Early Percutaneous Coronary Intervention Research Articles

Outpatient PCI - early discharge PCI, single center experience

Abstract Funding Acknowledgements None. Background Percutaneous coronary intervention (PCI) has undergone rapid evolution over the last years and is currently a widely generalized therapeutic option. In the past, it was associated with a significant rate of complications, yet, with the improvement of new generation drug eluting stents, and the radial access (RA) development, PCI has become safer and simpler, with a minimum rate of complications. This allows patient’s faster discharge. Besides the pressure from the limited number of beds in wards, the improvement of PCI has given the confidence to urge outpatient PCI programs. However, there are still centers where there is no ambulatory PCI. Purpose This study aims to describe our center experience of ambulatory PCI program, in terms of safety and efficacy. Methods We analyzed our center’s retrospective cohort of 723 PCI, in 2022. Ambulatory PCI was defined as PCI with same day hospital discharge. Our inclusion criteria were patients submitted to PCI. We excluded patients with acute coronary syndromes and patients needing hospital admission for other non-coronary reasons. Results 467 (65%), of the 723 PCI were performed in ambulatory setting. Patients mean age was 67,8±11 years and 23% (n=107) were female. In 12% (n=55) of the cases, the coronary anatomy was previously known, from a differed procedure. 63% (n=298) had a normal left ventricle ejection fraction (LVEF), 6% (n=26) had a moderate depression of LVEF and 3% (n=13) had LVEF severe depression. RA was possible in 82% of the cases (n=384), and 18% (n=83) of PCI was done by femoral access (FA). The access size was 6 Fr in 77% (n=359) of the cases, 7Fr in 22% (n=105) and 8Fr in 1% (n=2). The RA hemostasis was by compression (either manually or by external device) and FA hemostasis was first intended by closing device, however in 17% of the transfemoral PCI (n=14) had to be compressed, due to device hemostasis failure. PCI was successful in 97% of the cases (n=449), with revascularization of the goal lesion. The unsuccessful PCI (3% n=18) were because uncrossable lesion in 2% (n=14), and no reflow after PCI in 1% (n=4). 6 patients had to be admitted, after planned outpatient PCI, 5 due to peripheral access complication with hemorrhage of FA (after closing device and manual compression failure) and 1 due to PCI complication, with small coronary perforation. There was a higher probability of admission in patients submitted to transfemoral PCI (p<0,05), and there was no statistically significant relation between unplanned admission and patient’s LVEF. There were no episodes of death, MACE, non-planned hospital readmission and stent failure in the ambulatory PCI population. PCI has become a predictable and reliable technique, capable to treat outpatients. Patients undergoing successful non-complex PCI, without events, can safely be discharged on the same day. Outpatient PCI helps with the functioning of inpatient care, allowing beds to be freed up for other situations.

A-59 | Comparison of early vs late percutaneous coronary intervention in cirrhosis patients admitted with NSTEMI

A-59 | Comparison of early vs late percutaneous coronary intervention in cirrhosis patients admitted with NSTEMI

Incidence and predictors of heart failure with reduced and preserved ejection fraction after ST-elevation myocardial infarction in the contemporary era of early percutaneous coronary intervention.

The development and incidence of de-novo heart failure after ST-elevation myocardial infarction (STEMI) in the contemporary era of rapid reperfusion are largely unknown. We aimed to establish the incidence of post-STEMI heart failure, stratified by left ventricular ejection fraction (LVEF) and to find predictors for its occurrence. Furthermore, we investigated the course of left ventricular systolic and diastolic function after STEMI. A total of 1172 all-comer STEMI patients from the CardioLines Biobank were included. Patients were predominantly male (74.5%) and 64 ± 12 years of age. During a median follow-up of 3.7 years (2.0, 5.5) we found a total incidence of post-STEMI heart failure of 10.9%, of which 52.1% heart failure with reduced ejection fraction (HFrEF), 29.4% heart failure with mildly reduced ejection fraction and 18.5% heart failure with preserved ejection fraction (HFpEF). Independent predictors for the development of HFrEF were male sex (β = 0.97, p = 0.009), lung crepitations (β = 1.09, p = 0.001), potassium level (mmol/L, β = 0.43, p = 0.012), neutrophil count (109/L, β = 0.09, p = 0.001) and a reduced LVEF (β = 1.91, p < 0.001) at baseline. Independent predictors for the development of HFpEF were female sex (β = 0.99, p = 0.029), pre-existing kidney failure (β = 1.95, p = 0.003) and greater left atrial volume index (β = 0.04, p = 0.033) at baseline. Follow-up echocardiography (median follow-up 20 months) showed an improvement in LVEF (p < 0.001), whereas changes in diastolic function parameters showed both improvement and deterioration. In the current era of early STEMI reperfusion, still one in 10 patients develops heart failure, with approximately half of the patients with a reduced and half with a mildly reduced or normal LVEF. Predictors for the development of HFrEF were different from HFpEF.

