Percutaneous Coronary Intervention For Acute Coronary Syndrome Research Articles

Cohort Profile: the European Unified Registries On Heart care Evaluation and Randomised Trials (EuroHeart) - Acute Coronary Syndrome and Percutaneous Coronary Intervention.

The European Unified Registries On Heart care Evaluation And Randomized Trials (EuroHeart) aims to improve the quality of care and clinical outcomes for patients with cardiovascular disease. The collaboration of acute coronary syndrome/percutaneous coronary intervention (ACS/PCI) registries is operational in seven vanguard European Society of Cardiology member countries. Adults admitted to hospitals with ST-elevation myocardial infarction (STEMI) and non-ST-elevation myocardial infarction (NSTEMI) are included, and individual patient-level data collected and aligned according to the internationally agreed EuroHeart data standards for ACS/PCI. The registries provide up to 155 variables spanning patient demographics and clinical characteristics, in-hospital care, in-hospital outcomes, and discharge medications. After performing statistical analyses on patient data, participating countries transfer aggregated data to EuroHeart for international reporting.Between 1st January 2022 and 31st December 2022, 40021 admissions (STEMI 46.7%, NSTEMI 53.3%) were recorded from 192 hospitals in the seven vanguard countries: Estonia, Hungary, Iceland, Portugal, Romania, Singapore, and Sweden. The mean age for the cohort was 67.9 (standard deviation 12.6) years, and it included 12628 (31.6%) women. The EuroHeart collaboration of ACS/PCI registries prospectively collects and analyses individual data for ACS and PCI at a national level, after which aggregated results are transferred to the EuroHeart Data Science Centre. The collaboration will expand to other countries and provide continuous insights into the provision of clinical care and outcomes for patients with ACS and undergoing PCI. It will serve as a unique international platform for quality improvement, observational research, and registry-based clinical trials.

No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score.

Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI. We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005-2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006-2020; external validation cohort). A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment-elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively. The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials.

The efficacy of excimer laser coronary atherectomy in ST-elevation myocardial infarction: a report from the STELA registry

Abstract Backgrounds Previous studies have demonstrated potential effect of excimer laser coronary atherectomy (ELCA) to reduce thrombus burden within the vessel, and ELCA has been used during primary PCI for acute coronary syndrome. Especially, the culprit lesions of ST-segment elevation myocardial infarction (STEMI) are generally accompanied by large thrombus burden. Nevertheless, the clinical effectiveness of ELCA use for the culprit lesions of STEMI has not been elucidated. Purpose To investigate the clinical outcomes of the STEMI patients who were treated with ELCA during primary PCI in comparison with those treated without ELCA. Methods We conducted the registry study of STEMI for the assessment of the efficacy of ELCA, which was an observational multicenter registry of the consecutive patients undergoing primary PCI for STEMI within 24 hours from the onset between 2015 and 2019. The patients were divided into two groups according to the use of ELCA during primary PCI: ELCA group and non-ELCA group. The primary endpoint was the major adverse cardiovascular event (MACE), which was defined as the composite of cardiovascular death (CVD), target vascular revascularization and non-fatal AMI. Propensity score (PS) matching was performed to adjust the bias of confounding factors using 1:1 nearest-neighbor matching without replacement. PS was yielded from clinical characteristics, baseline angiographic findings, and hemodynamic status that were imbalanced between the two groups. Results A total of 2593 patients, 424 patients in ELCA group and 2169 patients in non-ELCA group, were included in the analysis. PS matched cohort comprised 824 patients including 412 ELCA and 412 non-ELCA group. Median follow-up duration in the total cohort was 816 (394-1388) days. In the total cohort, baseline characteristics showed that younger age, less prevalent hypertension, and more frequent prior statin use in ELCA group than in non-ELCA group. In terms of clinical outcomes, ELCA group showed a significantly lower rate of CVD than non-ELCA group (4.3% vs 7.5%, P for log-rank = 0.03), whereas MACE rate was similar between the two groups (HR:1.00 95%CI 0.74-1.34, P=0.99). In the PS matched cohort, the baseline characteristics were well balanced. Clinical outcomes including MACE and CVD were comparable between the two groups (MACE HR:1.13 95%CI 0.76-1.66, P=0.53 and CVD HR0.70 95%CI 0.38-1.29 P=0.25). In the subgroup analysis, MACE rate was lower in ELCA group than in non-ELCA group in the patients who presented with Killip class III or IV (P for interaction &amp;lt;0.01) (Abstract Picture 1). Conclusions The use of ELCA was not associated with improved MACEs in both total cohort and the PS matched cohort, whereas subgroup analysis suggested a potential benefit of ELCA in patients with heart failure. Further prospective investigations are warranted.Forest Plots for Subgroup Analysis

