Swedish Coronary Angiography And Angioplasty Registry Research Articles

Cangrelor versus no cangrelor during percutaneous coronary intervention in hemodynamically unstable patients: a cohort study on benefits and risks

Abstract Background Cangrelor is an intravenous P2Y12 inhibitor which, according to the European guidelines, may be considered for administration in acute coronary syndrome during percutaneous coronary intervention (PCI). Little is known regarding benefits and risks of such administration in hemodynamically unstable patients. Purpose To investigate the effects of cangrelor versus no cangrelor during PCI regarding major adverse cardiac events (MACE), in-hospital bleeding, and all-cause mortality in patients with cardiogenic shock and/or cardiac arrest. Methods The study population was extracted from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and included patients with cardiogenic shock or cardiac arrest undergoing PCI during the years 2016-2022. Propensity score matching (PSM) was used to create comparable groups. After matching, all variables used for calculating propensity score were balanced (standardized mean difference<0.1). Outcomes were MACE within 30 days, in-hospital bleeding, and all-cause mortality within 30 days. Risk ratios (RR) with 95% confidence intervals (CI) were calculated. When RR deviated from the null, the risk difference (RD) was determined. Results In all, 2,100 (66%) out of 3,206 patients with cardiogenic shock and/or cardiac arrest were included in the PSM analyses (median age: 69 years; 76% male; 78% ST-elevation myocardial infarction (STEMI)). Comparing cangrelor versus no cangrelor in this matched set of patients, the RR was 0.93 (95% CI: 0.84; 1.04) for MACE; 1.51 (1.02; 2.25) for in-hospital bleeding, with an RD of 1.9 percentage points (0.10; 3.7); and 0.93 (0.82; 1.04) for all-cause mortality (Table). In the PSM analysis regarding patients with cardiogenic shock, 1,098 (60%) out of 1,815 patients were included (median age: 71 years; 68% male; 82% STEMI). For these patients, RR was 0.85 (95% CI: 0.74; 0.97) for MACE, with an RD of -7.5 percentage points (-1.6; -13); 1.31 (0.82; 2.09) for in-hospital bleeding; and 0.83 (0.72; 0.95) for all-cause mortality, with an RD of -8.0 percentage points (-2.2; -14). In the PSM analysis regarding patients with cardiac arrest, 1,388 (76%) out of 1,827 patients were included (median age: 67 years; 81% male; 75% STEMI). RR was 0.98 (95% CI: 0.86; 1.12) for MACE; 1.53 (0.95; 2.49) for in-hospital bleeding; and 0.98 (0.86; 1.13) for all-cause mortality. Conclusion For patients with cardiogenic shock, but not for patients with cardiac arrest, administration of cangrelor versus no cangrelor during PCI was associated with a reduction in both MACE and all-cause mortality, with numbers needed to treat of 14 and 13, respectively. Overall, for patients with cardiogenic shock or cardiac arrest, administration of cangrelor versus no cangrelor during PCI was associated with an increased risk of in-hospital bleeding with a number needed to harm of 53.

Outcome of Saphenous Vein Graft Percutaneous Coronary Intervention Using Contemporary Drug-Eluting Stents: A SCAAR Report

BackgroundPercutaneous coronary intervention (PCI) of saphenous vein grafts (SVG) is associated with poor outcomes and is often regarded as inferior to native vessel PCI. We investigated clinical outcomes of SVG-PCI using contemporary drug-eluting stents (DES), in a complete, nationwide population. MethodsThe complete Swedish Coronary Angiography and Angioplasty Registry (SCAAR) was used to identify all patients in Sweden who underwent SVG-PCI with a contemporary DES between 2013 and 2020. Baseline characteristics, procedures, and outcomes were described. ResultsA total of 2198 SVG-PCI procedures with 3106 contemporary DES were included. Patients had a high incidence of comorbidities such as diabetes (40%), prior myocardial infarction (MI) (69%), and acute coronary syndrome (74%) at presentation. SVG-PCI procedures commonly involved multiple DES (41%). Native vessel PCI, in addition to SVG-PCI, was performed in only 13% of procedures. At 1 year, adverse clinical outcomes were frequent as exemplified by any death (9.2%), MI (9.1%), or revascularization (21.1%), whereas stent and lesion-related outcomes on a patient level were less common: stent thrombosis (1.2%), in-stent restenosis (4.3%) and target lesion revascularization (4.3%). Similarly, at 3 years, clinical outcomes were frequent: death (19.8%), MI (21.1%), revascularization (32.8%); and stent-related outcomes were less common: stent thrombosis (2.9%), restenosis (10.8), and target lesion revascularization (13.6%). ConclusionsIn this nationwide cohort of patients who underwent SVG-PCI with contemporary DES, patients were characterized by a high-risk profile and high rates of adverse clinical events. However, the incidence of stent and lesion-related events was low.

