In-hospital Revascularization Research Articles

Predictive utility of residual SYNTAX score for clinical outcomes after successful primary percutaneous coronary intervention

Background In patients presenting with ST-segment elevation myocardial infarction (STEMI), the prevalence of having concomitant severe non-culprit lesion(s) is ≥40%. While timely primary PCI (pPCI) for the culprit lesion is the standard practice, management of the non-culprit lesions remains unsettled. Results This prospective multi-center observational study recruited 492 acute STEMI patients who underwent successful pPCI for the culprit lesion. Culprit-only versus complementary non-culprit lesion(s) PCI (either immediate or staged during the same hospital stay) was according to the operator’s discretion. Clinical, echocardiographic, and angiographic data were collected and tabulated. The residual SYNTAX score (rSS) was completed by the time of discharge considering the residual lesions after all in-hospital revascularization procedures. Through a minimum follow-up of 12 months, older age, presentation with heart failure Killip class ≥ II, lower estimated glomerular filtration rate (eGFR) on admission, lower left ventricular ejection fraction (LVEF), and higher rSS by discharge were significantly associated with recurrent MACE. In multivariate regression analysis, Killip class ≥ II, LVEF, and rSS were found to be independent predictors for recurrent MACE. In the Receiver Operating Characteristics curve, an rSS of >8 had a sensitivity of 70.1%, and specificity of 75.3% to predict 1-year MACE. Conclusions Residual syntax score proved to be an independent predictor for recurrent MACE through the subsequent year post STEMI. Patients with rSS >8 seem to be at the highest risk for adverse events and are likely to be the most deserving for completing revascularization to reduce the disease burden.

In-hospital versus after-discharge complete revascularization in patients with ST segment elevation myocardial infarction and multivessel disease. REVIVA-ST trial.

Complete revascularization (CR) in patients with ST-segment elevation myocardial infarction (STEMI) and multivessel disease (MVD), is associated with a reduction in major adverse cardiovascular events (MACE). However, there is uncertainty about whether nonculprit-lesion revascularization should be performed, during index hospitalization or delayed, especially regarding health care resources utilization. In this study, we aimed to evaluate the impact of in-hospital nonculprit-lesion revascularization vs. delayed (after discharge) revascularization on the length of index hospitalization. In this single-center study, we randomly assigned patients with STEMI and MVD who underwent successful culprit-lesion PCI to a strategy of either CR during in-hospital admission or a delayed CR after discharge. The first primary endpoint was the length of hospital stay. The second endpoint was the composite of cardiovascular death, myocardial infarction or ischemia-driven revascularization at 12 months (MACE). From January 2018 to December 2022, we enrolled 258 patients (131 allocated to CR during in-hospital admission and 127 to an after-discharge CR). We found a significant reduction in the length of hospital stay in those assigned to after-discharge CR strategy [4 days (3-5) versus 7 days (5-9); p = 0.001]. At 12-month of follow-up, no differences were found in the occurrence of MACE, 7 (5.34%) patients in in-hospital CR and 4 (3.15%) in after-discharge CR strategy; (hazard ratio, 0.59; 95% confidence interval, 0.17 to 2.02; p = 0.397). In STEMI patients with MVD, an after-discharge CR strategy reduces the length of index hospitalization without an increased risk of MACE after 12 months of follow-up. ClinicalTrials.gov number: NCT04743154.

Trends and Outcomes of Acute Myocardial Infarction During the Early COVID-19 Pandemic in the United States: A National Inpatient Sample Study.

There are limited national data on the trends and outcomes of patients hospitalized with acute myocardial infarction (AMI) during the coronavirus disease 2019 (COVID-19) pandemic. We aimed to evaluate the impact of early COVID-19 pandemic on the trends and outcomes of AMI using the National Inpatient Sample (NIS) database. The NIS database was queried from January 2019 to December 2020 to identify adult (age ≥18 years) AMI hospitalizations and were categorized into ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) based on International Classification of Diseases, Tenth Revision, Clinical Modification codes. In addition, the in-hospital mortality, revascularization, and resource utilization of AMI hospitalizations early in the COVID-19 pandemic (2020) were compared to those in the pre-pandemic period (2019) using multivariate logistic and linear regression analysis. Amongst 1,709,480 AMI hospitalizations, 209,450 STEMI and 677,355 NSTEMI occurred in 2019 while 196,230 STEMI and 626,445 NSTEMI hospitalizations occurred in 2020. Compared with those in 2019, the AMI hospitalizations in 2020 had higher odds of in-hospital mortality (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], [1.23-1.32]; p<0.01) and lower odds of percutaneous coronary intervention (aOR, 0.95 [0.92-0.99]; p=0.02), and coronary artery bypass graft (aOR, 0.90 [0.85-0.97]; p<0.01). We found a significant decline in AMI hospitalizations and use of revascularization, with higher in-hospital mortality, during the early COVID-19 pandemic period (2020) compared with the pre-pandemic period (2019). Further research into the factors associated with increased mortality could help with preparedness in future pandemics.

