Percutaneous Coronary Intervention For Acute Coronary Syndrome Research Articles

Abstract 15442: Low Serum Levels of Insulin-like Growth Factor-1 Are Associated With Long-term Risk of Adverse Cardiovascular Events in Diabetic Patients Following Percutaneous Coronary Intervention

Background: Insulin-like growth factor-1 (IGF-1) is a protein which plays protective roles against cardiovascular disorders, including the endothelial dysfunction and the instability of atherosclerotic plaque. However, prognostic implication of serum IGF-1 level has been rarely evaluated in diabetic patients with established coronary artery disease. Methods: This single center observational study involved consecutive 819 diabetic patients underwent percutaneous coronary intervention (PCI) since 2008 to 2018. In frozen-stocked (-80°C) serum, IGF-1 was measured by ELISA assay. Endpoints were set as cardiovascular (CV) death and the composite of CV death, myocardial infarction and ischemic stroke (3-point MACE). The median and the range of follow-up period was 4.0 and 0-10.4 years, respectively. Results: Participants were divided by the median of IGF-1 (75 ng/ml) (low (n=412) and high IGF-1 group (n=407)). Unadjusted Kaplan-Meier analyses with log-rank test showed the significantly higher incidences of CV death and 3P-MACE in low IGF-1 group ( Figures ). Moreover, multivariate Cox proportional hazard analysis adjusted by covariates including age, sex, PCI for acute coronary syndrome, multivessel disease, renal function (eGFR, ml/min/1.73m 2 ) and glycated hemoglobin (HbA1c, %) demonstrated that low IGF-1≤75 ng/ml was associated with substantially increased risk of CV death (Hazard Ratio (HR): 1.9, 95% confidence interval (95%CI): 1.1-3.6, p=0.03) and 3P-MACE (HR 1.7, 95%CI:1.0-2.7, p=0.04), respectively. Conclusion: Findings in this study suggest that serum IGF-1 levels are a useful and independent prognostic indicator in diabetic patients following PCI.

Abstract 13499: Percutaneous Coronary Intervention for Bifurcation Lesions in Patients With Acute Coronary Syndrome

Introduction: Percutaneous coronary intervention (PCI) for the treatment of bifurcation lesions in acute coronary syndrome (ACS) setting is a high-risk procedure and is associated with higher periprocedural complications and a lower procedural success rate. Hypothesis: We assessed the hypothesis that PCI for bifurcation stenting in ACS is safe and effective as in non ACS condition. Methods: Out of 986 patients who underwent PCI for ACS, 144 (14.6%) patients having bifurcation lesion were included in study. Provisional stenting was favored whenever feasible (86.8%), elective bifurcation stenting (2 stent strategy) was reserved for significant long segment side branch involvement (13.2%). Occurrence of major adverse cardiac events (MACE), a composite of cardiac death, myocardial infarction, target lesion revascularization, and stent thrombosis, was observed during follow up. Results: LAD bifurcation was the most common lesion (49.3%), most common Medina class was 1, 1, 1 (52.1%), 70.8% of the procedures were done transradially, angiographic success rate for main vessel was 97.9% and there was no periprocedural mortality or stroke. There was no significant difference regarding risk factors (age, hypertension, diabetes mellitus, dyslipidemia and smoking history; p > 0.05) between 1 stent and 2-stent groups. Median Syntax score was 14(IQR 10-20) in 1 stent group and 22(IQR 17-25) in 2 stent group. The 2-stent group had higher proportion of left main coronary involvement as compared to 1 stent group (47.4 vs 24.8%). Crush was preferred elective 2-stent strategy as compared to TAP in provisional approach (used in 73.7 and 62.5%). Final kissing balloon inflation was used in 38.4% patients in 1- stent group, while it was utilised in all patients with 2- stent approach. Post procedural side branch diameter stenosis (by QCA) differed significantly between the 2 groups (1-stent vs 2-stent, 34.9 vs 6.4%).The rate of MACE was similar in both groups ( total 7 MACE events; median follow-up of 18 months) but radiation dose and contrast volume utilization were significantly more in 2-stent group. Conclusions: PCI for bifurcation lesions had acceptable success and MACE rate even during ACS settings and whenever feasible, provisional stenting should be preferred approach.

