Post Post Percutaneous Coronary Intervention Research Articles

Expected eligibility for PCSK9i therapy in secondary prevention, ESC/EAS guidelines vs Irish reimbursement criteria in post PCI patients

Abstract Introduction Reimbursement of proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i) in Ireland is determined by the national center for pharmacoeconomics (NCPE) managed access protocol. To be eligible for a PCSK9i, patients must have had a myocardial infarction or CABG, LDL of >3.5mmol/L, be treated with a high dose statin and ezetimibe. In contrast, the 2019 ESC/EAS dyslipidemias guidelines recommend that patients at ‘very high risk’ with an LDL-C of >1.4mmol/L on a maximally tolerated dose of a statin and ezetimibe, be considered for PCSK9i. In this study, we aimed to define the proportion of patients who are potentially suitable for a PCSK9i at follow-up outpatient post-percutaneous coronary intervention (PCI). Method We retrospectively analysed data on patients who had PCI in University Hospital Limerick (UHL) between January 2016 to December 2019, with follow-up complete lipid profiles at baseline and at 6 - 8 weeks during outpatient review. We sought to compare the potential PCSK9i eligible population in our cohort based on guideline recommendations vs Irish reimbursement criteria. We performed a hierarchal analysis of patients on high dose statin therapy with an LDL-C >1.4mmol/L at follow-up, who could potentially be eligible for a PCSK9i based on expected LDL-C. Expected LDL-C in these patients was calculated based on a 25% reduction in LDL-C with the addition of ezetimibe. Results Our analysis includes 1817 patients, with baseline characteristics; mean age 63.65years, 78.26% male, 40.01% smokers, 20.09% Diabetes Mellitus. 844 (46.45%) patients had a history of MI making them eligible for a PCSK9i based on NCPE clinical criteria. 12 patients (0.66%) in this group were on a high dose statin, and would have an expected LDL-C of >3.5mmol/L with the addition of ezetimibe, therefore making them eligible for a PCSK9i as per NCPE MAP criteria. In contrast to the NCPE MAP criteria all 1817 patients were deemed eligible for a PCSK9i based on ESC/EAS clinical criteria of "very high risk". 1275 patients (70.17%) had an LDL-C level >1.4mmol/L, 6 - 8 weeks post PCI despite high dose statin therapy. Only a minority of patients in this cohort were on ezetimibe, 57/1817 (3.14%). The addition of ezetimibe to patients with an LDL-C >1.4mmol/L, would result in 784 (43.14%) potentially being eligible for a PCSK9i based on current ESC guidelines, results are summarized in figure 1. Discussion Our data highlights the discrepancy between current ESC/EAS guidelines and reimbursement criteria for PCSK9i in Ireland. Based on expected attainable LDL-C minimal patients with coronary artery disease are eligible for reimbursement of a PCSK9i in Ireland for secondary prevention. Our findings also highlight that the majority of patients with established coronary disease do not meet their LDL-C goal at early follow-up. The addition of ezetimibe, would still result in over 40% of our cohort still having a significant lipid burden.

Appropriate ischemic criteria for type 4a myocardial infarction: insights from the ALPHEUS trial

Abstract Background Different troponin thresholds have been proposed to define periprocedural myocardial injury based on post percutaneous coronary intervention (PCI) troponin increase only, whereas the definition of type 4a myocardial infarction (MI) needs the association of post procedural troponin and one ischemic criterion. These criteria which evolved from the 3rd to the 4th Universal Definition of Myocardial Infarction (UDMI) are frequently under-reported in studies on periprocedural MI. Purpose We aimed to describe rates of type 4a MI additional diagnostic criteria among the ranges of post PCI troponin elevation in the randomized ALPHEUS trial which compared ticagrelor to clopidogrel in high-risk elective PCI patients. Methods 1698 patients with normal pre-PCI troponin values and centralized core laboratory angiogram analyzes were divided into 4 groups according to maximal post PCI troponin elevations (≤ 1x upper reference limit (URL) for group 1; > 1xURL and ≤ 5xURL for group 2; > 5xURL and < 35xURL for group 3 and ≥ 35xURL for group 4). The type 4a MI additional criteria (ischaemic imaging changes, ischaemic ECG changes, chest pain and angiographic complications) as defined by the 3rd and 4th UDMI were reported and the different angiographic complications were detailed for each group. Results The most prevalent additional ischemic criterion was the presence of angiographic complications detected by the core laboratory. The rate of angiographic complications increased in a stepwise manner with higher post PCI troponin elevation (Figure). Interestingly, we found a similar rate of angiographic complications in patients without any increase in post PCI troponin and troponin elevations below the 5xURL threshold (8.4% and 9.9% respectively). Most angiographic complications were related to transient main branch dissection and/or thrombosis, and transient or permanent side branch occlusions (Table). ECG changes and chest pain ischemic criteria also increased in a stepwise manner and were rarely found below the 5-fold threshold increase, although they might be underreported. Conclusion When using a core laboratory, angiographic complications are found even in patients with no or minor troponin elevation. Above the 5 xURL threshold the rates of angiographic complications are 2 to 3-fold more frequent, and ECG changes and chest pain ischaemic criteria are likely to be present. Our findings support the use of angiographic core laboratory in clinical trial using periprocedural MI as an endpoint; similarly, chest pain -which disappeared from the 4th UDMI- should be reconsidered as a diagnostic ischemic criterion.

