Coronary Thrombosis

Purpose of reviewTreatment of hypercholesterolemia with statins results in significant reductions in cardiovascular risk; however, individuals with well-controlled low-density lipoprotein cholesterol (LDL-C) levels, but persistent high triglycerides (TG), remain at increased risk. Genetic and epidemiologic studies have shown that elevated fasting TG levels are associated with incident cardiovascular events. At effective doses, omega-3 fatty acids, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), lower TG levels but may have additional atheroprotective properties compared to other TG-lowering therapies such as niacin and fibrates. The purpose of this review is to evaluate mechanisms related to the potential benefits of omega-3 fatty acids in atherothrombotic disease.Recent findingsLarge randomized clinical trials are currently under way to test the cardiovascular benefits of omega-3 fatty acids at a pharmacologic dosage (4 g/day). A large randomized trial with a prescription EPA-only formulation was shown to reduce a composite of cardiovascular events by 25% in statin-treated patients with established cardiovascular disease or diabetes and other CV risk factors. EPA and DHA have distinct tissue distributions as well as disparate effects on membrane structure and lipid dynamics, rates of lipid oxidation, and signal transduction pathways. Compared to other TG-lowering therapies, EPA has been found to inhibit cholesterol crystal formation, inflammation, and oxidative modification of atherogenic lipoprotein particles. The anti-inflammatory and endothelial benefits of EPA are enhanced in combination with a statin. Omega-3 fatty acids like EPA only at a pharmacologic dose reduce fasting TG and interfere with mechanisms of atherosclerosis that results in reduced cardiovascular events. Additional mechanistic trials will provide further insights into their role in reducing cardiovascular risk in subjects with well-managed LDL-C but elevated TG levels.

ObjectivesWe evaluate whether the thrombus aspiration (TA) before primary percutaneous coronary intervention (PPCI) may improve STEMI outcomes in hyperglycemic patients.BackgroundThe management of hyperglycemic patients during STEMI is unclear.MethodsWe undertook an observational cohort study of 3166 first STEMI. Patients were grouped on the basis of whether they received TA or not. Moreover, among these patients we selected a subgroup of STEMI patients with hyperglycemia during the event (glycaemia > 140 mg/dl). The endpoint at 1 year included all-cause mortality, cardiac mortality and re-hospitalization for coronary disease, heart failure and stroke.ResultsOne-thousand STEMI patients undergoing PPCI to plus TA (TA-group) and 1504 STEMI patients treated with PPCI alone (no-TA group) completed the study. In overall study-population, Kaplan-Meier-analysis demonstrated no significant difference in mortality rates between patients with and without TA (P = 0.065). After multivariate Cox-analysis (HR: 0.94, 95% CI 0.641-1.383) and the addition of propensity matching (HR: 0.86 95% CI 0.412-1.798) TA was still not associated with decreased mortality. By contrast, in hyperglycemic subgroup STEMI patients (TA-group, n = 331; no-TA group, n = 566), Kaplan-Meier-analysis demonstrated a significantly lower mortality (P = 0.019) in TA-group than the no-TA group. After multivariate Cox-analysis (HR: 0.64, 95% CI 0.379-0.963) and the addition of propensity matching (HR: 0.54, 95% CI 0.294-0.984) TA was still associated with decreased mortality.ConclusionsTA was not associated with lower mortality in PPCI for STEMI when used in our large all-comer cohort. Conversely, TA during PPCI for STEMI reduces clinical outcomes in hyperglycemic patients. Trial registration NCT02817542. 25th, June 2016.

PurposeTo develop a 3D whole-heart Bright-blood and black-blOOd phase SensiTive (BOOST) inversion recovery sequence for simultaneous noncontrast enhanced coronary lumen and thrombus/hemorrhage visualization.MethodsThe proposed sequence alternates the acquisition of two bright-blood datasets preceded by different preparatory pulses to obtain variations in blood/myocardium contrast, which then are combined in a phase-sensitive inversion recovery (PSIR)-like reconstruction to obtain a third, coregistered, black-blood dataset. The bright-blood datasets are used for both visualization of the coronary lumen and motion estimation, whereas the complementary black-blood dataset potentially allows for thrombus/hemorrhage visualization. Furthermore, integration with 2D image-based navigation enables 100% scan efficiency and predictable scan times. The proposed sequence was compared to conventional coronary MR angiography (CMRA) and PSIR sequences in a standardized phantom and in healthy subjects. Feasibility for thrombus depiction was tested ex vivo.ResultsWith BOOST, the coronary lumen is visualized with significantly higher (P ConclusionA new PSIR sequence for noncontrast enhanced simultaneous coronary lumen and thrombus/hemorrhage detection was developed. The sequence provided improved coronary lumen depiction and showed potential for thrombus visualization. Magn Reson Med 79:1460-1472, 2018. © 2017 International Society for Magnetic Resonance in Medicine. This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

BackgroundStent thrombosis (ST) remains a rare but potentially life-threatening complication of percutaneous coronary intervention (PCI), associated with high rates of myocardial infarction and mortality. Despite advances in stent technology and antithrombotic therapy, its multifactorial pathophysiology and optimal management remain challenging.MethodsWe performed a narrative review of the current literature focusing on the pathophysiological mechanisms, clinical predictors, and contemporary management strategies of ST. Particular attention was given to stent-related, pharmacological, and patient-related factors, as well as emerging therapeutic approaches and preventive strategies.ResultsST arises from the complex interplay between mechanical factors (e.g., stent malapposition, underexpansion, and neoatherosclerosis), pharmacological aspects (e.g., premature discontinuation or inadequate response to dual antiplatelet therapy), and patient-related conditions, including hypercoagulability and systemic inflammation. In the acute setting, prompt PCI with restoration of coronary flow remains the cornerstone of treatment, while intravascular imaging plays a key role in identifying underlying mechanisms and optimizing outcomes. Preventive strategies rely on procedural optimization, appropriate antithrombotic therapy, and careful patient selection. New-generation drug-eluting stents and imaging-guided PCI have reduced ST incidence, whereas emerging approaches-including drug-coated balloons, subcutaneous antiplatelet agents, and anti-inflammatory therapies-represent promising adjunctive strategies, although ST-specific benefits are not yet fully established.ConclusionsST is a multifactorial complication requiring an integrated approach combining optimized PCI techniques, tailored antithrombotic therapy, and careful risk stratification. Ongoing advances in device technology and pharmacological treatments, along with a growing understanding of inflammatory pathways, may further improve prevention and clinical outcomes.