Setting Of Acute Coronary Syndrome Research Articles

Colchicine Use in Acute Coronary Syndromes: An Update.

Coronary artery disease is the leading cause of death worldwide, and its main pathological substrate is represented by atherosclerosis. Inflammation is a major promoter of the atherosclerotic process and is involved in both the initiation and progression of atherosclerosis, as well as in the occurrence of fatal complications. Until the present moment, Colchicine Cardiovascular Outcomes Trial is the largest trial to demonstrate a major benefit of low-dose colchicine on major adverse cardiac events in patients with recent myocardial infarction (MI), but the mechanisms behind this relation are not completely known. The purpose of this review is to emphasize the possible pathways through which colchicine improves the clinical outcomes in the acute setting of acute coronary syndromes by referring to the results of the studies published in the past 5 years. Aside from its stated systemic anti-inflammatory effect, colchicine could be a valuable addition to the therapeutic approach of acute MI by reducing the infarct size, stabilizing the coronary plaque, as well as reducing platelet aggregation. Moreover, colchicine may improve endothelial function, reduce the transcoronary release of cytokines, and prevent a rise in inflammatory markers after percutaneous coronary intervention, thus diminishing the residual inflammatory risk.

Atrioventricular and intraventricular blocks in the setting of acute coronary syndromes: a narrative review.

Acute coronary syndromes (ACS) might be complicated by atrioventricular (AV) and intraventricular (IV) blocks in a significant number of cases, and often represent a diagnostic and a therapeutic challenge. These conduction disturbances are predictors of adverse prognosis, with complete AV blocks presenting the most severe outcomes, showing an increased in-hospital mortality. With the advent of emergency percutaneous coronary intervention (PCI) and the end of the thrombolysis era, the incidence of both AV and IV blocks has surely decreased, but their prognosis in this setting still remains a matter of debate. The aim of this review is to evaluate the current knowledge on AV and IV blocks in the AMI setting with or without ST segment elevation.

The role of serum laboratory parameters in Tunisian patients with new-onset atrial fibrillation after acute coronary syndrome

New-onset atrial fibrillation (NOAF) during hospitalization for acute coronary syndrome (ACS) is considered a frequent complication in the setting of acute coronary syndromes. To discuss the role of admission serum laboratory parameters and hematological indices in the occurrence of atrial fibrillation (AF) during ACS. A total of 402 patients who were hospitalized with a diagnosis of ACS were prospectively enrolled in the study. The patients were divided into two groups: the NOAF and the non-NOAF group. In our study, 39 patients develop NOAF during hospitalization for ACS. Mean platelet volume (MPV), neutrophil to lymphocyte ratio (NLR), C-reactive protein (CRP), creatinine and serum uric acid (SUA) were higher in the NOAF group compared with non NOAF group, while Hemoglobin (119 ± 1.8 g/l vs. 130 ± 1.9 g/l, P = 0.001) and red cell counts were significantly lower in the NOAF group than the non-NOAF group. In multivariate regression analysis, age, indexed left atrial volume, left ventricular ejection fraction, increased levels of CRP, MPV, SUA, NLR indepentently predict NOAF. Admission serum levels of MPV, SUA, CRP, NLR, hemoglobin were found to be independent predictors of NOAF after ACS.

Treatment Preferences for Cardiac Procedures of Patients With Chronic Kidney Disease in Acute Coronary Syndrome: Design and Pilot Testing of a Discrete Choice Experiment.