Long-term outcomes in high-bleeding risk patients undergoing PCI for acute coronary syndromes: results from a large single-center pci registry

Abstract Introduction Current clinical guidelines recommend prolonged dual antiplatelet therapy (DAPT) following percutaneous coronary intervention (PCI) in patients presenting with acute coronary syndromes (ACS). However, an extended DAPT duration in high-bleeding risk (HBR) patients amplifies the risk of post procedural complications. Hence, clinicians often face the dilemma of prolonging DAPT duration to prevent recurrent ischaemic events at the expense of increasing the incidence of bleeding in high-risk patients. The actual incidence of ischaemic and bleeding events in this particular population is not well elucidated. Purpose To evaluate one-year ischemic and bleeding outcomes following PCI for ACS in a real-world HBR population as defined by the Academic Research Consortium (ARC) consensus document. Methods We included all patients who presented with ACS to a high-volume single PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent implantation. Patients were classified as HBR if they met ≥1 major or ≥2 minor criteria according to the recent ARC-HBR consensus. The outcomes of interest were major adverse cardiovascular events (MACE), a composite of all-cause death, myocardial infarction (MI), and target lesion revascularization (TLR), and major bleeding events, including both peri-procedural and post-discharge bleeding. All outcomes were assessed at 1-year follow-up. The Kaplan-Meier method was used for time-to-event analyses. Results Out of 6,097 ACS patients included in this analysis, 2,717 (44.6%) fulfilled the ARC-HBR definition. Compared to non-HBR group, HBR patients were more frequently female, older, more likely to have cardiovascular risk factors (e.g., diabetes, hypertension, and hyperlipidemia) and complex coronary artery disease (e.g., multi-vessel disease, bifurcation lesions, and calcification). The 1-year incidence of MACE was significantly higher in HBR patients (16.3% vs. 8.1%, HR 2.16, 95% CI [1.81–2.59], p<0.001) (Figure 1A). This finding was driven by higher rates of all-cause death and MI (Figure 1B). The 1-year incidence of major bleeding was also significantly higher in HBR patients compared to non-HBR (11.1% vs. 3.1%, HR: 3.92, 95% CI 3.10–4.95; p<0.001). Conclusions HBR patients undergoing PCI for ACS are not only subject to bleeding complications but are also at an increased risk for ischemic events and all-cause mortality. Figure 1 Funding Acknowledgement Type of funding source: None

Intersection of the Academic Research Consortium – high bleeding risk criteria in patients undergoing PCI for acute coronary syndromes: insights from a high-volume single centre registry

Abstract Introduction Patients presenting for percutaneous coronary intervention (PCI) with acute coronary syndromes (ACS) often have overlapping bleeding and ischaemic risk factors that offset the long-term success of PCI and limit the post stenting therapeutic options. Aiming at improving outcomes following PCI, the Academic Research Consortium (ARC) recently published a set of major and minor criteria that identify, a priori, patients at high bleeding risk (HBR). Indeed, knowledge of these risk factors will help in optimization of pre-procedural therapy and minimization of post intervention complications. Nonetheless, the actual prevalence of these criteria among patients undergoing PCI for ACS is not well known. Purpose To determine the intersection and distribution of ARC-HBR major and minor criteria in a real-world ACS population presenting for PCI. Methods In this analysis, we included all patients who presented with ACS to a high-volume PCI centre from 2012 to 2017 and underwent PCI with 2nd generation drug-eluting stent (DES) implantation. Patients were then classified as HBR if they met ≥1 major or ≥2 minor criteria according to the ARC-HBR definition. Baseline clinical and procedural characteristics were extracted from each patient electronic health records. The most common exclusive intersections of ARC-HBR major and minor criteria were quantitatively visualized using an Upset Plot. Results Only 44.6% (n=2,717) of ACS patients (n=6,097) fulfilled the ARC-HBR definition. There were significant differences in baseline clinical characteristics between HBR and non-HBR groups: age (71.4±11.5 vs. 60.9±10.3 years, p<0.001), females (40.7% vs. 25.5%, p<0.001), cerebrovascular disease (19.5% vs. 3.9%, p<0.001), and diabetes (55.4% vs. 42.1%, p<0.001). The prevalence of active smoking, a major risk factor for bleeding, was higher in the non-HBR group (20.6% vs. 9.9%, p<0.001). The most frequent major and minor criteria were severe anemia (n=1,072) and age ≥75 (n=1,264), respectively. The top five criteria intersections were: severe anemia (n=215), age ≥75 and moderate chronic kidney disease (CKD) (n=145); moderate CKD and mild anemia (n=142); age ≥75 and mild anemia (n=140); age ≥75, moderate CKD, and mild anemia (n=130) (Figure 1). Conclusion Among patients who have undergone PCI for ACS, a significant proportion of individuals fulfilled the ARC-HBR definition. Severe anemia was the most prevalent major criteria. Different combinations of minor criteria, mainly age ≥75, moderate CKD and mild anemia, represented the most common intersections. Figure 1 Funding Acknowledgement Type of funding source: None

Sheathless guiding catheter versus “slender” sheath/guiding catheter combination in acute coronary syndrome: a propensity-matched analysis of two downsized devices

