Early Coronary Revascularization Research Articles

WELLENS SYNDROME: TIMELY RECOGNITION AND SUCCESSFUL REVASCULARIZATION

Abstract Wellens syndrome is a condition characterized by clinical and instrumental signs suggestive of a critical proximal left anterior descending (LAD) coronary artery stenosis and requires early revascularization. Diagnostic criteria include T–wave changes in ECG during asymptomatic periods in patients with a history of chest pain, absence of significant cardiac enzyme movement, no ST–segment elevation, preserved R–wave, and no pathological Q waves. Early recognition of this syndrome is crucial, due to its 10–15% prevalence, allowing proper management and myocardial function recovery, avoiding potentially catastrophic outcomes. A 64–year–old male, with hypertension, undiagnosed diabetes, and family history of CAD, presented to our ER with sudden, brief chest pain radiating to the left upper limb. Similar episodes had occurred in the past week. The patient denied previous cardiovascular events and home therapy. ECG conducted by the attending cardiologist, during free chest pain period, showed biphasic T–wave in V1–V3 (a). Admission ECG resembled the ambulatory one. Lab results: Hb 14.7 g/dl, Troponin I 0.059 ng/ml (cut–off 0.034). Echocardiogram indicated distal septum akinesia. Urgent coronary angiography was performed, detecting subocclusive stenosis in the proximal–mid LAD. Successful revascularization was achieved by PTCA and implantation of 1 DES. (b) Subsequently, the patient was admitted to the Cardiac Intensive Care Unit for multiparametric monitoring. The ECG showed deeply negative T waves from V1 to V6. (c) No complications during hospitalization. Discharge ECG showed repolarization anomalies improvement. Echocardiography revealed preserved systolic function, without global or segmental anomalies in wall motion. Wellens syndrome is a manifestation of acute coronary syndrome that precedes an anterior wall MI. This condition can be identified by its characteristic T–wave patterns on ECG. Patients with this syndrome have severe LAD occlusion and require early coronary intervention. In chest pain episodes, the ECG appears normal, and troponin levels often remain within the normal range, which can potentially provide false reassurance. Wellens syndrome is a cardiac emergency requiring immediate attention; it is crucial for the physician to promptly identify the typical ECG signs of Wellens Syndrome, facilitating early coronary revascularization to prevent adverse patient outcomes.

Mortality in patients with normal left ventricular function requiring emergency VA-ECMO for postcardiotomy cardiogenic shock due to coronary malperfusion.

To analyze outcomes in patients with normal preoperative left ventricular ejection fraction (LVEF) undergoing venoarterial extracorporeal membrane oxygenation (VA-ECMO) therapy due to postcardiotomy cardiogenic shock (PCCS) related to coronary malperfusion. Retrospective single-center analysis in patients with normal preoperative LVEF treated with VA-ECMO for coronary malperfusion-related PCCS between May 1998 and May 2018. The primary outcome was 30-day mortality, which was compared using the Kaplan-Meier method and the log-rank test. Multivariable logistic regression was performed to identify predictors of mortality. During the study period, a total of 62,125 patients underwent cardiac surgery at our institution. Amongst them, 59 patients (0.1%) with normal preoperative LVEF required VA-ECMO support due to coronary malperfusion-related PCCS. The mean duration of VA-ECMO support was 6 days (interquartile range 4-7 days). The 30-day mortality was 50.8%. Under VA-ECMO therapy, a complication composite outcome of bleeding, re-exploration for bleeding, acute renal failure, acute liver failure, and sepsis occurred in 51 (86.4%) patients. Independent predictors of 30-day mortality were lactate levels > 9.9 mmol/l before VA-ECMO implantation (odds ratio [OR]: 3.3; 95% confidence interval [CI] 1.5-7.0; p = 0.002), delay until revascularization > 278 minutes (OR: 2.9; 95% CI 1.3-6.4; p = 0.008) and peripheral arterial artery disease (OR: 3.3; 95% 1.6-7.5; p = 0.001). Mortality rates are high in patients with normal preoperative LVEF who develop PCCS due to coronary malperfusion. The early implantation of VA-ECMO before the development of profound tissue hypoxia and early coronary revascularization increases the likelihood of survival. Lactate levels are useful to define optimal timing for the VA-ECMO initiation.