Background:Chronic kidney disease is associated with a high incidence of acute coronary syndrome and related morbidity and mortality. Treatment choices for patients with chronic kidney disease involve trade-offs in the potential benefits and harms of invasive management options.Objective:The objective was to quantify preferences of patients with chronic kidney disease toward invasive heart procedures.Design:Design and pilot a discrete choice experiment.Setting:We piloted the discrete choice experiment in 2 multidisciplinary chronic kidney disease clinics in Calgary, Alberta, using an 8-question survey.Patients:Eligible patients included those aged 18 years and older, an estimated glomerular filtration rate < 45 mL/min/1.73 m2, not currently receiving dialysis, and able to communicate in English.Measurements:Quantification of the average importances of key attributes of invasive heart procedures.Methods:We identified attributes most important to patients and physicians concerning invasive versus conservative management for acute coronary syndrome, using semi-structured qualitative interviews. Levels for each attribute were derived from analysis of early invasive versus conservative acute coronary syndrome management clinical trials and cohort studies, where subgroups of patients with chronic kidney disease were reported. We designed the pilot study with patient partners with relevant lived experience and considered statistical efficiency to estimate main effects and interactions, as well as response efficiency. Hierarchical Bayesian estimation was used to quantify average importances of attributes.Results:We recruited 43 patients with chronic kidney disease, mean (SD) age 67 (14) years, 67% male, and 35% with a history of cardiovascular disease, of whom 39 completed the survey within 2 weeks of enrollment. The results of the pilot revealed acute kidney injury requiring dialysis and permanent kidney replacement therapy, as well as death within 1 year were the most important attributes. Measures of internal validity for the pilot discrete choice experiment were comparable to those for other published discrete choice experiments.Limitations:Discrete choice experiments are complex instruments and often cognitively demanding for patients. This survey included multiple risk attributes which may have been challenging for some patients to understand.Conclusions:This pilot study demonstrates the feasibility of a discrete choice experiment to quantify preferences of patients with chronic kidney disease toward the benefits and trade-offs related to invasive versus conservative management for acute coronary syndrome. These preliminary findings suggest that patients with chronic kidney disease may be on average similarly risk averse toward kidney replacement therapy and death. This pilot information will be used to inform a larger discrete choice experiment that will refine these estimates of patient preferences and characterize subgroups with distinct treatment preferences, which should provide new knowledge that can facilitate shared decision-making between patients with chronic kidney disease and their care providers in the setting of acute coronary syndrome.

Comprehensive Review of Complete Versus Culprit-only Revascularization for Multivessel Disease in ST-segment Elevation Myocardial Infarction.

Several organizations have developed guidelines for the management of ST-segment elevation myocardial infarction (STEMI). However, the optimal strategy regarding revascularization in the setting of multivessel disease, specifically with regards to culprit vessel versus complete revascularization, continues to evolve. While previous observational studies promoted culprit vessel-only intervention in patients with STEMI, recent randomized controlled trials suggest potential benefits with multivessel revascularization, either at the time of the index event or in a staged fashion, in patients without cardiogenic shock. This may be due to the known instability of non-culprit lesions in the setting of acute coronary syndrome, and the diffuse coronary processes involved. As additional literature examines culprit vessel versus multivessel revascularization strategies, clinicians continue to be tasked with determining optimal treatment plans for their patients and understanding the factors that promote selected revascularization strategies. This review summarizes and discusses observational studies, randomized control trials and current guidelines in order to evaluate optimal reperfusion strategies for patients presenting with STEMI in the setting of multivessel disease.

Risk factors and prognosis of New-Onset Atrial Fibrillation in Tunisian patients with acute coronary syndrome

New-onset atrial fibrillation (NOAF) during hospitalization is considered a frequent complication associated with worse outcomes in the setting of acute coronary syndromes (ACS) To assess the predictors and prognosis of NOAF during ACS. A total of 402 patients who were hospitalized with a diagnosis of ACS were prospectively enrolled. Clinical parameters, echocardiography, biochemical markers were collected. In-hospital mortality and incidence of in-hospital main adverse cardiovascular and cerebrovascular events (MACCE) were compared between NOAF and non-NOAF groups. In our study population, 39 (9.7%) patients developed NOAF during hospitalization. The patients in NOAF group were significantly older than those in the non-NOAF groups (65 ± 10 years vs 59 ± 10 years, P = 0.001). Moreover, the levels of serum uric acid ( P = 0.001), peak creatinine ( P = 0.001), CRP ( P = 0.02), neutrophil to lymphocyte ratio ( P = 0.04) and mean platelet volume (MPV, P = 0.02) were significantly higher in the NOAF group, while left ventricular ejection fraction (LVEF: 43 ± 12% vs 48 ± 10%, P = 0.01) and hemoglobin (119 ± 1.8 g/l vs 130 ± 1.9 g/l, P = 0.001) were significantly lower in the NOAF group. Logistic multivariate regression showed that age (OR = 1.08; P = 0.02), MPV (OR = 1.4; P = 0.03), LVEF (OR = 2; P = 0.001) and indexed left atrial volume (OR = 1.15; P = 0.004) were independent predictors of NOAF after ACS. Patients in the NOAF group had significantly longer hospital stay (4 ± 1.2 days vs 3.6 ± 1 days, P = 0.02). The in-hospital mortality (5% vs 0%, P = 0.009) and the incidence of bleeding complications (5% vs 0.5%, P = 0.04) in the NOAF group were significantly higher. There were no significant differences in stroke between the two groups. Age, LVEF, MPV and indexed left atrial volume are independent predictors of NOAF during ACS in Tunisian patients. This arrhythmia is associated with higher in-hospital mortality and bleeding complications.