Early initiation of PCSK9 inhibitor therapy versus placebo in patients with acute coronary syndrome: a systematic review and meta-analysis

Abstract Background In patients with stable atherosclerotic cardiovascular disease (ASCVD) and prior atherosclerotic events, PCSK9 inhibitors (PCSK9i) have shown a 50-60% reduction in LDL-C from baseline, on a background of high-intensity or maximally tolerated statin therapy, leading to a 15% relative reduction in the incidence of major adverse cardiovascular events. However, less is known about the impact of PCSK9i initiation acutely in the setting of an acute coronary syndrome (ACS). Purpose To assess the efficacy of early initiation of PCSK9i therapy in lipid parameters among patients presenting with ACS. Methods We performed a systematic review and meta-analysis comparing PCSK9i with placebo in the setting of ACS, added to guideline directed high-intensity or maximally tolerated statin therapy. Inclusion was restricted to randomized controlled trials (RCTs) with initiation of PCSK9i or placebo within 1 week of presentation or percutaneous coronary intervention for ACS. PubMed, EMBASE, and Cochrane Central were searched. The systematic review and meta-analysis followed Cochrane and PRISMA recommendations. Results Six RCTs with a total of 996 patients were included, of whom 503 (50.5%) received PCSK9i. Mean follow-up ranged from 4 to 52 weeks. Mean time from presentation to administration of first dose ranged from 3.6 hours to 6.5 days. LDL-C levels were significantly lower at follow-up in the PCSK9i group (mean difference [MD] -44 mg/dL; 95% CI -54.3 to -33.8 mg/dL; p&amp;lt;0.001; Figure 1A). Lp(a) was also significantly decreased with PCSK9i therapy (MD -24.0 nmol/L; 95% CI -43.0 to -4.9 nmol/L; p=0.01; Figure 1B). Similarly, total cholesterol (MD -49.2 mg/dL; 95% CI -59 to -39.3 mg/dL; p&amp;lt;0.001) and triglycerides (MD -19 mg/dL; 95% CI -29.9 to -8.2 mg/dL; p&amp;lt;0.001) were significantly reduced with PCSK9i therapy, respectively. HDL-C was marginally increased in this same group (MD 2.5 mg/dL; 95% CI 0.9 to 4.2 mg/dL; p=0.003). Conclusions In patients with ACS, early initiation of PCSK9i, in addition to statin therapy, leads to a significant reduction in LDL-C and Lp(a) as compared with placebo. Whether the differences in these lipoproteins translate into a reduction in clinical endpoints is yet to be determined.

Abstract 14077: Anticoagulation Following Percutaneous Coronary Intervention in Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

Introduction: To maximize reperfusion and thrombus breakdown, anticoagulation therapy may be continued after percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndrome (ACS). However, limited evidence exists to support this practice. Methods: An electronic search was conducted using MEDLINE and EMBASE databases from inception to March 19th, 2023. Eligible studies comparing 30-day outcomes of post-procedural anticoagulation (PPAC) with no PPAC after PCI in patients with ACS were screened for inclusion. The primary outcome was 30-day mortality. Pooled risk ratios (RRs) with 95% confidence intervals (CIs) were estimated using a random-effect model. Results: Total 6 studies (3 observational, 3 post-hoc analyses of randomized controlled trials) with 61,901 patients (PPAC=38,900, no PPAC=23,001) were selected. There were no significant differences in all-cause mortality (RR 0.79 [0.52-1.19], P=0.26), cardiac mortality (RR 0.69 [0.43-1.11], P=0.13), myocardial infarction (RR 0.86 [0.61-1.21] P=0.39), stroke (RR 1.18 [0.87-1.59], P=0.29), and major bleeding (RR 0.91 [0.65-1.27], P=0.58) between PPAC and no PPAC groups. However, PPAC was associated with a higher rate of stent thrombosis at 30 days (RR 1.34 [1.04-1.73], P=0.02). Conclusions: Overall, PPAC following PCI for ACS did not improve survival or cardiovascular morbidity. However, there was a slightly higher incidence of stent thrombosis in the PPAC cohort. Further randomized studies are necessary to confirm these findings.