Clinical characteristics of first myocardial infarction in women by history of adverse pregnancy outcomes

Abstract Background Adverse pregnancy complications are known risk factors for future coronary artery disease in women and small studies suggest that a history of hypertensive disorders of pregnancy are associated with ST-elevation myocardial infarction (STEMI) at the time of myocardial infarction. (1) Recent evidence from a population-based study also suggests that middle aged women with a history of either hypertensive disorders of pregnancy or a small for gestational age infant have a different segmental-level pattern of coronary artery atherosclerosis as detected by coronary computed tomography angiography. (2) Purpose To study clinical characteristics of first-time myocardial infarction by adverse pregnancy outcome history (preterm delivery, hypertensive disorders of pregnancy [including preeclampsia and gestational hypertension], and small for gestational age infant). Methods In 8,320 women age ≤65 years with first myocardial infarction in Sweden 2007-2022, we used logistic regression to estimate the association between adverse pregnancy outcome history and presenting with STEMI (vs. non ST-elevation myocardial infarction [NSTEMI]), in-hospital revascularization, and peak troponin &amp;gt;75th percentile, respectively. In addition to age-adjusted results, we also considered predictors of coronary artery disease (body mass index, diabetes, hypertension, smoking status and dyslipidemia). Results In total, 1301 (15.6 %) women with a first myocardial infarction had a history of preterm delivery, 887 (10.7 %) women had a history of small for gestational age infant, 1078 (13.0 %) women had a history of hypertensive disorders of pregnancy, and 3,128 (37.6%) women presented with STEMI. The odds of presenting with STEMI were higher in women with a history of delivering a small for gestational age infant (age-adjusted odds ratio 1.40, 95% CI 1.22-1.61), as well as the odds of in-hospital revascularization (odds ratio 1.30, 95% CI 1.12-1.50), and peak troponin &amp;gt;75th percentile (odds ratio 1.23, 95% CI 1.05-1.43). Accounting for predictors of coronary artery disease did not change these estimates substantially. No consistent associations were observed between preterm delivery or hypertensive disorders of pregnancy and outcomes. Conclusion(s) Among women presenting with a first myocardial infarction, a history of small for gestational age infant was associated with clinical characteristics indicating larger myocardial injury. The extent to which this is relevant for the prevention and treatment of coronary artery disease in women warrants further studies.

Prevalence and outcomes of acute coronary syndrome patients with and without standard modifiable risk factors undergoing percutaneous coronary intervention

Abstract Background Prevention strategies in acute coronary syndrome (ACS) have focused on patients with standard modifiable risk factors (SMuRFs; diabetes, hypercholesterolaemia, hypertension, and current smoking). There is increasing awareness that SMuRF-less patients may represent a unique subset of patients experiencing ACS. Purpose To investigate the prevalence, characteristics, and outcomes of SMuRF-less ACS patients compared to those with SMuRFs undergoing percutaneous coronary intervention (PCI) in a major city in Australia. Methods We analysed data from adult (≥18 years) ACS patients receiving PCI between 2005 and 2020 using a PCI Registry which contains data for all patients undergoing coronary intervention at one of six major hospitals. Patients with a known history of coronary artery disease were excluded. Overall clinical characteristics and outcomes for those with and without SMuRFs were examined. The primary outcome was 30-day all-cause mortality. Secondary outcomes included in-hospital outcomes, myocardial infarction (MI), revascularisation, and major adverse cardiovascular and cerebrovascular (MACCE) events at 30 days. Long-term mortality was investigated using Cox-proportional hazards regression. Results From 1 January 2005 to 31 December 2020, 2,727 (14.4%) of 18,988 patients were SMuRF-less. Mean (± standard deviation [SD]) age was similar between patients with and without SMuRFs (63±13 vs 63±12 years) and there were more females with SMuRFs (25% vs 20%, p&amp;lt;0.001). SMuRF-less patients were less likely to have a history of cerebrovascular disease (1.2% vs 4.2%, p&amp;lt;0.001), peripheral vascular disease (0.6% vs 3.0%, p&amp;lt;0.001), and chronic lung disease (8.6% vs 10.1%, p=0.014). They were more likely to present with out-of-hospital cardiac arrest (6.6% vs 3.9%, p&amp;lt;0.001) and ST-elevation MI (59% vs 51%, p&amp;lt;0.001). The left anterior descending artery was the target lesion in 46% of SMuRF-less patients compared to 39% of those with SMuRFs. During hospital stay, SMuRF-less patients were more likely to experience post-procedural cardiogenic shock (4.5% vs 3.6%, p=0.019) and arrhythmia (11.2% vs 9.9%, p=0.029). At 30 days, all-cause mortality did not differ between those with and without SMuRFs (3.2% vs 3.6%, p=0.290). Similarly, there were no differences in 30-day MI, revascularisation, and MACCE. During mean follow-up of approximately 7 years, being SMuRF-less was associated with a 12% decreased rate of mortality (adjusted Hazard Ratio 0.88 [95% confidence interval 0.78, 0.99], p=0.035). Conclusions Despite differences in characteristics (rates of cardiac arrest and ST-elevation MI), no difference in 30-day outcomes was observed among those with and without SMuRFs. However, SMuRF-less patients had lower hazard for long-term mortality. These findings suggest SMuRF-less patients may have novel risk factors and improved long-term outcome warranting further research.