Correlation of the Neutrophil-to-Lymphocyte Ratio (NLR) and Platelet-to-Lymphocyte Ratio (PLR) with Contrast-Induced Nephropathy in Patients With Acute Coronary Syndrome Undergoing Percutaneous Coronary Interventions.

IntroductionContrast-induced acute nephropathy (CIN) in patients undergoing percutaneous coronary intervention (PCI) in the setting of acute coronary syndromes (ACS) is associated with adverse outcomes, including longer hospitalization and short and long-term mortality. Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are inflammatory markers that have been validated separately in prior studies as a predictor of CIN in patients with ACS who undergo a left heart catheterization. Our study aims to further investigate the role of NLR and PLR together as markers for predicting CIN in patients with ACS. MethodsA retrospective chart review was performed on a total of 1,577 patients aged 18 - 90 who presented with ACS and underwent PCI between January 2011 to December 2015 at the Florida Hospital Orlando. Cut-off values used for a high PLR and NLR were PLR > 128 and NLR > 2.6. CIN was defined as an increased serum creatinine level by ≥ 0.5 mg/dL, or ≥ 25%, over the baseline value within 72 hours after contrast agent administration. Patients with end-stage renal disease (ESRD) were excluded. ResultsOf the 1,577 patients included in the study, 213 (13.51%) patients had CIN. On multivariate logistic regression analysis, high NLR showed an independent association with an elevated risk of CIN (OR 2.03, 95% CI: 1.403 - 3.176, P < 0.001). High PLR did not correlate with CIN (OR 0.831, 95% CI: 0.569 - 1.214, P = 0.339). ConclusionElevated NLR is an independent predictor of CIN in patients with acute myocardial infarction (AMI) and may be used to improve on current risk prediction models.

A pebble clogging a river: a case report of thrombosed coronary aneurysmal ectasia.

BackgroundCoronary artery ectasia (CAE) is a rare anomaly that can present at any age. Predisposing risk factors include Kawasaki disease in a younger population and atherosclerosis in the older generation. We present a unique case of the management of a young woman diagnosed with multivessel CAE with aneurysmal changes in the setting of acute coronary syndrome and subsequently during pregnancy.Case summaryA 23-year-old woman presented with acute onset chest pain. Electrocardiogram revealed no ischaemic changes; however, troponin I peaked at 16 ng/mL (reference range 0–0.04 ng/mL). Echocardiogram showed apical dyskinesis with preserved left ventricular ejection fraction. Coronary angiography showed multivessel CAE along with significant thrombus burden in an ectatic lesion of the left anterior descending artery. Since the patient was haemodynamically stable, conservative management with dual antiplatelet therapy and anticoagulation was started. On follow-up, coronary computed tomographic angiogram illustrated resolution of the coronary thrombi and echocardiogram showed improvement to the apical dyskinesis. It was presumed that Kawasaki disease was the most likely aetiology of her disease. Subsequently the patient reported that, contrary to medical advice, she was pregnant, adding another layer of complexity to her case.DiscussionCoronary artery ectasia can be discovered as an incidental finding or can present with an acute coronary syndrome. Management is challenging in the absence of randomized trials and large-scale data. Treatment options include medications, percutaneous intervention, and surgical revascularization. Close surveillance is required in these patients to assess progression of disease. Here we discuss treatment options during acute coronary syndrome and pregnancy.