Importance of hospital and clinical factors for early mortality in Takotsubo syndrome: Insights from the Swedish Coronary Angiography and Angioplasty Registry

BackgroundTakotsubo syndrome (TTS) is an acute heart failure syndrome with symptoms similar to acute myocardial infarction. TTS is often triggered by acute emotional or physical stress and is a significant cause of morbidity and mortality. Predictors of mortality in patients with TS are not well understood, and there is a need to identify high-risk patients and tailor treatment accordingly. This study aimed to assess the importance of various clinical factors in predicting 30-day mortality in TTS patients using a machine learning algorithm.MethodsWe analyzed data from the nationwide Swedish Coronary Angiography and Angioplasty Registry (SCAAR) for all patients with TTS in Sweden between 2015 and 2022. Gradient boosting was used to assess the relative importance of variables in predicting 30-day mortality in TTS patients.ResultsOf 3,180 patients hospitalized with TTS, 76.0% were women. The median age was 71.0 years (interquartile range 62–77). The crude all-cause mortality rate was 3.2% at 30 days. Machine learning algorithms by gradient boosting identified treating hospitals as the most important predictor of 30-day mortality. This factor was followed in significance by the clinical indication for angiography, creatinine level, Killip class, and age. Other less important factors included weight, height, and certain medical conditions such as hyperlipidemia and smoking status.ConclusionsUsing machine learning with gradient boosting, we analyzed all Swedish patients diagnosed with TTS over seven years and found that the treating hospital was the most significant predictor of 30-day mortality.

Percutaneous coronary intervention and medical therapy versus medical therapy alone in chronic coronary syndrome: A hierarchical win-ratio analysis from SCAAR

Abstract Background Revascularization of patients with chronic coronary syndrome (CCS) using percutaneous coronary intervention (PCI) is frequently done. However, the role of a PCI in this subgroup of patients with coronary artery disease remains controversial. Purpose The objective is to determine whether PCI plus medical therapy is associated with better outcomes for patients with CCS, compared to medical therapy only. Methods We conducted a population-based nationwide observational study. Using the Swedish Coronary Angiography and Angioplasty registry (SCAAR) we identified all patients with CCS undergoing coronary angiography between 2010-2020. Patients with obstructive coronary artery disease, defined as having at least one stenosis with ≥50% luminal obstruction were included. Patients were stratified into two groups according to their received treatment with PCI plus medical therapy or medical therapy only. Propensity score (PS) matching was used to match the two groups on their baseline characteristics. Outcome was assessed with win-ratio and the primary endpoint was net adverse clinical event (NACE) within 5-years. In the win-ratio analysis, the components of NACE were ranked (1) all-cause mortality, (2) stroke, (3) bleeding and (4) myocardial infarction. Subgroup analysis was also performed. Results After propensity score matching, two groups comprising 16,937 patients each, were formed. Baseline characteristics were comparable between the two groups (Table 1). However, patients who underwent PCI were more likely to receive dual antiplatelet therapy with aspirin and a P2Y12 inhibitor, while those treated with medical therapy were more commonly prescribed nitrates. Additionally, statins were prescribed more frequently to patients treated with PCI. The hierarchical outcome analysis showed no statistically significant difference between the two groups (win-ratio: 0.98; 95% confidence interval: 0.94-1.02; p=0.345). Subgroup analyses of men, women, patients aged 75 years and older, diabetic patients, and non-diabetic patients showed no significant differences in outcome between the two groups. Conclusion In this study, which aimed to assess the outcomes of patients with CCS using a hierarchical approach, revascularization with PCI did not result in better outcomes when compared to medical therapy alone. These findings suggest that for patients with CCS, medical therapy may be just as effective as PCI in improving outcomes.Baseline characteristicsWin-ratio