Assessing the Role of MAPH Score in Predicting Acute Coronary Syndrome: A Cross-sectional Study

Introduction: Incorporating the concepts of hyperviscosity, platelet hyperactivity, and age-related risk of Acute Coronary Syndrome (ACS), a new score has been put forward-the Mean platelet volume-Age-total Protein-Haematocrit (MAPH) score, which can determine the increased thrombotic tendency associated with ST-Segment Elevation Myocardial Infarction (STEMI). The MAPH score includes parameters such as Mean Platelet Volume (MPV), age, total protein, and haematocrit. Researchers have found that a high MAPH score is associated with a high thrombus burden in cases with STEMI and Non ST-Elevation Myocardial Infarction (NSTEMI). However, the association between MAPH score and ACS is undefined. Aim: To assess the role of MAPH score in predicting ACS. Materials and Methods: This cross-sectional study was conducted in the Department of Pathology, Srinivas Institute of Medical Sciences and Research Centre Mangalore, Karnataka, India for six months. The study included 100 clinically diagnosed cases of ACS and 100 healthy controls. The demographic data, MPV, total protein, and haematocrit values of all cases and controls were collected and tabulated, and statistical analysis was performed. Receiver Operating Characteristic (ROC) curve analysis was performed on each MAPH score parameter, and cutoff values for each parameter were obtained based on the Youden index. After calculating the MAPH score of cases and controls, multivariate logistic regression analysis was performed to evaluate the role of the MAPH score as an independent predictor of ACS. Results: A statistically significant increase in MPV (p-value =0.017) and total protein (p-value<0.001) was noted among the cases. The calculated cut-off values for MPV, age, total protein, and haematocrit were 8.4 fL, 54 years, 6.8 g/dL, and 49.1%, respectively. A statistically significant increase in the MAPH score was noted among the cases compared to the controls. Finally, multivariate logistic regression analysis identified the MAPH score as an independent predictor of ACS. Conclusion: This was the first study investigating the association between MAPH scores in patients with ACS. The MAPH score was identified as an independent predictor of ACS and can be used as a screening tool to predict and diagnose the condition in primary healthcare settings. This helps to ensure early coronary revascularisation and reduce Coronary Artery Disease (CAD)- related mortality and morbidity to a greater extent.

Abstract 18529: Early Coronary Revascularization Among "Stable" Patients With Non-ST-Segment Elevation Acute Coronary Syndromes: The Role of Diabetes and Age

Introduction: Despite improvement in the management of patients with non-ST-elevation acute coronary (NSTE-ACS), this condition is still linked to a substantially increased mortality and morbidity among diabetic patients. Specifically, it remains uncertain whether patients whose condition can safely be stabilized at hospital admission should routinely receive an early coronary revascularisation. Hypothesis: We tested the hypothesis that a strategy of early coronary revascularization within 24 hours of diagnosis is superior to an initial conservative strategy in terms of clinical outcomes in diabetic patients who met stabilisation criteria at hospital admission. Comparison was made with a cohort of nondiabetic patients. Methods: The ISACS-TC database was queried for a sample of diabetic and nondiabetic patients with diagnosis of NSTE-ACS. Those with recurrent angina after hospital admission, cardiac arrest, haemodynamic instability, and serious ventricular arrhythmias were excluded. The characteristics between groups were adjusted using inverse probability of treatment weighting models. Co-primary end points were all cause 30-day mortality and the composite end point of all cause 30-day mortality and left ventricular (LV) systolic dysfunction. Risk ratios (RRs) with their 95% CIs were employed. Results: Of the 7,473 NSTE-ACS patients identified, 2,220 were diabetics. Early revascularization was associated with survival benefit only in the elderly (≥65 years) both in diabetics (3.7% vs 6.6%; RR: 0.56; 95% CI: 0.32-0.96) and nondiabetic patients (2.8% vs 5.1%: RR: 0.55; 95% CI: 0.34-0.87). In the elderly population, an initial conservative strategy increased the risk of death or LV systolic dysfunction by 15.2% in diabetics compared with nondiabetic patients (37.7% vs 32.7%; RR: 1.15; 95% CI: 1.02-1.30). Conclusions: Early coronary revascularization does not lead to any survival advantage within 30 days from admission in a large number of NSTE-ACS patients who present to hospital in stable conditions. An early invasive management strategy may be best reserved for the elderly either with or without diabetes. The benefit of this strategy appears to be more pronounced in the diabetic population.