Global Registry of Acute Coronary Events Score Underestimates Post-Acute Coronary Syndrome Mortality among Cancer Patients

Background Patients with prior cancer are at increased risk of acute coronary syndrome (ACS) with poorer post-ACS outcomes. We aimed to ascertain if the Global Registry of Acute Coronary Events (GRACE) score accurately predicts mortality risk among patients with ACS and prior cancer. Methods We linked nationwide ACS and cancer registries from 2007 to 2018 in Singapore. A total of 24,529 eligible patients had in-hospital and 1-year all-cause mortality risk calculated using the GRACE score (2471 prior cancer; 22,058 no cancer). Results Patients with prior cancer had two-fold higher all-cause mortality compared to patients without cancer (in-hospital: 22.8% versus 10.3%, p &lt; 0.001; 1-year: 49.0% vs. 18.7%, p &lt; 0.001). Cardiovascular mortality did not differ between groups (in-hospital: 5.2% vs. 4.8%, p = 0.346; 1-year: 6.9% vs. 6.1%, p = 0.12). The area under the receiver operating characteristic curve of the GRACE score for prediction of all-cause mortality was less for prior cancer (in-hospital: 0.64 vs. 0.80, p &lt; 0.001; 1-year: 0.66 vs. 0.83, p &lt; 0.001). Among patients with prior cancer and a high-risk GRACE score &gt; 140, in-hospital revascularization was not associated with lower cardiovascular mortality than without in-hospital revascularization (6.7% vs. 7.6%, p = 0.50). Conclusions The GRACE score performs poorly in risk stratification of patients with prior cancer and ACS.

Nationwide Trends and Outcomes for Coronary Artery Bypass Grafting in End-Stage Kidney Disease and Stable Coronary Artery Disease

Patients with end-stage kidney disease (ESKD) on dialysis have an increased burden of coronary artery disease (CAD). This study assessed the trend and outcomes for coronary artery bypass surgery (CABG) in patients with ESKD and stable CAD. We conducted a longitudinal study using the United States Renal Data System of patients with ESKD and stable CAD who underwent CABG from the years 2009 to 2017. The outcomes included in-hospital, long-term mortality, and repeat revascularization. The follow-up was until death, end of Medicare AB coverage, or December 31, 2018. A total of 11,952 patients were identified. The mean age was 62.8years, 68% were male, and 67% were white. The common co-morbidities included hypertension (97%), diabetes mellitus (75%), and congestive heart failure (53%). A significant decrease in CABG procedures from 2.9 to 1.3 procedures per 1,000 patients with ESKD (p <0.001) was noted during the years studied. The overall in-hospital mortality rate was 5.9%, and there was a significant decrease over the study period (p=0.01). Although the 30-day mortality rate was 6.9% and remained steady (p=0.14), the 1-year mortality rate was 22.8% and decreased significantly (p <0.001). At 5years, the overall survival rate was 35%, and patients with internal mammary artery grafts showed better survival than those without (36% vs 25%). In conclusion, there has been a decrease in CABG procedures performed in patients with ESKD with stable CAD with decreasing in-hospital and 1-year mortality. Those with an internal mammary artery graft do better, but the overall long-term survival remains dismal in this population. There remains need for caution and individualization of revascularization decisions in this high-risk population.

