Presence Of Multivessel Disease Research Articles

Understanding long-term risk in Percutaneous Coronary Intervention (PCI) in the Australian contemporary era with a focus on defining Complex Revascularisation in High-Risk Indicated Patients (CHIP)

BackgroundComplex Revascularisation in High-Risk Indicated Patients (CHIP) is emerging in Percutaneous Coronary Intervention (PCI). We document the frequency and outcomes following CHIP PCI in the Australian population, to understand risk and guide clinical decision-making. We propose a scoring system to define CHIP procedures. MethodsPatients undergoing PCI from Melbourne Intervention Group registry between 2005 and 2018 were analysed. Patients were stratified based on the number of high-risk features defined as 1)presence of ≥3 patient factors including age > 75yo, COPD, diabetes, renal impairment (eGFR<60 mL/min/1.73 m2), PVD, and 2)LVEF<30 %, and/or 3)having one complex coronary anatomical feature such as LMCA PCI, ACC/AHA B2/C lesion PCI, presence of multi-vessel disease or CTO PCI. National Death Index linkage was performed for long-term mortality analysis. Outcomes were analysed according to 4 risk categories – low risk(score 0), intermediate risk(score 1), high-risk(score 2), and very high-risk(score 3). Results20,973patients were analysed. Majority of patients underwent intermediate-risk procedures(71.7 %), with low rates of high-risk(6.6 %), and very high-risk(0.2 %). Lesion success inversely correlates with risk; low-risk(99.4 %), intermediate-risk(95.1 %), high-risk(94.3 %), very high-risk(92.5 %),p < 0.001. In-hospital and 30-day death correlates with risk; low-risk(0.0 %/0.1 %), intermediate-risk(0.3 %/0.5 %), high-risk(1.5 %/2.9 %), very high-risk(2.4 %/7.1 %),p < 0.001. Long-term mortality correlates with risk; low-risk(12.3 %), intermediate-risk(15.8 %), high-risk(49.3 %), very high-risk(76.2 %),p < 0.001. On multivariate analysis, increasing risk correlates with long-term mortality; intermediate-risk(HR1.41), high-risk(HR6.42), and very high-risk(14.05). ConclusionIn the Australian practice, proportion of patients undergoing high and very high-risk PCI procedures are low. Despite good procedural success and in-hospital outcomes, long-term mortality is poor. Further research into appropriate patient selection, and direct comparison of CHIP PCI to those treated medically and surgically should be considered.

Factors associated with 30-day mortality in patients receiving mechanical circulatory support for cardiogenic shock

Abstract Introduction Mechanical circulatory support (MCS) is often deployed in patients with refractory cardiogenic shock complicating acute myocardial infarction (AMI-CS). Nevertheless, the mortality rate in these patients remains utterly high, around 50%. Purpose The aim of this study was to identify patient characteristics associated with 30-day mortality in patients receiving MCS for AMI-CS. Methods In the Netherlands, all patients undergoing percutaneous coronary intervention (PCI) are prospectively entered in the Netherlands Heart Registration (NHR). Additional data were retrieved for all CS patients between 2017-2021 in 14 Dutch hospitals, including MCS usage. Survivors and non-survivors amongst MCS treated patients were compared to identify patient characteristics associated with 30-day mortality. In addition, multivariate logistic regression analysis on imputed data was performed to quantify these associations in adjustment for confounders. Results MCS was deployed in 516 (23.3%) of all AMI-CS patients. MCS patients had a mean age of 64.2 (± 12.5) years and 74.6% were male. An intra-aortic balloon pump (IABP) was used in 49.0% of the patients. Impella, extracorporeal membrane oxygenation (ECMO) and multiple devices were used in 18.2%, 13.2% and 18.4% respectively. The overall 30-day mortality rate was 55.0%. At baseline, MCS survivors were younger (62.8 vs 65.2, p=0.03), had diabetes less often (18.4 vs. 28.0, p=0.02), and presented with a higher mean arterial pressure (MAP) (77.9 vs. 71.7, p&amp;lt;0.01). An out-of-hospital cardiac arrest (OHCA) preceded in 34.3% of the survivors versus 42.0% of the non-survivors (p=0.09). Survivors also had lower admission levels of lactate (5.0 vs. 7.8, p&amp;lt;0.01), glucose (12.1 vs. 15.2, p&amp;lt;0.01) and creatinine (94 vs. 115, p&amp;lt;0.01). Multivessel disease (MVD) was present less frequently in survivors compared to non-survivors (62.1% vs. 74.2%, p&amp;lt;0.01). In-hospital cardiac arrest (IHCA) occurred less often in survivors both prior to PCI (8.2% vs. 18.0%, p&amp;lt;0.01) and during PCI (22.8% vs. 34.6%, p&amp;lt;0.01). After multivariate logistic regression, higher age (OR 1.04, 95%CI: 1.02-1.05), resuscitation prior to (OR 2.11, 95 %CI: 1.09-4.09) or during PCI (OR 1.58, 95% CI: 1.01-2.47) and the presence of MVD (OR 2.07, 95% CI: 1.32-3.25) were independently associated with 30-day mortality in AMI-CS patients who received MCS. Conclusion In AMI-CS patients who received MCS, older age, the occurrence of an IHCA prior to or during PCI, and the presence of MVD were independently associated with an increased 30-day mortality.Figure 1.Table 1.

