Early Coronary Angiography Research Articles

Immediate and early percutaneous coronary intervention in very high-risk and high-risk non-ST segment elevation myocardial infarction patients.

BackgroundThe European Society of Cardiology (ESC) guidelines for the management of acute coronary syndromes in patients presenting without persistent ST‐segment elevation (non‐ST‐segment elevation myocardial infarction [NSTEMI]) has recommended immediate (<2 h) percutaneous coronary intervention (PCI) in very‐high risk patients and early (<24 h) PCI in high‐risk patients.HypothesisTo examine the ESC NSTEMI guidelines adherence in a nationwide survey in Israel using the Acute Coronary Syndrome Israeli Survey (ACSIS). We hypothesized that adherence to the guidlines' recommnded PCI timing in NSTEMI pateints will be inadequate, partly due to the inconsistent evidence regarding its effect on clinical outcomes.MethodsAll NSTEMI patients who underwent PCI during the ACSIS surveys in 2016 and 2018 were included in the analysis.ResultsOut of 1793 NSTEMI patients, 1643 (92%) patients underwent PCI, and door to balloon time was documented in 1078 of them. One hundred and fifty‐six (14.5%) patients and 922 (85.5%) patients were defined as very high‐risk and high‐risk NSTEMI patients, respectively. Of the very high‐risk NSTEMI patients, only 10 (6.4%) underwent immediate coronary angiography, and 50 (32.1%) underwent early coronary angiography. Acute heart failure 139 (89.1%) was the main reason for including NSTEMI patients in the very high‐risk category. Of the high‐risk patients, early coronary angiography was performed in only 405 (43.9%) patients. Patients in whom coronary angiography was postponed were older and had more comorbidities.ConclusionsDespite guidelines recommendations for immediate and early PCI in very high‐risk and high‐risk NSTEMI patients, respectively, most patients do not undergo immediate or early PCI according to contemporary guidelines. Further studies are needed to better understand the reasons for guidelines' nonadherence in those high‐risk patients.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Percutaneous Coronary Revascularization after Out-of-Hospital Cardiac Arrest: A Review of the Literature and a Case Series.

Out-of-hospital cardiac arrest (OHCA) is still associated with high mortality and severe complications, despite major treatment advances in this field. Ischemic heart disease is a common cause of OHCA, and current guidelines clearly recommend performing immediate coronary angiography (CAG) in patients whose post-resuscitation electrocardiogram shows ST-segment elevation (STE). Contrarily, the optimal approach and the advantage of early revascularization in cases of no STE is less clear, and decisions are often based on the individual experience of the center. Numerous studies have been conducted on this topic and have provided contradictory evidence; however, more recently, results from several randomized clinical trials have suggested that performing early CAG has no impact on overall survival in patients without STE.

Bleeding Episodes in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome Undergoing Very Early Versus Standard Care Invasive Examination (from the Very EaRly vs Deferred Invasive Evaluation Using Computerised Tomography [VERDICT] Trial)

Bleeding is known to influence the prognosis in patients with acute coronary syndromes. In this predefined secondary outcome analysis of the Very EaRly vs Deferred Invasive evaluation using Computerized Tomography (VERDICT) trial, we investigated whether a very early invasive coronary angiography (ICA), compared with one performed within 48 to 72hours (standard care), was associated with fewer serious bleedings. Furthermore, we tested the association between demographic data including GRACE score and serious bleedings as well as bleedings and mortality. In the 2,147 patients included in the main study, bleedings within 30days of admission were assessed based on Thrombolysis In Myocardial Infarction and Bleeding Academic Research Consortium criteria. Differences were calculated by cumulative incidence methods and Grays test. Variables associated with bleeding and mortality were estimated by Cox proportional hazard models. Serious (Bleeding Academic Research Consortium 3abc) bleeding rates were low (15 [1.4%, standard] vs 12 [1.2%, early], p=0.56). There were no fatal bleedings or serious bleedings before ICA in either group. By multivariate analysis, there was no difference in bleedings between the 2 groups. Female gender (hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.2 to 6.4; p=0.02), anemia (HR 7.0, 95% CI 2.8 to 17.0; p <0.001), and increasing blood pressure (HR 1.3, 95% CI 1.1 to 1.5; p=0.01) were individually associated with serious bleeding, whereas GRACE score >140 was not (HR 1.03, 95% CI 0.4 to 2.9; p=0.96). In conclusion, serious bleedings were few, and there were none before ICA in either group. A very early invasive strategy did not reduce serious bleedings within 30days, which was associated with female gender, increasing blood pressure, and anemia.