E-49 | Moderate to High Precise-DAPT Score Is Associated With Increased Risk of Bleeding and Mortality in a Predominantly Hispanic Population

Bleeding is a major complication for patients on dual anti-platelet therapy (DAPT) post percutaneous coronary intervention (PCI). Predicting Bleeding Complications in Patients Undergoing Stent Implantation and Subsequent Dual Antiplatelet Therapy (PRECISE-DAPT) score has been widely used inEurope for the prediction of bleeding during DAPT with a cut-off of ≥ 25 as high risk. We determined the predictive accuracy of PRECISE-DAPT scores in a predominantly Hispanic population. A retrospective single center cohort study was conducted with patients on DAPT post PCI between 2014 and 2021. PRECISE-DAPT score was assessed and classified into three categories (low: ≤17; moderate:18 to 24; high: ≥25). The primary endpoints were incidence of bleeding as evaluated using Bleeding Academic Research Consortium (BARC) ≥ 2 events and all-cause mortality. Kaplan Meier curve, log rank test and Cox proportional hazards models were performed. Receiver operating characteristic (ROC) curve analysis was performed to determine optimal cut-offs. Out of 829 patients(age 62 ± 12 years, 66% males, 78% Hispanic), 46 (5.5%) had BARC ≥ 2 bleeding complications and 38 (4.5%) had deaths after PCI for a mean follow up of 2.8 ± 2.4 years. Compared with low PRECISE-DAPT risk score, moderate and high-risk scores were associated with increased risk of bleeding (3.18%, 10.22%, and 7.69 %, respectively, p=0.002). Similarly, in comparison with low score, moderate and high score groups had higher incidence of all-cause mortality (2.12%, 6.57%, and 7.69% respectively, p<0.001). In the adjusted analysis, the combined moderate and high scores predicted higher risk of bleeding (hazard ratio [HR] 2.89; 95%CI: 1.47-5.71, p=0.002) and all-cause mortality (HR 5.78, 95%CI 2.41-13.83, p <.0001). A cut-off value ≥19 of the PRECISE-DAPT score classified bleeding (AUC=0.63; 95%CI: 0.55-0.71) and all-cause mortality (AUC=0.68; 95%CI: 0.60-0.77). Our results suggest moderate to high PRECISE-DAPT score was associated with the increased risk of bleeding and mortality in patients with DAPT post PCI in a predominantly Hispanic population with an optimal cut-off of ≥19 instead of 25.

E-48 | Safety and Efficacy of Dual Antiplatelet Therapy With Ticagrelor vs Clopidogrel in a Predominantly Hispanic Population

Current guidelines recommend potent P2Y12 platelet inhibitor in patients with acute coronary syndrome post percutaneous coronary intervention(PCI). However, ethnic and racial differences in responsiveness to P2Y12 have been reported. Little is known about the safety and efficacy of dual anti-platelet therapy (DAPT) with potent P2Y12 in the Hispanic population. We evaluated the risks and benefits associated with ticagrelor versus clopidogrel in a predominantly Hispanic population. We conducted a single center retrospective cohort study on patients who had PCI between Jan 2014 and Jun 2021. The safety endpoint was incident bleeding, defined as Bleeding Academic Research Consortium (BARC) ≥2events. Primary efficacy endpoints were all-cause mortality and major adverse cardiovascular event (MACE included death, myocardial infarction, stroke and revascularization). Kaplan Meier curve, log rank test and Cox proportional hazards models were performed to analyze time to specific event endpoint. A propensity scores-adjusted Cox model method was used in the adjusted analysis. Of 830 patients (age 62 ± 12 years, 67% males, 78% Hispanic), 357 (43%) patients received ticagrelor as their DAPT therapy. Patients who received clopidogrel at baseline were older and had more anemia, more bare metal stents and anticoagulation therapy. During an average follow-up of 2.8 ± 2.4 years, death occurred in 38 (4.6%) patients and bleeding events in 46 (5.5%) patients. After propensity scores-adjustment of baseline characteristics, BARC ≥2 bleeding events were not significantly different between ticagrelor and clopidogrel groups (4.76% versus 6.13%, hazard ratio [HR] =0.92, 95% CI:0.48-1.77, p=0.81). While there was no significant difference in the MACE event between the two P2Y12 groups (23.0% versus 22.7%, HR=1.08, 95% CI:0.79-1.48, p=0.65), the mortality rate was significantly lower in ticagrelor group (2.52% versus 6.13%, HR= 0.39, 95% CI:0.17-0.87, p=0.021). In a predominantly Hispanic population, ticagrelor use was associated with a lower mortality rate in patients post PCI compared to clopidogrel, with similar bleeding rates.

