Rate Of Percutaneous Coronary Intervention Research Articles

Non-ST elevation acute coronary syndrome in patients aged 80 years or older in Vietnam: An observational study.

There is limited evidence of non-ST elevation acute coronary syndrome (NSTE-ACS) in patients aged 80 or older in Vietnam. To describe the clinical characteristics of patients aged≥80 with NSTE-ACS in Vietnam, and to examine the effect of percutaneous coronary intervention (PCI) on adverse outcomes. Consecutive patients aged ≥80 with a diagnosis of NSTE-ACS admitted to two tertiary hospitals in Vietnam from 12/2018 to 06/2019 were recruited. The major outcomes were: (1) the composite of all-cause mortality, recurrent myocardial infarction and stroke, (2) re-admission rate during 3 months. Cox proportional-hazards regressions were conducted to examine the impact of PCI on the study outcomes, with results presented as hazard ratios (HR) and 95% confidence intervals (CI). There were 120 participants, mean age 84.8 ± 3.8, 50% were female. Angiography and PCI were performed in 42 participants (35.0%). Most of the participants had multimorbidity and multiple coronary vessel disease. Compared to participants who did not receive PCI, participants who received PCI had significantly lower rates of adverse events during hospitalisation and during 3 months of follow up. Cox proportional hazards models adjusted to age and GRACE score show that PCI was significantly associated with reduced the composite outcome of all-cause mortality, recurrent myocardial infarction and stroke during 3 months follow-up (adjusted HR 0.32, 95%CI 0.12-0.86). PCI was also associated with reduced re-admission. The rate of PCI was low in the very elderly patients with NSTE-ACS in this study, although PCI was significantly associated with reduced adverse outcomes.

Long-term outcomes of percutaneous coronary intervention for unprotected left main coronary artery according to the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) score.

Percutaneous coronary intervention (PCI) of unprotected left-main coronary artery (uLMCA) is increasingly performed. Although it is recommended to calculate the SYNTAX score, if uLMCA PCI is considered, data of outcomes by the SYNTAX score are scarce, particularly among patients with high score (SYNTAX ≥ 33). To evaluate long-term outcomes of uLMCA PCI according to SYNTAX score in real-world practice. Patients following PCI of uLMCA throughout 2006-2018, in a tertiary hospital, were included and classified into three groups according to the SYNTAX I score. The primary outcome was three-year major adverse cardiac event (MACE) comprising all-cause mortality, myocardial infarction (MI), target vessel revascularization (TVR), or coronary artery bypass surgery (CABG). Overall 632 patients were analyzed, mean age 72.8 ± 11.5, males: 69%, classified as following: SYNTAX <22 (n = 225); SYNTAX 22-32 (n = 250) and SYNTAX ≥33 (n = 157). Patients with greater SYNTAX score had higher prevalence of diabetes mellitus, renal failure, peripheral arterial disease and stroke. Additionally, they had lower ejection fraction, greater EuroScore, and number of vessels involved. Procedural success rates were very high (>95%) and did not depend on the SYNTAX score. The rates of MACE and its components were significantly higher in patients with higher SYNTAX score. Multivariate analysis showed that SYNTAX score is an independent predictor of three-year MACE following uLMCA PCI [HRSYNTAX22-32 = 3 (95% confidence interval [CI]: 1.2-11.5), HRSYNTAX≥33 = 3.4 (95% CI: 1.8-13.3]. Despite the high success rates of uLMCA PCI in real-world patients with high SYNTAX score, the latter was significantly associated with worse three-year outcomes.

Cost-effectiveness and Outcomes with Early or Same-Day Discharge After Elective Percutaneous Coronary Intervention.

Shorter hospital stay after percutaneous coronary intervention (PCI) can provide economic advantage. Same-day discharge (SDD) after transradial PCI is thought to reduce the cost of care while maintaining the quality and safety. This review summarizes the current knowledge of the benefits and safety of this concept. Increase in rate of transradial PCI over the last two decades has resulted in recent growth in rate of acceptance of SDD after a successful procedure. SDD is shown to result in savings of $3500 to $5200 per procedure with comparable adverse event rate of traditional discharge processes. SDD after PCI is shown to be safe and results in cost advantage maintaining the safety profile. The acceptance rate of SDD is still not optimum, and further market penetration of SDD practice would be achieved only if the institutional and operator preference barriers are addressed.