The influence of timing of coronary angiography on acute kidney injury in out-of-hospital cardiac arrest patients: a retrospective cohort study

BackgroundAcute kidney injury (AKI) is a frequent complication in cardiac arrest survivors and associated with adverse outcome. It remains unclear whether the incidence of AKI increases after the post-cardiac arrest contrast administration for coronary angiography and whether this depends on timing of angiography. Aim of this study was to investigate whether early angiography is associated with increased development of AKI compared to deferred angiography in out-of-hospital cardiac arrest (OHCA) survivors.MethodsIn this retrospective multicenter cohort study, we investigated whether early angiography (within 2 h) after OHCA was non-inferior to deferred angiography regarding the development of AKI. We used an absolute difference of 5% as the non-inferiority margin. Primary non-inferiority analysis was done by calculating the risk difference with its 90% confidence interval (CI) using a generalized linear model for a binary outcome. As a sensitivity analysis, we repeated the primary analysis using propensity score matching. A multivariable model was built to identify predictors of acute kidney injury.ResultsA total of 2375 patients were included from 2009 until 2018, of which 1148 patients were treated with early coronary angiography and 1227 patients with delayed or no angiography. In the early angiography group 18.5% of patients developed AKI after OHCA and 24.1% in the deferred angiography group. Risk difference was − 3.7% with 90% CI ranging from − 6.7 to − 0.7%, indicating non-inferiority of early angiography. The sensitivity analysis using propensity score matching showed accordant results, but no longer non-inferiority of early angiography. The factors time to return of spontaneous circulation (odds ratio [OR] 1.12, 95% CI 1.06–1.19, p < 0.001), the (not) use of angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker (OR 0.20, 95% CI 0.04–0.91, p = 0.04) and baseline creatinine (OR 1.05, 95% CI 1.03–1.07, p < 0.001) were found to be independently associated with the development of AKI.ConclusionsAlthough AKI occurred in approximately 20% of OHCA patients, we found that early angiography was not associated with a higher AKI incidence than a deferred angiography strategy. The present results implicate that it is safe to perform early coronary angiography with respect to the risk of developing AKI after OHCA.

Sex disparities in management and outcomes of cardiac arrest complicating acute myocardial infarction in the United States

BackgroundThere have been limited large scale studies assessing sex disparities in the outcomes of cardiac arrest (CA) complicating acute myocardial infarction (AMI). Methods and resultsUsing the National Inpatient Sample (2000–2017), we identified adult admissions (≥18 years) with AMI and CA. Outcomes of interest included sex disparities in coronary angiography (early [hospital day zero] and overall), time to angiography, percutaneous coronary angiography (PCI), mechanical circulatory support (MCS) use, in-hospital mortality, hospitalization costs, hospital length of stay and discharge disposition. In the period between January 1, 2000-December 31, 2017, 11,622,528 admissions for AMI were identified, of which 584,216 (5.0%) were complicated by CA. Men had a higher frequency of CA compared to women (5.4% vs. 4.4%; p < 0.001). Women were on average older (70.4 ± 13.6 vs 65.0 ± 13.1 years), of black race (12.6% vs 7.9%), with higher comorbidity, presenting with non-ST-segment-elevation AMI (36.4% vs 32.3%) and had a non-shockable rhythm (47.6% vs 33.3%); all p < 0.001. Women received less frequent coronary angiography (56.0% vs 66.2%), early coronary angiography (32.0% vs 40.2%), PCI (40.4% vs 49.7%), MCS (17.6% vs 22.0%), and CABG (8.3% vs 10.8%), with a longer median time to angiography (all p < 0.001). Women had higher in-hospital mortality (52.6% vs 40.6%, adjusted odds ratio 1.13 [95% confidence interval 1.11–1.14]; p < 0.001), shorter length of hospital stays, lower hospitalization costs and less frequent discharges to home. ConclusionDespite no difference in guideline recommendations for men and women with AMI-CA, there appears to be a systematic difference in the use of evidence-based care that disadvantages women.