Abstract 13402: Racial Differences in Incidence of Acute Kidney Injury in Patients With ST-Elevation Myocardial Infarction

Background: Racial differences in outcomes of STEMI patients continue to persist. Our study aimed to assess the difference in the incidence of acute kidney injury (AKI) post percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI), stratified by race into African Americans (AA) vs Caucasians. Methods: All STEMI patients who underwent PCI at the Cleveland Clinic main campus between January 1, 2011, to July 15, 2019, were included in our study. Patients were categorized into two groups depending on a diagnosis of the presence or absence of AKI post PCI. AKI was defined as &gt;0.3mg/dl rise in post PCI creatinine from pre-procedure value. Relative risk of developing AKI depending on race was calculated with the help of a two by two table. Results: Overall, 1847 patients were admitted to our hospital with a STEMI and underwent PCI during the study period. Of these, 267 (15%) developed AKI post PCI. 19% of AA patients developed AKI compared to 13% of Caucasian. Comparison of baseline characteristics amongst patients who developed AKI revealed that AA patients with AKI were younger than their Caucasian counterparts (median age 63 vs 68, p=0.006), but were more likely to having smoking history (52% vs 35%, p=0.014). Upon analyzing the association between race and AKI, AA patients were 48% more likely to develop AKI post PCI compared to Caucasian patients (RR of 1.48, 95% CI 1.17-1.86, p=0.0015). This difference was observed in spite of no significant differences in radial access, contrast dose, or mechanical circulatory support use between the two races. Conclusion: African Americans STEMI patients are almost 50% more likely than Caucasians to develop AKI post PCI. Developing race-specific process measures and further optimization of procedural characteristics may be necessary to improve the outcomes of AA STEMI patients.

Low dose rivaroxaban therapy in aspirin allergic patients undergoing percutaneous coronary intervention

Abstract Aspirin in combination with a P2Y12 inhibitor is the mainstay of treatment post percutaneous coronary intervention (PCI) for coronary artery disease (CAD). However, patients who are allergic to or intolerant to aspirin pose a therapeutic challenge especially when encountered in the setting of acute coronary syndrome. Aspirin desensitization strategies have been used in clinical practice to build tolerance prior to coronary intervention but clearly are not practical in the setting of ACS or significant symptomatic CAD. Low dose rivaroxaban (2.5 mg twice a day) has been previously shown to be safe in combination with a P2Y12 inhibitor post ACS compared to aspirin. We therefore sought to see if low dose rivaroxaban is a safe and effective alternative to aspirin in patients post PCI who are unable to take aspirin.This study aims to compare the efficacy (Major adverse cardiovascular events (MACE)) and safety (Bleeding events as defined by Bleeding Academic Research Consortium (BARC) criteria) in patients with confirmed aspirin allergy who were treated with low dose rivaroxaban therapy in place of aspirin in combination with P2Y12 inhibitors post PCI. Methods This was a single center observational study which looked at 50 cases of patients with aspirin allergy (47 cases) or significant confirmed aspirin intolerance (3 cases) who underwent PCI between December 2017 and February 2022. Patients were advised to take low dose rivaroxaban 2.5 mg twice a day as an alternative to aspirin 75 mg once a day. A comparator group of 50 matched patients without aspirin allergy who underwent PCI during the same time period and treated with standard aspirin therapy (75mg) along with a P2Y12 inhibitor. Outcomes over follow-up were MACE (mortality, myocardial infarction, stroke, and unscheduled revascularisation) and bleeding events defined by–BARC criteria. Results The median age of the aspirin allergy cohort was 62 years old with typical comorbidities associated with CAD. The cohort included a case mix of ACS and stable angina.The P2Y12 inhibitor in the majority of cases (76%) was Clopidogrel; Ticagrelor was used in 20% of cases and Prasugrel in 4% cases. No differences existed between the rivaroxaban and matched patient groups. The median follow-up as 626 days (Interquartile range 237–549). The duration of low dose rivaroxaban therapy was for 12 months with a P2Y12 in 72%, 1–3 months for 22% and finally continued long term (with P2Y12 discontinuation at 12 months) in 6%. No difference existed in the incidence of MACE between the low dose rivaroxaban group (12%) compared to the matched cohort (10% p=0.266). No difference in bleeding outcomes (any bleeding event BARC type &amp;gt;0) were seen (14% in rivaroxaban and 16% in control, p=0.329). Conclusions This study provides more supporting evidence that low dose rivaroxaban therapy is an alternative to aspirin when used in combination with a P2Y12 inhibitor post PCI. Funding Acknowledgement Type of funding sources: None.