TCT-412 Revascularization in Patients With Coronary Heart Disease at High Surgical Risk With the Presence of Multivessel Disease and Chronic Total Occlusions

TCT-412 Revascularization in Patients With Coronary Heart Disease at High Surgical Risk With the Presence of Multivessel Disease and Chronic Total Occlusions

Association of overweight and obesity with coronary risk factors and the presence of multivessel disease in patients with obstructive coronary artery disease – A nationwide registry study

BackgroundThe growing prevalence of obesity is expected to increase the burden of coronary artery disease. This study examined the prevalence of overweight and obesity in patients with a first-time diagnosis of obstructive coronary artery disease in a contemporary population. The association of body-mass-index (BMI) with age, traditional risk factors, and the presence of multivessel disease were explored. Methods and resultsUsing the Danish Nationwide registries, we identified 49,733 patients with a first-time diagnosis of obstructive coronary artery disease in the period 2012–2018. We investigated the association between BMI and coronary risk factors by multivariate logistic regression. Mean age was 65.8 ± 11.8 years, mean BMI was 27.5 kg/m2 ± 7.2, and 73.2 % were men. 66.3 % had a BMI ≥25 kg/m2 and 1.3 % were underweight. The prevalence of patients with BMI ≥25 kg/m2 decreased with increasing age and was 69 % in patients <50 year vs. 46.2 % in patients ≥80 years (p < 0.001). In all age groups, higher odds of BMI ≥25 kg/m2 were observed in males, former smokers, and patients with hypertension. In multivariate logistic regression, BMI ≥25 kg/m2 was not associated with presence of multivessel disease (p = 0.74). ConclusionIn this large, nationwide study, 66.3 % of patients with first time diagnosis of obstructive coronary disease had BMI ≥25 kg/m2. Young patients had higher BMI and were more likely to be current smokers. Overweight or obesity was independently associated with the presence of diabetes and hypertension. BMI ≥25 kg/m2 was not independently associated with the presence of multivessel disease.

Tandem lesions associate with angiographic progression of coronary artery stenoses

BackgroundAlthough the clinical factors associated with progression of coronary artery disease have been well studied, the angiographic predictors are less defined. ObjectivesOur objective was to study the clinical and angiographic factors that associate with progression of coronary artery stenoses. MethodsWe conducted a retrospective analysis of consecutive patients undergoing multiple, clinically indicated invasive coronary angiograms with an interval greater than 6 months, between January 2013 and December 2016. Lesion segments were analysed using Quantitative Coronary Angiography (QCA) if a stenosis ≥ 20 % was identified on either angiogram. Stenosis progression was defined as an increase ≥ 10 % in stenosis severity, with progressor groups analysed on both patient and lesion levels. Mixed-effects regression analyses were performed to evaluate factors associated with progression of individual stenoses. Results199 patients were included with 881 lesions analysed. 108 (54.3 %) patients and 186 (21.1 %) stenoses were classified as progressors. The median age was 65 years (IQR 56–73) and the median interval between angiograms was 2.1 years (IQR 1.2–3.0). On a patient level, age, number of lesions and presence of multivessel disease at baseline were each associated with progressor status. On a lesion level, presence of a stenosis downstream (OR 3.07, 95 % CI 2.04–4.63, p < 0.001) and circumflex artery stenosis location (OR 1.81, 95 % CI 1.21–2.7, p = 0.004) were associated with progressor status. Other lesion characteristics did not significantly impact progressor status or change in stenosis severity. ConclusionCoronary lesions which have a downstream stenosis may be at increased risk of stenosis progression. Further research into the mechanistic basis of this finding is required, along with its implications for plaque vulnerability and clinical outcomes.

Correlation of Coronary Artery Disease in Patients with Peripheral Artery Disease: Cross-Sectional Study