Transport decisions: acute coronary syndrome and high-risk electrocardiograms

Patients experiencing a high-risk non-ST-elevation myocardial infarction are likely to benefit from prehospital medical contact, transport to a percutaneous coronary intervention (PCI) centre and early definitive treatment. They may be provisionally diagnosed through the identification of a high-risk electrocardiogram (ECG). Advances in ECG interpretation have led to the identification of a cohort of at-risk patients whose treatment may previously have been delayed. Patients with certain ECG changes are considered high risk and may be experiencing coronary occlusions. Early PCI and direct transport to a PCI-capable hospital are associated with a reduction in mortality and morbidity; this is associated with a lower financial burden on the health service. Early paramedic identification of these high-risk ECGs and appropriate transport decision-making can positively influence patient outcomes. High-risk ECGs include those that are positive for the modified Smith-Sgarbossa criteria, DeWinter T waves, Wellens syndrome, posterior acute myocardial infarction and aVR elevation. Continued education is correlated with more accurate ECG interpretation.

Activity counseling early postelective percutaneous coronary intervention (ACE-PCI): Mixed-methods pilot randomized controlled trial.

Physical activity(PA) levels of people with coronary heart disease are low in the first 30 days after percutaneous coronary intervention (PCI), increasing the risk of recurrent cardiac events. Following PCI, PA counseling delivered by a physiotherapist before discharge may increase the PA levels of patients. Preliminary work is required to determine the effects of the counseling session compared to usual care. To investigate the feasibility and potential efficacy of a brief physiotherapist-led PA counseling session immediately after an elective PCI compared to usual care for improved PA early post-PCI. Using concealed allocation and blinded assessments, eligible participants (n = 30) were randomized to a physiotherapist-led PA counseling session (30 min) or usual care (nurse-led PA advice < 5 min). The primary outcome was daily minutes of moderate-to-vigorous PA (accelerometry; 3 weeks). Secondary outcomes included cardiac rehabilitation intention, anxiety and depression levels (Hospital Anxiety and Depression Scale), and quality-of-life (MacNew questionnaire). Recruitment, retention, and attrition were assessed for feasibility. Semistructured interviews were conducted with 13 participants to determine intervention acceptability, and barriers and enablers to PA. Between and within-group comparisons were not significant in intention-to-treat analyses. All feasibility criteria were met except for retention and attrition of participants. At 3 weeks, only 25% of participants were planning to attend cardiac rehabilitation, with no between-group differences. Increased PA at 3 weeks was associated with participants that were younger, without other chronic disease,s and more active immediately following discharge. Interviews revealed personal, environmental, and program-based themes for barriers and enablers to PA. A physiotherapist-led PA counseling session may not improve PA levels early post-elective PCI compared to very brief PA advice delivered by nurses. A larger multicentre randomized controlled trial is feasible with minor modifications to participant follow-up. Further research is required.

Analysis of the Weekend Effect on Mortality, Diagnostic Coronary Angiography, and Percutaneous Coronary Intervention in Acute Myocardial Infarction Across Rural US Hospitals.

Rural hospitals face several unique challenges in delivering healthcare to an underserved population. Achieving time-sensitive goals in a resource-scarce facility is often a difficult task without the right team at hand. Resources are further depleted on the weekends, exposing understaffed hospitals to poorer outcomes. Acute myocardial infarction (AMI) mortality depends on timely diagnosis and intervention. It is unknown to what extent resource shortages impact rural hospitals during weekends and how they affect AMI mortality. This cross-sectional study was performed on patients admitted on weekends with AMI using the National Inpatient Sample (NIS) 2019. Patients with type II non-ST-elevation myocardial infarction (NSTEMI) and missing information were excluded. The rates and timing of in-hospital diagnostic coronary angiograms, PCIs (percutaneous coronary interventions), and in-hospital mortality were studied. Regression models were used for data analyses. A total of 161,625 patients met the inclusion criteria (58,690 females (36%), 114,830 Caucasians (71%), 17,910 African American (11%), 13,920 Hispanic (8.6%); mean (SD) age, 66.5 (0.5) years), including 47,665 (29.5%) ST-elevation myocardial infarction (STEMI) and 113,960 (70.5%) NSTEMI. Patients admitted to rural hospitals were less likely to undergo diagnostic coronary angiogram (adjusted odds ratio (aOR), 0.69; CI, 0.57-0.83; p<0.001) and PCI (aOR, 0.83; CI, 0.72-0.96; p 0.012). Rural hospitals had lesser odds of early diagnostic angiograms (aOR, 0.79; CI, 0.67-0.95; p<0.05) and PCI (aOR, 0.78; CI, 0.66-0.92; p<0.05) within 24 hours. The mortality difference between rural and urban hospitals was not significant (aOR, 1.08; CI, 0.85-1.4; p 0.52). Diagnostic coronary angiograms and PCI are performed at a lesser rate in rural hospitals during weekends. This trend did not affect rural AMI mortality.