Abstract Purpose We investigated the differences between a sheathless guiding catheter and a Glidesheath slender/guiding catheter combination regarding access-site complications in percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Methods We enrolled consecutive 1108 patients undergoing transradial primary PCI for ACS at our hospital using either a 7.5-Fr sheathless guiding catheter (Sheathless group) or a 7-Fr Glidesheath slender/7-Fr guiding catheter combination (Glidesheath group); 1:1 propensity score matching was performed, and 718 subjects (359 in each group) were included in the propensity-matched sample. Results Compared with the Sheathless group, the Glidesheath group had significantly less frequent ultrasound-diagnosed radial artery occlusion at 30 days (Sheathless: 4.7% vs. Glidesheath: 1.4%, p=0.015). No significant differences were observed in severe radial spasm (Sheathless: 1.4% vs. Glidesheath: 2.0%, p=0.77) or access-site bleeding (Sheathless: 9.8% vs. Glidesheath: 8.6%, p=0.70). Conclusion Thus, 7-Fr Glidesheath slender/7-Fr guiding catheter combination is clearly more advantageous than 7.5-Fr sheathless guiding catheters for decreased risk of radial artery occlusion in transradial PCI for ACS. “Sheathless” vs. “Glidesheath slender” Funding Acknowledgement Type of funding source: None

Identifying high thrombotic risk in atrial fibrillation patients undergoing percutaneous coronary intervention: is there a benefit of triple therapy?

Abstract Introduction Patients requiring concomittant use of oral anticoagulants for atrial fibrillation and dual antiplatelet therapy after percutaneous coronary intervention (PCI) are at increased risk of bleeding and mortality. Omittance of aspirin (dual antithrombotic therapy, DAT) reduces bleeding as compared to triple antithrombotic therapy (TAT), but might not ascertain antithrombotic efficacy, especially in high-risk patients. Purpose To identify a subgroup of patients at high thrombotic risk that might benefit most from TAT over DAT. Methods The study was performed in a combined cohort of two randomised controlled trials (WOEST, RE-DUAL PCI) comparing TAT versus DAT after PCI. A Cox proportional hazards model predictive for the composite thrombotic endpoint of cardiovascular death, myocardial infarction (MI), stent thrombosis, and ischaemic stroke was built by stepwise selection of plausible predictor variables. Area under the receiver operating curve (AUC) was obtained, and clinical outcomes (thrombotic endpoint, bleeding [BARC 2,3+5], and all-cause mortality) were compared between the highest quintile of predicted thrombotic risk (high risk) and the remainder of patients (low-intermediate risk). Within the different risk groups, effect of TAT versus DAT was compared. Results A total of 3288 patients in the combined WOEST and RE-DUAL cohorts were included in this analysis. Approximately half underwent PCI for acute coronary syndrome. In 250 patients (7.6%) the composite thrombotic endpoint occurred during the first year. The final Cox proportional hazards model predicting thrombotic events contained: left ventricular ejection fraction, 3-vessel disease, MI at index PCI, peripheral artery disease, prior stroke, left circumflex coronary artery stenting, a history of MI, PCI to a bypass graft, and platelet count. The discriminatory capacity of the ischaemic model was fair (AUC 0.68, 95% confidence interval 0.64–0.71). Incidence of thrombotic events and mortality was higher in the high-risk as compared to low-intermediate risk patients (15.8% vs 5.6%, and 8.4% vs 3.2%, respectively, both p<0.001), whereas bleeding was comparable (20.5% vs 19.6%, p=0.60). No statistically significant effect of TAT over DAT was seen with regards to the thrombotic endpoint in both high and low-intermediate risk patients (13.9% vs 17.0%, p=0.36, and 6.5% vs 5.0%, p=0.11, respectively). Bleeding was significantly reduced with DAT versus TAT in both high and low-intermediate risk patients (minus 12.8% and 8.1%, both p<0.02). For low-intermediate risk patients a statistically significant increase in mortality was found with TAT versus DAT (4.2% vs 2.5%, p=0.02), whereas this was not found in high-risk patients (7.2% vs 9.1%, p=0.47). Conclusions No significant antithrombotic advantage of TAT over DAT was found in high-risk patients. However, TAT increased bleeding risk in all patients, and increased mortality in low-intermediate risk patients. Funding Acknowledgement Type of funding source: None

A look into stent‐related thrombus‐burden: Bivalirudin versus heparin

Use of optical coherence tomography (OCT) adds an assessment of thrombus burden remaining on stents after PCI for acute coronary syndromes. Potential variations in stent-related thrombus burden can be documented by OCT as a function of peri-procedural pharmacology supporting the use of OCT in future hypothesis testing. Bivalirudin remains a reliable and expensive alternative to heparin in cases of HIT or patients at high bleeding risk during transfemoral PCI.

