The edition · Cardiology
Intravenous nicorandil did not improve one-year outcomes after primary PCI for STEMI
A 1,503-patient blinded trial finds no benefit on its primary endpoint; IVUS guidance helped far more in East Asian trials than elsewhere; and flutter alone carried a lower stroke rate than atrial fibrillation.
The edition in brief
The CLEAN trial randomised 1,503 patients with STEMI in China to intravenous nicorandil or placebo around primary PCI. The one-year composite of cardiovascular death, reinfarction, target vessel revascularisation or heart failure admission was 13.1% in both groups (rate ratio 0.87, 95% CI 0.65 to 1.16). Lower cardiovascular death and revascularisation were secondary findings only. A meta-analysis of 17 trials found IVUS-guided PCI reduced cardiac death overall (RR 0.71), but the benefit was concentrated in East Asian trials (RR 0.56) and absent in non-Asian ones (RR 1.23); stent thrombosis fell everywhere. In BRIGHT-4, bivalirudin with a post-PCI high-dose infusion reduced 30-day death or major bleeding in STEMI patients at low bleeding risk (1.4% vs 2.9%), with a similar direction in higher-risk patients. A Finnish registry of about 41,000 patients found atrial flutter alone carried a lower ischaemic stroke rate than atrial fibrillation (adjusted IRR 0.60), though this does not change anticoagulation guidance. An investigational amyloid-binding PET tracer showed 94% sensitivity and 86% specificity for cardiac amyloidosis across amyloid types.
IVUS-guided PCI cut cardiac death in East Asian trials but not elsewhere
IVUS helps when it changes what the operator does; use it with defined stent optimisation criteria, not as passive confirmation.
Bivalirudin's benefit in BRIGHT-4 held in patients at low bleeding risk
Where bivalirudin with a post-PCI high-dose infusion is used in STEMI, low bleeding risk is not a reason to withhold it.
Atrial flutter alone carried a lower stroke rate than atrial fibrillation
Anticoagulate atrial flutter as you would atrial fibrillation; the lower stroke rate in pure flutter is not yet a reason to change thresholds.
An amyloid PET tracer detected cardiac amyloidosis across amyloid types
An investigational amyloid PET tracer performed well across amyloid types, but the standard scintigraphy-plus-light-chain pathway remains the work-up.
Check the monoclonal protein before calling amyloid transthyretin
Do not diagnose transthyretin cardiac amyloidosis from a bone scan until a monoclonal protein has been excluded.
Routine intravenous nicorandil in primary PCI did not improve one-year outcomes
Stop giving intravenous nicorandil routinely to every patient having primary PCI; this trial found no effect on its primary outcome.
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