Baseline risk, time window, and indications for delayed percutaneous coronary interventions, their significance in treatment of ST-segment elevation myocardial infarction

The aim of the study was to estimate the significance of delayed percutaneous coronary interventions (PCIs) in the treatment of ST-segment elevation myocardial infarction (STEMI), to weigh the initial mortality risk (MR) while determining the indications for their use and the time window for the use of mechanical reperfusion in late hospital admission. Total 2226 patients admitted to the Institute with STEMI for the period 2008–2017 were studied. Emergency coronary angiography was performed in 945 admitted patients in the initial 12 hours and in 834 patients after 12–72 hours of STEMI onset; PCI was performed in 784 and 619 patients, respectively. In all patients, MR was scored by TIMI; angiographic success was assessed as TIMI 3 coronary flow and compared to ECG signs of reperfusion. The baseline MR score averaged 5 or 12.5%, being corresponded to score 4.2 or 8% in patients with PCI performed in the initial 12 hours, score 5 or 12.5% in those with PCI performed after 12–72 hours, and score 6 or 16% in patients without PCI; or with respect to the patient age, MR scored 3.7 or 7%, 6 or 16%, and 7.5 or 25%, for those under the age of 65 years, those from 65–75 years, and those over 75 years old, respectively. Mortality in patients with an early and delayed PCI was 5.2% and 4.2%, respectively, and 15.6% in patients without PCI; after patient distribution by age under 65, 65–75, and over 75 years old, the respective mortality rates were 3.8%, 4.9%, and 10.8% after an early PCI; 2.6%, 5.8%, and 8.2% after a delayed PCI; and 8.4%, 19.4%, and 28% among those without PCI. For 10 years, the number of primary PCIs had increased from 39% to 78%. The ratio of early to delayed PCI made 56% to 44%. Of 195 deaths (67 patients with PCI and 128 without PCI), 90% of patients had a three-vessel disease; 83% of patients had the MI area over 30%; and the cause of death in 84% was pulmonary edema. The presented data suggest a high practical significance of delayed PCI in patients with initially high MR, its most weighty components being the age over 75 years and severe manifestations of acute heart failure (AHF). Unlike early PCIs, the delayed PCIs are used less frequently, the initial MR is not taken into account, and they are abstained from in respect to people over 75 years of age. The reduction in mortality, proportional to the baseline MR, suggests their correlation to PCI results and the feasibility of PCI use without age restrictions. The use of primary PCIs in late hospital admissions, by analogy with early ones or selectively in high MR, will help to optimize the treatment tactics and minimize mortality.

Abstract 15135: Timing of Percutaneous Coronary Intervention and Risk of New-Onset Acute Ischemic Stroke in Non-ST Elevation Myocardial Infarction: An Insight of National Inpatient Sample 2016-2019

Introduction: Current guidelines recommend an early invasive strategy within 24 hours only in high-risk non-ST elevation myocardial infarction (NSTEMI). New-onset acute ischemic stroke (NAIS) is a rare but fatal complication of percutaneous coronary intervention (PCI). However, the effect of the timing of the PCI and the risk of NAIS in NSTEMI is not well defined. Hypothesis: Late PCI is associated with NAIS risk in NSTEMI. Methods: NSTEMI patients who underwent PCI were queried from the National Inpatient Sample Database (2016-2019) and stratified into three groups: early (&lt;24 h), medium (24-72 h), and late PCI (&gt;72 h). Multivariable logistic regression models were used to determine the timing of PCI and NAIS, adjusted for demographics, comorbidities, and hospital characteristics. Results: Among 633,115 weighted hospitalizations in 2016-2019, late PCI patients had a higher incidence of NAIS (1.3%) compared to early (0.67%) and medium PCI (0.71%). Late PCI patients were older, more likely to be female, and had a higher prevalence of comorbidities (diabetes mellitus, congestive heart failure, chronic pulmonary and renal disease, and atrial fibrillation) than early and medium PCI. After adjustment, only late PCI was significantly associated with a 55% increased NAIS risk (adjusted OR: 1.55 [95% CI: 1.30-1.84]). There was heterogeneity in the magnitude of risk by age and gender. Younger people (&lt;65 years) ( p for interaction &lt;0.0001) and males (interaction -value p =0.0433) were more likely to encounter NAIS. The incidence of NAIS increased from 2016 to 2019 in both medium and late PCI. Conclusions: Late PCI over 72 hours was associated with a higher risk of NAIS than PCI performed within 24 hours, particularly among young and male people.