Background Peripheral Artery Disease (PAD) and Coronary Artery Disease (CAD) represent two facets of atherosclerotic cardiovascular disease, significantly impacting global health. Despite their high morbidity and mortality rates, the epidemiological and clinical nexus between PAD and CAD remains underexplored. Understanding the interrelation of these conditions is paramount for optimizing diagnostic and therapeutic strategies. Objective This study aimed to delineate the incidence and clinical correlation of CAD in patients diagnosed with PAD, thereby providing insights into the epidemiological characteristics and enhancing the clinical management of these conditions. Methods A cross-sectional analysis was conducted at Afridi Medical Complex's departments of vascular surgery and cardiology from 2021 to 2023. One hundred PAD patients referred for peripheral angiography were enrolled. Demographic data, Ankle Brachial Index (ABI) readings, ejection fraction percentages, and the presence of multivessel disease were evaluated. Statistical analyses were performed using SPSS version 25, focusing on mean, median, range, and significance levels to elucidate the prevalence of CAD among PAD patients. Results The study revealed a median age of 58 years among participants, with a significant male predominance (84%). ABI analysis showed that 74% and 108% of patients had mild and moderate PAD severity, respectively. The incidence of CAD in the PAD population was 56%, with angiographic assessments indicating single, double, and triple vessel disease in 23.21%, 39.29%, and 37.5% of patients, respectively. Notably, diabetes and dyslipidemia were prominent predictors of CAD presence in PAD patients. Conclusion The high prevalence of CAD in PAD patients underscores the critical need for comprehensive cardiovascular risk assessment and suggests the potential benefit of routine coronary angiography in symptomatic PAD cases, particularly among those with diabetes and dyslipidemia. This study reinforces the intertwined nature of PAD and CAD, advocating for an integrated approach to the diagnosis and management of these atherosclerotic conditions.

Association of Periprocedural Inflammatory Activation With Increased Risk for Early Coronary Stent Thrombosis.

Stent thrombosis is a rare but deleterious event. Routine coronary angiography with percutaneous coronary intervention (PCI) is often deferred in the presence of laboratory markers of acute inflammation to prevent complications. The aim of this study was to investigate whether an acute inflammatory state is associated with an increased risk of early stent thrombosis. Within a prospective single-center registry, the association between preprocedural acute inflammatory activation, defined as C-reactive protein plasma levels >50 mg/L or a leukocyte count >12 g/L, and occurrence of early (≤30 days) stent thrombosis was evaluated. In total, 11 327 patients underwent PCI and of those, 6880 patients had laboratory results available. 49.6% of the study population received PCI for an acute coronary syndrome and 50.4% for stable ischemic heart disease. In patients with signs of acute inflammatory activation (24.9%), PCI was associated with a significantly increased risk for stent thrombosis (hazard ratio, 2.89; P<0.00001), independent of age, sex, kidney function, number and type of stents, presence of multivessel disease, choice of P2Y12 inhibitor, and clinical presentation. Elevated laboratory markers of acute inflammation were associated with the occurrence of stent thrombosis in both patients with acute coronary syndrome (hazard ratio, 2.63; P<0.001) and in patients with stable ischemic heart disease (hazard ratio, 3.57; P<0.001). An acute inflammatory state at the time of PCI was associated with a significantly increased risk of early stent thrombosis. Evidence of acute inflammation should result in deferred PCI in elective patients, while future studies are needed for patients with acute coronary syndrome.

Cardiogenic shock complicating acute myocardial infarction; mechanical circulatory support use in the Netherlands

Abstract Introduction Mortality rates in cardiogenic shock complicating acute myocardial infarction (AMICS) linger around 40-50%. Despite the lack of evidence, the use of mechanical circulatory support (MCS) in this population is increasing rapidly worldwide. Purpose This study aimed to give insights in MCS use in the Netherlands and to assess how the use of MCS is associated with mortality. Methods Data from all patients undergoing percutaneous coronary intervention (PCI) in the Netherlands is prospectively registered in the Netherlands Heart Registration (NHR) database. On top of the obligatory registration, additional data were retrieved for all patients with cardiogenic shock undergoing PCI between 2017 and 2021 in 14 Dutch hospitals. The additional variables included the use of different types of MCS. Multivariate logistic regression was used to test the association between MCS and mortality in adjustment for confounders. Results In total, we included 2328 patients, with a mean age of 66.4 ± 12.3 years and of whom 72.9% were male. Of all patients, 23.6% received a form of MCS (11.5% an IABP, 4.5% an Impella, 3.1% VA-ECMO, 4.2% a combination of devices and 0.3% other). Compared to patients who did not receive MCS, MCS supported patients were younger (64.2 vs. 67.1 years, p &amp;lt;0.001), presented after an out-of-hospital cardiac arrest (OHCA) less often (33.3% vs. 39.9%, p = 0.008), had complaints for over three hours more often (50.3% vs. 38.8%, p = 0.001) and had a lower mean arterial pressure (MAP) (74.9 vs. 78.6 mmHg, p &amp;lt;0.005) and higher heartrate (88.2 vs 81.8 beats per minute, p &amp;lt;0.001) at admission. Also, mean admission lactate (6.4 vs. 5.2, p &amp;lt;0.001), glucose (13.4 vs. 11.8, p &amp;lt;0.001) and creatinine levels (104 vs. 99, p &amp;lt;0.001) were higher in MCS-receiving patients. Additionally, patients who received MCS support more often suffered from multivessel disease (68.7% vs. 58.4%, p &amp;lt;0.001) and chronic total occlusions (CTO) (3.5% vs. 1.9%, p = 0.027) and were treated with inotropes prior to PCI more often (54.9% vs. 46.2%, p &amp;lt;0.001). The overall 30-day mortality was higher in the MCS cohort than in the no-MCS cohort, namely 54.4% vs. 34.3% (OR = 2.28, 95%CI = 1.88-2.78). In adjustment for age, OHCA, complaints duration, admission MAP, heartrate, lactate, glucose and creatinine, the presence of multivessel disease and CTO and inotrope use before PCI, MCS was independently associated with 30-day mortality (adjusted OR = 2.23, 95% CI = 1.54-3.23). Conclusion MCS was deployed in 23.6% of the patients in this cohort. Despite the results of the IABP-SHOCK II trial, IABP was the most frequently used device. In this cohort, MCS was independently associated with 30-day mortality. However, residual confounding is probably present. Besides randomised controlled trials guiding clinical decision making regarding MCS use and timing, future research should also focus on investigating barriers to implement the results of previous trials.KM-curve of unadjusted survival