Cardiac procedures in ST-segment-elevation myocardial infarction - the influence of age, geography and Aboriginality

BackgroundTimely restoration of bloodflow acute ST-segment elevation myocardial infarction (STEMI) reduces myocardial damage and improves prognosis. The objective of this study was describe the association of demographic factors with hospitalisation rates for STEMI and time to angiography, Percutaneous Coronary Intervention (PCI) and Coronary Artery Bypass Graft (CABG) in New South Wales (NSW) and the Australian Capital Territory (ACT), Australia.MethodsThis was an observational cohort study using linked population health data. We used linked records of NSW and the ACT hospitalisations and the Australian Government Medicare Benefits Schedule (MBS) for persons aged 35 and over hospitalised with STEMI in the period 1 July 2010 to 30 June 2014. Survival analysis was used to determine the time between STEMI admission and angiography, PCI and CABG, with a competing risk of death without cardiac procedure.ResultsOf 13,117 STEMI hospitalisations, 71% were among males; 55% were 65-plus years; 64% lived in major cities, and 2.6% were Aboriginal people. STEMI hospitalisation occurred at a younger age in males than females. Angiography and PCI rates decreased with age: angiography 69% vs 42% and PCI 60% vs 34% on day 0 for ages 35-44 and 75-plus respectively. Lower angiography and PCI rates and higher CABG rates were observed outside major cities. Aboriginal people with STEMI were younger and more likely to live outside a major city. Angiography, PCI and CABG rates were similar for Aboriginal and non-Aboriginal people of the same age and remoteness area.ConclusionsThere is a need to improve access to definitive revascularisation for STEMI among appropriately selected older patients and in regional areas. Aboriginal people with STEMI, as a population, are disproportionately affected by access to definitive revascularisation outside major cities. Improving access to timely definitive revascularisation in regional areas may assist in closing the gap in cardiovascular outcomes between Aboriginal and non-Aboriginal people.

Percutaneous Coronary Intervention for Chronic Total Occlusion—The Michigan Experience: Insights From the BMC2 Registry

ObjectivesThe aim of this study was to describe the performance and outcomes of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in Michigan. BackgroundCTO PCI has been associated with reduction in angina, but previous registry analyses showed a higher rate of major adverse cardiac events with this procedure. MethodsTo study uptake and outcomes of CTO PCI in Michigan, patients enrolled in the BMC2 (Blue Cross Blue Shield of Michigan Cardiovascular Consortium) registry (2010 to 2017) were evaluated. CTO PCI was defined as intervention in a 100% occluded coronary artery ≥3 months old. ResultsAmong 210,172 patients enrolled in the registry, 7,389 CTO PCIs (3.5%) were attempted, with 4,614 (58.3%) achieving post-procedural TIMI (Thrombolysis In Myocardial Infarction) flow grade 3. The proportion of PCIs performed on CTOs increased over the study period (from 2.67% in 2010 to 4.48% in 2017). Thirty of 47 hospitals performed >50 CTO interventions in 2017. Pre-procedural angina class ≤2 was present in one-quarter, and functional assessment for ischemia was performed in 46.6% of patients. Major complications occurred in 245 patients (3.3%) and included death (1.4%), post-procedural stroke (0.4%), cardiac tamponade (0.5%), and urgent coronary artery bypass graft surgery (1.3%). Procedural success improved modestly from 44.5% in 2010 to 54.9% in 2017 (p for trend < 0.001). Rates of in-hospital mortality (p for trend = 0.247) and major adverse cardiac event (p for trend = 0.859) for CTO PCI remained unchanged over the study period. ConclusionsThe rate of CTO PCI in Michigan increased over the study period. Although the success rate of CTO PCI has increased modestly in contemporary practice, it remained far below the >80% reported by select high-volume CTO operators. The rate of periprocedural major adverse cardiac events or death remained unchanged over time. These data suggest room for improvement in the selection and functional assessment of CTO lesions before subjecting patients to the increased procedural risk associated with CTO PCI.

