 30 days. The secondary objectives were its individual components, safety (bleeding) and the impact on platelet count during hospital stay. The composite efficacy endpoint was similar in the abciximab and tirofiban groups (6.1% vs 7.3%; p = .632). There were also no differences in cardiovascular death (2.5% vs 2.4%; p = .958), nonfatal myocardial infarction (3% vs 4.3%; p = .521) and nonfatal stroke (0.5% vs 1.8%; p = .332). Tirofiban administration was associated with a higher incidence of bleeding (11.6% vs 22%; p = .008) with no differences in BARC ≥ 3b bleeding (3.6 vs 2.5%; p = .760). In STEMI patients undergoing PPCI with ticagrelor, abciximab and tirofiban had similar rates in the composite efficacy endpoint at 30 days. The 30-day bleeding rate was significantly higher in the tirofiban group. Tirofiban administration was an independent predictor of both bleeding and platelet count drop.

The authors provide a detailed 1-year follow-up of a patient with jailed pacemaker leads from transcatheter caval valve implantation. Clinical Images from Journal of Invasive Cardiology. pacemaker transcatheter caval valve implantation

A 76-year-old woman presented in cardiology clinic with New York Heart Association class II dyspnoea for the last 4 months. She had a history of severe mitral and moderate aortic stenosis that required double mechanical valve replacement 15 years ago. B-type natriuretic peptide was normal, and transthoracic echocardiogram showed that both prostheses had similar gradients to the last ones measured. Pulmonary function tests were normal. The patient kept referring persistent dyspnoea and other non-specific symptoms. Physical examination revealed significant aortic and mitral systolic murmurs. Erythematous painless macules on the palms and dark red subungual lesions in the nail beds of the fourth finger were found on both hands ( Figure 1). Routine blood cultures detected growth of Streptococcus gordonii. Although initial transthoracic echocardiogram could not detect any vegetation, a transoesophageal echocardiogram was performed and showed two mobile images in the atrial side of the mitral ring of 7 mm in length, suggesting vegetation, causing a mild periprosthetic leak in the mitral–aortic junction. F-fluorodeoxyglucose (F-FDG) positron emission tomography (PET)/computed tomography (CT) was performed due to the limitation of echocardiogram, and revealed two foci of hypermetabolism, in the aortic and predominantly the mitral valve ( Figure 2). According to modified Duke Criteria, patient was diagnosed of definite infective endocarditis fulfilling two major (positive echocardiography, abnormal activity around the site of prosthetic valve implantation by ¹⁸F-FDG PET/CT) and three minor criteria (predisposing heart condition, vascular phenomena—Janeway lesions—and positive blood culture). The case was discussed in a multidisciplinary heart team and a conservative medical approach based on ceftriaxone was decided. Janeway lesions are irregular, painless, erythematous or haemorrhagic macules, or papules commonly found on the palms and soles. The pathogenesis of Janeway lesions is still a controversial topic in the literature, but the main hypothesis is based on septic embolic events. Although current diagnosis of endocarditis is unlikely to be made only on the basis of Janeway lesions, the use of classic cutaneous signs of this entity could not be forgotten by clinicians, even in the post-antibiotic era of the developed world, to achieve the correct diagnosis.

Heart failure with reduced ejection fraction (HFrEF) is a major contributor to cardiovascular morbidity and mortality, with ischemic heart disease as the leading etiology. Despite advances in optimal medical treatment (OMT), the additional benefit of coronary revascularization in this population remains uncertain. While some studies describe a potential benefit in revascularization—particularly with coronary artery bypass grafting (CABG)—this benefit has not been consistently observed with percutaneous coronary intervention (PCI). Moreover, in this context, the role of myocardial hibernation has been called into question. Additionally, recent advances in the medical management of heart failure complicate the current interpretation of previous studies and underscore the need for new clinical trials. This review synthesizes the current evidence on the potential benefits of coronary revascularization in patients with heart failure with reduced ejection fraction (HFrEF).