Management of Cardiogenic Shock: Present and Future.

Management of Cardiogenic Shock: Present and Future.

Cardiogenic shock related cardiovascular disease mortality trends in US population: Heart failure vs. acute myocardial infarction as contributing causes

BackgroundObservational and trial data have revealed significant improvement in cardiogenic shock (CS) mortality due to acute myocardial infarction (AMI) after introducing early coronary revascularization. Less is known about CS mortality due to heart failure (HF), which is increasingly recognized as a distinct entity from AMI-CS. Methods and resultsIn this nationwide observational study, the CDC WONDER database was used to identify national trends in age-adjusted mortality rates (AAMR) due to CS (HF vs. AMI related) per 100,000 people aged 35–84.AAMR from AMI-CS decreased significantly from 1999 to 2009 (AAPC: -6.9% [95%CI -7.7, −6.1]) then stabilized from 2009 to 2020. By contrast, HF-CS associated AAMR rose steadily from 2009 to 2020 (AAPC: 13.3% [95%CI 11.4,15.2]). The mortality rate was almost twice as high in males compared to females in both AMI-CS and HF-CS throughout the study period. HF-CS mortality in the non-Hispanic Black population is increasing more quickly than that of the non-Hispanic White population (AAMR in 2020: 4.40 vs. 1.97 in 100,000). The AMI-CS mortality rate has been consistently higher in rural than urban areas (30% higher in 1999 and 28% higher in 2020). ConclusionsThese trends highlight the fact that HF-CS and AMI-CS represent distinct clinical entities. While mortality associated with AMI-CS has primarily declined over the last two decades, the mortality related to HF-CS has increased significantly, particularly over the last decade, and is increasing rapidly among individuals younger than 65. Accordingly, a dramatic change in the demographics of CS patients in modern intensive care units is expected.

Cost-effectiveness of follow-up invasive coronary angiography after percutaneous coronary stenting: a real-world observational cohort study in Japan

ObjectivesFollow-up invasive coronary angiography (FUICA) after percutaneous coronary intervention (PCI) has been shown to increase the rate of early coronary revascularisation without reducing the incidence of subsequent myocardial infarction or...

Impact of revascularization guided by functional testing in ischaemic cardiomyopathy.

The burden of ischaemia is a risk factor for adverse outcomes in ischaemic cardiomyopathy (ICM) but is not systematically tested when deciding on revascularization. Limited data exists in patients with ICM regarding the interaction between ischaemia and early coronary revascularization (ECR). This study sought to determine if the burden of ischaemia modifies the outcomes of ECR in ICM. Consecutive patients with ICM (left ventricular ejection fraction < 40%) with a stress-rest gated single-photon emission computed tomography (N = 747) were followed-up for ECR and major cardiovascular events (MACEs, cardiovascular death, myocardial infarction, or heart failure hospitalization). A 1:1 matched population was selected using a propensity score for ECR. The interaction between ischaemia and ECR was evaluated in the matched cohort. In the initial cohort, 131 patients underwent ECR. Of them, 109 were matched to non-ECR patients. After a median follow up of 4.1 years, 102 (46.8%) patients experienced a MACE. The effect of revascularization on MACE was dependent of the percent of ischaemia (P for the interaction at 10% ischaemia = 0.021), so that a trend towards a decreased risk of MACE was seen in patients with >10% of ischaemia [hazard ratio (HR) = 0.59 (0.30-1.18)], whereas a non-significant increase of MACE was observed in those with <10% ischaemia (HR = 1.67 [0.94-2.96]). In a contemporary cohort of patients with ICM, the beneficial effects of ECR may be mediated by the percent of ischaemia. This study supports stress testing in ICM and an ischaemia-guided approach for ECR.