Early Initiation of PCSK9 Inhibitor Therapy Versus Placebo in Patients With Acute Coronary Syndrome: A Systematic Review and Meta-Analysis

In patients with stable atherosclerotic cardiovascular disease, proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9is) have shown a 50% to 60% reduction in low-density lipoprotein cholesterol (LDL-C) from baseline when added to high-intensity statin therapy. However, less is known about the impact of PCSK9is in the setting of an acute coronary syndrome (ACS). Therefore, we performed a systematic review and meta-analysis comparing PCSK9is with placebo in the setting of ACS added to guideline-directed high-intensity or maximally tolerated statin therapy. We included randomized controlled trials with initiation of a PCSK9i or placebo within 1week of presentation or percutaneous coronary intervention for ACS. PubMed, EMBASE, and Cochrane Central were searched. This study followed the Cochrane and Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) recommendations. A total of 6 randomized controlled trials were included, with a total of 996 patients, of whom 503 (50.5%) received PCSK9is. The mean follow-up ranged from 4 to 52weeks. The LDL-C (mean difference [MD] -44.0mg/100ml, CI -54.3 to -33.8, p <0.001) and lipoprotein (a) levels (MD -24.0nmol/L, confidence interval [CI] -43.0 to -4.9, p = 0.01) were significantly lower at follow-up with PCSK9is. Similarly, the total cholesterol (MD -49.2mg/100ml, CI -59.0 to -39.3), triglycerides (MD -19.0mg/100ml, CI -29.9 to -8.2), and apolipoprotein B (MD -33.3mg/100ml, CI -44.4 to -22.1) were significantly reduced with PCSK9is. In conclusion, in patients with ACS, early initiation of PCSK9i added to statin significantly reduces LDL-C and lipoprotein (a) levels compared with placebo. Whether the differences in these atherogenic lipoproteins translate into a reduction in clinical end points is yet to be determined.

Validation of prediction tools for GI bleeding in patients on dual anti-platelet therapy after percutaneous coronary intervention

Background & AimsThe management of dual anti-platelet therapy (DAPT) after percutaneous coronary intervention (PCI) and gastrointestinal bleeding (GIB) remains a clinical dilemma. We sought to identify predictors of a GIB and a rebleed and to determine whether a rebleed increases the risk of major adverse cardiovascular events (MACE). MethodsIn this single-center retrospective study, patients undergoing PCI were identified. The primary and secondary endpoints were a GIB at 180 days, and a rebleed or MACE at 365 days. Logistic regression was used to identify predictors of GIB and rebleed. Cox Proportional Hazard modeling was used to determine whether rebleed can predict MACE. ResultsA total of 536 patients were included. On multivariable analysis, PCI for acute coronary syndrome was associated with 95% increased odds of GIB, p < 0.001. The P2Y12 inhibitor was continued in > 90% of patients, which trended towards significance for a rebleed, p < 0.10. The HAS-BLED score, including a labile INR and prior major bleeding, were strongly associated with a rebleed, p ≤ 0.009. A rebleed was associated with a 115% increased risk of MACE, p = 0.02. We derived a novel risk score, named the SIGE score, to predict a rebleed at 365 days with a high predictive accuracy, AUC 0.773 (95% CI: 0.702 – 0.845). ConclusionThe SIGE score may help to predict rebleeding, which was shown to be associated with an increased risk of MACE. Further external validation is needed.

Association of prognostic nutritional index with long-term mortality in patients receiving percutaneous coronary intervention for acute coronary syndrome: a meta-analysis

The predictive value of the prognostic nutritional index (PNI) for the long-term prognosis of patients with acute coronary syndrome (ACS) remains uncertain. Medline, Embase, Cochrane Library, and Google Scholar were searched from inception until January 2023 to study the relationship between all-cause mortality risk and PNI in patients receiving percutaneous coronary intervention for ACS (i.e., primary outcome). Thirteen observational studies were included in this meta-analysis. Analysis of seven studies using PNI as a categorical variable showed a pooled hazard ratio (HR) of all-cause mortality of 2.97 (95% CI 1.65 to 5.34, p = 0.0003, I2 = 89%, n = 11,245) for patients with a low PNI. The meta-analysis also showed a higher risk of major adverse cardiovascular events (MACEs) in patients with a low PNI (HR 2.04; 95% CI 1.59 to 2.61; p < 0.00001; I2 = 21%; n = 8534). Moreover, advanced age, diabetes mellitus, and high Global Registry of Acute Coronary Events risk scores were associated with a high risk of all-cause mortality, whereas a high body mass index was associated with a low risk of all-cause mortality. The results showed an association between a low PNI and an increased risk of long-term mortality in patients undergoing coronary interventions for ACS. Further randomized controlled trials are necessary to confirm these findings.

Effect of frailty on major bleeding in octogenarian patients undergoing percutaneous coronary intervention.