Abstract 16710: CYP2C19 Polymorphisms and Clinical Outcomes Following Percutaneous Coronary Intervention (PCI) in the Million Veterans Program (MVP)

Introduction: CYP2C19 reduced function (RF) alleles (*2, *3) have been shown to impair clopidogrel effectiveness following percutaneous coronary intervention (PCI) in the setting of acute coronary syndromes (ACS); however, this association has not been explored in the Veterans Health Administration. Hypothesis: CYP2C19 RF alleles are associated with major adverse cardiac events (MACE) in patients treated with clopidogrel Methods: MACE and CYP2C19 genotype were determined in MVP participants who underwent PCI between 2009-2017 with 1 year follow-up. Age was restricted to &lt;65 years of age to exclude Veterans likely receiving care outside VHA. DNA extracted from whole blood was genotyped using a customized array and imputed to the 1000 Genomes reference panel. MACE, encompassing all-cause mortality, myocardial infarction and ischemic stroke, was ascertained in VA electronic health records using ICD 9/10 codes. Time to first MACE was determined in the whole cohort and in the subgroup with ACS and stable coronary disease using Kaplan-Meier estimators and Cox proportional hazard models adjusted for clinical covariates and clopidogrel exposure modeled as a time-varying covariate. Results: Among 4,490 Veterans (age 59.1 ± 5 years, 18% African American, 6% Hispanic, 44% ACS) who were prescribed clopidogrel following PCI, 1,261 (28%) had RF CYP2C19 alleles. The overall MACE rate was 7.0%. MACE was associated with ACS as initial presentation, diagnosis of diabetes, chronic kidney disease, peripheral vascular disease, congestive heart failure, history of stroke, prior MI. Among the subgroup presenting with ACS, the adjusted risk of MACE was greater in participants with RF alleles compared to those with wildtype alleles (HR 1.38, 95% CI 1.002-1.916). There was no impact of RF alleles on MACE risk in those in the non-ACS group (HR 1.00, 95% CI 0.702-1.429). Conclusions: These data from the largest integrated health system in the US demonstrate that in Veterans presenting with ACS undergoing PCI, there was a higher risk of MACE in CYP2C19 RF carriers prescribed clopidogrel vs. wildtype carriers. The impact of the CYP2C19-clopidogrel interaction was not observed in the non-ACS patients. Further studies should explore the role of pharmacogenetic testing in Veterans.

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

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

Bedside assessment of the risk of non-compliance to medication is associated with mortality in elderly patients admitted for acute coronary syndromes

Abstract Background Elderly patients are at high risk of mortality in the setting of acute coronary syndromes (ACS). Purpose We investigated whether compliance assessed by Compliance Evaluation Test (CET) in elderly patients admitted for acute coronary syndromes was associated with higher risk of one-year mortality. Methods We used the data from a prospective, open, ongoing cohort of patients ≥75 years old admitted for ACS to a tertiary center. The CET is a validated 6 item test easily performed at bedside. Non-compliance is defined by ≥ “Yes” answers. We used a Cox model, un-adjusted and adjusted on predefined correlates of mortality (age, gender, and GRACE score) to assess the relationship between the risk of non-compliance and 1-year mortality. Results Two hundred fifty-five consecutive patients (age 83±5, female gender 59.6%, GRACE score 175±24) with CET assessment within 48 hours after admission and 1 year follow-up were included in the analysis. 225 (88%) were identified as compliant and 30 (12%) as non-compliant based on the CET. Thirthy-six deaths occurred at 1 year follow-up, 24 (10.6%) and 12 (30%) in compliant and non-compliant patients respectively. There was an almost 4-fold increase in the risk of one-year mortality in association with non-compliance (HR 4.16; 95% CI 2.03 to 8.5, p&amp;lt;0.0001) and adj-HR 3.93; 95% CI 1.87 to 8.3, p=0.003), independent of other covariables. Conclusions In elderly patients admitted for ACS, the risk of non-compliance assessed by the simple bedside test is associated with a 4-fold increase in the risk of 1-year mortality independent of other correlates of mortality. Our results support specific measures to improve compliance in such patients. Survival based on compliance test Funding Acknowledgement Type of funding source: None

Heavy drinking habits are associated with worse in-hospital outcomes in patients with acute coronary syndrome