Post-procedural high platelet reactivity with prasugrel loading predicts in-hospital adverse events in ACS patients

Abstract Background/Introduction High platelet reactivity (HPR) is associated with adverse cardiovascular events, primarily intrastent thrombosis, after a percutaneous coronary intervention (PCI). However, the relationship between hyperacute postprocedural HPR with prasugrel loading and clinical outcomes in acute coronary syndrome (ACS) remains unclear. Moreover, factors contributing to HPR in ACS with prasugrel loading are also unknown. Purpose To assess the effects of post-procedural HPR with prasugrel loading on clinical outcomes in ACS during hospitalization, and to define the appropriate cut-off values and identify factors contributing to HPR. Methods A single-center, retrospective observational study that enrolled 154 patients who underwent emergent PCI for ACS with prasugrel loading was performed. The P2Y12 reaction unit (PRU) value was measured immediately after PCI using the VerifyNowR system. The primary end-point was major adverse cardiac events (MACE, defined as the composite of death, myocardial infarction, stroke, heart failure, ventricular arrhythmia needing defibrillation). Results The mean patient age (standard deviation) was 70.7 (±12.5) years, 76.6% were men, and the average time from the prasugrel intake to PRU calculation was 103.2 (±48.5) min. During the mean hospital stay of 15.6 (±8.5) days, 24 in-hospital MACE (15.5%) and 8 deaths (5.2%) occurred. Thrombosis events, including myocardial infarction recurrence, did not occur (only one case of spontaneous coronary artery dissection was considered as myocardial infarction recurrence). PRU was significantly higher in the MACE group than that in Non-MACE group (287±55 and 232±64, respectively, p<0.001). The ROC curve analysis of PRU for discriminating the significant in-hospital MACE showed the cut-off value of 293 (sensitivity: 62.5%, specificity: 83.1% [AUC=0.756, p<0.0001]). A total of 37 patients (24%) were thus categorized as HPR (PRU>293) immediately after the emergent PCI. Kaplan-Meier curve showing MACE events occurred in the HPR group than that in the non-HPR group (40.5% vs 7.6%, p<0.001). Multiple cox analysis demonstrated that HPR was independent predictors of MACE in patients with ACS who underwent PCI (OR 11.01, 95% CI 2.39–20.2, p<0.0001). Multiple logistic regression model showed old age, female sex, low systolic blood pressure, short prasugrel intake to measure time, and large acute gain were independent predictors of HPR. Conclusion PRU was significantly higher in the MACE group, with an appropriate cut-off value of HPR of 293 in this study. HPR was an independent predictor of MACE during hospitalization; however, thrombosis events were not significant. HPR predictors were old age, female sex, low systolic blood pressure, short prasugrel intake to measure time, and large acute gain. This study shows the post-procedural HPR with prasugrel loading in patients with ACS can be a useful predictive marker of adverse events during hospitalization. Funding Acknowledgement Type of funding source: None

Incidence of major adverse cardiovascular events with genotype test guided antiplatelet treatment strategy after percutaneous coronary intervention

ObjectiveTo estimate the incidence of major adverse cardiovascular events (MACE) with genotype test-guided antiplatelet therapy in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome. MethodsPatients who had undergone PCI for acute coronary syndrome as well as stable coronary artery disease were recruited. Salivary samples were obtained from these patients and genotyped for CYP2C19∗2, CYP2C19∗3 variations by sequencing method (GAAP x method). Patients were categorized as normal (GG, GG) (29%), intermediate (AG) (52%) or poor metabolizes (homozygous variant AA) (19%). Dual antiplatelets were given based on the genotyping data. Poor metabolizes received newer agent (ticagrelor), intermediate metabolizes received double-dose of clopidogrel and normal metabolizes received therapeutic doses of clopidogrel. All subjects were followed-up for six months. ResultsBased on the genotyping data of CYP2C19∗2 and CYP2C19∗3 variations, it was found that most patients were categorized as ‘intermediate’ (78, 51.65%), followed by ‘normal’ (43, 28.48%) and ‘poor’ metabolizes (30, 19.87%). Only 3 (1.5%) of 151 patients reported MACE at follow-up. ConclusionsGenotyping for CYP2C19 variations to assess clopidogrel resistance in patients undergoing PCI and subsequent drug selection helps reduce MACE after coronary intervention.