Association of inflammatory activation with acute stent thrombosis

Abstract Background Acute stent thrombosis (ST) is a rare but deleterious event. Acute infection and inflammation may lead to activation of the coagulation system and of platelets. Coronary angiography with stent implantation is often deferred because of increased inflammatory markers. Purpose The aim of this study was to investigate whether an acute inflammatory state is associated with increased risk of early stent thrombosis. Methods Within a prospective single-center registry, the association between pre-procedural acute inflammatory activation, defined as C-reactive protein (CRP) plasma levels &amp;gt;5mg/dL or leukocytes &amp;gt;12 G/L, and occurrence of early stent thrombosis within 30 days after PCI was evaluated. Results We included 11327 patients that underwent coronary stenting. 3964 (35%) were treated for acute coronary syndrome (ACS) and 7363 (65%) had chronic coronary artery disease. The number of definite early ST within 30 days was 91 (0.8 %). Leukocyte count and plasma levels of C-reactive protein (CRP) were available in 6880 patients (87 patients with ST). 1715 patients showed signs of an acute inflammatory state as defined by a leukocyte count &amp;gt; 12 G/L or plasma levels of CRP &amp;gt; 5mg/dL. Stent implantation in patients with acute inflammation was associated with significant increased risk for ST (HR 3.01; p&amp;lt;0.0000001) independent of age, gender, kidney function, number and type of stents, presence of multivessel disease, choice of P2Y12 inhibitor and clinical presentation. This was the case in patients with (HR 2.48; p&amp;lt;0.001) and without acute coronary syndromes (HR 3.59; p&amp;lt;0.001). The incidence of ST in patients with ACS with and without signs of inflammation was 2.7% vs. 1.1% (p&amp;lt;0.001) and in patients with chronic coronary artery disease with and without inflammation was 2.3% vs 0.7% (p&amp;lt;0.001) Conclusions An acute inflammatory state as defined by a leukocyte count &amp;gt; 12 G/L or plasma levels of CRP &amp;gt; 5mg/dL at time of stent implantation was associated with a significant increased risk of acute ST. In particular in patients with chronic coronary artery disease acute inflammatory activation should lead to a deferral of elective interventions. In patients with ACS and increased inflammatory parameters, in which acute PCI is mandatory, future studies are needed, whether more intensive therapy could reduce risk of early ST in this particular high-risk cohort.

Predictors of In-Hospital Death in Patients With Acute Myocardial Infarction.

Factors such as age, vital signs, renal function, Killip class, cardiac arrest, elevated cardiac biomarker levels, and ST deviation predict survival in patients with acute myocardial infarction (AMI). However, the existing risk assessment tools lack comprehensive consideration of catheter-related factors, and short-term prognostic predictors are unknown. This study aimed to clarify in-hospital prognostic predictors in hospitalized patients with AMI. Five hundred and thirty-six patients who underwent percutaneous coronary intervention (PCI) for AMI were divided into non-survivor (n = 36) and survivor (n = 500) groups. Coronary risk factors, laboratory findings, angiographic findings, and clinical courses were compared between the two groups. Multiple logistic regression was used to analyze in-hospital death in pre- and post-PCI phases. In the pre-PCI phase, multiple logistic regression analysis revealed several predictors of in-hospital death, including systolic blood pressure [odds ratio (OR) = 0.985, p = 0.023)], Killip class ≥2 (OR = 14.051, p <0.001), and chronic kidney disease (OR = 4.859, p = 0.040). In the post-PCI phase, multiple logistic regression analysis revealed additional predictors of in-hospital death, including Killip class ≥2 (OR = 5.982, p = 0.039), presence of lesions in the left main trunk (OR = 51.381, p = 0.044), utilization of intra-aortic balloon pumps and percutaneous cardiopulmonary support (OR = 6.141, p = 0.016), and presence of multi-vessel disease (OR = 6.323, p = 0.022). Predictors of in-hospital death in AMI extend beyond conventional risk factors to include culprit lesions, mechanical support, and multi-vessel disease that manifest post-PCI.