There has been an increase in the number of percutaneous coronary intervention (PCI) procedures performed in octogenarian patients due to increased life expectancy and developments in modern medicine. Frailty is associated with the aging process, gradual loss of multiple body functions, and poor health outcomes. We examined the association between frailty and major bleeding in octogenarian patients undergoing PCI. We retrospectively analyzed the records of two local research hospitals in Turkey. In total, 244 patients were enrolled in this study. Patients were divided into two groups based on their Clinical Frailty Scale (CFS) score. The non-frail group included patients with CFS scores of 1 (very fit) to 4 (living with very mild frailty), while the frail group included those with CFS scores of 5 (living with mild frailty) to 9 (terminally ill). Of the 244 patients, 131 were classified into the non-frail group and 113 into the frail group. Ticagrelor use was significantly more common in the non-frail group (31.3% vs. 20.4%, p=0.036). Major bleeding was more common in the frail than non-frail group (20.4% vs. 6.1%, p<0.001). The rates of stroke and all-cause death were higher in the frail than in non-frail group (stroke 15.9% vs. 3.8%, p<0.001, as well as all-cause mortality rate (27.4% vs. 2.3%, p<0.001). Frailty is an independent predictor of major bleeding in patients undergoing PCI for acute coronary syndrome. Use of the P2Y12 inhibitor ticagrelor increases the risk of major bleeding in frail patients.

Intracoronary imaging in PCI for acute coronary syndrome: Insights from British Cardiovascular Intervention Society registry

BackgroundWhile previous studies have demonstrated the superiority of ICI-guided PCI over an angiography-based approach, there are limited data on all-comer ACS patients.This study aimed to identify the characteristics and in-hospital outcomes of patients undergoing intracoronary imaging (ICI) guided percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). MethodsAll patient undergoing PCI for ACS in England and Wales between 2006 and 2019 were retrospectively analyzed and stratified according to ICI utilization. The outcomes assessed were in-hospital all-cause mortality and major adverse cardiovascular and cerebrovascular events (MACCE) using multivariable logistic regression models. Results598,921 patients underwent PCI for ACS, of which 41,716 (7.0 %) had ICI which was predominantly driven by IVUS use (5.6 %). ICI use steadily increased from 1.4 % in 2006 to 13.5 % in 2019. Adjusted odds of mortality (OR 0.69, 95%CI 0.58–0.83) and MACCE (OR 0.77, 95%CI 0.73–0.83) were significantly lower in the ICI group. The association between ICI and improved outcomes varied according to vessel treated with both left main stem (LMS) and LMS/left anterior descending (LAD) PCI associated with significantly lower odds of mortality (OR 0.34, 95%CI 0.27–0.44, OR 0.51 95%CI 0.45–0.56) and MACCE (OR 0.44 95%CI 0.35–0.54, OR 0.67 95%CI 0.62–0.72) respectively. ConclusionsAlthough ICI use has steadily increased, less than one in seven patients underwent ICI-guided PCI. The association between ICI use and improved in-hospital outcomes was mainly observed in PCI procedures involving LMS and LAD.

Assessing the Clinical Treatment Dynamics of Antiplatelet Therapy Following Acute Coronary Syndrome and Percutaneous Coronary Intervention in the US