Zawał serca u chorych na cukrzycę — nowości terapeutyczne

Diabetes mellitus is a risk factor for coronary heart disease and increase the risk of cardiovascular complications. Moreover, diabetes mellitus adversely affects the prognosis after myocardial infarction increasing the risk of complications in shortand long-term follow-up. Despite early coronary revascularization, diabetes significantly increases the mortality rate in myocardial infarction. Results from clinical trials published in recent years showed, in addition to glucose-lowering effect, sodium-glucose cotransporters inhibitors 2 and glucagon-like peptide-1 receptor agonists proved to reduce the cardiovascular risk and mortality in diabetic patients, which resulted in recommendation in Task Force for diabetes, pre-diabetes, and cardiovascular diseases of the European Society of Cardiology and the European Association for the Study of Diabetes. Moreover, empagliflozin and dapagliflozin reduce the risk of heart failure hospitalization and death in patients with heart failure. This publication aimed to discuss the most important differences in the currently recommended pharmacotherapy, in particular, the above-mentioned new hypoglycaemic drugs and dual antiplatelet therapy, and qualification for invasive and surgical treatment in myocardial infarction and diabetes compared to non-diabetic patients.

Outcomes with revascularization and medical therapy in patients with coronary disease and chronic kidney disease: A meta-analysis

Background and aimsChronic kidney disease (CKD) confers a high risk for poor cardiovascular outcomes. We conducted a systematic review and meta-analysis to estimate the effects of revascularization as the initial management strategy compared with medical therapy among patients with CKD and coronary artery disease. MethodsA Medline/PubMed literature research was conducted to identify randomized studies comparing early coronary revascularization with optimal medical therapy or medical therapy alone in patients with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2 or maintenance dialysis). The primary outcome was myocardial infarction. The secondary outcomes were all-cause mortality or progression to kidney failure. The risk ratio (RR) was estimated using a random-effects model. ResultsEleven randomized trials were included (3422 patients). Revascularization was associated with lower incidence of myocardial infarction compared with medical therapy in patients with CKD: RR 0.71 (95% confidence interval [CI] 0.54–0.94; p=0.02). This result was mainly driven from a significantly lower incidence of myocardial infarction with early revascularization among patients with stable coronary artery disease: RR 0.59; 95% CI 0.37–0.93. A similar incidence of all-cause mortality was observed with both treatment strategies: RR 0.88 (95% CI 0.72–1.08; p=0.22). A trend towards lower incidence of all-cause mortality was observed with revascularization in the subgroup of patients presenting with NSTE-ACS: RR 0.73 (95% CI 0.51–1.04; p=0.08) but not among patients with stable coronary disease. There was no difference in progression to kidney failure between the two strategies. ConclusionsCoronary revascularization may be superior to medical therapy among patients with CKD and coronary disease.

Mechanical circulatory support in acute myocardial infarction complicated by cardiogenic shock.

Patients with acute myocardial infarction (MI) complicated by cardiogenic shock (CS) have poor prognosis. Over the last two decades, there has been some improvement in mortality rates associated with CS. Initial measures to stabilise patients should follow a shock protocol, including therapies such as volume expansion, inotropes/vasopressors, and early coronary revascularisation. The use of mechanical circulatory support (MCS) devices demonstrated better haemodynamic and metabolic profiles for patients with CS. However, these benefits have not been consistently translated into significant reductions in cardiovascular adverse events. This review aims to discuss emerging concepts related to CS including an update on its classification and pathophysiology. The focus is on recent evidence regarding the use of MCS and the timing of initiating in patients with CS.

Functional ischemic mitral regurgitation in acute myocardial infarction: Importance of changes in left ventricular shape and regional function

Functional ischemic mitral regurgitation (IMR) is common in patients with ischemic left ventricular dysfunction after myocardial infarction, and significantly worsens prognosis. The aim of this study is to determine the relative importance of the global and regional left ventricular (LV) remodelling in the occurrence of IMR. Eighty-one patients (mean age = 61 ± 11 years) admitted with acute myocardial infarction (AMI) were screened. Patients with atrial fibrillation and organic valvular diseases were excluded from the study. Echocardiography (two-dimensional and Doppler echocardiograms) was performed in the first week after admission. The 81 patients were divided in 2 groups: with IMR (group1 = 39 patients) and without IMR (group2 = 42 patients). LV volumes were calculated by apical biplane Simpson's rule. The LV wall-motion score (WMS) index was obtained in a 17-segment model according to established methods. To identify the influence of regional wall-motion impairment for each individual LV segment, the mean WMS was calculated for each segment and compared between the 2 groups. The echocardiographic parameters that were associated with IMR were: LV dilatation and sphericity ( P < 0.0001), reduced ejection fraction ( P < 0.0001), inferior ( P < 0.001) inferolateral ( P = 0.01) and anterolateral ( P = 0.02) asynergy. The results of this study indicate the importance of abnormalities of both LV geometry and regional wall motion in the pathogenesis of IMR after myocardial infarction. Clinically, these findings imply that myocardial salvage by early coronary revascularisation may improve outcome by preserving LV function and decreasing the incidence of IMR.