Implementing modified same-day discharge protocol

Abstract Funding Acknowledgements Type of funding sources: None. Introduction To accomplish overcapacity and bed lacks same-day discharge post percutaneous coronary intervention (PCI) has appeared as a key to improve resource consumption. Also, to focus on evaluating the length of hospital stay (LOS) post PCI’s patients and how to decrease the LOS or same day discharge . Aim A quality improvement project that aimed for implementing new modified Same Day Discharge (SDD) protocol post- Percutaneous Coronary Intervention (PCI) in purpose to decreasing the patient LOS, resources utilization, improving patient satisfactions, manage overcrowded, bed shortages, and bed-flow efficiency. Methods After modifying the protocol to fit with the new cardiac care setting. Orientation for staff nurses about SDD protocol. Statistical results compared to determine the impact of the new modified SDD protocol regarding the LOS. (Figure B) Patients who fit the criteria will be discharge on the same day post PCI. (Figure C) Results &amp; Data Analysis During Sep. 2020, the total patients were 196 (PCI 64 Patients ) compared to 165 (PCI 26 Patients) on Sep. 2021. PCI patients who met the SDD criteria and did not discharge were 48% on Sep. 2020 compared to 19% on Sep. 2021. As showing on the data there is significant impact of the SDD modified protocol, there are 29% increased on the patient discharge. Recommendation Continuous using of these criteria. Link the patient LOS to the data to assess how the SDD Impact and to support the result. Conclusion SDD protocol for post PCI patient in carefully selected patients that improve the patient discharge process.

Do eHealth literacy and socio-demographics predict patients' preferences for use of eHealth programmes after percutaneous coronary intervention?

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): The Western Norway Health Authority Background Evidence supports the use of electronic health (eHealth) programmes for patients with coronary artery disease. To date, there has been little attention toward patients’ preferences for the use of eHealth programmes, and their associations with eHealth literacy and socio-demographic factors post percutaneous coronary intervention (PCI). Purpose To determine how eHealth literacy and socio-demographics are associated with patients’ preferences for use of eHealth programmes assessed 12-month post PCI. Methods An observational cohort study recruited 3417 adult patients treated by PCI at three Norwegian and four Danish university hospitals, June 2017-May 2019. Socio-demographic data and self-reported outcomes on eHealth literacy (eHealth literacy scale) were assessed at baseline. De novo questions on preferences for use of eHealth programmes were collected 12-month post PCI. Hierarchical logistic regression models were performed. Results The majority of patients were men (78%), and the mean age was 66 years. Almost 40% were interested in participating in eHealth programmes. The odds of being interested in accessing a webpage with quality ensured information, health applications and online chat function with healthcare providers increased with 2-3% for each point higher eHealth literacy score, which indicates better eHealth literacy. After controlling for age, education and gender (Step 2), eHealth literacy no longer remained a significant predictor for patients’ preferences. Males had 49% higher odds for interest in a webpage with quality ensured information than females. Females had 33-34% higher odds for interest in an online chat function with healthcare providers and an individually tailored text message. The odds for interest in a webpage with quality ensured information, health applications, online chat function with healthcare providers and individually tailored text messages, decreased with 2-5% per year higher age. For individual tailored feedback on email, the odds for interes was 1% higher per year higher age. Educational level above primary school was a robust predictor for the interest in a webpage with quality ensured information (63-240%). Compared to those with primary school education level, those with college/university education had 67% higher odds for interest in short online information videos, 123% higher odds for interest in online chat function with healthcare providers and 61% higher odds for interest in individually tailored feedback on email compared to patients’ whit primary school. Patients with high school and college/university education had 34-57% lower odds for interest in individually tailored text messages than those with primary school. Conclusions Age, educational level and gender were important predictors of patients’ preferences for using eHealth programmes post PCI. These results are important for the further development of personalized eHealth programmes.

Incorporation of Laboratory Test Biomarkers Into Dual Antiplatelet Therapy Score Improves Prediction of Ischemic and Bleeding Events in Post-percutaneous Coronary Intervention Patients.

This study aimed to examine the performance of the dual antiplatelet therapy (DAPT) score in two retrospective cohorts of post-percutaneous coronary intervention (PCI) patients and to explore whether incorporating additional biomarkers could further improve the predictive power of the DAPT score. In a retrospective derivation cohort of 4,798 PCI patients, the validity of DAPT score for stratifying ischemic/bleeding risks was explored. Then, the association between the baseline status of 54 laboratory test biomarkers and ischemic/bleeding events was revealed while adjusting for the DAPT score. Combinations of individual laboratory test biomarkers that were significantly associated with ischemic/bleeding events were explored to identify the ones that improved discrimination of ischemic and bleeding events when incorporated into DAPT score. Finally, the impact of the combination of biomarkers with DAPT score was validated in an independent retrospective validation cohort of 1,916 PCI patients. Patients with a high DAPT score (DAPT score ≥ 2) had significantly higher risk of ischemic events and significantly lower risk of bleeding than patients with a low DAPT score (DAPT score < 2). Moreover, the addition of aspartate aminotransferase (AST) and red cell distribution width CV (RDW-CV) into the DAPT score further improved discrimination of ischemia and bleeding. Furthermore, the incremental predictive value of AST + RDW-CV maintained with measurements was updated at post-baseline time points. DAPT score successfully stratified the risks of ischemia/bleeding post PCI in the current cohorts. Incorporation of AST + RDW-CV into the DAPT score further improved prediction for both ischemic and bleeding events.