Angiography after Out-of-Hospital Cardiac Arrest without ST-Segment Elevation

BackgroundMyocardial infarction is a frequent cause of out-of-hospital cardiac arrest. However, the benefits of early coronary angiography and revascularization in resuscitated patients without electrocardiographic evidence of ST-segment elevation are unclear.MethodsIn this multicenter trial, we randomly assigned 554 patients with successfully resuscitated out-of-hospital cardiac arrest of possible coronary origin to undergo either immediate coronary angiography (immediate-angiography group) or initial intensive care assessment with delayed or selective angiography (delayed-angiography group). All the patients had no evidence of ST-segment elevation on postresuscitation electrocardiography. The primary end point was death from any cause at 30 days. Secondary end points included a composite of death from any cause or severe neurologic deficit at 30 days.ResultsA total of 530 of 554 patients (95.7%) were included in the primary analysis. At 30 days, 143 of 265 patients (54.0%) in the immediate-angiography group and 122 of 265 patients (46.0%) in the delayed-angiography group had died (hazard ratio, 1.28; 95% confidence interval [CI], 1.00 to 1.63; P=0.06). The composite of death or severe neurologic deficit occurred more frequently in the immediate-angiography group (in 164 of 255 patients [64.3%]) than in the delayed-angiography group (in 138 of 248 patients [55.6%]), for a relative risk of 1.16 (95% CI, 1.00 to 1.34). Values for peak troponin release and for the incidence of moderate or severe bleeding, stroke, and renal-replacement therapy were similar in the two groups.ConclusionsAmong patients with resuscitated out-of-hospital cardiac arrest without ST-segment elevation, a strategy of performing immediate angiography provided no benefit over a delayed or selective strategy with respect to the 30-day risk of death from any cause. (Funded by the German Center for Cardiovascular Research; TOMAHAWK ClinicalTrials.gov number, NCT02750462.)

Early angiography in elderly patients with non-ST-segment elevation acute coronary syndrome: The cardio CHUS-HUSJ registry

In elderly patients with non-ST elevation acute coronary syndrome (NSTEACS), while routine invasive management is established in high-risk NSTEACS patients, there is still uncertainty regarding the optimal timing of the procedure. This study analyzes the association of early coronary angiography with all-cause mortality, cardiovascular mortality, heart failure (HF) hospitalization, and major adverse cardiovascular events (MACE) in patients older than 75years old with NSTEACS. This retrospective observational study included 7811 consecutive NSTEACS patients who were examined between the years 2003 and 2017 at two Spanish university hospitals. There were 2290 patients older than 75years old. We compared their baseline characteristics according to the early invasive strategy used (coronarography ≤24h vs. coronarography >24h) after the diagnosis of NSTEACS. Among the study participants, 1566 patients (68.38%) underwent early invasive coronary intervention. The mean follow-up period was 46months (interquartile range 18-71months). This association was also maintained after propensity score matching: early invasive strategy was significantly related to lower all-cause mortality [HR 0.61 (95% CI 0.51-0.71)], cardiovascular mortality [HR 0.52 (95% CI 0.43-0.63)], and MACE [HR 0.62 (CI 95% 0.54-0.71)]. In a contemporary real-world registry of elderly NSTEACS patients, early invasive management significantly reduced all-cause mortality, cardiovascular mortality, and MACE during long-term follow-up. In this real-world retrospective observational study that included 2451 patients older than 75years old, 1566 patients (68.38%) underwent early invasive coronary intervention. After performing a propensity score matching, the early invasive strategy was still associated with lower all-cause mortality [HR (hazard ratio) 0.61, 95% CI (95% confidence interval) (0.51-0.71)], cardiovascular mortality [HR 0.52 (95%CI 0.43-0.63)], and MACE [HR 0.62 (95%CI 0.54-0.71)] during long-term follow-up.