Recurrence of Protruding Calcified Nodule Visualized Using Optical Coherence Tomography Following Stent Implantation

Disparities in access to percutaneous coronary intervention (PCI) for patients with acute myocardial infarction may result from openings and closures of PCI-providing hospitals, potentially leading to low hospital PCI volume, which is associated with poor outcomes.The authors sought to determine whether openings and closures of PCI hospitals have differentially impacted patient health outcomes in high- vs average-capacity PCI markets.In this retrospective cohort study, the authors identified PCI hospital availability within a 15-minute driving time of zip code communities. The authors categorized communities by baseline PCI capacity and identified changes in outcomes associated with PCI-providing hospital openings and closures using community fixed-effects regression models.From 2006 to 2017, 20% and 16% of patients in average- and high-capacity markets, respectively, experienced a PCI hospital opening within a 15-minute drive. In average-capacity markets, openings were associated with a 2.6 percentage point decrease in admission to a high-volume PCI facility; high-capacity markets saw an 11.6 percentage point decrease. After an opening, patients in average-capacity markets experienced a 6.5% and 8.6% relative increase in likelihood of same-day and in-hospital revascularization, respectively, as well as a 2.5% decrease in mortality. PCI hospital closures were associated with a 10.4% relative increase in admission to high-volume PCI hospitals and a 1.4 percentage point decrease in receipt of same-day PCI. There was no change observed in high-capacity PCI markets.After openings, patients in average-capacity markets derived significant benefits, whereas those in high-capacity markets did not. This suggests that past a certain threshold, facility opening does not improve access and health outcomes.

Do PCI Facility Openings and Closures Affect AMI Outcomes Differently in High- vs Average-Capacity Markets?

BackgroundDisparities in access to percutaneous coronary intervention (PCI) for patients with acute myocardial infarction may result from openings and closures of PCI-providing hospitals, potentially leading to low hospital PCI volume, which is associated with poor outcomes. ObjectivesThe authors sought to determine whether openings and closures of PCI hospitals have differentially impacted patient health outcomes in high- vs average-capacity PCI markets. MethodsIn this retrospective cohort study, the authors identified PCI hospital availability within a 15-minute driving time of zip code communities. The authors categorized communities by baseline PCI capacity and identified changes in outcomes associated with PCI-providing hospital openings and closures using community fixed-effects regression models. ResultsFrom 2006 to 2017, 20% and 16% of patients in average- and high-capacity markets, respectively, experienced a PCI hospital opening within a 15-minute drive. In average-capacity markets, openings were associated with a 2.6 percentage point decrease in admission to a high-volume PCI facility; high-capacity markets saw an 11.6 percentage point decrease. After an opening, patients in average-capacity markets experienced a 6.5% and 8.6% relative increase in likelihood of same-day and in-hospital revascularization, respectively, as well as a 2.5% decrease in mortality. PCI hospital closures were associated with a 10.4% relative increase in admission to high-volume PCI hospitals and a 1.4 percentage point decrease in receipt of same-day PCI. There was no change observed in high-capacity PCI markets. ConclusionsAfter openings, patients in average-capacity markets derived significant benefits, whereas those in high-capacity markets did not. This suggests that past a certain threshold, facility opening does not improve access and health outcomes.

Safety and efficacy of the expressman extension system for complex coronary lesions during percutaneous coronary intervention.

Safety and efficacy of the expressman extension system for complex coronary lesions during percutaneous coronary intervention.

Prognostic significance of obstructive coronary artery disease in patients admitted with acute decompensated heart failure: the ARIC study community surveillance.