Outcomes in non-ST-segment elevation myocardial infarction complicated by in-hospital cardiac arrest based on management strategy

BackgroundThere are limited data on in-hospital cardiac arrest (IHCA) complicating non-ST-segment-elevation myocardial infarction (NSTEMI) based on management strategy. MethodsWe used National Inpatient Sample (2000–2017) to identify adults with NSTEMI (not undergoing coronary artery bypass grafting) and concomitant IHCA. The cohort was stratified based on use of early (hospital day 0) or delayed (≥hospital day 1) coronary angiography (CAG), percutaneous coronary intervention (PCI), and medical management. Outcomes included incidence of IHCA, in-hospital mortality, adverse events, length of stay, and hospitalization costs. ResultsOf 6,583,662 NSTEMI admissions, 375,873 (5.7 %) underwent early CAG, 1,133,143 (17.2 %) received delayed CAG, 2,326,391 (35.3 %) underwent PCI, and 2,748,255 (41.7 %) admissions were managed medically. The medical management cohort was older, predominantly female, and with higher comorbidities. Overall, 63,085 (1.0 %) admissions had IHCA, and incidence of IHCA was highest in the medical management group (1.4 % vs 1.1 % vs 0.7 % vs 0.6 %, p < 0.001) compared to early CAG, delayed CAG and PCI groups, respectively. In adjusted analysis, early CAG (adjusted OR [aOR] 0.67 [95 % confidence interval {CI} 0.65–0.69]; p < 0.001), delayed CAG (aOR 0.49 [95 % CI 0.48–0.50]; p < 0.001), and PCI (aOR 0.42 [95 % CI 0.41–0.43]; p < 0.001) were associated with lower incidence of IHCA compared to medical management. Compared to medical management, early CAG (adjusted OR 0.53, CI: 0.49–0.58), delayed CAG (adjusted OR 0.34, CI: 0.32–0.36) and PCI (adjusted OR 0.19, CI: 0.18–0.20) were associated with lower in-hospital mortality (all p < 0.001). ConclusionEarly CAG and PCI in NSTEMI was associated with lower incidence of IHCA and lower mortality among NSTEMI-IHCA admissions.

Antithrombotic Treatment in Coronary Artery Disease.

Coronary artery disease exhibits growing mortality and morbidity worldwide despite the advances in pharmacotherapy and coronary intervention. Coronary artery disease is classified in the acute coronary syndromes and chronic coronary syndromes according to the most recent guidelines of the European Society of Cardiology. Antithrombotic treatment is the cornerstone of therapy in coronary artery disease due to the involvement of atherothrombosis in the pathophysiology of the disease. Administration of antiplatelet agents, anticoagulants and fibrinolytics reduce ischemic risk, which is amplified early post-acute coronary syndromes or post percutaneous coronary intervention; though, antithrombotic treatment increases the risk for bleeding. The balance between ischemic and bleeding risk is difficult to achieve and is affected by patient characteristics, procedural parameters, concomitant medications and pharmacologic characteristics of the antithrombotic agents. Several pharmacological strategies have been evaluated in patients with coronary artery disease, such as the effectiveness and safety of antithrombotic agents, optimal dual antiplatelet treatment schemes and duration, aspirin de-escalation strategies of dual antiplatelet regimens, dual inhibition pathway strategies as well as triple antithrombotic therapy. Future studies are needed in order to investigate the gaps in our knowledge, including special populations.

Temporal analysis of non-ST segment elevation-acute coronary syndrome (NSTEACS) outcomes in ‘young’ patients under the age of fifty: A nationwide cohort study

BackgroundThe characteristics and risk factor profile of young patients presenting with non-ST segment elevation acute coronary syndrome (NSTEACS) and how they may have changed over time is not well reported. MethodsWe identified 26,708 NSTEACS patients aged under 50 presenting to United Kingdom (UK) hospitals between 2010 and 2017 from Myocardial Ischaemia National Audit Project (MINAP). We calculated incidence of NSTEACS per 100,000 UK population, using Office of National Statistics (ONS) population estimates, prevalence of comorbidities, ethnicity, and in-hospital mortality. We formed biennial groups to enable comparison, 2010–2011, 2012–2013, 2014–2015 and 2016–2017. ResultsThe incidence of NSTEACS per 100,000 population showed minimal change between 2010 and 2017 (2010: 5.4 per 100,000 and 2017; 4.9 per 100,000). Rates of smoking (2010–11; 58% and 2016–17; 53%), and family history of coronary artery disease (CAD) (2010–11; 51% and 2016–17; 44%) fell, but the proportion of patients from an ethnic minority background (2010–11; 12% and 2016–17; 20%), with diabetes mellitus (DM) (2010–11; 14%, and 2016–17; 18%) and female patients (2010–11; 22% and 2016–17; 24%) increased over the study period. Mortality from NSTEACS remained unchanged (2010–11; 1% and 2016–17; 1%). ConclusionsThe incidence of NSTEACS in patients aged under fifty has not reduced despite reduction in prevalence of risk factors such as smoking hypercholesterolaemia in those admitted to UK hospitals. Despite improved rates of early invasive coronary angiography and percutaneous coronary intervention in ‘young’ NSTEACS patients, in-hospital mortality remains unchanged.