Effect of Genotype-Guided Oral P2Y12 Inhibitor Selection vs Conventional Clopidogrel Therapy on Ischemic Outcomes After Percutaneous Coronary Intervention

After percutaneous coronary intervention (PCI), patients with CYP2C19*2 or *3 loss-of-function (LOF) variants treated with clopidogrel have increased risk of ischemic events. Whether genotype-guided selection of oral P2Y12 inhibitor therapy improves ischemic outcomes is unknown. To determine the effect of a genotype-guided oral P2Y12 inhibitor strategy on ischemic outcomes in CYP2C19 LOF carriers after PCI. Open-label randomized clinical trial of 5302 patients undergoing PCI for acute coronary syndromes (ACS) or stable coronary artery disease (CAD). Patients were enrolled at 40 centers in the US, Canada, South Korea, and Mexico from May 2013 through October 2018; final date of follow-up was October 2019. Patients randomized to the genotype-guided group (n = 2652) underwent point-of-care genotyping. CYP2C19 LOF carriers were prescribed ticagrelor and noncarriers clopidogrel. Patients randomized to the conventional group (n = 2650) were prescribed clopidogrel and underwent genotyping after 12 months. The primary end point was a composite of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia at 12 months. A secondary end point was major or minor bleeding at 12 months. The primary analysis was in patients with CYP2C19 LOF variants, and secondary analysis included all randomized patients. The trial had 85% power to detect a minimum hazard ratio of 0.50. Among 5302 patients randomized (median age, 62 years; 25% women), 82% had ACS and 18% had stable CAD; 94% completed the trial. Of 1849 with CYP2C19 LOF variants, 764 of 903 (85%) assigned to genotype-guided therapy received ticagrelor, and 932 of 946 (99%) assigned to conventional therapy received clopidogrel. The primary end point occurred in 35 of 903 CYP2C19 LOF carriers (4.0%) in the genotype-guided therapy group and 54 of 946 (5.9%) in the conventional therapy group at 12 months (hazard ratio [HR], 0.66 [95% CI, 0.43-1.02]; P = .06). None of the 11 prespecified secondary end points showed significant differences, including major or minor bleeding in CYP2C19 LOF carriers in the genotype-guided group (1.9%) vs the conventional therapy group (1.6%) at 12 months (HR, 1.22 [95% CI, 0.60-2.51]; P = .58). Among all randomized patients, the primary end point occurred in 113 of 2641 (4.4%) in the genotype-guided group and 135 of 2635 (5.3%) in the conventional group (HR, 0.84 [95% CI, 0.65-1.07]; P = .16). Among CYP2C19 LOF carriers with ACS and stable CAD undergoing PCI, genotype-guided selection of an oral P2Y12 inhibitor, compared with conventional clopidogrel therapy without point-of-care genotyping, resulted in no statistically significant difference in a composite end point of cardiovascular death, myocardial infarction, stroke, stent thrombosis, and severe recurrent ischemia based on the prespecified analysis plan and the treatment effect that the study was powered to detect at 12 months. ClinicalTrials.gov Identifier: NCT01742117.

Sex Differences in Radial Access for Percutaneous Coronary Intervention in Acute Coronary Syndrome Are Independent of Body Size

Radial access reduces bleeding and is associated with improved survival following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). We evaluated the association between sex, markers of body size and radial access, and its impact on bleeding and mortality following PCI for ACS. From 2013-2016, consecutive patients treated with PCI for ACS across 30 centres were prospectively entered into the Victorian Cardiac Outcomes Registry and followed for 30 days. Multivariate logistic regression was used to analyse predictors of the primary endpoint of PCI access site and secondary endpoints of major bleeding and mortality. A total of 16,330 ACS patients (40.9% ST elevation myocardial infarction [STEMI]) underwent PCI (23.5% female). Women were older with significantly lower weight and height compared to men. Women had lower radial access use (41.6% versus 51.0%, p<0.001), with higher 30-day major bleeding (2.4% versus 1.4%, p<0.001) and mortality (4.4% versus 3.4%, p<0.001) than men. Female sex independently predicted lower radial access use (OR 0.75, 95% CI 0.68-0.83, p<0.001) while body surface area, height and body mass index did not. Female sex was an independent predictor of higher 30-day major bleeding (OR 1.38, 95% CI 1.05-1.81, p=0.019) and mortality in STEMI patients (OR 1.31, 95% CI 1.01-1.70. p=0.039). Radial access was associated with lower major bleeding (OR 0.70, 95% CI 0.53-0.91, p=0.009) and mortality (OR 0.60, 95% CI 0.48-0.75, p<0.001). Radial access, despite being associated with lower bleeding and mortality, was used less frequently in women, independent of co-morbidities and objective markers of body size.

Radial access first for PCI in acute coronary syndrome : Are we propping up astraw man?