Abstract Introduction The association between alcohol consumption and the occurrence of coronary heart disease is well described in literature. Data regarding the impact of regular alcohol consumption on in-hospital outcomes in the setting of acute coronary syndrome (ACS) are lacking. Purpose We aimed to evaluate the impact of self-reported alcohol consumption on in-hospital outcomes in patients with ACS. Methods Data derived from patients enrolled between 2007 and 2019 in the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry were retrospectively analyzed. The primary endpoint was all-cause in-hospital mortality, while secondary endpoints were set as incidence of major adverse cardiac and cerebrovascular events (MACCEs). Outcomes comparisons according to quantity of daily alcohol intake were also performed. Results Records concerning alcohol consumption were available in 25707 patients; 5298 of them (21%) fulfilled the criteria of regular alcohol consumption. Daily alcohol intake was reported in 4059 (77%), of these patients (regular drinkers) with 2640 light drinkers (≤2 drinks/day) and 1419 heavy drinkers (&amp;gt;2 drinks/day). Regular drinkers were predominantly male, younger, smokers, more comorbid and with a worse clinical presentation as compared to abstainers/occasional drinkers. In-hospital mortality and MACCEs of heavy drinkers were significantly higher compared to light drinkers (5.4% vs. 3.3% and 7.0% vs. 4.4%, both p=0.001). When tested together with GRACE risk score parameters, heavy alcohol consumption was independently associated to in-hospital mortality (p=0.004). Conclusions Heavy alcohol consumption is an additional independent predictor of in-hospital mortality in patients presenting with ACS. Figure 1. Study flowchart. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Swiss Heart Foundation

One stent versus two stents for distal LM PCI: insights from the experience of a high volume center

Abstract Introduction Distal left main (LM) PCIremains a challenge. One of the most debated issues is whether to use a single vs 2 stent provisional strategy. While most studies and guidelines favour a single stent strategy, the recent DK-CRUSH V trial has shown better results with a 2 stent strategy. Objective To evaluate the performance of a single vs dual stent strategy for LM PCI in a real-world population setting. Methods Single-center procedural prospective registry of patients (pts) submitted to LM PCI from 2015–2018, with retrospective event analysis. Demographic, clinical data and procedure characteristics were analysed. Results were obtained with χ2 test, T student test, Kaplan-Meier survival analysis, logistic and Cox regression. Results 100 pts (73 men; 69±11 years) were included. Co-morbidities were very frequent (85 had hypertension, 54 had diabetes, 71 had dyslipidemia and 39 were past smokers). 32 had reduced LVEF (&amp;lt;40%) and 45 previous CABG. The decision to proceed to PCI vs surgery was undertaken individually by the local HeartTeam. Most of the procedures (57) were in an acute coronary syndrome setting (11 in STEMI, 7 with cardiogenic shock). The anatomical distribution of the lesions was: distal in 69 pts (61 involved the LAD and or Cx ostium), mid shaft in 7 pts, ostial in 18 pts and diffuse in 6 pts. Protected left main PCI encompassed 41% of the procedures. The complication rate was 7%. During a mean follow-up of 866±400 days, there were 4 peri-procedural deaths, 1-year mortality rate of 10% and 22 pts died overall. In pts submitted to distal LM PCI, a single stent was used in 49 pts (66%) versus a 2 stent approach in 23 pts (31%). The only significant difference between these groups were diabetes (66% in the single stent vs 32% in the 2 stent group, p=0.006) and protected LM (51% in the single stent vs 26.1% in the two stent group, p=0.046). While a 2 stent strategy was associated with higher mortality by Kaplan Meyer analysis (LogRank = 11.07, p=0.001), it was not an independent predictor of mortality in Cox regression. Cox univariate analysis identified LVEF &amp;lt;40% (OR 2.2, CI 1.01–4.9, p=0.047) and complications (OR 3.1, CI 1.4 – 6.9, p=0.004) as the only predictors of death. In multivariate analysis, only the latter was an independent predictor of mortality (OR 2.6, IC 1.1–5.9, p=0.028). The use of a 2 stent strategy was significantly associated with complications (χ2=5.1 p=0.024)) and was the only independent predictor of it (OR 3.8, IC 1.1–12.8, p=0.03). This was true even in the subgroup of protected LM PCI. Conclusion In a real-world setting of challenging LM PCI cases, a single stent strategy for distal LM PCI performed better. The use of 2 stents was an independent predictor of complications, strongly associated with increased risk of death. While a LM PCI must be undertaken on an individual basis, a single stent provisional strategy, whenever feasible, seems to be the best option. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Hospita Santa Maria

Derivation and validation of a scoring system to predict after discharge risk of cardiac events in patients with acute myocardial infarction undergoing percutaneous coronary revascularization