A platelet ADP P2Y12 receptor (P2Y12) inhibitor plus aspirin is standard therapy for patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Compared with clopidogrel, prasugrel and ticagrelor are associated with superior antiatherothrombotic effects but increased bleeding risk; with recent guideline updates, it is important to describe current treatment patterns and the role of bleeding risk in treatment choice. To describe secular trends and determinants of initial P2Y12 inhibitor choice and switching, including deescalation (switch from prasugrel or ticagrelor to clopidogrel). This retrospective cohort study used MarketScan Commercial Claims Data from 2010 to 2019 for patients aged 18 years or older who underwent PCI for ACS, had no P2Y12 inhibitor use in the past year, and filled a P2Y12 inhibitor prescription within 30 days after PCI hospitalization discharge. Data were analyzed from February to May 2022. Clopidogrel, prasugrel, and ticagrelor, with determinants including bleeding risk measured using Academic Research Consortium for High Bleeding Risk criteria, sociodemographic characteristics, P2Y12 inhibitor copays, and bleeding events during follow-up. The prevalence of each P2Y12 inhibitor among patients who initiated the drugs and the prevalence of switching within 12 months after PCI were evaluated. The association between baseline bleeding risk and bleeding manifestations during follow-up and initial treatment and deescalation were calculated using multivariable logistic and Cox proportional hazards regression models. Between 2010 and 2019, 62 423 patients were identified who initiated P2Y12 inhibitors (females, 22.4%; males, 77.6%; mean [SD] age, 54.32 [7.13] years). The prevalence of clopidogrel as initial therapy decreased from 77.5% in 2010 to 29.6% in 2019, while initial use of prasugrel or ticagrelor increased from 22.5% to 60.4%. Within 1 year after PCI, 11.0% of patients switched therapy, mostly for deescalation. Deescalation prevalence increased from 1.8% in 2010 to 12.6% in 2018. Between 2016 and 2018, 8588 of 22 886 (37.5%) patients had major baseline bleeding risk, which decreased the selection of prasugrel or ticagrelor as initial therapy (adjusted odds ratio, 0.78; 95% CI, 0.74-0.84). Among 11 285 patients who initiated prasugrel or ticagrelor, major bleeding risk at baseline (adjusted hazard ratio, 1.11; 95% CI, 1.00-1.23) and the occurrence of bleeding during follow-up (adjusted hazard ratio, 4.42; 95% CI, 3.62-5.93) were associated with deescalation. A strong shift in preference for prasugrel and ticagrelor as initial therapy following PCI for ACS was observed. Deescalation increased over the study period. Major bleeding risk at baseline was moderately associated with initial treatment choice but had a limited association with deescalation. The increasing use of more potent P2Y12 inhibitors emphasizes opportunities to enhance preemptive patient-centered treatment strategies to maintain optimal antiplatelet activity while reducing bleeding risk during the subacute period following PCI for ACS.

Echocardiographic Measures of Left Atrial Structure and Function and the Association with Atrial Fibrillation following Acute Coronary Syndrome

Introduction: Acute coronary syndrome (ACS) is associated with an increased risk of developing atrial fibrillation (AF). This arrhythmia is associated with adverse outcomes, making it important to identify high-risk patients. The aim was to evaluate the prognostic value of measures of left atrial (LA) structure and function in AF prediction following ACS. Methods: Three hundred and eighty-one patients who had a percutaneous coronary intervention for ACS were included in the study. Our endpoint was new-onset AF. Results: With a median follow-up time of 5.4 [3.9–6.8] years, 56 patients (14.7%) developed AF. Patients developing AF had significantly (p ≤ 0.05) increased maximal and minimal LA volumes (LAV_max and LAV_min, respectively). LAV_max and LAV_min remained significantly increased in AF patients when indexing to either body surface area (LAV_max/BSA and LAV_min/BSA, respectively), left ventricle length in end diastole (LAV_max/LVLd and LAV_min/LVLd, respectively), or late mitral annular diastolic velocity (LAV_max/a’ and LAV_min/a’, respectively), while LA expansion index (LAEi), LA emptying fraction (LAEF), and peak LA longitudinal strain (PALS) were decreased. In univariable Cox regressions, all LA measures were found to be predictors of AF. After multivariable adjustment for clinical and echocardiographic parameters, all measures reflecting atrial function (LAV_min, LAV_min/BSA, LAV_min/LVLd, LAV_min/a’, LAV_max/a’, LAEF, LAEi, and PALS) (p ≤ 0.05) but no structural measures (LAV_max, LAV_max/BSA, and LAV_max/LVLd) remained significant independent predictors of AF. Conclusion: Echocardiographic measures of LA function are independent predictors of AF following ACS. Evaluation of LA function might improve the prognostic workup, aid in risk stratification for AF, and improve selection for further examinations.

Optimising adherence to secondary prevention medications following acute coronary syndrome utilising telehealth cardiology pharmacist clinics: a matched cohort study

BackgroundAdherence to secondary prevention medications following acute coronary syndromes (ACS) is a predictor of future major adverse cardiovascular events. Underutilisation of these medications is associated with higher risk of major adverse cardiovascular events globally.AimTo explore the effects of a telehealth cardiology pharmacist clinic on patient adherence to secondary prevention medications in the 12 months following ACS.MethodRetrospective matched cohort study within a large regional health service comparing patient populations before and after implementation of pharmacist clinic with 12-month follow up. Patients who received percutaneous coronary intervention for ACS were consulted by the pharmacist at 1, 3- and 12-months. Matching criteria included age, sex, presence of left ventricular dysfunction and ACS type. Primary outcome was difference in adherence in adherence at 12 months post ACS. Secondary outcomes included major adverse cardiovascular events at 12 months and validation of self-reported adherence using medication possession ratios from pharmacy dispensing records.ResultsThere were 156 patients in this study (78 matched pairs). Analysis of adherence at 12 months demonstrated an absolute increase in adherence by 13% (31 vs. 44%, p = 0.038). Furthermore, sub-optimal medical therapy (less than 3 ACS medication groups at 12 months) reduced by 23% (31 vs. 8%, p = 0.004).ConclusionThis novel intervention significantly improved adherence to secondary prevention medications at 12 months, a demonstrated contributor to clinical outcomes. Primary and secondary outcomes in the intervention group were both statistically significant. Pharmacist-led follow up improves adherence and patient outcomes.