Coronary angiography and percutaneous coronary intervention (PCI) represent the recommended revascularization strategy for patients presenting with acute coronary syndrome (ACS). However, periprocedural bleeding events, of which up to 50% are related to the access site, remain an important complication of PCI and are associated with higher costs, prolonged hospital stays, and increased mortality. Several randomized trials have demonstrated that PCI performed via radial artery (RA) access is associated with areduction in bleeding events, and perhaps areduction in mortality compared with femoral artery (FA) access. As aresult, current practice guidelines from the European Society of Cardiology and the Canadian Cardiovascular Society recommend that RA be the default strategy for PCI in patients presenting with ACS. The recently published Safety and Efficacy of Femoral Access vs. Radial Access in ST-Segment Elevation Myocardial Infarction (SAFARI-STEMI) trial challenges the benefits of adefault RA approach in acontemporary setting where additional bleeding-reduction strategies (i.e., avoidance of glycoprotein IIb/IIIa inhibitors, routine use of bivalirudin for procedural anticoagulation, and vascular closure devices) were employed. In order to better understand the evidence that has shaped the current recommendations, we present areview of the background studies and major randomized trials comparing RA with FA in patients presenting with ACS.

Invasive strategy for COVID patients presenting with acute coronary syndrome: The first multicenter Italian experience.

ObjectiveTo report our initial experience of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)/acute coronary syndrome (ACS) patients undergoing standard of care invasive management.BackgroundThe rapid diffusion of the SARS‐CoV‐2 together with the need for isolation for infected patients might be responsible for a suboptimal treatment for SARS‐CoV‐2 ACS patients. Recently, the group of Sichuan published a protocol for COVID/ACS infected patients that see the thrombolysis as the gold standard of care.MethodsWe enrolled 31 consecutive patients affected by SARS‐COV‐2 admitted to our emergencies room for suspected ACS.ResultsAll patients underwent urgent coronary angiography and percutaneous coronary intervention (PCI) when required except two patients with severe hypoxemia and unstable hemodynamic condition that were conservatively treated. Twenty‐one cases presented diffuse ST‐segment depression while in the remaining cases anterior and inferior ST‐elevation was present in four and six cases, respectively. PCI was performed in all cases expect two that were diagnosed as suspected myocarditis because of the absence of severe coronary disease and three with apical ballooning at ventriculography diagnostic for Tako‐Tsubo syndromes. Two patients conservatively treated died. The remaining patients undergoing PCI survived except one that required endotracheal intubation (ETI) and died at Day 6. ETI was required in five more patients while in the remaining cases CPAP was used for respiratory support.ConclusionsUrgent PCI for ACS is often required in SARS‐CoV‐2 patients improving the prognosis in all but the most advanced patients. Complete patient history and examination, routine ECG monitoring, echocardiography, and careful evaluation of changes in cardiac enzymes should be part of the regular assessment procedures also in dedicated COVID positive units.

A scoring system to predict the occurrence of very late stent thrombosis following percutaneous coronary intervention for acute coronary syndrome

We aimed to derive and validate an effective risk score to identify high-risk patients of very late stent thrombosis (VLST), following percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). Stepwise multivariable Cox regression was used to build the risk model using data from 5,185 consecutive ACS patients treated with PCI (derivation cohort) and 2,058 patients from the external validation cohort. Eight variables were independently associated with the development of VLST: history of diabetes mellitus, previous PCI, acute myocardial infarction as admitting diagnosis, estimated glomerular filtration rate <90 ml/min/1.73 m2, three-vessel disease, number of stents per lesion, sirolimus-eluting stent, and no post-dilation. Based on the derived score, patients were classified into low- (≤7), intermediate- (8–9), and high- (≥10) risk categories. Observed VLST rates were 0.5%, 2.2%, and 8.7% and 0.45%, 2.3%, and 9.3% across the 3 risk categories in the derivation and validation cohorts, respectively. High discrimination (c-statistic = 0.80 and 0.82 in the derivation and validation cohorts, respectively) and excellent calibration were observed in both cohorts. VLST risk score, a readily useable and efficient tool to identify high-risk patients of VLST after PCI for ACS, may aid in risk-stratification and pre-emptive decision-making.

Residual SYNTAX Score and One-Year Outcome in Elderly Patients With Acute Coronary Syndrome