We aimed to investigate the impact of obstructive coronary artery disease (CAD) in patients with acute decompensated heart failure (ADHF), and examine potential differences in prognostic utility for heart failure with reduced (HFrEF) versus preserved ejection fraction (HFpEF). The Atherosclerosis Risk in Communities study conducted hospital surveillance of ADHF from 2005 to 2014. Obstructive CAD was defined as ≥50% or ≥75% stenosis, respectively, for the left main and other major epicardial arteries. Adjusted associations between obstructive CAD and 30-, 60-, and 90-day mortality were analysed. A total of 934 (4146 weighted) patients admitted with ADHF (mean age 72 years, 46% women, 30% Black, 30% HFpEF) had available angiography (61% performed in hospital). Obstructive CAD was more prevalent with HFrEF than HFpEF, whether at the left main (15% vs. 11%), left anterior descending (LAD) (48% vs. 30%), left circumflex (37% vs. 32%), right coronary (42% vs. 32%), or multiple coronary arteries (45% vs. 33%). In-hospital revascularization was performed in 25% and 22% of patients with HFrEF and HFpEF, respectively. Obstructive CAD was associated with higher adjusted mortality, particularly with left main or LAD involvement, and had a more pronounced association with 90-day mortality in HFrEF (odds ratio [OR] 2.77; 95% confidence interval [CI] 1.53-5.02) than HFpEF (OR 0.94; 95% CI 0.36-2.41) (p-interaction=0.05). Patients hospitalized with ADHF and coexisting obstructive CAD have higher short-term mortality, warranting the need for effective interventions and secondary prevention.

Modified Shock Index as Simple Clinical Independent Predictor of In-Hospital Mortality in Acute Coronary Syndrome Patients: A Retrospective Cohort Study.

IntroductionDespite being the current most accurate risk scoring system for predicting in-hospital mortality for patients with acute coronary syndrome (ACS), the Global Registry of Acute Coronary Events (GRACE) risk score is time consuming due to the requirement for electrocardiography and laboratory examinations. This study is aimed to evaluate the association between modified shock index (MSI), as a simple and convenient index, with in-hospital mortality and revascularization in hospitalized patients with ACS.MethodsA single-centered, retrospective cohort study, involving 1,393 patients with ACS aged ≥ 18 years old, was conducted between January 2018 and January 2022. Study subjects were allocated into two cohorts: high MSI ≥ 1 (n = 423) and low MSI < 1 group (n = 970). The outcome was in-hospital mortality and revascularization. The association between MSI score and interest outcomes was evaluated using binary logistic regression analysis. The area under the curve (AUC) between MSI and GRACE score was compared using De Long’s method.ResultsModified shock index ≥ 1 had 61.1% sensitivity and 73.7% specificity. A high MSI score was significantly and independently associated with in-hospital mortality in patients with ACS [odds ratio (OR) = 2.72(1.6–4.58), p < 0.001]. However, ST-segment elevation myocardial infarction (STEMI) and non-STEMI (NSTEMI) patients with high MSI did not significantly increase the probability of revascularization procedures. Receiver operating characteristic (ROC) analysis demonstrated that although MSI and GRACE scores were both good predictors of in-hospital mortality with the AUC values of 0.715 (0.666–0.764) and 0.815 (0.775–0.855), respectively, MSI was still inferior as compared to GRACE scores in predicting mortality risk in patients with ACS (p < 0.001).ConclusionModified shock index, particularly with a score ≥ 1, was a useful and simple parameter for predicting in-hospital mortality in patients presenting with ACS.

Predictors of the Development of Major Adverse Cardiac Events following Percutaneous Coronary Intervention

Background: Coronary artery disease remains the greatest cause of morbidity and mortality worldwide despite the growing access to percutaneous coronary intervention (PCI). Data regarding the factors predicting the development of major adverse cardiac events (MACE) in patients undergoing PCI are, however, lacking in the gulf region. In this study, we analyze demographics and risk profile of all patients undergoing PCI in a tertiary cardiovascular center located in Dubai – UAE. In our study, we aimed to analyze the risk profile of all patients undergoing PCI and determine the independent predictors of MACE. Methods: Data were collected prospectively on all patients who underwent PCI in our hospital between September 2017 and September 2018. Patients aged 18 years and above were included in the study and there were no exclusion criteria. The definition of MACE was a composite of death, in-hospital recurrent myocardial infarction (MI), in-hospital target vessel revascularization (TVR), and stroke. The patients’ characteristics, risk factor, and demographics were analyzed to identify the predictors of MACE using logistic regression model which is presented in odds ratio. Results: Data were available for 789 patients. Of these, 741 (94%) were male. The mean age was 52 ± 11 years. Twenty-two (3%) patients died, 7 (1%) had an in-hospital recurrent MI, 6 (1%) had in-hospital TVR, and 1 (0.1%) had a stroke. Of the patients who died, 16 (73%) patients presented with cardiogenic shock. Major adverse cardiovascular events occurred in 29 (3.7%) patients. In the multivariable regression model, only cardiogenic shock (odds ratio [OR] = 32.43) and the presence of diabetes mellitus (OR = 3.36) were predictors of MACE. Conclusion: Our study showed that cardiogenic shock and diabetes mellitus are the independent predictors of MACE in patients undergoing PCI.