Role of Coronary Computed Tomography Angiography in Percutaneous Coronary Intervention of Chronic Total Occlusions

Despite significant advances in procedural techniques for revascularization of chronic total occlusions (CTO), comprehensive procedural planning and accurate prediction of procedural success remain the Achilles’ heels of CTO percutaneous coronary intervention (PCI). Understanding the unique anatomic characteristics of CTOs that may predict relative success and complication rates of revascularization is imperative. Coronary computed tomography angiography (CCTA) has evolved as an adjunct to invasive angiography to better characterize CTO lesions to improve success rates of CTO PCI. Invasive angiography may be inadequate to characterize CTOs due to its inability to fully visualize the occluded segment. CCTA has evolved as a valuable adjunct to angiography, as it permits imaging of the arterial wall in the absence of luminal contrast, and thereby provides additional information regarding both the vessel course and lesion characteristics. CCTA-derived data can also be used in either standalone or combined scoring systems to assess the difficulty level of CTO PCI and has been shown to predict procedural success in clinical trials. Real-time CT fusion with X-ray angiography provides intraprocedural guidance to help resolve proximal cap ambiguity and better determine vessel course. In this review, we discuss the role of CCTA in guiding and improving outcomes of CTO PCI, both pre-procedurally and in real time.

Effects of Medicaid expansion on access, treatment and outcomes for patients with acute myocardial infarction.

IntroductionUninsured patients have decreased access to care, lower rates of percutaneous coronary intervention (PCI), and worse outcomes after acute myocardial infarction (AMI). The aim of this study was to determine whether expanding insurance coverage through the Affordable Care Act’s expansion of Medicaid eligibility affected access to PCI hospitals, rates of PCI, 30-day readmissions, and in-hospital mortality after AMI.MethodsQuasi-experimental, difference-in-differences analysis of Medicaid and uninsured patients with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act, and Florida, which did not, from 2010–2015. This study accounts for the early expansion of Medicaid in certain California counties that began as early as July 2011. Main outcomes included rates of admission to PCI hospitals, rates of transfer for patients who initially presented to non-PCI hospitals, rates of PCI, rates of early PCI defined as within 48 hours of hospital admission, in-hospital mortality, and 30-day readmission.Results55,991 hospital admissions between 2010–2015 met inclusion criteria. Of these, 32,540 were in California, which expanded Medicaid, and 23,451 were in Florida, which did not. 30-day readmission rates after AMI decreased by an absolute difference of 1.22 percentage points after the Medicaid expansion (95% CI -2.14 to -0.30, P < 0.01). This represented a relative decrease in readmission rates of 9.5% after AMI. No relationship between the Medicaid expansion and admission to PCI hospitals, transfer to PCI hospitals, rates of PCI, rates of early PCI, or in-hospital mortality were observed.ConclusionsHospital readmissions decreased by 9.5% after the Affordable Care Act expanded Medicaid eligibility, although there was no association found between Medicaid expansion and access to PCI hospitals or treatment with PCI. Better understanding the ways that Medicaid expansion might affect care for vulnerable populations with AMI is important for policymakers considering whether to expand Medicaid eligibility in their state.

Changes in treatment for NSTEMI in women and the elderly over the past 16 years in a large real-world population

AimsThis study investigates the changes in therapy for Non-ST-Elevation Myocardial Infarction (NSTEMI) over the past 16 years in a large German registry. In particular, the high-risk population of female and elderly patients was analyzed. MethodsIn total, 19.383 patients presenting with NSTEMI were included in this study. Patients were stratified by age groups <75 years and ≥75 years and by sex. Four different time periods from 2000–2004, 2005–2008, 2009–2012 and 2013–2016 were compared. Influence on hospital mortality as the primary outcome measure was assessed by logistic regression analysis. Secondary outcome measures included percutaneous coronary intervention (PCI), the use of drug eluting stents (DES), radial access route and major adverse cardiovascular events (MACE), defined as all-cause mortality, stroke, re-infarction, percutaneous re-intervention, intervention-related bleeding, cardiopulmonary resuscitation and new onset of cardiogenic shock or need for mechanical ventilation. ResultsMortality decreased in all age groups between the initial time period and the most recent one (8.9% vs. 4.5%, p < 0.01), particularly in female patients ≥75 years (18.2% in 2000–2004 vs. 7.9% in 2013–2016, p < 0.01). Revascularization rates differed by gender (68.3% in women vs. 78.1% in men, p < 0.01) and by age (64.2% for ≥75 years vs. 80.9% for <75 years, p < 0.01). PCI rates in elderly female patients increased from 28.7% to 69.8% (p < 0.01) from the initial to the latest period. ConclusionsThe present study demonstrates, that revascularization rates improved in all patient groups over the study period. However, females and elderly patients still remain less likely to be treated according to current guidelines.