Abstract P1053: Circulating Mitochondrial DNA Level Is A Biomarker Of Acute Myocardial Infarction And Mediates Cardiac Ischemia-reperfusion Injury

Introduction: Ischemia/reperfusion (I/R) injury occurs after reperfusion, causing significant myocardial damage. Circulating mitochondrial DNA (mtDNA) levels are elevated in acute myocardial infarction patients, and act as Damage Associated Molecular Patterns (mtDNA DAMP) that induce inflammation via immune processes, including the toll-like receptor 9 (TLR9) pathway. However, mtDNA DAMP levels have not been measured in ST-elevation myocardial infarction (STEMI) patients before and after percutaneous coronary intervention (PCI) and the role of mtDNA DAMPs in I/R injury remains unknown. Hypothesis: Pre- and post-PCI levels of mtDNA DAMPs serve as markers of STEMI related cardiac injury. Limiting mtDNA DAMP levels by increasing autophagy or blocking their downstream effects on TLR9 will decrease cardiac I/R injury. Methods: Troponin and mtDNA DAMP levels were measured pre- and 24 hours post- PCI in 55 STEMI patients (90%-100% blockage) and compared to 37 healthy controls. MtDNA DAMP levels in cell-free plasma were measured by real-time qPCR. Using a C57BL6J mouse model of I/R injury, Tat-Beclin (TB, an autophagy inducer), ODN2088 (a TLR9 inhibitor) or negative control were given at reperfusion and infarct size, cardiac function, and mtDNA DAMP levels were determined. Results: Pre- PCI mtDNA DAMP levels were increased ~200 folds (p&lt;0.0001) in STEMI patients compared to healthy controls; post- PCI mtDNA DAMP levels were significantly decreased in the majority of patients. In contrast, troponin T levels increased, suggesting that mtDNA DAMP levels are early markers of STEMI. Interestingly, a greater decrease in mtDNA DAMP levels was associated with shorter symptom-to-PCI time. In mice, both TB induction of autophagy and TLR9 blockage by ODN2088 decreased infarct size by ~50% and preserved systolic function. As expected, TB induction of autophagy decreased mtDNA DAMP levels, while ODN2088 had no impact on mtDNA DAMP levels. Conclusions: Circulating mtDNA DAMP level is an early marker of STEMI and may predict the success of early PCI. Moreover, limiting the downstream effects of mtDNA DAMPs via induction of autophagy or blocking their action on TLR9 ameliorates cardiac I/R injury, and thus may provide a viable therapeutic avenue for STEMI patients.

Isolated Right Ventricular Infarction without Right Ventricular Dysfunction: A Case Report

BACKGROUND: Myocardial infarction is the leading cause of the occlusion of the coronary artery. Meanwhile, right ventricular myocardial infarction (RVMI) is usually associated with inferior left ventricular infarction in 10–50% of cases. We presented isolated RV infarcts which are rare cases that happen in only 3% of total myocardial infarction. CASE PRESENTATION: We presented a case of a 67-year-old man with sudden chest pain, shortness of breath, and a history of diabetes mellitus. From his 12 lead electrocardiogram, there is no specific ST elevation yet elevation in V3R and V4R and elevated troponin I highly sensitive value. The patient developed junctional bradycardia and early percutaneous coronary intervention backup temporary pacemaker showed total occlusion in the proximal right coronary artery (RCA) CONCLUSION: The RVMI commonly occurs in the dominant RCA that also supplies the sinoatrial node and atrioventricular node. Therefore, due to its location that passed through the RCA, bradycardia to complete heart block may happen. Isolated right ventricular (RV) infarction may happen because either RV marginal as the predominant location is occluded, or non-dominant RCA occluded by thrombus. RV infarction may impair RV contractility causing a decrease in RV stroke volume and this condition leads to hypotension, shock, and severe hemodynamic derangement. Meanwhile, acute proximal RCA occlusions do not result in significant RV necrosis, one of the reasons is collateral flow from the left coronary system further protects from RV dysfunctions in our patient.