First Experience Using the Sheathless Hyperion Guiding Catheter System Designed for Direct Insertion.

Background Use of sheathless guiding catheters for transradial PCI has the potential to reduce radial trauma and allow use of larger catheters to facilitate complex PCI. The new sheathless Hyperion guide catheter (SHGC) system allows direct insertion of the SHGC using a 20G needle or IV cannula, a 0.025″ Silverway wire, and a dilator. We report the first clinical experience. Methods We prospectively evaluated outcomes in consecutive patients undergoing PCI using radial access and the SHGC catheter at our institution between June 2020 and June 2021. There were no exclusion criteria. Results The study included 120 patients, mean age 67 ± 12.6 years, 79.2% male. Insertion of a SHGC was attempted in 128 radial arteries and was successful in all cases. The SHGC was inserted directly in 74 (57.8%), following initial sheath removal in 24 (20.5%) and through the initial sheath in 30 (26.2%). Coronary artery engagement with a SHGC was successful in 126 (98.4%). A total of 150 lesions were treated, the majority being complex: 16.1% chronic total occlusions, 37.1% calcified, 30.6% bifurcation, and 43.5% long lesions. Angiographic success was achieved in 149 (99.2%) lesions. Periprocedural myocardial infarction occurred in 5 (4.2%) patients. There was no in-hospital urgent revascularisation or death and no major bleeding or vascular complications. Occlusion occurred in 2 (1.6%) radial arteries. Conclusion This first clinical experience with the SHGC demonstrates that direct insertion is safe and effective and that the use of the SHGC allows complex interventions to be undertaken transradially with a high success rate.

Initial clinical experience with a new sheathless guiding catheter designed for direct insertion

Abstract Funding Acknowledgements Type of funding sources: None. Background Radial access for percutaneous coronary intervention (PCI) is growing rapidly as this approach has been shown to improve patient comfort and reduce complications. Use of a sheathless guiding catheter for transradial PCI has the potential reduce trauma to the radial artery and to further expand the type of cases where this approach can be utilised. The new Sheathless Hyperion system allows direct insertion of the Sheathless Hyperion guiding catheter using a 20 G needle or IV cannula, a 0.25" Silverway wire and a custom dilator. Purpose We report the first clinical experience with the new Sheathless Hyperion guiding catheter designed for direct insertion. Methods We prospectively evaluated outcomes in consecutive patients who underwent PCI using the Sheathless Hyperion catheter at our institution between June 2020 and March 2021. All procedures were performed via radial access. There were no exclusion criteria. Results Eighty one patients were included with 99 lesion being treated using 85 Sheathless Hyperion catheters. Mean age 67.7 ± 11.8 years, 77.8% male, 22.2% diabetic and 38.8% had acute coronary syndromes. The Sheathless Hyperion was inserted directly into the radial artery in 46 (54.1%) cases with 100% success rate and inserted following initial sheath insertion for the remaining 39 (45.9%). Of the Sheathless Hyperion catheters used 30 (35.3%) were 6F in 55 (64.7%) were 7F. The Sheathless Hyperion was passed into the ascending aorta successfully in all cases. The target coronary artery was successfully engaged in 85 (98.8%). In one case the coronary could not be engaged because of excessive brachiocephalic tortuosity and conversion to femoral access occurred. In 4 cases the Sheathless Hyperion catheter had to be exchanged for one with a small curve. The majority of lesions were complex: 18.2% CTO, 39.4% heavily calcified, 44.4% long lesions and 31.3% bifurcation lesions. Adjunctive devices included rotational atherectomy (12.1%), intravascular lithotripsy 14.1%, IVUS (56.6%) and OCT (28.3%). Angiographic success was achieved in 100%. Peri-procedural non-ST-elevation myocardial infarctions defined by the 4th Universal definition occurred in 3 (3.7%) patients. No patient meet the SCAI criteria for periprocedural MI. There was no in-hospital target vessel revascularisation or death. Radial artery occlusion was infrequent occurring in one patient. No major haematomas or vascular complications occurred. Conclusion First clinical experience with the Sheathless Hyperion demonstrates that direct insertion is safe and effective and that it allows complex interventions to be undertaken transradially with a high success rate.