Intracoronary injection of nitroglycerine can prevent unnecessary percutaneous coronary intervention

BackgroundDespite the recommendation of the current guidelines, intracoronary administration of nitroglycerine during coronary angiography is often neglected. We investigated the effect of intra-coronary nitroglycerin on the relief of coronary artery stenosis in the candidates for percutaneous coronary intervention (PCI).MethodsWe included patients with angina pectoris or myocardial infarction who were candidates for PCI. In the coronary angiography, the culprit vessel involved was evaluated, and bolus nitroglycerin at a dose of 25–200 mcg was injected into the affected coronary artery. A significant change in the percentage of coronary artery stenosis was considered a positive response, and these patients were then compared with patients who did not have a substantial change in the percentage of stenosis at the same time. Univariate analysis and then multivariate logistic regression analysis was performed to determine the predictors of response to intracoronary nitroglycerin.ResultsAmong 360 patients, 27 (7.5%) responded to nitroglycerine, and 333 (92.5%) were non-responsive. The mean age of patients was 60.2 ± 11.6 years, ranging from 23 to 93 years, and 265 (73.6%) were men. The study groups were not significantly different in the baseline demographic characteristics. The presence of multivessel disease (Odds ratio (OR) = 16.26, 95% confidence interval (CI):2.07–127.6; P = 0.008) and stenosis in the left circumflex artery (OR = 3.62, 95% CI: 1.03–12.70; P = 0.044) were the independent predictors for nonresponse to nitroglycerine, leading to PCI.ConclusionIn some cases, especially those without multivessel diseases, intracoronary nitroglycerine administration can efficiently relieve coronary stenosis and prevent unnecessary PCI.

A Japanese Dose of Prasugrel versus a Standard Dose of Clopidogrel in Patients with Acute Myocardial Infarction from the K-ACTIVE Registry.

Background: Dual antiplatelet therapy (DAPT) with aspirin plus P2Y12 inhibitor is used as a standard therapy for patients with acute myocardial infarction (AMI) treated with drug-eluting stents (DESs). In Japan, clopidogrel was the major P2Y12 inhibitor used for a decade until the new P2Y12 inhibitor, prasugrel, was introduced. Based on clinical studies considering Japanese features, the set dose for prasugrel was reduced to 20 mg as a loading dose (LD) and 3.75 mg as a maintenance dose (MD); these values are 60 and 10 mg, respectively, globally. Despite this dose discrepancy, little real-world clinical data regarding its efficacy and safety exist. Methods: From the K-ACTIVE registry, based on the DAPT regimen, patients were divided into a prasugrel group and a clopidogrel group. The ischemic event was a composite of cardiovascular death, non-fatal MI, and non-fatal stroke. The bleeding event was type 3 or 5 bleeding based on the Bleeding Academic Research Consortium (BARC) criteria. Results: Substantially more patients were prescribed prasugrel (n = 2786) than clopidogrel (n = 890). Clopidogrel tended to be selected over prasugrel in older patients with numerous comorbidities. Before adjustments were made, the cumulative incidence of ischemic events at 1 year was significantly greater in the clopidogrel group than in the prasugrel group (p = 0.007), while the cumulative incidence of bleeding events at 1 year was comparable between the groups (p = 0.131). After adjustments were made for the age, sex, body weight, creatine level, type of AMI, history of MI, approach site, oral anticoagulation therapy, presence of multivessel disease, Killip classification, and presence of intra-aortic balloon pumping, both ischemic and bleeding events became comparable between the groups. Conclusion: A Japanese dose of prasugrel was commonly used in AMI patients in the real-world database. Both the prasugrel and clopidogrel groups showed comparable rates of 1 year ischemic and bleeding events.

Combined assessment of stress cardiovascular magnetic resonance and angiography to predict the effect of revascularization in chronic coronary syndrome patients.

The role of revascularization in chronic coronary syndrome (CCS) and the value of ischaemia vs. anatomy to guide decision-making are in constant debate. We explored the potential of a combined assessment of ischaemic burden by vasodilator stress cardiovascular magnetic resonance (CMR) and presence of multivessel disease by angiography to predict the effect of revascularization on all-cause mortality in CCS. The study group comprised 1066 CCS patients submitted to vasodilator stress CMR pre-cardiac catheterization (mean age 66 ± 11 years, 69% male). Stress CMR-derived ischaemic burden (extensive if >5 ischaemic segments) and presence of multivessel disease in angiography (two- or three-vessel or left main stem disease) were computed. The influence of revascularization on all-cause mortality was explored and adjusted hazard ratios (HRs) with the corresponding 95% confidence intervals were obtained. During a median 7.51-year follow-up, 557 (52%) CMR-related revascularizations and 308 (29%) deaths were documented. Revascularization exerted a neutral effect on all-cause mortality in the whole study group [HR 0.94 (0.74-1.19), P = 0.6], in patients without multivessel disease [n = 598, 56%, HR 1.12 (0.77-1.62), P = 0.6], and in those with multivessel disease without extensive ischaemic burden [n = 181, 17%, HR 1.66 (0.91-3.04), P = 0.1]. However, compared to non-revascularized patients, revascularization significantly reduced all-cause mortality in patients with simultaneous multivessel disease and extensive ischaemic burden (n = 287, 27%): 3.77 vs. 7.37 deaths per 100 person-years, HR 0.60 (0.40-0.90), P = 0.01. In patients with CCS submitted to catheterization, evidence of simultaneous extensive CMR-related ischaemic burden and multivessel disease identifies the subset in whom revascularization can reduce all-cause mortality.