Clinical value of GRACE score combined with DFR in predicting short-term prognosis of patients undergoing early PCI after thrombolysis for acute myocardial infarction.

The aim of the study was to investigate the clinical value of the Global Registry of Arterial Events in Acute Coronary Syndromes (GRACE) score combined with the D-dimer/fibrinogen ratio (DFR) in predicting the short-term prognosis of patients undergoing percutaneous coronary intervention (PCI) early after thrombolysis for acute myocardial infarction (AMI). A total of 102 patients who underwent PCI early after thrombolysis for AMI during April 2020 to January 2022 in our hospital were picked as study subjects. These subjects were assigned as the good prognosis group (without adverse cardiovascular events) and poor prognosis group (with adverse cardiovascular events) according to whether adverse cardiovascular events occurred during hospitalization and follow-up. Changes in GRACE scores and DFR levels in patients with different prognoses were analyzed. The GRACE score and DFR level of patients with different prognosis were analyzed. The clinic pathological characteristics were collected, and the risk factors for poor prognosis of AMI patients were analyzed by logistic risk regression; ROC curve was used to analyze the prognostic value of GRACE score combined with DFR in early PCI patients after AMI thrombolysis. Compared with the good prognosis group, the GRACE score and DFR level in the poor prognosis group were much higher (p<0.001). Significant differences existed in blood pressure, ejection fraction, number of diseased branches, and Killip grading between the patients with good prognosis and those with poor prognosis (p<0.05). There existed no significant difference in clinical medication between the patients with good prognosis and those with poor prognosis (p>0.05). Logistic multivariate analysis indicated that GRACE score, DFR, ejection fraction, number of lesion branches, and Killip grade were all risk factors influencing the prognosis of patients undergoing early PCI after thrombolysis in AMI (p<0.05). The ROC curve was established and the area under the curve (AUC) of GRACE score, DFR, and combined detection were 0.815, 0.783, and 0.894, respectively, and the sensitivity and specificity were 80.24%, 60.42%, 83.71%, 66.78%, 91.42% and 77.83%, respectively. The AUC, sensitivity, and specificity of combined detection were higher than those of the two alone and had a higher predictive value for the short-term prognosis of patients. The GRACE score combined with DFR was of great value in diagnosing the short-term prognosis of patients undergoing PCI early after thrombolysis for AMI. Furthermore, the GRACE score, DFR, ejection fraction, number of lesion branches, and Killip classification were all important factors influencing the short-term prognosis of patients, which were of great significance in determining the prognosis of patients.

Characteristics of Wellens' Syndrome in the Current PCI Era: A Single-Center Retrospective Study.

The goal of this retrospective study was to reveal the prevalence, angiographic characteristics, clinical presentation, and long-term outcomes of non-ST-segment elevation myocardial infarction (NSTEMI) patients with Wellens' syndrome. Procedural results for percutaneous coronary intervention (PCI) in acute coronary syndrome (ACS) have improved in recent years. However, there is still a paucity of available clinical trial data for Wellens' syndrome even though it is a well-known high-risk ACS. Among a total of 3528 patients with ACS who underwent angioplasty from 2017 to 2019 at the Cardiovascular Center of Beijing Friendship Hospital, 476 NSTEMI patients with culprit left anterior descending (LAD) vessels were enrolled in this study. According to electrocardiographic criteria of Wellens' syndrome, the patients were divided into a Wellens group (n = 138) and a non-Wellens group (n = 338). The primary endpoint was cardiac death; the secondary endpoints were main adverse cardiovascular and cerebrovascular events (MACCEs), a composite of all-cause death, cardiac death, heart failure, target lesion revascularization, recurrent myocardial infarction, and stroke. All of the medical and follow-up data were obtained from our institutional database. The incidence of Wellens' syndrome in all ACS patients was 5.7% (200 of 3528). Among the 200 patients with Wellens' syndrome, 138 had NSTEMI, for a proportion of 69%. There was a significant decrease in the percentage of preexisting coronary heart disease (CHD), prior myocardial infarction, and previous PCI (P < 0.05) in the Wellens group compared with the non-Wellens group. On coronary angiography, single-vessel lesions were more common in the Wellens group (11.6% vs. 5.3%, P=0.016), and almost all (97.1%) of these patients received drug-eluting stents. Notably, the Wellens group had a higher proportion of early PCI than the non-Wellens group (71% vs. 61.2%, P=0.044). At 24 months, there was no statistically significant difference in cardiac death (P=0.111) between the two groups, but the MACCEs were comparable (Wellens: 5.1% vs. non-Wellens: 13.3%, P=0.009). Age ≥65 years was the largest independent risk factor for adverse prognosis. With early recognition and aggressive intervention, Wellens' syndrome is no longer a risk factor for adverse prognosis in patients with NSTEMI in the current PCI era.