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.)

Isolated congenital cleft mitral valve leaflet: a rare cause of refractory cardiogenic shock complicating acute myocardial infarction

We report a unique presentation of isolated congenital cleft mitral valve complicating cardiogenic shock from acute myocardial infarction. Isolated cleft mitral valve is an uncommon diagnosis that can have significant clinical implications, especially if not recognized in patients presenting to the catheterization lab with acute myocardial infarction and cardiogenic shock. A review of this rare diagnosis including the options and timing of therapeutic interventions, which can include MitraClip, is important for publication.The case is of a patient who presented with an anterior acute ST elevation myocardial infarction. Despite early coronary revascularization and conventional support, refractory cardiogenic shock ensued requiring mechanical circulatory support escalation to Veno-arterial extracorporeal membrane oxygenation. Subsequently, left ventriculography revealed a massively dilated left atrium and severe mitral regurgitation raising concerns for a mechanical mitral valve complication. The patient was taken to the operating room for possible mitral valve surgery, but a preoperative transesophageal echocardiogram revealed an isolated posterior cleft mitral valve. Since the patient had stabilized on mechanical circulatory support, emergent surgery was deferred. The patient successfully recovered during index hospitalization with mechanical circulatory support and discharged on guideline directed medical therapy.In conclusion, isolated cleft mitral valve is a rare diagnosis that can often be underrecognized without comprehensive 3-dimensional transesophageal echocardiography evaluation. If diagnosed early with significant regurgitation, surgical treatment results in good outcomes and preservation of LV systolic function. Percutaneous correction of a CMVL with MitraClip has been described and may offer an alternative approach for high risk surgical patients.

Myocardial stress perfusion scintigraphy for outcome prediction in patients with severe left ventricular systolic dysfunction.

We evaluated 1576 consecutive patients referred to MPS and stratified into 3 LV ejection fraction (LVEF) categories: ≤35%, 36-49%, and ≥ 50%. Patients with LVEF ≤35% were oldest, most often men, and with the highest likelihood of prior early (elective or urgent) coronary revascularization. They had also the highest values or summed stress score (SSS), summed rest score (SRS), and summed difference score (SDS), as well as the highest frequency of significant coronary artery disease, and a greater number of diseased vessels. In this subgroup, 32 cardiovascular death or non-fatal myocardial infarction (MI) (21%), 35 all-cause deaths (22%), and 37 cardiovascular deaths, non-fatal MI, or late revascularizations (27%) were recorded with the shortest survival among all LVEF classes. SRS, SSS, and SDS had very low area under the curve values for the prediction of the 3 endpoints, with very high cut-offs, respectively. SRS and SSS cut-offs predicted a worse outcome in Cox regression models including the number of diseased vessels and early revascularization. In patients with LVEF ≤35%, SRS and SSS are less predictive of outcome than in patients with better preserved systolic dysfunction, but their cut-offs retain independent prognostic significance from the number of vessels with significant stenoses and from early revascularization.

Development and validation of optimal phenomapping methods to estimate long-term atherosclerotic cardiovascular disease risk in patients with type 2 diabetes.