Incidence and predictors of sudden cardiac arrest in the immediate post-percutaneous coronary intervention period for ST-elevation myocardial infarction: a single-center study.

Data on the incidence, predictors, and outcomes of sudden cardiac arrest (SCA) in the immediate post-percutaneous coronary intervention (PCI) period for ST-elevation myocardial infarction (STEMI) are limited. The study aimed to investigate the trends and predictors of SCA occurring within 48 h post PCI for STEMI. We systematically reviewed data from the electronic medical records of 403 patients who underwent PCI for STEMI between January 2014 and December 2019. Trends in the incidence of SCA 48 h post PCI for STEMI were assessed using the Cochrane-Armitage test. Multivariable logistic regression was used to determine the predictors of SCA within 48 h post PCI for STEMI. Of the 403 patients who underwent PCI for STEMI, 44 (11%) had SCA within 48 h post PCI. The incidence of SCA within 48 h post PCI decreased from 22% in 2014 to 8% in 2019; P = 0.03. After adjusting for underlying confounding variables in the multivariable logistic regression models, out of hospital cardiac arrest [adjusted odds ratio (aOR), 23.9; confidence interval (CI), 10.2-56.1], left main coronary artery disease (aOR, 3.1; CI, 1.1-9.4), left main PCI (aOR, 6.6; CI: 1.4-31.7), new-onset heart failure (aOR, 2.0; CI, 4.3-9.4), and cardiogenic shock (aOR, 5.8; CI, 1.7-20.2) were statistically significant predictors of SCA within 48 h post PCI for STEMI. We identified essential factors associated with SCA within 48 h post PCI for STEMI. Future studies are needed to devise effective strategies to decrease the risk of SCA in the early post-PCI period.

Comparison of invasive blood pressure monitoring versus normal non-invasive blood pressure monitoring in ST-elevation myocardial infarction patients with percutaneous coronary intervention

BackgroundHypotension post percutaneous coronary intervention (PCI) causes stent thrombosis and reduced coronary perfusion, which aggravate myocardial ischemia and lead to patient death. Therefore, the accuracy and timeliness of blood pressure monitoring (BPM) are crucial for the nursing of patients post PCI. However, it is still controversial whether invasive blood pressure monitoring (IBPM) or non-invasive blood pressure monitoring (NIBPM) should be used for patients post PCI, and the magnitude of their assistance for patients’ recovery remains unclear. MethodsA randomized controlled trial was performed in this study. 126 ST-segment elevation myocardial infarction (STEMI) patients post PCI were recruited and randomly divided into two groups (NIBPM group n = 63; IBPM group n = 63). ResultsClinical characteristics and physiological outcomes of participants received different BPM methods were collected and analyzed to compare the effects of these two methods on the nursing of PCI patients. Compared to NIBPM group, IBPM assisted to shorten the time of myocardial ischemia, promote coronary reperfusion, reduce the occurrence of cardiovascular disease and other complications, and ultimately reduce the mortality of patients post PCI. ConclusionThe application of IBPM contributed to reduce the occurrence of complications, shorten the time of vascular reperfusion, and guide treatment of clinicians in time.

Evaluation of quality of life-based on the length of use and the number of stents of post percutaneous coronary intervention (PCI) patients

Percutaneous Coronary Intervention (PCI) is intended to improve patients’ quality of life (QoL). This study aims to evaluate the QoL of post PCI patients based on the length of use and the number of stents at the cardiology outpatient clinic of Indonesian Public Hospital. An analytic survey method with a cross-sectional approach was used in this study. A total of 60 samples were included using a purposive sampling method. Data were analyzed with the Spearman correlation test with a confidence level of 95%. The study shows that there was a correlation of the length of use ( p = 0.039; r = 0.267) and the number of stents ( p = 0.001; r = 0.406) with the patients’ QoL. Patients with more prolonged PCI use and a lower number of stents will have better QoL. Hence, nurse practitioners should provide holistic care for post PCI patients to optimize their condition.