Clinical Significance of Early Echocardiographic Changes after Resuscitated Out-of-Hospital Cardiac Arrest

BackgroundLeft Ventricular Systolic Dysfunction (LVSD) is common after out-of-hospital cardiac arrest (OOHCA) and can manifest globally or regionally, although its clinical significance has not been robustly studied. This study evaluates the association between LVSD, extent of coronary artery disease (CAD) and outcome in those undergoing early echocardiography and coronary angiography after OOHCA. MethodsTrans-thoracic echocardiography (TTE) was performed in OOHCA patients on arrival to our centre between May 2012 and December 2017. Rates of cardiogenic shock and extent of CAD, respectively classified by SCAI grade and the SYNTAX score, were measured. The primary end-point was 12-month mortality. ResultsFrom 398 patients in the King’s Out of Hospital Cardiac Arrest Registry (KOCAR), 266 patients (median age 61 [53–71], 76% male) underwent both TTE and coronary angiography on arrival. 96 patients (36%) had significant LVSD (Left Ventricular Ejection Fraction [LVEF] <40%) and 139 (52.2%) patients had regional wall motion abnormalities (RWMAs). Patients with LVEF <40% had more SCAI grade C-E shock (65.3% vs. 34.5%, p <0.001) and higher 12-month mortality (55.2% vs 31.8%, p <0.001) which was more likely to be due to a cardiac aetiology (27.3% vs 5.3%, p <0.001). Patients with RWMAs had higher median SYNTAX scores (14.75 vs 7, p=0.001), culprit coronary lesions (83.5% vs. 45.3%, p <0.001) and lower 12-month mortality (29.5% vs 52%, p <0.001). ConclusionsPatients with LVEF <40% at presentation have an increased mortality, driven by cardiac aetiology death, while the presence of RWMAs is associated with a higher rate of culprit coronary lesions, representing a potentially reversible cause of the arrest, and improved survival at 1 year.

61-Year-Old Man With Nausea and Vomiting

61-Year-Old Man With Nausea and Vomiting

Timing of Coronary Angiography in Patients Following Out-of-Hospital Cardiac Arrest Without ST-Segment Elevation: A Systematic Review and Meta-Analysis of Randomized Trials

IntroductionOut-of-hospital cardiac arrest (OHCA) has a poor prognosis. The timing and role of early coronary angiography (CAG) in OHCA patients without ST elevation remains unclear. ObjectiveWe performed a meta-analysis of randomized controlled trials (RCTs) that compared early CAG to delayed CAG in OHCA patients without ST elevation. MethodsWe searched PubMed, Cochrane, and ClinicalTrials.gov databases (from inception to September 2021) for studies comparing early CAG to delayed CAG in OHCA patients without ST elevation. We used a random-effect model to calculate relative ratio (RR) with 95% confidence interval (CI). The primary outcome was all-cause mortality at 30 days. Secondary outcomes included neurological status with cerebral performance category ≤2 (CPC) and the rate of percutaneous coronary intervention (PCI) following CAG. ResultsA total of 6 RCTs including 1822 patients, of whom 895 underwent early CAG, and 927 underwent delayed CAG, were included in this meta-analysis. There was no statistically significant difference between the 2 groups in terms of 30-day all-cause mortality (Relative risk [RR] 1.06; 95%CI 0.94–1.20; P = 0.32; I2 = 13%), neurological status (CPC ≤2) (RR 1.01; 95%CI 0.90–1.13; P = 0.85, I2 = 37%), and rates of PCI following CAG (RR 1.08; 95%CI 0.84–1.39; P = 0.56; I2 = 49%). ConclusionIn patients suffering OHCA without ST-elevation, early CAG is not associated with reduced 30-day mortality when compared to patients who underwent delayed CAG. Given our meta-analysis results including multiple trials that have not shown a benefit, it is likely that updated guidelines will not support early angiography in patients suffering OHCA without ST-elevation.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group.