Omission of Heart Transplant Recipients From the Appropriate Use Criteria for Revascularization and the Ramifications on Heart Transplant Centers

Guidelines endorse routine coronary angiography and percutaneous coronary intervention (PCI) to screen for and treat cardiac allograft vasculopathy in heart transplant recipients. However, the current Appropriate Use Criteria for Revascularization (AUC-R) do not recognize prior heart transplant as a unique PCI indication. Whether this affects rates of rarely appropriate (RA) PCIs is unknown. To assess the rate of RA PCI procedures in heart transplant recipients and how it pertains to hospital PCI appropriateness metrics and pay-for-performance scorecards. This observational study used National Cardiovascular Data Registry CathPCI Registry data on all patients undergoing elective PCIs from 96 Medicare-approved heart transplant centers from quarter 3 of 2009 to quarter 2 of 2017. The data were analyzed in July 2018. Prior heart transplant. Rates of RA elective PCIs in heart transplant recipients compared with nonrecipients and hospital rates of RA PCI before vs after exclusion of heart transplant recipients using paired t tests. In a subset of heart transplant centers participating in the Anthem Blue Cross and Blue Shield's Quality-In-Sights Hospital Incentive Program (Q-HIP), we compared the change in Q-HIP scorecards before vs after excluding heart transplant recipients. Of 168 802 participants, 123 124 (72.9%) were men, 137 457 were white, and the mean (SD) age was 66.3 (11.4) years. Of 168 802 elective PCIs performed in heart transplant centers, 1854 (1.1%) were for heart transplant recipients. Heart transplant recipients were less likely to have ischemic symptoms (14.6% vs 61.4%, P < .001), had lower rates of antecedent stress testing (15.0% vs 58.4%, P < .001), and had higher RA PCI rates (66.0% vs 16.9%, P < .001) compared with nonrecipients. In heart transplant centers, the absolute difference in RA rates (before vs after excluding transplant recipients) was directly associated with the proportion of PCIs performed in heart transplant recipients (r = 0.91; P < .001). In the subset of heart transplant centers participating in Q-HIP during the 2016 and 2017 calendar years, 8 of 20 (40%) and 8 of 16 centers (50%), respectively, could have benefited from a change in their Q-HIP scorecards if their RA PCI rates excluded transplant recipients. Two-thirds of PCIs in heart transplant recipients were deemed RA by the AUC-R. The failure of the AUC-R to consider prior heart transplant as a unique PCI indication may lead to inflated RA PCI rates with the potential for affecting quality reporting and pay-for-performance metrics in heart transplant centers.

Tendencias temporales en los pacientes con IAMCEST y presentación tardía: datos del registro AMIS Plus 1997-2017

Introduction and objectivesA substantial proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) have a late presentation. There is a lack of temporal trends drawn from large real-word scenarios in these patients. MethodsAll STEMI patients included in the AMIS Plus registry from January 1997 to December 2017 were screened and patient-related delay was assessed. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or> 12hours, respectively). ResultsA total of 27 231 STEMI patients were available for the analysis. During the study period, the prevalence of late presentation decreased from 22% to 12.3% (P <.001). In latecomer STEMI patients, there was a gradual uptake of evidence-based pharmacological treatments (rate of P2Y12 inhibitors at discharge, from 6% to 90.6%, P <.001) and a marked increase in the use of percutaneous coronary intervention (PCI), particularly in 12- to 48-hour latecomers (from 11.9%-87.9%; P <.001). In-hospital mortality was reduced from 12.4% to 4.5% (P <.001). On multivariate analysis, PCI had a strong independent protective effect on in-hospital mortality in 12- to 48-hour latecomers (OR, 0.29; 95%CI, 0.15-0.55). ConclusionsDuring the 20-year study period, there was a progressive reduction in the prevalence of late presentation, a gradual uptake of main evidence-based pharmacological treatments, and a marked increase in PCI rate in latecomer STEMI patients. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%); in 12- to 48-hour latecomers, this reduction seemed to be mainly associated with the increasing implementation of PCI.