Variability in Reassessment of Left Ventricular Ejection Fraction After Myocardial Infarction in the Acute Myocardial Infarction Quality Assurance Canada Study

Persistently depressed left ventricular ejection fraction (LVEF) after myocardial infarction (MI) is associated with adverse prognosis and directs the use of evidence-based treatments to prevent sudden cardiac death and/or progressive heart failure. To assess adherence with guideline-recommended LVEF reassessment and to study the evolution of LVEF over 6 months of follow-up. This was a multicenter cohort study at Canadian academic and community hospitals with on-site cardiac catheterization services. Patients with type 1 acute MI and LVEF less than or equal to 45% during the index hospitalization were enrolled between January 2018 and August 2019 and were followed-up for 6 months. Data analysis was performed from May 2020 to September 2021. Baseline clinical factors, in-hospital care and LVEF, and site-specific features. The main outcomes were receipt of repeat LVEF assessment by 6 months and the presence of a persistent LVEF reduction at 2 thresholds: LVEF less than or equal to 40%, prompting consideration of additional medical therapy for heart failure, or LVEF less than or equal to 35%, prompting referral for implanted cardioverter defibrillator in addition to medical therapy. This study included 501 patients (mean [SD] age, 63.3 [13.0] years; 113 women [22.6%]). Overall, 370 patients (73.4%) presented with STEMI, and 454 (90.6%) had in-hospital revascularization. The median (IQR) baseline LVEF was 40% (34%-43%). Of 458 patients (91.4%) who completed the 6-month follow-up, 303 (66.2%; 95% CI, 61.7%-70.5%) had LVEF reassessment, with a range of 46.7% to 90.0% across sites (χ213 = 19.6; P = .11). Participants from community hospitals were more likely than those from academic hospitals to undergo LVEF reassessment (73.6% vs 63.2%; χ21 = 4.50; P = .03), as were those with worse LVEF at baseline. Follow-up LVEF improved by an absolute median (IQR) of 8% (3%-15%). However, 103 patients (34.1%) met the definitions of clinically relevant LVEF reduction, including 52 patients (17.2%) with LVEF less than or equal to 35% and 51 patients (16.9%) with LVEF of 35.1% to 40.0%. In this cohort study, approximately 1 in 3 patients with at least mild LVEF reduction after acute MI did not undergo indicated LVEF reassessment within 6 months, suggesting that programs to improve the quality of post-MI care should include measures to ensure that indicated repeat cardiac imaging is performed. In those with follow-up imaging, clinically relevant persistent LVEF reduction was identified in more than one-third of patients.

Risk-associated management disparities in acute myocardial infarction

Despite improvements in the treatment of myocardial infarction (MI), risk-associated management disparities may exist. We investigated this issue including temporal trends in a large MI cohort (n = 179,291) registered 2005–2017 in SWEDEHEART. Multivariable models were used to study the associations between risk categories according to the GRACE 2.0 score and coronary procedures (timely reperfusion, invasive assessment ≤ 3 days, in-hospital coronary revascularization), pharmacological treatments (P2Y12-blockers, betablockers, renin–angiotensin–aldosterone-system [RAAS]-inhibitors, statins), structured follow-up and secondary prevention (smoking cessation, physical exercise training). High-risk patients (n = 76,295 [42.6%]) experienced less frequent medical interventions compared to low/intermediate-risk patients apart from betablocker treatment. Overall, intervention rates increased over time with more pronounced increases seen in high-risk patients compared to lower-risk patients for in-hospital coronary revascularization (+ 23.6% vs. + 12.5% in patients < 80 years) and medication with P2Y12-blockers (+ 22.2% vs. + 7.8%). However, less pronounced temporal increases were noted in high-risk patients for medication with RAAS-blockers (+ 8.5% vs. + 13.0%) and structured follow-up (+ 31.6% vs. + 36.3%); pinteraction < 0.001 for all. In conclusion, management of high-risk patients with MI is improving. However, the lower rates of follow-up and of RAAS-inhibitor prescription are a concern. Our data emphasize the need of continuous quality improvement initiatives.

Prognosis Impact of Diabetes in Elderly Women and Men with Non-ST Elevation Acute Coronary Syndrome.