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Cardiogenic shock complicating non-ST-segment elevation myocardial infarction: An 18-year study

To evaluate the epidemiology and outcomes of non-ST-segment-elevation myocardial infarction-cardiogenic shock (NSTEMI-CS) in the United States. Adult (>18 years) NSTEMI-CS admissions were identified using the National Inpatient Sample (2000-2017) and classified by tertiles of admission year (2000-2005, 2006-2011 and 2012-2017). Outcomes of interest included temporal trends of prevalence and in-hospital mortality, use of cardiac procedures, in-hospital mortality, hospitalization costs, and length of stay. In over 7.3 million NSTEMI admissions, CS was noted in 189,155 (2.6%). NSTEMI-CS increased from 1.5% in 2000 to 3.6% in 2017 (adjusted odds ratio 2.03 [95% confidence interval 1.97-2.09]; P < .001). Rates of non-cardiac organ failure and cardiac arrest increased during the study period. Between 2000 and 2017, coronary angiography (43.9%-63.9%), early coronary angiography (13.6%-25.6%), percutaneous coronary intervention (14.8%-31.6%), and coronary artery bypass grafting use (19.0%-25.8%) increased (P < .001). Over the study period, the use of intra-aortic balloon pump remained stable (28.6%-28.8%), and both percutaneous left ventricular assist devices (0%-9.1%) and extra-corporeal membrane oxygenation (0.1%-1.6%) increased (all P < .001). In hospital mortality decreased from 50.2% in 2000 to 32.3% in 2017 (adjusted odds ratio 0.27 [95% confidence interval 0.25-0.29]; P < .001). During the 18-year period, hospital lengths of stay decreased, and hospitalization costs increased. In the United States, prevalence of CS in NSTEMI has increased 2-fold between 2000 and 2017, while in-hospital mortality has decreased during the study period. Use of coronary angiography and percutaneous coronary intervention increased during the study period.

Early Coronary Angiography Is Associated with Improved 30-Day Outcomes among Patients with Out-of-Hospital Cardiac Arrest.

We evaluated the association between early coronary angiography (CAG) and outcomes in resuscitated out-of-hospital cardiac arrest (OHCA) patients, by linking data from the Singapore Pan-Asian Resuscitation Outcomes Study, with a national registry of cardiac procedures. The 30-day survival and neurological outcome were compared between patients undergoing early CAG (within 1-calender day), versus patients not undergoing early CAG. Inverse probability weighted estimates (IPWE) adjusted for non-randomized CAG. Of 976 resuscitated OHCA patients of cardiac etiology between 2011–2015 (mean(SD) age 64(13) years, 73.7% males), 337 (34.5%) underwent early CAG, of whom, 230 (68.2%) underwent PCI. Those who underwent early CAG were significantly younger (60(12) vs. 66(14) years old), healthier (42% vs. 59% with heart disease; 29% vs. 44% with diabetes), more likely males (86% vs. 67%), and presented with shockable rhythms (69% vs. 36%), compared with those who did not. Early CAG with PCI was associated with better survival and neurological outcome (adjusted odds ratio 1.91 and 1.82 respectively), findings robust to IPWE adjustment. The rates of bleeding and stroke were similar. CAG with PCI within 24 h was associated with improved clinical outcomes after OHCA, without increasing complications. Further studies are required to identify the characteristics of patients who would benefit most from this invasive strategy.