Retrograde Chronic Total Occlusion Percutaneous Coronary Intervention via Saphenous Vein Graft

ObjectivesThe aim of this study was to examine the use of saphenous vein grafts (SVGs) for retrograde crossing during chronic total occlusion (CTO) percutaneous coronary intervention (PCI). BackgroundThe use of SVGs for retrograde crossing during CTO PCI has received limited study. MethodsA total of 1,615 retrograde CTO PCIs performed between 2012 and 2019 at 25 centers were examined. Clinical, angiographic, and technical characteristics and procedural outcomes were compared among retrograde cases via SVGs (SVG group) versus other collateral vessels (non-SVG group). ResultsRetrograde CTO PCI via SVGs was performed in 189 cases (12%). Patients in the SVG group were older (mean age 70 ± 9 years vs. 64 ± 10 years; p < 0.01) and had higher rates of prior myocardial infarction (62% vs. 51%; p < 0.01) and prior PCI (81% vs. 70%; p < 0.01). They were more likely to have moderate or severe calcification (81% vs. 65%; p < 0.01) and moderate or severe tortuosity (53% vs. 44%; p = 0.02) and had similar J-CTO (Multicenter CTO Registry in Japan) scores (3.2 ± 1.0 vs. 3.1 ± 1.1; p = 0.13) but higher PROGRESS-CTO (Prospective Global Registry for the Study of Chronic Total Occlusion Intervention) scores (4.7 ± 1.7 vs. 3.1 ± 1.1; p < 0.01). Technical (85% vs. 78%; p = 0.04) and procedural (81% vs. 74%; p = 0.04) success rates were higher in the SVG group, with no difference in in-hospital major adverse events (6.4% vs. 4.4%; p = 0.22). Contrast volume was lower in the SVG group (225 ml [173 to 325 ml] vs. 292 ml [202 to 400 ml]; p < 0.01). ConclusionsUse of SVGs for retrograde crossing is associated with higher rates of technical and procedural success and similar rates of in-hospital major adverse cardiac events compared with retrograde CTO PCI via other collateral vessels.

Appropriate Use Criteria and Health Status Outcomes Following Chronic Total Occlusion Percutaneous Coronary Intervention: Insights From the OPEN-CTO Registry.

The American College of Cardiology/American Heart Association Appropriate Use Criteria were designed to aid clinical decision-making, yet their association with health status outcomes after chronic total occlusion percutaneous coronary intervention (PCI) is unknown. We analyzed 769 patients with baseline and 1-year health status data after chronic total occlusion PCI. Procedures were categorized as appropriate, may be appropriate, or rarely appropriate. Mean changes in patient-reported health status, assessed by the Seattle Angina Questionnaire (SAQ), were compared across appropriate use criteria categories from baseline to 1 year. Change in SAQ summary score was stratified as little to no benefit (≤10 points), intermediate (10-19 points), large (20-29 points), and very large (≥30 points). The appropriate use criteria indication was appropriate in 573 patients (74.5%), may be appropriate in 191 (24.8%), and rarely appropriate in 5 (0.7%). Patients in the appropriate group reported greater improvement in SAQ summary scores (27.3±21.3 points) at 1 year compared with the may be appropriate (22.5±20.9; P=0.01). A similar pattern was noted for SAQ angina frequency (mean change 24.0±27.2 versus 18.7±25.6; P=0.02). The appropriate group had the highest proportion of very large improvements in SAQ summary scores (44.5% versus 33.3%; P=0.01). Among patients undergoing chronic total occlusion PCI, the rate of rarely appropriate PCI was low. The rate of appropriate PCI was high and was associated with the greatest health status improvement at 1 year. A substantial proportion of patients in the may be appropriate group experienced meaningful health status benefits as well.

Trends and predictors of coronary revascularization in patients with coronary artery anomalies and acute myocardial infarction: a nationwide analysis of 8131 patients.