Contrast Induce Nephropathy in Patients Undergoing Percutaneous Coronary Intervention for Acute Coronary Syndrome: Differences in STEMI and NSTEMI

Contrast-induced nephropathy (CIN) is a common complication of percutaneous coronary intervention (PCI) in patients with acute coronary syndrome. The incidence and risk factors for CIN in patients with ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) undergoing PCI are not well understood. In this prospective observational study, we enrolled 314 patients who underwent PCI for acute coronary syndrome at the cardiology department of KGMC MTI-HMC, Peshawar from June 1, 2022 to December 31, 2022. The incidence of CIN was higher in patients with STEMI compared to those with NSTEMI (18.5% vs. 8.7%, p=0.036). Hypertension was found to be a significant risk factor for CIN (OR 3.36, 95% CI 1.49-7.57, p=0.003), but it did not fully explain the differential risk between the two groups. Our findings suggest that the underlying pathophysiology of STEMI and NSTEMI may play a role in the development of CIN. Further studies are needed to identify the contributing factors and potential interventions to reduce the risk of CIN in patients undergoing PCI for acute coronary syndrome.

Efficacy and Safety of Prolonged Dual Antiplatelet Therapy after Percutaneous Coronary Intervention in Acute Coronary Syndrome Patients.

It remains controversial whether to extend the course of dual antiplatelet therapy (DAPT) after percutaneous coronary intervention (PCI). We conducted a study to investigate the benefits and risks of applying DAPT for different durations after PCI in acute coronary syndromes (ACS) patients in China. What's more, we explored the efficacy of extended DAPT regimen based on ticagrelor. This single-center prospective cohort study used data obtained from the PHARM-ACS Patient Registration Database. We included all patients who were discharged between April and December 2018. All patients had at least 18 months of follow-up. Patients were divided into two groups according to the duration of DAPT: a 1-year group and a >1-year group. Potential bias between the two groups was adjusted for by propensity score matching using logistic regression. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), defined as a composite of death, myocardial infarction, and stroke occurring from 12 months after discharge to follow-up visit. The safety endpoint was any significant bleeding event (BARC ≥ 2). Of 3,205 patients enrolled, 2,201 (68.67%) had DAPT prolonged beyond one year. A total of 2,000 patients were successfully propensity score-matched; patients who received DAPT > 1-year (n = 1000), compared with DAPT = 1-year patients (n = 1000), had a similar risk of MACCE (adjusted HR 0.23, 95% CI 0.05-1.10) and significant bleeding events (adjusted HR 0.63, 95% CI 0.32-1.24). The DAPT > 1-year group had a higher risk of revascularization (adjusted HR 3.36, 95% CI 1.64-6.87). Prolonged DAPT may not be of sufficient benefit to ACS patients within 12-18 months after the index PCI to offset the increased risk of significant bleeding events.

Trends in antiplatelet strategies 12-months following coronary stent placement in anticoagulated patients

BackgroundAntithrombotic guidelines for patients undergoing percutaneous coronary interventions (PCIs) and also requiring anticoagulant medications are evolving. This study describes changes to antithrombotic therapy and associated outcomes 12-months following PCI in patients requiring ongoing anticoagulation therapy.MethodsRecords of patients identified from queries of electronic medical records were manually reviewed to verify changes to antithrombotic therapy from discharge to 12-months and at 12-months following PCI, and episodes of major bleeding, clinically relevant non-major bleeding (CRNMB), major adverse cardiovascular or neurological events (MACNE), and all-cause mortality outcomes during an additional 6-months follow-up.ResultsPatients (n = 120) receiving anticoagulation therapy at 12-months post PCI were classified into the following groups according to antiplatelet therapy status: no antiplatelet therapy (n = 16), single antiplatelet therapy (SAPT) (n = 85), and dual antiplatelet therapy (DAPT) (n = 19). Between 12- and 18-months following PCI there were 2 major bleeds, 7 CRNMB, 6 MACNE, 2 venous thromboembolisms, and 5 deaths. All but one bleeding episode occurred in the SAPT group. The odds of remaining on DAPT at 12-months were higher in patients who had PCI for acute coronary syndrome (odds ratio [OR] 2.91, 95% confidence interval [CI] 0.96, 8.77), and in those experiencing MACNE in the 12-months following PCI (OR 1.95, 95% CI 0.67, 5.66), but these associations were not statistically significant.ConclusionMost anticoagulated patients were continued on antiplatelet therapy 12-months post PCI. Bleeding was numerically more common in anticoagulated patients continuing SAPT therapy beyond 12 months. There was significant variability in antithrombotic prescribing patterns 12-months post PCI suggesting a potential opportunity for standardizing care in this patient population.