Electrocardiogram predictors of multivessel disease in ST-elevation myocardial infarction patients undergoing primary percutaneous coronary intervention

Objective: The objective was to study the role of 12-lead electrocardiogram (ECG) changes in predicting the association of severe stenosis of other coronary arteries along with infarct-related artery in patients who presented with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Materials and Methods: We studied the admission ECG, clinical records, and coronary angiography of 201 patients with STEMI who underwent primary PCI within the first 12 h of symptoms. Patients with first episode of STEMI and coronary angiogram showing coronary artery disease between January 2015 and July 2016 were included in this study. Results: Most of the patients in this study were males (82.1%). The mean age of the patients was 55.20 ± 11.79 years. Diabetic mellitus (37.8%), hypertension (37%), and smoking (49.7%) were the main risk factors. This study had 117 (58.2%) patients of anterior wall myocardial infarction (MI) (Group I) while inferior wall MI was present in 84 (41.8%) patients (Group II). In Group I, 83 (70.9%) patients had single-vessel disease (SVD) while 34 (29.1%) patients had multivessel disease (MVD). The presence of ST-segment depression ≥0.1 mV in leads I, aVL, and V6 significantly correlated with the presence of MVD (P = 0.001, 0.001, and 0.001, respectively). In Group II, 39 (51.3%) patients had SVD while 37 (48.7%) patients had MVD. The presence of ST-segment depression in leads aVL, V5, and V6 significantly correlated with the presence of MVD (P = 0.049, 0.001, and 0.001, respectively). Conclusion: The presence of ST-segment depression of ≥0.1 mv in leads I, aVL, and V6 on admission ECG in the setting of acute anterior wall STEMI and in leads aVL, V5, and V6 on admission ECG in the setting of acute inferior wall STEMI was associated with MVD.

Clinical Impact of Medical Therapy Versus Revascularization in Patients With Chronic Coronary Total Occlusions.

Chronic total occlusions (CTOs) are prevalent angiographic findings in patients with suspected coronary artery disease. Conflicting results of randomized controlled trials and registries have not clarified the therapeutic approach for patients with CTO in clinical practice. Therefore, we sought to analyze variables influencing the decision-making process and their relationship with clinical outcomes according to the type of selected therapy. A total of 1248 consecutive patients with at least 1 CTO were identified between 2010 and 2014 at our institution. Clinical and angiographic variables were collected to allow the calculation of several predictive scores. Primary outcome was all-cause death at the longest follow-up available. Other endpoints of interest included cardiac mortality and myocardial infarction. Medical therapy (MT) alone was indicated in 719 patients (58%), whereas percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) were used in 240 (19%) and 298 (24%), respectively. Age, acute myocardial infarction, previous CABG, and age, creatinine, ejection fraction (ACEF) score were independently associated with the decision for MT alone. Conversely, the presence of multivessel disease, left main coronary artery involvement, and high SYNTAX score favored the decision for CABG. At a median follow-up of 4.3 years, revascularization strategies were independently associated with all-cause mortality and cardiac mortality (hazard ratio [HR], 0.42; 95% confidence interval [CI] 0.27-0.65; P<.001 and HR, 0.32; 95% CI, 0.17-0.60; P<.001, respectively) for PCI and (HR, 0.39; 95% CI, 0.26-0.58 and HR, 0.51; 95% CI, 0.32-0.81; P<.01, respectively) for CABG. Several clinical and angiographic parameters influence the decision-making process of patients with CTO. CTO revascularization with either PCI or CABG appeared to be associated with improved clinical outcomes at long-term follow-up as compared with MT alone.

Cardiogenic shock without severe left ventricular dysfunction after acute myocardial infarction: population characterization and impact in prognosis