Few studies have addressed to date the interaction between sex and diabetes mellitus (DM) in the prognosis of elderly patients with non-ST-segment elevation acute coronary syndrome (NSTEACS). Our aim was to address the role of DM in the prognosis of non-selected elderly patients with NSTEACS according to sex. A retrospective analysis from 11 Spanish NSTEACS registries was conducted, including patients aged ≥70 years. The primary end point was one-year all-cause mortality. A total of 7211 patients were included, 2,770 (38.4%) were women, and 39.9% had DM. Compared with the men, the women were older (79.95 ± 5.75 vs. 78.45 ± 5.43 years, p < 0.001) and more often had a history of hypertension (77% vs. 83.1%, p < 0.01). Anemia and chronic kidney disease were both more common in women. On the other hand, they less frequently had a prior history of arteriosclerotic cardiovascular disease or comorbidities such as peripheral artery disease and chronic pulmonary disease. Women showed a worse clinical profile on admission, though an invasive approach and in-hospital revascularization were both more often performed in men (p < 0.001). At a one-year follow-up, 1090 patients (15%) had died, without a difference between sexes. Male sex was an independent predictor of mortality (HR = 1.15, 95% CI 1.01 to 1.32, p = 0.035), and there was a significant interaction between sex and DM (p = 0.002). DM was strongly associated with mortality in women (HR: 1.45, 95% CI = 1.18–1.78; p < 0.001), but not in men (HR: 0.98, 95% CI = 0.84–1.14; p = 0.787). In conclusion, DM is associated with mortality in older women with NSTEACS, but not in men.

Homocysteine and long-term recurrent infarction following an acute coronary syndrome.

There are no well-established predictors of recurrent ischemic coronary events after an acute coronary syndrome (ACS). Higher levels of homocysteine have been reported to be associated with an increased atherosclerotic burden. The primary endpoint was to assess the relationship between homocysteine at discharge and very long-term recurrent myocardial infarction (MI). 1306 consecutive patients with ACS were evaluated (862 with non-ST-segment elevation ACS [NSTEACS] and 444 with ST-segment elevation myocardial infarction [STEMI]) discharged from October 2000 to June 2003 in a single teaching-center. The relationship between homocysteine at discharge and recurrent MI was evaluated through bivariate negative binomial regression accounting for mortality as a competitive event. The mean age was 66.8 ± 12.4 years, 69.1% were men, and 32.2% showed prior diabetes mellitus. Most of the patients were admitted for an NSTEACS (66.0%). The median (interquartile range) GRACE risk score, Charlson comorbidity index, and homocysteine were 144 (122-175) points, 1 (1-2) points, and 11.9 (9.3-15.6) μmol/L, respectively. In-hospital revascularization was performed in 26.3% of patients. At a median follow-up of 9.7 (4.5-15.1) years, 709 (54.3%) deaths were registered and 779 recurrent MI in 478 (36.6%) patients. The rates of recurrent MI were higher in patients in the upper homocysteine quartiles (p < 0.001). After a multivariate adjustment, homocysteine along its continuum remained almost linearly associated with a higher risk of recurrent MI (p = 0.001) and all-cause mortality (p < 0.001). In patients with ACS, higher homocysteine levels identified those at a higher risk of recurrent MI at very long-term follow-up.

Surgical procedures for coronary arteries in pediatric cardiac surgery: Risk factors and outcomes.

Limited data exist regarding the coronary revascularization procedures needed during the repair of several congenital and pediatric cardiac malformations. We aimed to determine risk factors for in-hospital mortality and long-term outcomes of various pediatric coronary revascularization procedures. We retrospectively reviewed the records of 32 consecutive pediatric patients who underwent coronary revascularization procedures at our institution between May 1995 and June 2020. In-hospital mortality, risk factors, surgical indications, revascularization patency, and mid- and long-term follow-up data were investigated. Patients were categorized into the coronary artery bypass grafting (n = 11) and other coronary artery procedure (n = 21) groups. The median age and weight of patients at the time of surgery were 9 months and 4.8 kg, respectively. There were five in-hospital deaths (5/32, 15.6%). The mortality rates were 27.2% (3/11) in the coronary artery bypass grafting group and 9.5% (2/21) in the other coronary artery procedure group (p = .206; 95% confidence interval: 0.496-25.563). The mortality rates for planned and rescue procedures were 8.3% (2/24) and 37.5% (3/8) (p = .06), respectively. The median follow-up time was 12.5 years. Control imaging studies for coronary patency were performed in 70.3% (19/27) of surviving patients. The overall coronary patency rate was 94.7% (18/19). Pediatric coronary revascularization procedures with elective-planned indications can be performed with good outcomes. Young age and rescue and emergency procedures may carry an increased risk of in-hospital mortality, although not found to be statistically significant. Surviving patients require lifelong follow-up regarding the patency of reperfused coronary arteries.