Early vs. Late Readmission following Percutaneous Coronary Intervention: Predictors and Impact on Long-Term Outcomes.

Readmissions within 1 year after percutaneous coronary intervention (PCI) are common (18.6-50.4% in international series) and a burden to patients and health services, however their long-term implications are not well characterised. We compared predictors of 30-day (early) and 31-day to 1-year (late) unplanned readmission and the impact of unplanned readmission on long-term clinical outcomes post-PCI. Patients enrolled in the GenesisCare Cardiovascular Outcomes Registry (GCOR-PCI) from 2008 to 2020 were included in the study. Multivariate logistic regression analysis was performed to identify predictors of early and late unplanned readmission. A Cox proportion hazards regression model was used to explore the impact of any unplanned readmission during the first year post-PCI on the clinical outcomes at 3 years. Finally, patients with early and late unplanned readmission were compared to determine which group was at the highest risk of adverse long-term outcomes. The study comprised 16,911 consecutively enrolled patients who underwent PCI between 2009-2020. Of these, 1422 patients (8.5%) experienced unplanned readmission within 1-year post-PCI. Overall, the mean age was 68.9 ± 10.5 years, 76.4% were male and 45.9% presented with acute coronary syndromes. Predictors of unplanned readmission included increasing age, female gender, previous CABG, renal impairment and PCI for acute coronary syndromes. Unplanned readmission within 1 year of PCI was associated with an increased risk of MACE (adjusted HR 1.84 (1.42-2.37), p < 0.001) and death over a 3-year follow-up (adjusted HR 1.864 (1.34-2.59), p < 0.001) compared with those without readmission within 1-year post-PCI. Late compared with early unplanned readmission within the first year of PCI was more frequently associated with subsequent unplanned readmission, MACE and death between 1 and 3 years post-PCI. Unplanned readmissions in the first year following PCI, particularly those occurring more than 30 days after discharge, were associated with a significantly higher risk of adverse outcomes, such as MACE and death at 3 years. Strategies to identify patients at high risk of readmission and interventions to reduce their greater risk of adverse events should be implemented post-PCI.

Frequency of Subacute Stent Thrombosis (SAT) in Patients Presenting with Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention (PCI)

Objective: To assess the rate of occurrence of sub-acute Stent Thrombosis (SAT) after primary PCI in the patients presented with the acute coronary syndrome.&#x0D; Study Design: Retrospective cross-sectional study.&#x0D; Place and Duration of Study: At Tertiary Cardiac Care Center of Lahore Pakistan, from Jul 2019 to Jun 2021.&#x0D; Methodology: The retrospective demographical and angiographic data of the admitted patients who underwent PCI for ACS,was gathered from the Hospital Registry of a tertiary cardiac care center of Lahore. The sampling technique was nonprobability consecutive sampling, and all the data was analyzed using SPSS 20.0 and continuous data was presented as Mean±SD and frequencies &amp; percentages for categorical variables. Chi square test (CI=95%, α=5%) was used to find the association of SAT with predisposing factors. p-value &lt; 0.05 was taken as statistically significant.&#x0D; Results: Out of (n=551) patient underwent PPCI, the stent thrombosis was observed to occur in 29(5.2 %), among which 4.9 % were subacute stent thrombosis. The predisposing factors of sub-acute stent thrombosis were Diabetes Mellitus, ACS, smaller vessel size, presence of bifurcation lesion, under sizing of the stent and edge dissection and were in significant association with SAT (p &lt; 0.05).&#x0D; Conclusion: Our study reveals that subacute stent thrombosis is an event with a comparatively higher frequency in patients who go through primary PCI for acute coronary syndrome, demonstrating a frequency of 4.9% and a mortality rate of 74% within 30 days of the procedure.