Abstract Introduction Traditionally, severe left ventricular dysfunction is assumed to be the main predictor of CS afte acute myocardial infarction (AMI), however trials and registries show that in average left ventricular function is only moderately depressed in CS after acute myocardial infarction. Purpose To characterize the population of patients (Pts) with CS after AMI but without severe left ventricular dysfunction (defined as ejection fraction &amp;gt;30%) and assess their impact in mortality. Methods From a national multicenter registry, we evaluated 16332 Pts with AMI and ejection fraction (EF) &amp;gt;30%. We considered 2 groups: Group 1 – Pts who developed CS and Group 2 – Pts who didn't developed CS. We registered age, gender, cardiovascular and non-cardiovascular co-morbidities, electrocardiographic presentation and coronary anatomy. We also evaluated the following in-hospital complications: Re-Infarction, mechanical complications, high-grade atrial ventricular block, sustained ventricular tachycardia (VT) atrial fibrillation (AF) and stroke. We compared the in-hospital mortality. Results The presence of CS without severe left ventricular dysfunction was observed in 3,2% pts (n=518) with AMI, being CS present at admission in 46,8% of these pts. The mean EF was lower in group 1 pts (44% ± 11 vs 53±11%, p&amp;lt;0,001). Patients in group 1 were older (71±13 vs 65±13 years, p&amp;lt;0,001), more females (38,8% vs 26,6%, p&amp;lt;0,001), had a higher prevalence of previous valvular heart disease (6,1% vs 3,0%, p&amp;lt;0,001), heart failure (10,1% vs 4,8%, p&amp;lt;0,001, peripheral artery disease (7,5% vs 5,3%, p=0,03), chronic kidney disease (9,8% vs 5,4%, p&amp;lt;0,001), chronic pulmonary obstructive disease (9,1% vs 4,9%, p&amp;lt;0,001) and previous stroke (11,0% vs 7,2%, p&amp;lt;0,001). At admission, Group 1 pts had more ST-elevation AMI (72,6% vs 43,0%, p&amp;lt;0,001), more AF (11,4% vs 6,6%, p&amp;lt;0,001) and more right bundle block (9,9%% vs 5,8%, p&amp;lt;0,001). Group 1 patients received less coronary angiography (80,9% vs 88,2%, p&amp;lt;0,00. The presence of multivessel disease (64,3% vs 51,4%, p&amp;lt;0,001), left main disease (12,2% vs 7,2%, p&amp;lt;0,001), left anterior descending disease (72,4% vs 64,3%, p&amp;lt;0,001) and right coronary disease (64,8% vs 55,5%, p&amp;lt;0,001) were more prevalent in Group 1 pts. Group 1 pts had more in-hospital complications: Re-Infarction (4,4% vs 0,9%, p&amp;lt;0,001), AF (23,0% vs 4,3%, p&amp;lt;0,001), mechanical complications (8,9% vs 0,3%, p&amp;lt;0,001), high atrial ventricular block (21,9% vs 2,3%, p&amp;lt;0,001), VT (10,8% vs 1,2%, p&amp;lt;0,001) and major bleeding (8,9% vs 1,3%, p&amp;lt;0,001). In-hospital mortality was also much higher in Group 1 pts (29,5% vs 1,2%, p&amp;lt;0,001). Conclusions Cardiogenic shock is present in 3,2% of AMI pts without severe ventricular dysfunction. These pts were older, more frequent female, had higher morbidities and in-hospital complications. Even without severe ventricular dysfunction, cardiogenic shock in these patients was associated with a much higher in-hospital mortality. Funding Acknowledgement Type of funding source: None

Cardiac mortality, diabetes mellitus, and multivessel disease in ST elevation myocardial infarction

BackgroundIn patients with diabetes mellitus presenting with ST elevation myocardial infarction (STEMI) the degree to which cardiac death rates may be attributed to an increased burden of coronary artery disease is not clear. MethodsThis prospective observational study examines rates of cardiac death between those with and without diabetes at long term follow up, stratified by presence of multivessel disease (MVD), in consecutive STEMI patients from 5 Australian hospitals. ResultsAmongst 2083 patients, 393 patients had diabetes (18.8%), and 810 (38.8%) had MVD. Patients with diabetes were more likely to have MVD 48.6% (191/393) than patients without diabetes 36.6% (619/1690; p < .001). At final follow up (median 3.6 years [IQR 2.4–5.4]) cardiac death occurred in 37/393 diabetic patients and 92/1690 nondiabetic patients (adjusted HR1.67, 95% CI 1.10–2.52). In those with MVD cardiac death occurred in 27/191 diabetic patients, and 54/619 non-diabetic patients (adjusted HR 1.94; 95% CI 1.17–3.23). In single vessel disease (SVD) cardiac death occurred in 10/202 diabetic patients, and 38/1071 non-diabetic patients (adjusted HR 1.37; 95% CI 0.65–2.89). Both diabetes and MVD were independently associated with cardiac death. ConclusionsSTEMI patients with diabetes are more likely to have MVD, with an absolute difference in MVD rates of 12%, and higher rates of cardiac death. Randomized trials studying these high risk patients are needed to reduce cardiac mortality in patients with diabetes, MVD and STEMI.

Epidemiological Variation of Acute Myocardial Infarction Relevant to In-Hospital Outcomes-Tertiary Center Experience-Saudi Arabia.