Acute myocardial infarction (AMI) is rarely associated with coronary artery anomalies (CAA). This confluence makes it difficult to identify and treat the culprit lesion with percutaneous coronary intervention (PCI). Our objective was to evaluate trends and predictors of revascularization in patients with CAA and AMI using a large national database. We included adult patients with CAA presenting as ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) and undergoing coronary angiography from Nationwide Inpatient Sample from 2000 to 2011, using ICD-9 diagnosis code of 746.85 for CAA. Chi-square test for trend was used to compare revascularization rates over time. Multivariate logistic regression was used to identify predictors of revascularization. There were almost 4.7 million subjects with AMI undergoing coronary angiography from 2000 to 2011. Of these, there were 8131 patients with CAA, including 3425 STEMI and 4706 NSTEMI patients. Mean age of the CAA population was 59 years with 63.6% males. Overall PCI rate was 47.8% and coronary artery bypass grafting rate was 8.8%. In STEMI patients with CAA, PCI rate increased from 49.9% in 2000 to 77.8% in 2011 (P < 0.001). In NSTEMI patients with CAA, PCI rate remained unchanged from 33.3% in 2000 to 37.3% in 2011 (P = 0.34). Revascularization trends in AMI patients with CAA mirrored those in AMI patients without CAA. Despite the technical challenges associated with PCI in CAA, PCI rates in STEMI patients with CAA continue to increase over time. On the contrary, PCI rates continue to remain low in CAA patients with NSTEMI, reflecting overall contemporary NSTEMI treatment trends.

Effect of Operator Volume on In-Hospital Outcomes Following Primary Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction: Based on the 2014 Cohort of Korean Percutaneous Coronary Intervention (K-PCI) Registry.

Background and ObjectivesThe relationship between operator volume and outcomes of percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI) has not been fully investigated. We aimed to investigate the relationship between operator PCI volume and in-hospital outcomes after primary PCI for STEMI.MethodsAmong the total of 44,967 consecutive cases of PCI enrolled in the Korean nationwide, retrospective registry (K-PCI registry), 8,282 patients treated with PCI for STEMI by 373 operators were analyzed. PCI volumes above the 75th percentile (>30 cases/year), between the 75th and 25th percentile (10–30 cases/year), and below the 25th percentile (<10 cases/year) were defined as high, moderate, and low-volume operators, respectively. In-hospital outcomes including mortality, non-fatal myocardial infarction (MI), stent thrombosis, stroke, and urgent repeat PCI were analyzed.ResultsThe average number of primary PCI cases performed by 373 operators was 22.2 in a year. In-hospital mortality after PCI for STEMI was 571 cases (6.9%). In-hospital outcomes by operator volume showed no significant differences in the death rate, cardiac death, non-fatal MI, and stent thrombosis. However, the rate of urgent repeat PCI tended to be lower in the high-volume operator (0.6%) than in the moderate-(0.7%)/low-(1.5%) volume operator groups (p=0.095). The adjusted odds ratios for adverse in-hospital outcomes were similar in the 3 groups. Multivariate analysis also showed that operator volume was not a predictor for adverse in-hospital outcomes.ConclusionsIn-hospital outcomes after primary PCI for STEMI were not associated with operator volume in the K-PCI registry.

Association of coronary artery dominance and mortality rate and complications in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention.

Background:Percutaneous coronary intervention (PCI) is the treatment of choice for patients with ST-segment elevation myocardial infarction (STEMI). Effect of coronary artery dominance on the patients' outcome following primary PCI (PPCI) is not fully investigated. We investigated the association of coronary artery dominance with complications and 1-year mortality rate of PPCI.Materials and Methods:In this retrospective study, patients with STEMI treated with PPCI from March 2016 to February 2018 were divided into three groups based on their coronary dominancy: left dominance (LD), right dominance (RD), and codominant. Demographic characteristics, medical history, results of physical examination, electrocardiography, angiography, and echocardiography were compared between the groups.Results:Of 491 patients included in this study, 34 patients (7%) were LD and 22 patients (4.5%) were codominant. Accordingly, 54 propensity-matched RD patients were included in the analysis. The demographics and comorbidities of the three groups were not different (P > 0.05); however, all patients in the RD group had thrombolysis in myocardial infarction (TIMI) 3, while five patients in the LD and five patients in the codominant group had a TIMI ≤2 (P = 0.006). At admission, the median left ventricular ejection fraction (LVEF) was highest in RD patients and lowest in LD and codominant patients (34%, P = 0.009). There was no difference in terms of success or complications of PCI, in-hospital, and 1-year mortality rate (P > 0.05).Conclusion:Patients with left coronary artery dominance had a higher value of indicators of worse outcomes, such as lower LVEF and TIMI ≤ 2, compared with RD patients, but not different rates of success or complications of PCI, in-hospital, and 1-year mortality. This finding may suggest that interventionists should prepare themselves with protective measures for no-reflow and slow-flow phenomenon and also mechanical circulatory support before performing PPCI in LD patients.