The 11-year outcome of PCI for treatment of left main stem disease

Abstract Background Left Main Stem Disease (LMS) has historically been treated with coronary artery bypass surgery (CABG). However, not all patents with LMS are candidates for CABG due to co-morbidities. There is limited long-term follow-up of patients undergoing PCI in the real world. The primary objective of this study was to investigate the long-term mortality following LMS PCI. Methods We conducted a retrospective study of patients who had undergone PCI for LMS disease at our hospital over a 11-year period between July 2010-July 2021. Data was collected from electronic medical records and analyzed using Kaplain-Meier survival analysis. Follow-up was obtained through linkage with the Office of National Statistics. Results 498 patients underwent LMS PCI (5.1% of the total PCI cases). The overall survival rate was 70%. Median survival following PCI was 1,196 days (IQR = 1,796). The mean age of the patients was 70.7 years; 70.5% were males. 70.9% of patients underwent PCI for Acute Coronary Syndrome (ACS), and 15.3% had STEMI. 33.7% of patients had a history of diabetes, 8% had stroke, 8.2% had COPD, and 8.8% had PVD. 51 patients went into cardiogenic shock, and 25 died prior to discharge. Survival of the ACS group was significantly lower than the stable group (67% vs 77%, p&amp;lt;0.01); the STEMI group did not significantly differ from rest of the ACS group (62% vs 66%, p=0.87). Survival in those &amp;lt;60 years of age was significantly higher than in those &amp;gt;60 years (80% vs 68%; p&amp;lt;0.01). The presence of one or more co-morbidities was associated with higher survival compared to zero co-morbidities (74% vs 65%, p&amp;lt;0.01). Patients with a history of diabetes had a significantly lower survival rate than those without diabetes (63% vs 73%, p&amp;lt;0.01). Patients with an LV ejection fraction ≤35% had a significantly lower survival than those with an ejection fraction &amp;gt;35% (22% vs 29%, p&amp;lt;0.01); only 259 patients had data on LV function. Patients who developed cardiogenic shock had a significantly lower survival rate than those who did not develop shock (38% vs 70%; p&amp;lt;0.01). When these patients were excluded from the data set, the overall survival rate increased from 70% to 74%. Lastly, a multinomial analysis showed that the only independent predictors of mortality were age (p&amp;lt;0.01) and cardiogenic shock (p&amp;lt;0.01). Conclusion Our results show that the real world 10-year mortality rate following LMS PCI is influenced by multiple factors including age, shock, and LV function. The high mortality rate was potentially due to the significant number of acute cases (70.1%) in non-operable patients. While factors such as age and past medical history are considered in the decision-making process regarding CABG vs PCI, we saw that specific subgroups within these factors may have decreased the effectiveness of PCI as a treatment for LMS disease, suggesting that deeper analysis into these risk factors is required when deciding between CABG and PCI for LMS disease management. Funding Acknowledgement Type of funding sources: None.

Optical Coherence Tomography Fractional Flow Reserve and Cardiovascular Outcomes in Patients With Acute Coronary Syndrome

BackgroundOptical coherence tomography–derived fractional flow reserve (OCT-FFR) correlates strongly with wire-based FFR; however, its clinical significance remains uncertain. ObjectivesThis study sought to investigate the relationship between post–percutaneous coronary intervention (PCI) OCT-FFR and long-term clinical outcomes in acute coronary syndrome (ACS). MethodsThis retrospective, multicenter, observational cohort study included consecutive patients with ACS who underwent OCT-guided emergency PCI. We analyzed post-PCI OCT images and calculated OCT-FFR to identify independent factors associated with target vessel failure (TVF) after PCI. ResultsAmong 364 enrolled patients, 54 experienced TVF during a median follow-up of 36 (IQR: 26-48) months. Vessel-level OCT-FFR was significantly lower in the TVF group than in the non-TVF group (0.87 vs 0.94; P < 0.001). In the multivariable Cox regression analysis, low vessel-level OCT-FFR (HR per 0.1 increase: 0.38; 95% CI: 0.29-0.49; P < 0.001) and thin-cap fibroatheroma in the nonculprit lesion were independently associated with TVF. The TVF rate of vessels with both low vessel-level OCT-FFR (<0.90) and thin-cap fibroatheroma in the nonculprit lesion was 8.1 times higher than that of all other vessels (69.3% vs 12.4%; HR: 8.13; 95% CI: 4.33-15.25; log-rank P < 0.001). Furthermore, adding vessel-level OCT-FFR to baseline characteristics and post-PCI OCT findings improved discriminatory and reclassification ability in identifying patients with subsequent TVF. ConclusionsVessel-level OCT-FFR was an independent factor associated with TVF after PCI in patients with ACS. Adding the OCT-FFR measurement to post-PCI OCT findings may enable better discrimination of patients with subsequent TVF after PCI for ACS. (Relationship between Intracoronary Optical Coherence Tomography Derived Virtual Fractional Flow Reserve and cardiovascular outcome on Acute coronary syndrome; UMIN000043858)