Long-term survival after a pharmacoinvasive strategy in patients with ST-elevation myocardial infarction and long distances to primary percutaneous coronary intervention – a prospective cohort study

Abstract Background In patients with ST-elevation myocardial infarction (STEMI), a pharmacoinvasive (PI) strategy is the recommended reperfusion method if primary percutaneous coronary intervention (pPCI) cannot be performed within 120 minutes from diagnosis. Long-term prognosis for STEMI patients with long transfer distances to pPCI is sparsely documented. Purpose To compare short- and long-term survival, and cardiovascular (CV) death in STEMI patients treated with PI or pPCI strategy. Methods Consecutive STEMI patients admitted to our cardiac invasive centre were registered prospectively during 2005–2011 in a local quality registry. Follow-up data throughout 2013 were provided by the Norwegian Cause of death registry. Effects of treatment strategy were determined using a propensity score weighted analysis, adjusting for treatment-outcome confounding. Outcomes were 30-day mortality, overall survival and CV death during follow-up. Results Of 4762 STEMI patients, 543 (11.4%) were treated with thrombolysis before admission for rescue- or early coronary angiography (PI strategy), and 4044 (84.9%) were admitted for a pPCI strategy (3,7% excluded due to unspecified treatment strategy). Median age was 60 and 63 years in the PI and pPCI groups (19.5% and 24.1% women, respectively). Median time to reperfusion was 110 minutes (25–75th percentile: 75–163; symptom-to-thrombolysis) versus 230 minutes (149–435; symptom-to-balloon). Crude 30-day mortality was 3.9% and 6.6% in the PI- and pPCI groups. Median follow-up was 4.5 years (max 8.3 years). The overall 8-year survival was 84.6% (95% CI 79.4–88.4) in the PI group and 72.6% (95% CI 70.1–74.9) in the pPCI group (crude hazard ratio [HR] 0.56 (95% CI 0.43–0.72, p&amp;lt;0.0001). After propensity score weighting (based on age, gender, smoking, previous hypertension, stroke, diabetes, myocardial infarction, angina pectoris and peripheral artery disease, kidney function and pre-hospital resuscitation), patients had estimated 25% lower risk of long-term mortality with a PI strategy (weighted HR 0.75; 95% CI 0.53–1.07, p=0.113, Figure 1A). Cumulative incidence rate of CV death was 12.8 (PI strategy) and 27.8 (pPCI strategy) pr 1000 person-years (crude incidence rate ratio 0.46; 95% CI 0.32–0.68, p&amp;lt;0.0001), and was significantly lower in the PI group after weighting on the propensity score (p=0.048, Figure 1B). Conclusions There was a non-significant 25% lower risk of mortality up to 8 years with a PI versus pPCI strategy in STEMI patients with long transfer distances to PCI, after adjustment for treatment-outcome confounding. Importantly, long-term incidence of CV death was significantly lower in the PI group. These findings from real life practice support the use of a PI strategy in STEMI patients without contraindications to thrombolysis, when pPCI within 120 minutes from diagnosis is not possible. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Funded by grant form the Scientific Board of the Southeastern Norway Regional Health Authority, Hamar, Norway.

Complete Revascularisation is associated with Improved Survival after Out of Hospital Cardiac Arrest