Abstract 14311: Gene Guided Antiplatelet Therapy for Acute Coronary Syndrome: An Updated Meta-Analysis

Introduction: Clopidogrel has been the mainstay oral antiplatelet regimen to treat Acute Coronary syndrome (ACS) post percutaneous coronary intervention (PCI) with stents. However, there is marked inter-individual variability due to genetic polymorphisms in the hepatic cytochrome P450 (CYP) 2C19 in the antiplatelet effects of clopidogrel and a reduced response to this drug may be a risk factor for ischemic complications. There has been varied evidence in gene-guided antiplatelet therapy post PCI. An updated meta-analysis was conducted to study the effect of gene-guided antiplatelet therapy in ACS. Methods: A systematic literature review was performed in Embase, PubMed and SCOPUS for all the related articles until May 2021 yielding 180 publications. Nine studies fulfilled inclusion criteria including 8 randomized clinical trials and 1 observational study. The Mantel- Haenszel random-effects model was used to calculate odds ratio (OR) and 95% confidence intervals (CI). Outcomes analyzed were the composite major adverse cardiovascular events (MACE), stent thrombosis, myocardial infarction (MI), bleeding and cardiovascular (CV) death. Results: Gene guided antiplatelet therapy was performed in 7106 patients and conventional therapy in 3970 patients. The MACE events was significantly lower in gene-guided therapy arm (OR = 0.67, 95% CI [0.51 -0.87], P=0.003) driven by lower stent thrombosis (OR=0.47, 95% CI [0.25 -0.88], P=0.02) and lower MI in the gene guided therapy (OR=0.61, 95% CI [0.41 -0.92], P=0.02). The bleeding rates trended to be lower in the gene guided therapy as well (OR = 0.75, 95% CI [0.54-1.02], P=0.07). There is no significance difference in CV death. (OR=0.57, 95% CI [0.21-1.55]) Conclusions: Genotype guided antiplatelet therapy in ACS has lower adverse cardiovascular outcomes driven by lower stent thrombosis and MI with lower bleeding trends as well.

Residual quantitative flow ratio to estimate post-intervention fractional flow reserve

Abstract Objective To assess the performance of residual quantitative flow ratio (QFR) to estimate post percutaneous coronary intervention (PCI) fractional flow reserve (FFR). Background QFR computes FFR based on invasive coronary angiography (ICA) images. Residual QFR is a novel tool that assesses the functional outcome of an intervention by estimating post-PCI FFR. Methods Residual QFR analyses, using pre-PCI ICA images, were attempted in 159 vessels with post-PCI FFR measurements. QFR lesion location was matched with the treated segment to allow virtual removal of the lesion similar to the performed PCI and computation of residual QFR (Picture 1: case example of residual QFR analysis). A post-PCI FFR &amp;lt;0.90 was used to define a suboptimal PCI result. Results Residual QFR computation was successful in 128 (81%) vessels. Median residual QFR was higher than post-PCI FFR (0.96 interquartile range (IQR): 0.91–0.99 vs. 0.91 IQR: 0.86–0.96, p&amp;lt;0.001). A moderate correlation and agreement was observed between residual QFR and post-PCI FFR (Spearman correlation coefficient=0.56 and Intraclass correlation coefficient=0.47, p&amp;lt;0.001 for both). Following PCI, an FFR &amp;lt;0.90 was observed in 54 (42%) vessels. Specificity, positive predictive value, sensitivity, and negative predictive value of residual QFR for determining a suboptimal PCI result were 96% (95% confidence interval (CI): 87–99%), 89% (95% CI: 72–96%), 44% (95% CI: 31–59%), and 70% (95% CI: 65–75%), respectively. Overall, residual QFR had an accuracy of 74% (95% CI: 66–82%) and an area under the receiver operating characteristic curve of 0.79 for assessing a post PCI FFR &amp;lt;0.90. Conclusion A moderate correlation and agreement between residual QFR and post-PCI FFR was observed. Residual QFR ≥0.90 does not necessarily commensurate with an optimal PCI result. However, residual QFR &amp;lt;0.90 is a good indicator of a post-PCI FFR &amp;lt;0.90 and might therefore be utilized to determine PCI location in order to obtain a satisfactory PCI result (Picture 2: central illustration). Funding Acknowledgement Type of funding sources: None. Case example of residual QFR analysisCentral illustration

USE AND OUTCOME OF DUAL ANTIPLATELET THERAPY FOR ACUTE CORONARY SYNDROME IN PATIENTS WITH CHRONIC KIDNEY DISEASE: INSIGHTS FROM THE CANADIAN OBSERVATIONAL ANTIPLATELET STUDY (COAPT), A MULTICENTRE PROSPECTIVE COHORT STUDY