Abstract Background In the acute coronary syndromes (ACS) setting, despite the extensive use of coronary revascularization and P2Y12 inhibitors such as prasugrel and ticagrelor, with a more pronounced inhibitory effect on platelets than clopidogrel, the rate of death and recurrent myocardial infarction (MI) at 1 year is still high. In this clinical setting the development of a risk score which takes into account patient's and procedural characteristics could represent a useful tool to identify patients at high risk for ischaemic events at 1 year who could take advantage from more aggressive secondary prevention strategies. Purpose The aim of our study was to develop a risk score to predict 1-year probability of after discharge cardiac events (recurrent MI and cardiac death) in patients with acute MI treated with percutaneous coronary intervention (PCI). Methods We prospectively enrolled all consecutive patients hospitalized for acute MI between 2003 and 2017 treated with PCI with/without stent placement at our center. We excluded patients who died in-hospital or who experienced in-hospital recurrent MI and patients undergoing surgical revascularization by coronary artery bypass graft (CABG). The patients of the final study cohort were therefore randomly assigned to either a derivation sample (60%) or a validation sample (40%). Based on the multivariate analysis we developed a point system according to the “Framingham Risk Score” method. Results The final study cohort, represented by 4922 patients, was split in a derivation sample of 2972 patients and in a validation sample of 1950 patients: in both groups the median age was around 70 years; the male prevalence was 73%; 65% of patients were dagnosed with ST-segment elevation MI. The clinical prediction score underlined as risk factors for recurrent cardiac events older age, diabetes mellitus, peripheral arterial disease, prior MI, Killip class &amp;gt;2 at presentation, higher platelet count and creatinine values, lower left ventricular ejection fraction; radial access and the use of second generation drug eluting stents resulted to be protective. This model showed a good discrimination power in both the derivation and the validation samples with an area under the curve (AUC) of 0.75 and 0.71, respectively. The calibration showed a good concordance between predicted and observed events in both the derivation and the validation samples. Same results were observed in patients with/without ST-segment elevation MI and in gender subgroups. Conclusions The present study, conducted retrospectively on a large population of patients with acute MI treated with PCI enrolled prospectively, enabled us to derivate and validate a risk score of cardiac death and recurrent MI at 1 year which took into account both clinical and procedural characteristics and which demonstrated a good predictive performance. After-discharge events by risk subgroups Funding Acknowledgement Type of funding source: None

Rationale and Design of the ACS-BP Study: Prognostic Value of In-Hospital Blood Pressure and Indices of Atherosclerosis in Acute Coronary Syndromes.

High blood pressure (BP) is a leading risk factor for coronary artery disease and other major cardiovascular events. Blood pressure variability (BPV), ambulatory arterial stiffness index (AASI) and ankle- brachial index (ABI) have been proposed as indices that can improve risk stratification for an adverse cardiac outcome. However, their utility in the setting of acute coronary syndromes (ACS) is unclear. The ACS-BP study is a single-centre observational cohort study designed to investigate the prognostic role of haemodynamic load and arterial stiffness indices for cardio-renal outcomes in patients with acute myocardial infarction (AMI). All consecutive patients admitted with a diagnosis of acute AMI with or without ST segment elevation were screened for inclusion in the study. The management of AMI will follow current guidelines. Data from baseline clinical and laboratory parameters during their hospitalization were collected. The haemodynamic load of each patient was determined by clinical BP values as well as 24-h ambulatory BP monitoring. The AASI was calculated from the raw 24-h BP data and ABI was measured after the third day of hospitalization using a certified device. Patients were followed-up for 12 months in order to collect data for hard cardiovascular and renal endpoints. The study results should clarify the role of these non-invasive tools in secondary risk stratification of such patients.

Heavy Drinking Habits Are Associated with Worse In-Hospital Outcomes in Patients with Acute Coronary Syndrome: An Insight from the AMIS Plus Registry