BackgroundThe residual burden of coronary artery disease after percutaneous coronary intervention (PCI) has been associated with worse ischemic outcome. However, data are conflicting in elderly patients. The aim of our study was to verify the incremental value of the residual Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery (SYNTAX) score (rSS) over clinical variables and baseline SYNTAX score (bSS) in predicting 1-year mortality or cardiovascular events. MethodsA post hoc analysis of data collected in the Elderly-ACS 2 multicenter randomized trial was performed. We included 630 patients aged > 75 years with multivessel coronary disease undergoing PCI for acute coronary syndrome (ACS). The primary outcome was a composite of death, recurrent myocardial infarction, and stroke at 1-year follow up. Change in c-statistic and standardized net benefit were used to evaluate the incremental value of the rSS. ResultsEvent rates were significantly higher in patients with incomplete revascularization (rSS > 8). When the rSS was included in a core Cox regression model containing age, previous myocardial infarction, and ACS type, the hazard ratio for patients with score values > 8 was 2.47 (95% confidence interval, 1.51-4.06). However, the core model with rSS did not increase the c-statistic compared with the core model with the bSS (from 0.69 to 0.70) and gave little incremental value in the standardized net benefit. ConclusionsIn elderly patients with ACS with multivessel disease undergoing PCI, incomplete revascularization was associated with worse outcome at 1-year follow-up. However, there was no clear incremental value of the rSS in the prediction of 1-year adverse outcome compared with a model including clinical variables and bSS.

Abstract P477: Clinical Outcomes In Individuals With And Without Heart Failure Presenting With Acute Coronary Syndromes

Objective: To determine the risk for major adverse cardiovascular events (MACE) following acute coronary syndrome (ACS) in patients with and without heart failure (HF) and whether this risk varies by race and comorbidity. Methods: We studied adults with and without HF who underwent percutaneous coronary intervention (PCI) for the treatment of ACS in the Pharmacogenomic Resource to improve Medication Effectiveness Genotype Guided Antiplatelet Therapy study. ACS was defined by the presence of ≥2 of the following: ischemic symptoms, acutely elevated cardiac troponin, or ischemic electrocardiographic changes. HF was defined prior to PCI as a known history of HF, left ventricular ejection fraction &lt;50%, or brain natriuretic peptide level &gt;400 pg/mL. Demographic and clinical characteristics were collected prior to PCI. Race was self-reported. Participants were followed for up to 1 year for MACE. We constructed Cox proportional hazard models, adjusted for demographic and clinical characteristics, separately in those with and without HF to identify independent predictors of MACE. Results: Since 2014, 1,230 individuals have undergone PCI for ACS. Those with HF (n=419) were older and had more comorbidities than those without HF (n=811). The incidence of MACE per 100 person years was 40.4 in those with HF and 22.2 in those without HF (p&lt;0.001). African American race was associated with increased risk for MACE following ACS in those without but not with a history of HF. Other clinical factors associated with MACE following ACS were older age and end stage renal disease in those with HF and diabetes, end stage renal disease, and peripheral arterial disease in those without HF (Table). Conclusions: Individuals with HF are at increased risk of MACE following ACS irrespective of race. However, in those without HF, African Americans have a higher risk of MACE following ACS relative to their white counterparts. Individuals with end stage renal disease are at high risk of MACE following ACS regardless of HF status.

Current practice of percutaneous coronary intervention on patients with acute coronary syndrome in Iran: A prospective observational study.

Background: Frequent Percutaneous Coronary Intervention (PCI) procedures are being performed on a daily basis in Iran. However, no study has been reported on the current PCI practice in patients with acute coronary syndrome (ACS) in Iran. We aimed to describe the clinical characteristics and treatment patterns in Iranian ACS patients treated with PCI. Methods: Between February 2017 and July 2017, ACS patients presented to 5 referral hospitals in two major cities of Iran (Tehran and Shiraz) were included in this observational study if aged > 18 years and underwent PCI for ACS during hospitalization; and their clinical and procedural characteristics were collected. All data were entered into SPSS v.21 and descriptive statistics were performed. Results: Of a total of 314 patients, 228 (73%) were males, 162 (52%) were diagnosed with ST-elevation myocardial infarction and 152 (48%) with Unstable angina/ Non-ST elevation myocardial infarction. Trans-femoral approach was more often (64%) used for PCI procedures. Stent placement was the most frequent (98%) treatment strategy on PCI, with drug-eluting stent selected in the majority of subjects (98%). The overall rate of PCI success was 95%, with 4.1% PCI-related complications, and 1.6% post-PCI bleeding events. The vast majority of the study patients (99%) were discharged with dual anti-platelet therapy. Conclusion: In this study, we observed a high level of adherence to the currently accepted guidelines in the current PCI practice on ACS patients in Iran. Also we found our practice is highly in line with the global reduction trend in the PCI-related complications.