Abstract Introduction Coronary artery disease (CAD) is common in patients with Out of Hospital Cardiac Arrest (OOHCA) but the clinical relevance of burden of CAD and evidence for revascularisation strategies in relation to outcomes and modes of death remains unclear. Purpose This study sought to assess the extent of CAD as defined by the SYNTAX score and prognostic value of complete compared with incomplete revascularisation by evaluating the SYNTAX revascularisation index (SRI) in patients with OOHCA. Methods 619 patients with OOHCA were admitted at our centre between 1st May 2012 and 31st December 2017. 237 were excluded for having a non-cardiac aetiology or prior neurological disability. 398 patients were included into the study and of these 272 (68.3%) had early coronary angiography (CAG) and were included in the final analysis. The baseline SYNTAX score (bSS) and residual SYNTAX score (rSS) were determined from the coronary angiograms by a cardiologist blinded to the outcome. Patients were subdivided into 4 subgroups according to quartiles of the baseline syntax score (bSS) of 0, Group A: 1–10, Group B: 11–20 and Group C: ≥21. Complete revascularisation (CR) was defined as SRI of 1 and incomplete (IR) as SRI &amp;lt;1 where the SRI=(1-[rSS/bSS]) ×100 (Figure 1). Results Patients with a bSS of 0 were younger, had less shockable initial arrest rhythms and worse lactate and pH on arrival.Patients with bSS&amp;gt;0 (i.e., those with coronary artery disease) had similar cardiac arrest circumstances in terms of rates of witnessed, bystander CPR and shockable rhythms. Admission metabolic status reflected by pH and lactate and rates of ST elevation/LBBB were also identical for all three groups. However, LVEF on admission decreased significantly as coronary complexity increased (P&amp;lt;0.0001). While early angiography was more preferentially performed in those with higher coronary complexity, paradoxically, those with bSS 1–4 had highest rates of culprit lesions which was reflected in higher rates of PCI (Figure 1). 124 (45.4%) had CR compared with 54.2% with IR. CR was most likely to be achieved as the coronary complexity reduced (Group A – 71.7%, Group B – 41.1%, Group C - 23.3%). There was no difference in rates of cardiogenic shock between both groups (CR 61.1% vs. IR 69% p=ns), but patients with complete revascularisation were younger (58.8 vs 67.8, p&amp;lt;0.0001), lower rates of hypertension and previous CABG (16.2% vs 3.2%, p≤0.0001) CR was associated with decreased mortality at 30 days (45.9% vs 34.6%, p=0.046) and 12 months (49.3% vs 35.4%, p=0.022). The lower mortality rate in CR appeared to partly be driven by lower cardiac deaths though this was not statistically significant (22% vs 7%, p=0.1) (Figure 2). Conclusions CR in a primary coronary aetiology OOHCA group is associated with reduced early and long-term mortality, which may be driven by a reduction in cardiac deaths. Prospective randomised trials in this population are warranted. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Association of quality indicators for acute myocardial infarction and mortality: feasibility and validation study using linked nationwide registry data

BackgroundQuality indicators (QIs) have been increasingly used as tools to assess and improve the quality of care for acute myocardial infarction (AMI). However, it is not known if it is feasible to use the 2020 iteration of international AMI QIs using routinely collected data and, if so, whether higher performance is associated with improved outcomes.ObjectiveTo investigate if routine data are available to measure care quality against the 2020 European Society of Cardiology (ESC) Association for Acute Cardiovascular Care (ACVC) QIs for AMI, investigate whether higher performance is associated with reduced mortality, and to report quality of care during the COVID-19 pandemic.MethodsCohort study of linked data from the AMI and percutaneous coronary intervention (PCI) registries in England and Wales with outcome data from the Civil Registration of Deaths Register between 2017 and 2020 (representing 236 743 patients from 186 hospitals). Baseline ischaemic risk was estimated using the Global Registry of Acute Coronary Events (GRACE) risk score. The likelihood of attainment for each QI based on GRACE risk was quantified using logistic regression and the association with mortality at 30 days, 6 months, 1 year and long-term (maximum 1243 days) was obtained from Cox proportional hazard models.ResultsOf 26 QIs, 17 (65.3%) could be directly measured using nationwide registry data and were each inversely associated with risk-adjusted 1-year and long-term mortality. At 30 days, the measured QIs with exception of early invasive coronary angiography for non-ST elevation myocardial infarction, were associated with improved survival, and the QIs that had the greatest magnitude for a reduction in mortality were the prescription of secondary prevention medications at discharge; hazard ratio 0.13 (95% CI 0.12–0.14) for statins, 0.16 (95% CI 0.15–0.18) for adequate P2Y12 inhibition, and 0.18 (95% CI 0.17–0.20) for dual antiplatelet therapy (Figure 1). The magnitude of association between the composite QI (CQI) and survival attenuated over time, with greater long-term survival gains observed for the high GRACE risk compared with low- and intermediate-risk (Figure 2). During the first UK lockdown there was an improvement in the attainment for 62.5% of the measured QIs compared with before the COVID-19 pandemic, with a higher attainment for the CQI (43.8% to 45.2%, odds ratio 1.06, 95% CI 1.02–1.10).ConclusionCare quality for AMI may be evaluated using routinely collected clinical data from the national registries, whereby higher performance is associated with reduced mortality. Such QIs will have a role in monitoring hospital care as demonstrated for COVID-19.Funding AcknowledgementType of funding sources: None. Figure 2. QI association with long-term mortality