Temporal trends in latecomer STEMI patients: insights from the AMIS Plus registry 1997-2017.

A substantial proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) have a late presentation. There is a lack of temporal trends drawn from large real-word scenarios in these patients. All STEMI patients included in the AMIS Plus registry from January 1997 to December 2017 were screened and patient-related delay was assessed. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or> 12hours, respectively). A total of 27 231 STEMI patients were available for the analysis. During the study period, the prevalence of late presentation decreased from 22% to 12.3% (P <.001). In latecomer STEMI patients, there was a gradual uptake of evidence-based pharmacological treatments (rate of P2Y12 inhibitors at discharge, from 6% to 90.6%, P <.001) and a marked increase in the use of percutaneous coronary intervention (PCI), particularly in 12- to 48-hour latecomers (from 11.9%-87.9%; P <.001). In-hospital mortality was reduced from 12.4% to 4.5% (P <.001). On multivariate analysis, PCI had a strong independent protective effect on in-hospital mortality in 12- to 48-hour latecomers (OR, 0.29; 95%CI, 0.15-0.55). During the 20-year study period, there was a progressive reduction in the prevalence of late presentation, a gradual uptake of main evidence-based pharmacological treatments, and a marked increase in PCI rate in latecomer STEMI patients. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%); in 12- to 48-hour latecomers, this reduction seemed to be mainly associated with the increasing implementation of PCI.

Factors associated with the rates of coronary artery bypass graft and percutaneous coronary intervention

BackgroundKorea has seen a rapid increase in the use of percutaneous coronary intervention (PCI) with the ratio of PCI to coronary artery bypass graft (CABG) the highest in the world. This study was performed to examine the factors associated with the rates of CABG and PCI.MethodsThe data were acquired from the National Health Insurance database in Korea in 2013. We calculated the age-sex standardized rates of CABG and PCI. We examined the factors associated with the CABG and PCI rates by performing a regression analysis.ResultsThe rate of CABG showed a negative association with the deprivation index score, and other factors, such as the number of providers or hospital beds, did not show any significant association with the CABG rate. The rate of PCI had a strong negative association with the number of cardiothoracic surgeons and a strong positive association with the number of hospital beds.ConclusionsThe positive association between the PCI rate and the number of hospital beds suggests that the use of PCI may be driven by the supply of beds, and the inverse association between the PCI rate and the number of cardiothoracic surgeons indicates the overuse of PCI due to lack of the providers of CABG. Policy measures should be taken to optimize the use of revascularization procedures, the choice of which should primarily be based on the patient’s need.

Outcomes with retrograde versus antegrade chronic total occlusion revascularization.

The aim of the study was to evaluate the outcomes of retrograde versus antegrade approach in chronic total occlusion (CTO) percutaneous coronary intervention (PCI). The retrograde approach has increased the success rate of CTO PCI but has been associated with a higher risk for complications. We conducted a meta-analysis of studies published between 2000 and August 2019 comparing the in-hospital and long-term outcomes with retrograde versus antegrade CTO PCI. Twelve observational studies (10,240 patients) met our inclusion criteria (retrograde approach 2,789 patients, antegrade approach 7,451 patients). Lesions treated with the retrograde approach had higher J-CTO score (2.8 vs. 1.9, p < .001). Retrograde CTO PCI was associated with a lower success rate (80.9% vs. 87.4%, p < .001). Both approaches had similar in-hospital mortality, urgent revascularization, and cerebrovascular events. Retrograde CTO PCI was associated with higher risk of in-hospital myocardial infarction (MI; odds ratio [OR] 2.37, 95% confidence intervals [CI] 1.7, 3.32, p < .001), urgent pericardiocentesis (OR 2.53, 95% CI 1.41-4.51, p = .002), and contrast-induced nephropathy (OR 2.12, 95% CI 1.47-3.08; p < .001). During a mean follow-up of 48 ± 31 months retrograde crossing had similar mortality (OR 1.79, 95% CI 0.84-3.81, p = .13), but a higher incidence of MI (OR 2.07, 95% CI 1.1-3.88, p = .02), target vessel revascularization (OR 1.92, 95% CI 1.49-2.46, p < .001), and target lesion revascularization (OR 2.08, 95% CI 1.33-3.28, p = .001). Compared with antegrade CTO PCI, retrograde CTO PCI is performed in more complex lesions and is associated with a higher risk for acute and long-term adverse events.