Background: The association between alcohol consumption and the occurrence of coronary heart disease is well described in the literature, while data regarding the impact of regular alcohol consumption on in-hospital outcomes in the setting of acute coronary syndrome (ACS) are lacking. We aimed to evaluate the impact of self-reported alcohol consumption on in-hospital outcomes in patients with ACS. Methods: Data derived from patients enrolled between 2007 and 2019 in the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry were retrospectively analyzed. Patients were stratified based on alcohol drinking pattern. Primary outcome was all-cause in-hospital mortality, while secondary outcomes were set as incidence of major adverse cardiac and cerebrovascular events (MACCEs). Outcome comparisons according to quantity of daily alcohol intake were also performed. Results: Records concerning alcohol consumption were available in 25,707 patients; 5,298 of them (21%) fulfilled the criteria of regular alcohol consumption. Regular drinkers were predominantly male, younger, smokers, more comorbid and with a worse clinical presentation as compared with abstainers/occasional drinkers. Daily alcohol intake was reported in 4,059 (77%) of these patients (regular drinkers). Among them, 2,640 were light drinkers (≤2 drinks/day) and 1,419 heavy drinkers (>2 drinks/day). In-hospital mortality and MACCEs of heavy drinkers were significantly higher compared with those of light drinkers (5.4 vs. 3.3% and 7.0 vs. 4.4%, both p = 0.001). When tested together with Global Registry of Acute Coronary Events risk score parameters, heavy alcohol consumption was independently associated with in-hospital mortality (p = 0.004). Conclusions: Our results support that heavy alcohol consumption is an independent predictor of in-hospital mortality in patients presenting with ACS.

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English

Higher neutrophil-to-lymphocyte ratio (NLR) increases the risk of suboptimal platelet inhibition and major cardiovascular ischemic events among ACS patients receiving dual antiplatelet therapy with ticagrelor

BackgroundNeutrophil to lymphocyte ratio (NLR) has emerged as a useful and easy-to-assess prognostic tool and biomarker of cardiovascular risk. However, few studies have evaluated its role on platelet inhibition among patients on dual antiplatelet therapy (DAPT), and especially in the settings of acute coronary syndromes (ACS). We aimed at assessing the impact of NLR on platelet reactivity and the risk of major ischemic events at long-term follow-up among ACS patients on DAPT with ticagrelor. MethodsPatients on dual antiplatelet therapy with ASA + ticagrelor (90 mg/twice a day) after percutaneous coronary revascularization for ACS were scheduled for platelet function assessment 30–90 days post-discharge. Aggregation tests were performed by Multiple Electrode Aggregometry (MEA). Suboptimal platelet inhibition (HRPR-high residual platelet reactivity was defined if above the lower limit of normality (417 AU*min). The primary study endpoint was defined as the occurrence of major cardiovascular events (a composite of cardiovascular death, recurrent acute coronary syndrome, target vessel revascularization) at longest available follow-up. ResultsWe included 397 patients, that were divided according to NLR tertiles. Patients with higher NLR were older (p < .001), less frequently smokers (p = .03), with higher rates of renal failure (p = .001), previous bypass surgery (p = .05) and use of statins (p = .03) and diuretics (p = .01). Higher white blood cells count and C-reactive protein (p < .001) and lower haemoglobin (p = .001) were associated with NLR. Mean platelet reactivity and the prevalence of high platelet reactivity (HRPR) on ticagrelor were significantly associated to higher NLR tertiles values (7% vs 12% vs 14.3%, p = .04), with a significant relationship between NLR and platelet reactivity being confirmed for all the different activating stimuli.At a mean follow-up of 939 ± 581.4 days, 21.2% of the patients experienced the primary composite endpoint, with a trend for a higher risk of events across NLR tertiles (15.4% vs 24.2% vs 24.4%, p = .09), that became statistically significant after correction for baseline confounders (adjusted HR[95%CI] = 1.13[1.008–1.26], p = .036). Moreover, NLR was significantly associated to overall mortality and recurrent ACS (adjusted p = .008, p = .06 and p = .02 respectively). ConclusionsIn the present study we found that among ACS patients treated with ASA and ticagrelor after PCI, suboptimal platelet inhibition despite DAPT was significantly increased for higher values of Neutrophil-to-Lymphocyte Ratio. Moreover, mortality and the risk of recurrent major ischemic events at long-term were associated to NLR.