Type 2 diabetes is a heterogeneous disease process with variable trajectories of CVD risk. We aimed to evaluate four phenomapping strategies and their ability to stratify CVD risk in individuals with type 2 diabetes and to identify subgroups who may benefit from specific therapies. Participants with type 2 diabetes and free of baseline CVD in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial were included in this study (N = 6466). Clustering using Gaussian mixture models, latent class analysis, finite mixture models (FMMs) and principal component analysis was compared. Clustering variables included demographics, medical and social history, laboratory values and diabetes complications. The interaction between the phenogroup and intensive glycaemic, combination lipid and intensive BP therapy for the risk of the primary outcome (composite of fatal myocardial infarction, non-fatal myocardial infarction or unstable angina) was evaluated using adjusted Cox models. The phenomapping strategies were independently assessed in an external validation cohort (Look Action for Health in Diabetes [Look AHEAD] trial: n = 4211; and Bypass Angioplasty Revascularisation Investigation 2 Diabetes [BARI 2D] trial: n = 1495). Over 9.1years of follow-up, 789 (12.2%) participants had a primary outcome event. FMM phenomapping with three phenogroups was the best-performing clustering strategy in both the derivation and validation cohorts as determined by Bayesian information criterion, Dunn index and improvement in model discrimination. Phenogroup 1 (n = 663, 10.3%) had the highest burden of comorbidities and diabetes complications, phenogroup 2 (n = 2388, 36.9%) had an intermediate comorbidity burden and lowest diabetes complications, and phenogroup 3 (n = 3415, 52.8%) had the fewest comorbidities and intermediate burden of diabetes complications. Significant interactions were observed between phenogroups and treatment interventions including intensive glycaemic control (p-interaction = 0.042) and combination lipid therapy (p-interaction < 0.001) in the ACCORD, intensive lifestyle intervention (p-interaction = 0.002) in the Look AHEAD and early coronary revascularisation (p-interaction = 0.003) in the BARI 2D trial cohorts for the risk of the primary composite outcome. Favourable reduction in the risk of the primary composite outcome with these interventions was noted in low-risk participants of phenogroup 3 but not in other phenogroups. Compared with phenogroup 3, phenogroup 1 participants were more likely to have severe/symptomatic hypoglycaemic events and medication non-adherence on follow-up in the ACCORD and Look AHEAD trial cohorts. Clustering using FMMs was the optimal phenomapping strategy to identify replicable subgroups of patients with type 2 diabetes with distinct clinical characteristics, CVD risk and response to therapies.

Current evidence in the diagnosis and management of cardiogenic shock complicating acute coronary syndrome.

Cardiogenic shock (CS) is a hemodynamically complex and highly morbid syndrome characterized by circulatory collapse and inadequate end-organ perfusion due to impaired cardiac output. It is usually associated with multiorgan failure and death. Mortality rate is still high despite advancement in treatment. CS has been conceptualised as a vicious cycle of injury and decompensation, both cardiac and systemic. Interrupting the vicious cycle and restoring the hemodynamic stability is a fundamental treatment of CS. Acute coronary syndrome (ACS) is the most frequent cause of CS. Early coronary revascularization is a cornerstone therapy that reduces mortality in patients with ACS complicated by CS. Early diagnosis of CS accompanied with invasive hemodynamics, helps in identification of CS phenotype, classification of CS severity, stratification of risk and prognostication. This can guide a tailored and optimized therapeutic approach. Inotropes and vasopressors are considered the first-line pharmacological option for hemodynamic instability. The current availability of the mechanical circulatory support devices has broadened the therapeutic choices for hemodynamic support. To date there is no pharmacological or nonpharmacological intervention for CS that showed a mortality benefit. The clinical practices in CS management remain inconsistent. Herein, this review discusses the current evidence in the diagnosis and management of CS complicating ACS, and features the changes in CS definition and classification.

Abstract 335: The Impact of Early Coronary Angiography on Outcomes in Out-of-hospital Cardiac Arrest: The Singapore Experience

Background and Aim: The benefit of early coronary angiography (CAG) and revascularization in resuscitated out-of-hospital cardiac arrest (OHCA) is unclear. We evaluated the association between early CAG and clinical outcomes in these patients. Methods: Data on all resuscitated adult OHCA cases of cardiac etiology between 2011-2015 were extracted from the prospective Singapore Pan-Asian Resuscitation Outcomes Study and linked with data from the national database of cardiac procedures. The 30-day survival and neurological outcomes (good outcome defined as Cerebral Performance Category [CPC] 1 or 2) were compared between patients undergoing early CAG (within 1-calender day) and patients not undergoing early CAG. Inverse probability weighted estimator was used to adjust for propensity to perform early CAG and PCI. Results: Of 976 consecutive patients who survived to admission (mean age 64±13, 73.7% males), 401 (41.1%) patients underwent CAG and obstructive coronary artery disease (CAD) was present in 352 (87.8%), of whom 284 (70.8%) underwent revascularization. Patients who underwent early CAG (n=337[34.5%]) were significantly different compared to those who underwent delayed or no CAG (n=639[65.5%]) (Table 1). Early CAG and PCI patients had improved survival and better neurological outcomes (adjusted odds ratio [AOR] 3.806 [95% CI 1.675 - 8.648] and AOR 3.075 [95% CI 1.119 - 8.451]), compared to those without. The odds of survival decreased with epinephrine administration (AOR 0.357 [95% CI 0.199 - 0.640]), but increased with an initial shockable rhythm (AOR 6.587 [95% CI 3.659 - 11.861]). The rates of bleeding (2% vs 0%, p=0.300) and stroke (1.6% vs 1.9%, p=0.880) were not increased with early intervention. Conclusion: Early CAG and PCI after OHCA were 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.