Current status of percutaneous coronary intervention in patients with atrial fibrillation: The Fushimi AF Registry

BackgroundAntithrombotic therapies that are optimal for atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI) have been studied but remain uncertain. We often encounter difficulties in choosing an appropriate antithrombotic therapy with antiplatelet agents after PCI in AF patients treated with oral anticoagulant due to a high CHADS2 score. Since there are no data on the incidences of PCI procedures in AF patients, we evaluated those incidences as well as the association between PCI and the CHADS2 score using data from the Fushimi AF Registry. MethodsThe Fushimi AF Registry is a community-based prospective cohort study of AF patients in Fushimi-ku, Kyoto, Japan. Follow-up data were available for 4325 patients, and the median follow-up was 3.6 (interquartile range: 1.9–5.9) years. ResultsThere were 143 PCI procedures performed in 122 patients during follow-up, and 28 (20%) were emergent ones. The crude incidence of PCI procedures was 9.36 per 1000 person-years. At 1 and 3 years, the cumulative incidences of PCI were 46 (1.1%) and 85 (2.4%), respectively. As for 4 age groups: <65 (n = 765), 65–75 (n = 1359), 75–85 (n = 1586), and 85≤ years (n = 615), the rates of PCI were 0.4%, 1.4%, 1.4%, and 0.6% at 1 year, and were 1.4%, 2.7%, 2.8%, and 1.6% at 3 years, respectively. The incidence of PCI procedures in patients with a CHADS2 score ≥2 (n = 2651, 61.3%) was higher than that in patients with a CHADS2 score ≤1 (n = 1674, 38.7%). Among the factors making up the CHADS2 score, only diabetes mellitus was associated with PCI procedures in patients with AF (hazard ratio, 1.95; 95% confidence interval, 1.34–2.83; p = 0.0005). ConclusionsAbout 1 in 100 AF patients underwent PCI annually, and patients with a CHADS2 score ≥2 were associated with higher incidences of PCI procedures.

463Temporal trends in latecomer ST-segment elevation myocardial infarction patients: Insights from the AMIS Plus Registry 1997–2017

Abstract Introduction A relevant proportion of patients experiencing ST-segment elevation myocardial infarction (STEMI) has a late presentation after symptoms onset. Temporal trends deriving from a large real-word scenario for this subgroup of patients are lacking. Purpose The aim of the present study was to provide a comprehensive analysis of temporal trends in latecomer STEMI patients, with particular regard to implementation of evidence-based treatments in this population and major in-hospital outcomes. Methods All STEMI patients included in the AMIS Plus Registry from January 1997 to December 2017 were included and patient-related delay was assessed: 27 231 patients were available for the final analysis. STEMI patients were classified as early or latecomers according to patient-related delay (≤ or &gt;12 hours, respectively). Results 22 928 patients were earlycomers (84%) and 4303 patients were classified as latecomers (16%). Across the study period we observed a significant decrease in prevalence of late presentation from 22% to 12.3% (p&lt;0.001, Figure 1). In latecomer STEMI patients there was a gradual uptake of evidence-based pharmacological treatments with an increase in discharge prescription of P2Y12 inhibitors from 6% to 90.7% (p&lt;0.001). Similarly, a marked increase in percutaneous coronary intervention (PCI) rate was observed (12.1–86.6%; p&lt;0.001). Across this 20-year period, in-hospital mortality was reduced to a third (to an absolute rate of 4.5%, p&lt;0.001) and a significant reduction in prevalence of both cardiogenic shock (14.6–4.3%) and re-infarction (5.4–0.2%) during the index hospitalisation was observed (p&lt;0.001 for both variables). Length of hospitalisation in acute care facilities significantly decreased from 10 (6,14) days to 4 (1,7) days (p&lt;0.001). At multivariate analysis, PCI had a strong independent protective effect toward in-hospital mortality (odds ratio 0.3, 95% confidence interval 0.187 to 0.480). Figure 1 Conclusion The present study provides a comprehensive picture of temporal trends in late presentation in STEMI over the last 20 years in Switzerland. During the study period in latecomer STEMI population there was a gradual uptake of evidence-based pharmacological treatments and a marked increase in PCI rate. In-hospital mortality was reduced to a third (to an absolute rate of 4.5%) and this reduction seems to be mainly associated with the increasing implementation of PCI.