Impact of Surgeon Experience and Centre Volume on Outcome After Off-Pump Coronary Artery Bypass Surgery: Results From the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) Registry.

The aim of this study was to assess the impact of surgeon experience and centre volume on early operative outcomes in patients undergoing off-pump coronary artery bypass (OPCAB) surgery. Of 7,352 patients in the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry, 1,549 underwent OPCAB and were included in the present analysis. Using adjusted regression analysis, we compared major early adverse events after procedures performed by experienced OPCAB surgeons (i.e., ≥20 cases per year; n=1,201) to those performed by non-OPCAB surgeons (n=348). Furthermore, the same end points were compared between procedures performed by OPCAB surgeons in high OPCAB volume centres (off-pump technique used in >50% of cases; n=894) and low OPCAB volume centres (n=307). In the experienced OPCAB surgeon group, we observed shorter procedure times (β -43.858, 95% confidence interval [CI] -53.322 to -34.393; p<0.001), a lower rate of conversion to cardiopulmonary bypass (odds ratio [OR] 0.284, 95% CI 0.147-0.551; p<0.001), a lower rate of prolonged inotrope or vasoconstrictor use (OR 0.492, 95% CI 0.371-0.653; p<0.001), a lower rate of early postprocedural percutaneous coronary interventions (OR 0.335, 95% CI 0.169-0.663; p=0.002), and lower 30-day mortality (OR 0.423, 95% CI 0.194-0.924; p=0.031). In high OPCAB volume centres, we found a lower rate of prolonged inotrope use (OR 0.584, 95% CI 0.419-0.814; p=0.002), a lower rate of postprocedural acute kidney injury (OR 0.382, 95% CI 0.198-0.738; p=0.004), shorter duration of intensive care unit (β -1.752, 95% CI -2.240 to -1.264; p<0.001) and hospital (β -1.967; 95% CI -2.717 to -1.216; p<0.001) stays, and lower 30-day mortality (OR 0.316, 95% CI 0.114-0.881; p=0.028). Surgeon experience and centre volume may play an important role on the early outcomes after OPCAB surgery.

In-Hospital cardiac arrest complicating ST-elevation myocardial Infarction: Temporal trends and outcomes based on management strategy

BackgroundThere are limited data on the relationship of ST-segment-elevation myocardial infarction (STEMI) management strategy and in-hospital cardiac arrest (IHCA). AimsTo investigate the trends and outcomes of IHCA in STEMI by management strategy. MethodsAdult with STEMI complicated by IHCA from the National Inpatient Sample (2000–2017) were stratified into early percutaneous coronary intervention (PCI) (day 0 of hospitalization), delayed PCI (PCI ≥ day 1), or medical management (no PCI). Coronary artery bypass surgery was excluded. Outcomes of interest included in-hospital mortality, adverse events, length of stay, and hospitalization costs. ResultsOf 3,967,711 STEMI admissions, IHCA was noted in 102,424 (2.6%) with an increase in incidence during this study period. Medically managed STEMI had higher rates of IHCA (3.6% vs 2.0% vs 1.3%, p < 0.001) compared to early and delayed PCI, respectively. Revascularization was associated with lower rates of IHCA (early PCI: adjusted odds ratio [aOR] 0.44 [95% confidence interval (CI) 0.43–0.44], p < 0.001; delayed PCI aOR 0.33 [95% CI 0.32–0.33], p < 0.001) compared to medical management. Non-revascularized patients had higher rates of non-shockable rhythms (62% vs 35% and 42.6%), but lower rates of multiorgan damage (44% vs 52.7% and 55.6%), cardiogenic shock (28% vs 65% and 57.4%) compared to early and delayed PCI, respectively (all p < 0.001). In-hospital mortality was lower with early PCI (49%, aOR 0.18, 95% CI 0.17–0.18), and delayed PCI (50.9%, aOR 0.18, 95% CI 0.17–0.19) (p < 0.001) compared to medical management (82.5%). ConclusionEarly PCI in STEMI impacts the natural history of IHCA including timing and type of IHCA.

Pre-percutaneous coronary intervention sudden cardiac arrest in ST-elevation myocardial infarction: Incidence, predictors, and related outcomes.