Relationship between age and the impact of revascularization on mortality in patients with non-ST-elevation myocardial infarction

Abstract Background It is known that the early coronary revascularization in patients with non-ST-elevation myocardial infarction (NSTEMI) was associated with favorable clinical outcomes. However, it is still unclear whether this efficacy is equivalent over all the ages of the patients. Methods Patients with NSTEMI were screened from the database of the Tokyo CCU network registry. Of those, the patients treated without revascularization (medical treatment) were matched with the patients receiving revascularization by propensity score matching. The probabilities of in-hospital death were calculated in the logistic regression model. In two subgroups stratified according to median of the age (elderly and non-elderly subgroups), the odds ratios of revascularization for in-hospital death were calculated. Results In the patients registered between 2013 and 2017, 4,851 patients with NSTEMI were identified. After the screening, 370 patients with medical treatment were matched with 370 patients treated with revascularization. The incidence of in-hospital death was significantly higher in the patients with medical treatment (20.3% vs 13.0%, P=0.01). The two probability curves of in-hospital death in patients with and without revascularization converged as age increased. In the elderly subgroup, the revascularization was not significantly associated with favorable outcome of mortality, whereas it had a significant impact on mortality in the non-elderly subgroup (odds ratio: 0.47 [95% CI 0.23–0.95]). Conclusion The impact of revascularization on short-term mortality in patients with NSTEMI tended to be reduced as age increased. Funding Acknowledgement Type of funding source: None

Outcomes of Early Coronary Angiography or Revascularization After Cardiac Surgery

Early coronary ischemic events are uncommon after cardiac surgery, with little known about their management or associated outcomes. We evaluated clinical outcomes of patients undergoing coronary angiography ± percutaneous coronary intervention or redo coronary artery bypass grafting for suspected coronary ischemia within 3 weeks after index cardiac surgery. This is a retrospective observational study based on data from 53,287 patients who underwent cardiac surgery at our institution (1996-2017); 180 patients (0.34%) satisfied the inclusion criteria. The primary outcome was 1-year all-cause mortality. Statistical evaluation involved χ2, analysis of variance, Kaplan-Meier, and receiver operating characteristic curve analyses. Most coronary angiography ± percutaneous coronary intervention and redo coronary artery bypass grafting procedures occurred in the first 2 weeks after index cardiac surgery. Patients presenting with ST elevation myocardial infarction (STEMI)/non-STEMI had the lowest 1-year mortality (13.5%), followed by patients with ventricular tachycardia/fibrillation (28.1%), and patients with non-ventricular tachycardia/fibrillation arrest or hemodynamic instability alone the worst (38.6%) (χ2= 17.3, P= .001). Peak troponin T level after cardiac surgery was strongly predictive of 1-year mortality (area under the curve, 0.74; 95% confidence interval, 0.65-0.84; P < .001) but did not predict the presence of coronary compromise. For acute graft failure, 1-year mortality was better with percutaneous coronary intervention (18.2%) than redo coronary artery bypass grafting (23.5%) or no indicated/feasible intervention (29.2%). Although suspected myocardial ischemia requiring coronary angiography or intervention early after cardiac surgery was rare, mortality was high, particularly in presentations other than STEMI/non-STEMI. In patients with overt signs and symptoms of myocardial ischemia after index cardiac surgery, troponin T was not a reliable marker of underlying coronary or graft obstruction but was a robust predictor of 1-year mortality.