Progression of atherosclerosis in smokers: a longitudinal nation-wide serial angiography study

Abstract Introduction Smoking is a modifiable risk factor for coronary artery disease (CAD). Cross-sectional studies have shown that prevalence of CAD is higher among smokers as is incidence of myocardial infarction. However, few studies have assessed how smoking affects the incidence of coronary artery plaque progression. Purpose To investigate how CAD progress in smokers. Method All coronary artery segments with <50% luminal stenosis in patients having a first-time coronary angiogram between 1989-2017 were identified from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and followed until a clinically indicated angiography within 15 years was performed or death or end of follow-up occurred. The patients were divided into cohorts based on smoking status and studied with regard to plaque progression defined as the occurrence of ≥50 luminal stenosis on subsequent coronary angiogram. Results A total of 2,272,518 coronary artery segments in 215,364 patients were included of whom 48.1% were never smokers (NS), 33.4% were previous smokers and 18.5% were active smokers (S). The plaque progression incidence rate (IR) was 2.1 (2.04-2.16) per 1000 segment years (SY) for S, 1.77 (1.73-1.81) per 1000 SY for PS, and 1.33 (1.30-1.36) per 1000 SY for NS. The largest increase in plaque progression IR per 1000 SY in relation to smoking status was the middle right coronary artery (RCA) segment (NS: 1.36 (1.27-1.45), PS: (2.23 (2.08-2.39), S: 3.25 (3.01-3.51)). Kaplan-Meier curves depict increased progression in the RCA among smokers (supplementary picture 1). Discussion: In this nationwide longitudinal coronary angiography study, plaque progression occurred more frequently in smokers and in whom the right coronary artery was more commonly affected by coronary atherosclerosis.Plaque progression in RCA vs LAD

Incidence of flow-limiting coronary artery stenoses in patients with diabetes - a coronary angiography natural history study

Abstract Background Diabetes is an established risk factor for the development of coronary atherosclerosis. We sought to assess the association between diabetes and the incidence of coronary artery atherosclerosis progression on coronary angiography. Methods Using the Swedish Coronary Angiography and Angioplasty Registry (SCAAR), we included all coronary artery segments with mild to no atherosclerosis defined as <50% luminal obstruction in patients undergoing a first-time coronary angiography in Sweden between 1989 and 2017. Patients with two or more vessel disease were excluded as were patients with a previous history of coronary artery disease. In patients with one vessel disease, the diseased vessel including all its branches were excluded. Patients were followed for 15 years until a clinically indicated re-angiography was done, death occurred or end of follow-up (April 2018). The primary outcome was plaque progression to flow-limiting coronary artery stenosis defined as ≥50% luminal obstruction on repeat angiography assessed using epidemiological tables, Kaplan Meier event rates, and Cox proportional hazard models. The importance of selected risk factors (smoking, hypertension, hyperlipidemia, and established coronary artery disease) was assessed. Results A total of 2 661 245 coronary segments in 248 736 patients were included in the study. Diabetes was present in 30 533 patients and 320 815 coronary artery segments. Kaplan-Meier event rates and incidence rates (IR) per 1000 segment-years were higher in patients with diabetes (5.5%, IR 2.78 [95% CI 2.70–2.85] vs. 3.0%, 1.44 [1.42–1.46]) resulting in an almost two-folded hazard ratio (HR) of plaque progression (HR 1.93 [95% CI 1.87– 2.00]). The anatomical distribution of plaque progression was similar between the two cohorts on all levels of analysis (coronary artery level, main artery and branches level, and coronary segment level artery). Diabetic patients with established coronary artery disease had a significantly higher risk of future events compared to those without clinically significant coronary artery disease. Conclusions Diabetes was associated with an almost twofold higher incidence rate of plaque progression but did not appear to alter the anatomical location of plaque development compared to the absence of diabetes. Once coronary artery disease is established, the rate of atherosclerotic events accelerates. Therefore, adopting aggressive primary prevention strategies is crucial to reduce the risk of adverse outcomes in diabetic patients.Event rates and anatomical distributionProgression of stenoses by risk factor