CRT-100.59 Duration of Dual Antiplatelet Therapy After Percutaneous Coronary Intervention With Drug-Eluting Stent Implantation — Meta-Analysis of Randomized Controlled Trials

DAPT is superior to aspirin to reduce thrombotic events after percutaneous coronary intervention (PCI).The recommended duration of DAPT after PCI for acute coronary syndrome is 12 months compared to 6 months after stable coronary artery disease. This analysis investigates the optimal duration of

Association of Ticagrelor vs Clopidogrel With Major Adverse Coronary Events in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Intervention

Guidelines currently recommend ticagrelor over clopidogrel for patients with acute coronary syndrome (ACS) based on randomized clinical trial data in which ticagrelor reduced major adverse coronary events (MACE) vs clopidogrel but increased bleeding and dyspnea. To compare the risk of MACE with ticagrelor vs clopidogrel in patients with ACS treated with percutaneous coronary intervention (PCI), to compare major bleeding and dyspnea, and to evaluate the association between P2Y12 inhibitor adherence and MACE. Population-based cohort study using data of patients discharged alive after PCI for ACS from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease registry from April 1, 2012, to March 31, 2016, with follow-up to 1 year. Analysis began April 2018. Outpatient prescription for ticagrelor or clopidogrel within 31 days after PCI. Adherence was defined as a medication refill adherence value of 80% or higher. Major adverse coronary events, a composite of all-cause death, hospitalization for ACS, unplanned coronary revascularization, or stent thrombosis within 365 days after index PCI. Secondary outcomes included hospitalization for major bleeding and emergency department visit for dyspnea. Of 11 185 individuals who underwent PCI, the median (interquartile range) age was 61 (54-71) years, and 2760 (24.7%) were women. Ticagrelor users (4076 [36.4%]) were generally younger and had fewer cardiac and noncardiac comorbidities than clopidogrel users. Ticagrelor was not associated with lower risk of MACE (adjusted hazard ratio [aHR], 0.97; 95% CI, 0.85-1.10); however, it was associated with an increased risk of major bleeding (aHR, 1.51; 95% CI, 1.29-1.78) and dyspnea (aHR, 1.98; 95% CI, 1.47-2.65). A total of 3328 ticagrelor users (81.6%) were adherent during the study vs 5256 of clopidogrel users (73.9%) (P < .001; χ2 = 86.4). In the full cohort, adherence was associated with a lower MACE risk (aHR, 0.79; 95% CI, 0.69-0.90 for adherence of ≥80% vs <80%). Differences in other secondary outcomes were not statistically significant. Sensitivity and subgroup analyses were consistent with primary analyses. In this population-based cohort study of patients with ACS who underwent PCI, outpatient use of ticagrelor was not associated with a statistically significant reduction in MACE vs clopidogrel; however, it was associated with more major bleeding and dyspnea.

Impact of renal function on clinical outcomes after PCI in ACS and stable CAD patients treated with ticagrelor: a prespecified analysis of the GLOBAL LEADERS randomized clinical trial.

Impaired renal function (IRF) is associated with increased risks of both ischemic and bleeding events. Ticagrelor has been shown to provide greater absolute reduction in ischemic risk following acute coronary syndrome (ACS) in those with versus without IRF. A pre-specified sub-analysis of the randomized GLOBAL LEADERS trial (n = 15,991) comparing the experimental strategy of 23-month ticagrelor monotherapy (after 1-month ticagrelor and aspirin dual anti-platelet therapy [DAPT]) with 12-month DAPT followed by 12-month aspirin after percutaneous coronary intervention (PCI) in ACS and stable coronary artery disease (CAD) patients stratified according to IRF (glomerular filtration rate < 60ml/min/1.73m2). At 2years, patients with IRF (n = 2171) had a higher rate of the primary endpoint (all-cause mortality or centrally adjudicated, new Q-wave myocardial infarction [MI](hazard ratio [HR] 1.64, 95% confidence interval [CI] 1.35-1.98, padj = 0.001), all-cause death, site-reported MI, all revascularization and BARC 3 or 5 type bleeding, compared with patients without IRF. Among patients with IRF, there were similar rates of the primary endpoint (HR 0.82, 95% CI 0.61-1.11, p = 0.192, pint = 0.680) and BARC 3 or 5 type bleeding (HR 1.10, 95% CI 0.71-1.71, p = 0.656, pint = 0.506) in the experimental versus the reference group. No significant interactions were seen between IRF and treatment effect for any of the secondary outcome variables. Among ACS patients with IRF, there were no between-group differences in the rates of the primary endpoint or BARC 3 or 5 type bleeding; however, the rates of the patient-oriented composite endpoint (POCE) of all-cause death, any stroke, MI, or revascularization (pint = 0.028) and net adverse clinical events (POCE and BARC 3 or 5 type bleeding) (pint = 0.045), were lower in the experimental versus the reference group. No treatment effects were found in stable CAD patients categorized according to presence of IRF. IRF negatively impacted long-term prognosis after PCI. There were no differential treatment effects found with regard to all-cause death or new Q-wave MI after PCI in patients with IRF treated with ticagrelor monotherapy. The trial has been registered with ClinicalTrials.gov, number NCT01813435.