BackgroundEpidemiological related differences in patients presenting with ST-elevation myocardial infarction (STEMI) have not yet been fully characterized in the Middle East countries. The aim of this study was to assess gender, ethnic and racial variation in clinical profiles, presentation and treatment strategies with relation to the in-hospital outcomes.MethodThis is a retrospective, single center study reviewing the epidemiological details of STEMI patients who were admitted to our center during the period between October 2015 and August 2019.ResultOut of 3079 patients presented with STEMI, 498 (16%) were women, 2170 (70%) were from Middle Eastern Countries and only 1200 (39%) were non- Arabic speakers. Women were older in age compared to men (60.04 ± 11.2 vs 55.35 ± 11.8; P < 0.001). They showed significantly higher rates of cardiovascular risk factors (P < 0.001 for diabetes mellitus (DM), hypertension (HTN) and obesity) and lower prevalence of smoking and old history of previous revascularization (P < 0.001 and 0.007, respectively). Middle Eastern Countries- STEMI patients were elderly, showed higher prevalence of DM, HTN, smoking and obesity compared to South Asian patients (p = 0.001, 0.057, <0.001, <0.001 respectively). Arabic speaking - STEMI patients showed more prevalence of DM, smoking and obesity compared to non-Arabic speaking patients (p < 0.001). Regarding STEMI localization, post myocardial infarction complications and in-hospital length of stay, there were no detected significant gender, ethnic or racial variation. Women showed higher rates of all in-hospital mortality compared to men (5% vs 3%; p = 0.027) however, no ethnic/racial mortality difference was recorded among STEMI patients. Being elderly, presence of multivessel coronary artery disease and left ventricular systolic dysfunction (LVEF < 30%) are the three independent predictors of mortality among our patients (p = 0.013, 0.048 and <0.0001 respectively).ConclusionOur study demonstrates that there are gender, ethnic/racial-related differences in the demographics and clustered cardiovascular risk factors. However, there were no significant detected variation between both genders and different ethnic groups regarding post MI complications, management provided, and hospital outcomes except for increased the mortality rates among women. Old age, presence of multi-vessel disease and severe left ventricular systolic dysfunction have the greatest effect on in-hospital mortality among STEMI patients.

Clinical utility of serum cystatin C for prediction of multi-vessel disease by coronary angiography in type 2 diabetes mellitus patients with normal renal function

BackgroundThe aim of this study was to evaluate whether serum cystatin C could serve as a predictor of multivessel coronary artery disease identified by coronary angiography in type 2 diabetes patients with normal renal function and to suggest the cutoff point of serum cystatin C for predicting multivessel disease.MethodsSerum cystatin C concentrations were measured by using particle-enhanced immunonephelometric assays before coronary angiography in 135 consecutive type 2 diabetes patients and 179 nondiabetic patients with normal renal function. Routine anthropometric and serologic data were collected. The severity of multivessel disease was assessed with the Gensini score after coronary angiography. The associations of serum cystatin C with the Gensini score were investigated, and the independent risk factors associated with multivessel disease were assessed.ResultsSerum cystatin C and the Gensini score were significantly elevated in diabetes patients. Cystatin C had a positive correlation with Gensini score. A multiple logistic regression analysis demonstrated that cystatin C was independently associated with the presence of multivessel disease (the OR score is 2.21, P = 0.003). Based on the ROC curve, a cystatin C level of 0.865 mg/L showed 67.7% sensitivity and 76.3% specificity with an AUC of 0.748 in diabetes patients for detecting multivessel disease.ConclusionSerum cystatin C is significantly correlated with the presence of multivessel disease, suggesting that cystatin C might be utilized as a screening tool for predicting multivessel disease in type 2 diabetes mellitus patients with normal renal function.

Long-term outcome after deferred revascularization due to negative fractional flow reserve in intermediate coronary lesions.

ObjectivesThe aim was to assess long‐term outcome after deferring intervention of coronary lesions with a fractional flow reserve (FFR) value of >0.80 in a real‐world patient population and then to identify factors associated with deferred target lesion failure (DTLF).BackgroundDeferring coronary interventions of intermediate lesions based on FFR measurement is safe, irrespective of the extent of coronary artery disease. However, FFR values near the cut‐off of >0.80 may have less favorable outcome.MethodsA retrospective analysis was performed in patients with deferred coronary intervention based on FFR value >0.80. The primary endpoint was DTLF, a composite of acute coronary syndrome (ACS) and any coronary revascularization, related to the initially deferred stenosis.ResultsA total of 600 patients, mean age of 66 ± 10 years, and 751 coronary lesions with negative FFR values (mean 0.88 ± 0.04) were included. The mean follow‐up was 27 ± 15 months. DTLF occurred in 44 patients (7.3%), revascularization in 42 (7%), and ACS without revascularization in 2 patients (0.3%). Patients with DTLF more often had diabetes mellitus, previous coronary artery bypass grafting, multivessel disease (MVD), and lower FFR at inclusion. Multivariable regression analysis showed that lower deferred FFR values [FFR 0.81–0.85: hazard ratio (HR) 2.79 (95% CI [confidence interval]; 1.46–5.32), p .002], MVD [HR 1.98 (95% CI; 1.05–3.75), p .036], distal lesions [HR 2.43 (95% CI; 1.29–4.57), p .006], and lesions located in a saphenous vein graft (SVG) [HR 6.35 (95% CI; 1.81–22.28), p .004] were independent predictors for DTLF.ConclusionsThe long‐term rate of DTLF of initially deferred coronary lesions was 7.3%. Independent predictors for DTLF are lower deferred FFR value, the presence of MVD, distal lesions, and lesions in SVG.