ST-segment elevation myocardial infarction (STEMI) is a frequent cause of sudden cardiac arrest (SCA) and early percutaneous coronary intervention (PCI) is associated with increased survival. Despite constant improvements in SCA management, survival remains poor. We aimed to assess pre-PCI SCA incidence and related outcomes in patients admitted with STEMI. This was a prospective cohort study of patients admitted with STEMI in a tertiary university hospital over 11 years. All patients were submitted to emergency coronary angiography. Baseline characteristics, details of the procedure, reperfusion strategies, and adverse outcomes were assessed. The primary outcome was in-hospital mortality. The secondary outcome was 1-year mortality after hospital discharge. Predictors of pre-PCI SCA was also assessed. During the study period 1,493 patients were included; the mean age was 61.1 years (±12), and 65.3% were male. Pre-PCI SCA was present in 133 (8.9%) patients. In-hospital mortality was higher in the pre-PCI SCA group (36.8% vs. 8.8%, p < 0.0001). In multivariate analysis, anterior MI, cardiogenic shock, age, pre-PCI SCA and lower ejection fraction remained significantly associated with in-hospital mortality. When we analyzed the interaction between pre-PCI SCA and cardiogenic shock upon admission there is a further increase in mortality risk when both conditions are present. For predictors of pre-PCI SCA, only younger age and cardiogenic shock remained significantly associated after multivariate analysis. Overall 1-year mortality rates were similar between pre-PCI SCA survivors and non-pre-PCI SCA group. In a cohort of consecutive patients admitted with STEMI, pre-PCI SCA was associated with higher in-hospital mortality, and its association with cardiogenic shock further increases mortality risk. However, long-term mortality among pre-PCI SCA survivors was similar to non-SCA patients. Understanding characteristics associated with pre-PCI SCA may help to prevent and improve the management of STEMI patients.

Intervention in Cardiogenic Shock

Cardiogenic shock is characterized by hypotension along with signs of hypoperfusion. It has been defined by various societies and clinical trials in different manner. Acute myocardial infarction is the most common cause of cardiogenic shock. Despite early percutaneous coronary intervention, shock secondary to acute coronary syndrome carries mortality rates reaching up to 40–50%. Mechanical circulatory support has been designed to potentially improve outcomes in such patients, but data remains scarce on mortality benefits and long-term outcomes.

PS-BPC07-8: ARTERIAL HYPERTENSION AS PROGNOSTIC MARKER IN PATIENTS WITH ST-ELEVATION MYOCARDIAL INFARCTION AND EARLY PERCUTANEOUS CORONARY INTERVENTION

Objective: Strong evidence points to the prognostic value of renin angiotensin system (RAS)-inhibitors (ACE inhibitors or AT1-receptor blockers) and beta blockers (BB) in the secondary prevention after myocardial infarction (MI). However, adequate dosing of these drugs is often limited due to their blood pressure lowering effects, especially early after MI. The present study therefore sought to identify differences in rates of prescription, persistence and dosing of RAS-inhibitors and BB early after acute ST-elevation MI (STEMI) and its impact on survival in hypertensive and non-hypertensive patients. Design and method: 1003 consecutive patients with adjudicated STEMI treated by early percutaneous coronary intervention (PCI) between 2007 and 2011 in a single centre as part of the Cologne Infarction Model (KIM) were retrospectively dichotomized according to their history of arterial hypertension at the time of hospital admission. Comparisons were made using students T-test. Qualitative analyses were done using Chi square-test or given as odds ratio (OR (95% KI). Results: Mean age was 63 ± 13 years, body mass index 27 ± 5 kg/m2, 24% were women. 749 patients were diagnosed with hypertension. Mortality was 11.3% at 30 days and 17.2% at 1 year follow up. History of hypertension at time of hospital admission was significantly associated with lower mortality on follow up (OR, at 30 days: 0.41 (0.27–0.64), at 1 year 0.37 (0.26–0.53)). Long term persistence to RAS-inhibitors was significantly higher in hypertensive patients compared to non-hypertensives (84% vs. 70%, p = 0.004). However, persistence to BB did not differ between groups (88% vs 86%, n.s.). At discharge the rate of prescription of RAS-inhibitors and BB was significantly higher in hypertensive patients (RAS-inhibitors: 87.3% vs. 69.8%, p &lt; 0.001; BB: 92.8% vs. 84.3%, p &lt; 0.001). In addition, the defined daily dose (DDD) among patients receiving RAS-inhibitors at discharge was higher in hypertensive versus non-hypertensive patients (DDD: RAS-inhibitors, 0.40 vs. 0.30, p &lt; 0.001), whereas there was no difference for BB. At 30 days and at 1 year follow up survival was significantly associated with the prescription of RAS-inhibitors as well as BB at discharge. Conclusion: Patients with a history of hypertension show higher prescription rates at discharge, better long-term persistence as well as higher individual dosing of RAS-inhibitors after STEMI. This, as well as the higher prescription rates of BB, may contribute to the better survival that we observed in STEMI patients with history of hypertension compared to non-hypertensive controls.