<h3>BACKGROUND</h3> Chronic kidney disease (CKD) increases the risk of adverse outcomes in acute coronary syndrome (ACS). The optimal regimen of dual antiplatelet therapy (DAPT) post percutaneous coronary intervention (PCI) is challenging due to both increased bleeding and thrombotic risks in patients with CKD, particularly since these patients were under-represented in randomized controlled trials. We examined the patterns of DAPT use in ACS patients post PCI stratified by presence of CKD. <h3>METHODS AND RESULTS</h3> The multi-centre prospective Canadian Observational Antiplatelet Study (COAPT) enrolled patients with an ACS diagnosis from 43 hospitals between December 2011-May 2013. The present study is a subgroup analysis comparing type and duration of DAPT, and associated outcomes among patients with and without CKD defined as eGFR < 60 ml/min/1.73m2 (calculated by CKD-EPI). COAPT enrolled 1921 patients (mean age: 61; 21.4% female) with a median eGFR of 85 ml/min/1.73 m2 (25th and 75th percentiles [69, 97]). Of those, 275 (14.3%) had CKD. CKD patients were older, more likely to be female and have comorbidities including previous ACS, heart failure, hypertension, cerebrovascular disease, atrial fibrillation and gastrointestinal bleeding. Patients with CKD were less frequently prescribed the more potent P2Y12 inhibitors prasugrel/ticagrelor (18.5% vs 25.8%, p=0.01) and had a shorter duration of DAPT therapy than patients without CKD (median 382 vs 402 days, p=0.003). CKD was associated with major adverse cardiovascular events (MACE) at 12 months (p < 0.001) but not bleeding when compared to patients without CKD (figure 1). CKD was associated with MACE in both patients on prasugrel/ticagrelor (p=0.017) and those on clopidogrel (p < 0.001) (p for heterogeneity=0.70). CKD was associated with increased bleeding only among patients receiving prasugrel/ticagrelor (p=0.007), but not among those receiving clopidogrel (p=0.64) (p for heterogeneity=0.036). Patients with CKD were more frequently considered to have an ongoing indication for DAPT therapy during follow-up. Discontinuation of DAPT was more likely in patients with CKD due to the need for an oral anticoagulant. <h3>CONCLUSION</h3> Patients with CKD had a shorter DAPT duration and were less frequently prescribed potent P2Y12 inhibitors than patients without CKD. Overall, compared with patients without CKD, patients with CKD had higher rates of MACE and similar bleeding rates. However, among those prescribed more potent P2Y12 inhibitors, CKD was associated with more bleeding than those without CKD. Further studies are needed to better define the benefit/risk ratio, and establish a more tailored and evidence-based DAPT regimen for this high-risk patient group.

Trends in Major Bleeding Post Percutaneous Coronary Intervention (PCI)

The Victorian Cardiac Outcomes Registry (VCOR) is a clinical quality registry that reports key performance indicators, including in-hospital bleeding outcomes according to Bleeding Academic Research Consortium (BARC) criteria. This study aimed to investigate temporal trends in major bleeding post PCI.

Abstract 15728: Machine Learning Helps Predict Short and Intermediate-term Risk for All Cause Mortality in Patients Undergoing Percutaneous Coronary Intervention

Background: Identifying patients at a high risk of mortality post percutaneous coronary intervention (PCI) is of vital clinical importance. We investigated the utility of machine learning algorithms to predict short and intermediate-term risk of all-cause mortality in patients undergoing PCI. Methods: Patient-level demographics, clinical, electrocardiographic ,echocardiographic and angiographic data from January 2006 to December 2017 were extracted from the Mayo Clinic CathPCI registry and clinical records. For patients with multiple PCI events, data collected at the time of the index PCI was used for analysis. Patients who underwent bailout coronary artery bypass graft surgery (CABG) prior to discharge were excluded. 306 variables were incorporated into random forest machine learning model (RF) to predict all-cause mortality at 6 months and 1 year after PCI. Ten-fold cross-validation repeated five times was used to optimize the hyperparameters and estimate its external performance. The National Cardiovascular Data Registry (NCDR) based logistic regression model was used for comparison. The area under receiver operator characteristic curves (AUC) was calculated to assess the ability of the models to predict all-cause mortality. Results: A total of 17356 unique patients were included for the final analysis after excluding 165 patients who underwent CABG surgery during the index hospitalization. The mean age was 66.9 ± 12.5 years;71% were male. Indications for PCI were ST-elevation myocardial infarction (9.4%), non-ST elevation myocardial infarction (12.9%), unstable angina (17.7%), and stable angina (52.8%) in the cohort. In-hospital, 6-month &amp; 1 year mortality rates were 1.9%,4.2% &amp; 5.8% respectively. The RF model was superior to the NCDR model in predicting inhospital, 6-month, 1 year mortality (p&lt;0.0001) ( Figure 1 ). Conclusion: Machine learning is superior to NCDR model in predicting short and intermediate risk of all-cause mortality post PCI.

Abstract 15360: Coronary Artery Dominance, Anatomical Variants and Anomalies in African American Population