Long-term validation of the GRACE and PRECISE-DAPT scores in patients with non-ST elevation acute coronary syndrome

Abstract Introduction and objectives There is insufficient data regarding risk scores validation in patients with diabetes mellitus and non-ST elevation acute coronary syndrome (NSTEACS). We performed a diabetes mellitus-specific analysis of cardiovascular outcomes after NSTEACS using a large contemporary cohort of patients from two tertiary hospitals. Methods This work is a retrospective analysis from a prospective registry, that included 7415 consecutive NSTEACS patients from two Spanish Universitary Hospitals between the years 2003 and 2017. We tested the predictive power of the GRACE and PRECISE DAPT score, calculating the area under the ROC curve among with and without diabetes mellitus patients. Results Among the study participants, 2124 patients (28.0%) were diabetic. The median follow up was 54,3 months (IQR 24.7–80.0 months). Diabetic patients were more women (30.5% vs 25.7%) and older (70.0±10.8 vs 65.3±13.2 years old); they had higher GRACE (146±36 vs 137±36), PRECISE DAPT (15±7 vs 18±9) and CRUSADE (17±14 vs 30±18) at admission. Early invasive coronary angiography (≤24 hours after admission) was performed more frequently in non-diabetic. We tested the predictive power of the GRACE and PRECISE DAPT risk scores among diabetic and non-diabetic. PRECISE DAPT risk score showed a good predictive power for all-cause mortality, cardiovascular mortality and MACE in diabetic admitted with NSTEACS, without differences compared to non diabetic. Conclusions PRECISE DAPT risk score has an appropriate predictive power in diabetic patients admitted with NSTEACS compared to non diabetic NSTEACS. However, GRACE would be predictive worse in non diabetic during long term follow up in a large contemporary registry. Funding Acknowledgement Type of funding sources: None.

Prognostic benefit from an early invasive strategy in patients with non ST elevation acute coronary syndrome (NSTEACS): evaluation of the new risk stratification in the NSTEACS European guidelines

Abstract Objectives The objective of our work is to evaluate the prognostic benefit of an early invasive strategy in patients with high-risk NSTACS according to the recommendations of the 2020 clinical practice guidelines during long-term follow-up. Methods This retrospective observational study included 6454 consecutive NSTEACS patients. We analyze the effects of early coronary angiography (&amp;lt;24 h) in patients with: (a) GRACE risk score &amp;gt;140 and (b) patients with “established NSTEMI” (non ST-segment elevation myocardial infarction defined by an increase in troponins) or dynamic ST-T-segment changes with a GRACE risk score &amp;lt;140. Results From 2003 to 2017, 6454 patients with “new high-risk NSTEACS” were admitted, and 6031 (93.45%) of these underwent coronary angiography. After inverse probability of treatment weighting, the long-term cumulative probability of being free of all-cause mortality, cardiovascular mortality and MACE differed significantly due to an early coronary interven- tion in patients with NSTEACS and GRACE &amp;gt;140 [HR 0.62 (IC 95% 0.57–0.67), HR 0.62 (IC 95% 0.56–0.68), HR 0.57 (IC 95% 0.53–0.61), respectively]. In patients with NSTEACS and GRACE &amp;lt;140 with established NSTEMI or ST/T-segment changes, the benefit of the early invasive strategy is only observed in the reduction of MACE [HR 0.62 (IC 95% 0.56–0.68)], but not for total mortality [HR 0.96 (IC 95% 0.78–1.2)] and cardiovascular mortality [HR 0.96 (IC 95% 0.75–1.24)]. Conclusions An early invasive management is associated with reduced all-cause mortality, cardiovascular mortality and MACE in NSTEACS with high GRACE risk score. However, this benefit is less evident in the subgroup of patients with a GRACE score &amp;lt;140 with established NSTEMI or ST/T-segment changes. Funding Acknowledgement Type of funding sources: None.