P514Externalised pacemakers are valuable in treatment of brady as well as tachyarrhythmias - a single tertiary non device extraction cardiac center experience

Abstract Introduction Temporary transvenous pacing (TPW) is a very useful procedure to control symptoms and/or correct significant hemodynamic compromise secondary to acute bradycardia as well as ventricular arrhythmias. It can be associated with significant complications (14-40%) e.g., loss of capture, displacement, infection, perforation, venous thrombosis, pulmonary embolism, or rarely, even death. The 2018 ACC/AHA/HRS guidelines on the management of bradycardia give a Class IIa indication for externalised pacemakers (ExPPM) in patients requiring prolonged TPW support while the 2015 ESC guidelines on ventricular arrhythmias and sudden cardiac death give a Class IIa indication for overdrive pacing in the setting of acute coronary syndromes. However, published evidence for the former indication is modest (Level of evidence: B-NR) and lacking for the latter (Level of evidence: C). Aim To describe the experience of use of ExPPM in a high volume single tertiary non device extraction cardiac center over 45 months. Methods Retrospective study of medical records from January 2016 - September 2019. Results N = 34 during which the centre undertook 1341 new simple and complex device implants. Mean age: 73 ± 12 years, 20/34 (58.8%) males. Indication: symptomatic sinus node disease: 7/34 (20.6%), AV node disease: 23/34 (67.6%%), overdrive pacing for ventricular arrhythmias: 4/34 (11.8%) - late monomorphic VT secondary ST elevation myocardial infarction 2/4, polymorphic VT secondary to methadone toxicity 1/4, ventricular fibrillation secondary to bradyarrhythmia 1/4. Majority (27/34, 79.4%) had an ExPPM because of sepsis (pneumonia 12/27; unknown focus 3/27, TPW site infection 2/27, biliary sepsis, necrotising fasciitis, urinary tract infection, sternal wound infection, endocarditis, thrombophlebitis 1 each. Mean duration of implantation: 13.9 ± 11 days. Right internal jugular vein was the most common site (22/34, 64.7%) for introduction of the active fixation lead. Type of ExPPM: single chamber (VVI): 32/34 (94.1%), dual chamber (DDD): 2/34 (5.9%). 13/15 (38.2%) underwent permanent pacemaker implantation and 2/15 (13.3%) cardiac resynchronisation therapy - defibrillator following an ExPPM. Complications: 1/34 (2.9%) bleeding from the puncture site requiring transfusion. Six patients died during the course with deterioration in co-existing medical condition. Conclusion In our experience, ExPPM are not only a very useful intervention in patients who require prolonged support for bradyarrhythmias but can also be used to stabilise patients with recurrent tachyarrhythmias who need overdrive suppression, buying vital time before proceeding to definite therapy. They are associated with a low complication rate. We recommend that centers should have a low threshold for implanting such devices at the outset, in preference to TPW, in those patients where prolonged stabilisation of the heart rhythm is anticipated.

Mid-term clinical outcomes from use of Sirolimus coated balloon in coronary intervention; data from real world population.

Use of drug coated balloons (DCBs) in coronary intervention is escalating. There is a plethora of data on Paclitaxcel-DCB. However, when it comes of stents, Limus-drugs are preferred over Paclitaxel. There is very limited data on Sirolimus coated balloons (SCB). MagicTouch-SCB (Concept Medical, FL) elutes Sirolimus via nano-technology and have been used in our centers since March 2018. We report a mid-term follow-up with this relatively novel-technology. We retrospectively analyzed all patients treated with MagicTouch-SCB between March-2018 and February-2019. Results are reported as cardiac-death, target-vessel myocardial-infarction (TVMI), target lesion revascularization (TLR) and Major Adverse Cardiac Events (MACE). During the study period, 288-patients (373-lesions) with a mean age of 65.8 were treated with MagicTouch-SCB. 84% (n=241) were male, 155 (54%) were in the setting of acute coronary syndrome, 38% (n=110) had diabetes and 62% (n=233) were in de-novo lesions. Most lesions treated were in the LAD/diagonal-system (n=170; 46%). Pre-dilatation was performed in 92% (n=345) of cases. Bailout stenting was required in 9% lesions (n=35). The mean diameter and length of SCBs were 2.64 ± 0.56 mm and 24 ± 8.9 mm respectively. During a median follow-up of 363 days (IQR: 278-435), cardiac death and TVMI occurred in 5-patients (1.7%) and 10-patients (3.4%) respectively, TLR per-lesion was 12%. The MACE rate was 10%. There were no documented cases of acute vessel closure. The results from mid-term follow-up with this relatively new technology SCB is encouraging with a low rates of hard endpoints and acceptable MACE rates despite complex group of patients and lesion subsets.