Introduction: Coronary arterial dominance is defined by the vessel which gives rise to the posterior descending artery (PDA). The prevalence of right dominance is 80- 85%, left dominance is 8% and codominance is 7% among the general population. The coronary dominance in African Americans is not well known. The aim of this study was to investigate the coronary dominance in African Americans. Previous studies showed that left dominance and codominance are associated with increased post-percutaneous coronary intervention (PCI) in-hospital mortality in patients with acute coronary syndrome (ACS). Methods: A retrospective analysis of coronary angiograms performed in our facility was done. A total of 556 cases were reviewed from 2018 to 2019. All the data was collected from the electronic medical records. Patients were categorized by race, gender, age, and comorbidities. Angiograms were reviewed and coronary dominance was determined by the vessel which supplied the PDA. Results: From the 556 charts reviewed, 430(77%) cases were performed in African Americans. Of the 430 patients, 220(51%) were male and 210(49%) were female. Mean age was 62.6 years. 370(86%) patients had hypertension, 171(39.7%) had diabetes, 28(6.5%) had peripheral vascular disease, 149(34.6%) had heart failure, 33(7.6%) had history of stroke. 28(6.5%) were on dialysis, 201(46.7%) had dyslipidemia, 14(3.2%) had HIV, 43 (10%) had atrial arrhythmias, 237(55.1%) had history of tobacco use and 21(4.8%) had history of cocaine use. In 390(90.7%) patients, left main coronary artery bifurcated into left anterior descending coronary artery (LAD) and left circumflex artery (LCX). In 40(9.3%) patients, left main coronary artery trifurcated into LAD, LCX and ramus intermedius artery. Among these patients, 303(70.4%) had right coronary dominance, 38(8.8%) had left coronary dominance and 89(20.7%) had codominance. 7 patients had ectasia of the coronary vessels and 8 patients had anomalous origin of coronary vessels. Conclusions: Our study showed that African Americans have higher prevalence of codominance compared to general population. It is important to identify it at the time of coronary angiogram since it has been associated with increased post PCI in-hospital mortality in patients with ACS.

What troponin I level post PCI in SIHD is predictive of higher risk of MACE?

Abstract Background According to the 4th universal definition of myocardial infarction (MI), post percutaneous coronary intervention (PCI) MI is defined as an elevation of cardiac troponin values more than five times above the 99th percentile upper reference limit. The ISCHEMIA Trial in stable ischaemic heart disease (SIHD) patients reported post PCI troponin rise as part of the primary endpoint. What represents a clinically significant troponin rise post PCI has not been clearly established. Purpose The aim of our study was to correlate the level of troponin I rise with adverse events post PCI in SIHD. Methods We performed a retrospective analysis of our PCI registry in patients with SIHD between 2014 and 2018. Patients with acute coronary syndrome were excluded. HS-troponin I was measured one day after the procedure. The primary end point was major adverse cardiac events (MACE) including death, MI, stent thrombosis (ST) and need for repeat revascularization within 12 months from index procedure. Results Between 2014 and 2018, 920 patients (mean age 67.5 years, 78% male) underwent PCI for SIHD. Troponin rise post PCI was a common event and a level more than 100ng/L (reference range &amp;lt;26 ng/L) occurred in 54% of patients. Mean and median troponin I level post PCI was 675 ng/L±2530 and 118 ng/L respectively. In patients with MACE, mean troponin I level was 1361 ng/L compared with 611 ng/L in patients without MACE (P=0.0176). Correlation of troponin I level with one year MACE rates are shown in the Graph. MACE rates were steady at 8.5% with troponin I levels below 2500 ng/L after which there was a significant increase in the MACE rates. At troponin I level above 5000 ng/L MACE was 13.6% and above 10,000 ng/L it was 33.3%. Conclusion Troponin I levels above 2500 ng/L (x100 upper limit normal) correlated with an increase in the risk of MACE in patients undergoing PCI for SIHD. Our results suggest that current definitions of procedural MI overestimate the clinical significance of post PCI troponin rise. Funding Acknowledgement Type of funding source: None

Validation of novel 3-dimensional quantitative coronary angiography based software to calculate fractional flow reserve post stenting.

ObjectivesTo validate novel dedicated 3D‐QCA based on the software to calculate post PCI vessel‐FFR (vFFR) in a consecutive series of patients, to assess the diagnostic accuracy, and to assess inter‐observer variability.BackgroundLow post percutaneous coronary intervention (PCI) fractional flow reserve (FFR) predicts future adverse cardiac events. However, FFR assessment requires the insertion of a pressure wire in combination with the use of a hyperemic agent.MethodsFAST POST study is an observational, retrospective, single‐center cohort study. One hundred patients presenting with stable angina or non ST‐elevation myocardial infarction, who underwent post PCI FFR assessment using a dedicated microcatheter were included. Two orthogonal angiographic projections were acquired to create a 3D reconstruction of the coronary artery using the CAAS workstation 8.0. vFFR was subsequently calculated using the aortic root pressure.ResultsMean age was 65±12 years and 70% were male. Mean microcatheter based FFR and vFFR were 0.91±0.07 and 0.91±0.06, respectively. A good linear correlation was found between FFR and vFFR (r = 0.88; p <.001). vFFR had a higher accuracy in the identification of patients with FFR values <0.90, AUC 0.98 (95% CI: 0.96‐1.00) as compared with 3D‐QCA AUC 0.62 (95% CI: 0.94‐0.74). Assessment of vFFR had a low inter‐observer variability (r = 0.95; p <.001).Conclusion3D‐QCA derived post PCI vFFR correlates well with invasively measured microcatheter based FFR and has a high diagnostic accuracy to detect FFR <0.90 with low inter‐observer variability.