Intracoronary imaging of complex coronary artery lesions: A lesion-level analysis from SCAAR simulating the IMPROVE trial

Abstract Background Intravascular ultrasound (IVUS) and optical coherence tomography (OCT) are two intracoronary imaging modalities which can be used to optimize stent implantation and expansion. The IMPROVE trial is an ongoing randomized study investigating the impact of IVUS on percutaneous coronary intervention (PCI) of complex lesions. We conducted a nationwide retrospective observational study simulating the IMPROVE trial. Purpose The aim of this study is to determine whether intracoronary imaging is associated with improved outcome after PCI of complex lesions. Methods Using the Swedish Coronary Angiography and Angioplasty registry (SCAAR) we identified complex lesions undergoing PCI between 1 January 2016 and 15 January 2022. Complex lesions were defined as (1) in-stent restenosis, (2) chronic total occlusions, (3) bifurcations and (4) lesions stented with a ≥ 28 mm stent. Lesions were stratified into two groups according to use of intracoronary imaging or not. The groups underwent propensity score (PS) matching to balance baseline demographics. Outcome was assessed with univariable cox regression models and Kaplan Meier estimates. The primary endpoint was target lesion revascularization (TLR) within 2-years assessed on lesion level where each patient could contribute with more than one lesion. Secondary endpoint included all-cause mortality analyzed on patient level. Results After PS-matching, two groups with 9,404 lesions each were formed. Baseline characteristics after PS matching did not show any significant demographic differences. The intracoronary imaging group contributed more often with more than one lesion. Intracoronary imaging was associated with significantly lower rates of TLR (hazard ratio (HR): 0.80 (95% confidence interval (CI): 0.67-0.94), p=0.008) and all-cause mortality (HR: 0.69 (95% CI 0.61-0.78), p<0.001). Conclusion In this study on complex lesions undergoing PCI, the use of intracoronary imaging was associated with an improved outcome. These results encourage intracoronary imaging when assessing complex lesions.Baseline characteristicsOutcome

Clinical Outcome of Revascularization Deferral With Instantaneous Wave-Free Ratio and Fractional Flow Reserve: A 5-Year Follow-Up Substudy From the iFR-SWEDEHEART Trial.

Background Although physiology-based assessment of coronary artery stenosis using instantaneous wave-free ratio (iFR) and fractional flow reserve (FFR) are established methods of guiding coronary revascularization, its clinical outcome in long-term deferral needs further evaluation, especially with acute coronary syndrome as a clinical presentation. The aim was to evaluate the long-term clinical outcome of deferral of revascularization based on iFR or FFR. Methods and Results This is a substudy of the iFR-SWEDEHEART (Instantaneous Wave-Free Ratio Versus Fractional Flow Reserve in Patients With Stable Angina Pectoris or Acute Coronary Syndrome) randomized clinical trial, where patients deferred from revascularization from each study arm were selected. Nine hundred eight patients deferred from coronary revascularization with iFR (n=473) and FFR (n=435) were followed for 5 years. The national quality registry, SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies), was used for patient data collection and clinical follow-up. The end point was major adverse cardiac events and their individual components all-cause death, cardiovascular death, noncardiovascular death, nonfatal myocardial infarction, and unplanned revascularization. No significant difference was found in major adverse cardiac events (iFR 18.6% versus FFR 16.8%; adjusted hazard ratio, 1.08 [95% CI, 0.79-1.48]; P=0.63) or their individual components. Conclusions No differences in clinical outcomes after 5-year follow-up were noted when comparing iFR versus FFR as methods for deferral of coronary revascularization in patients presenting with stable angina pectoris and acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02166736.

On the Natural History of Coronary Artery Disease: A Longitudinal Nationwide Serial Angiography Study.

Background The long-term course of coronary atherosclerosis has not been studied in large nationwide cohorts. Understanding the natural history of coronary atherosclerosis could help identify patients at risk for future coronary events. Methods and Results All coronary artery segments with <50% luminal stenosis in patients with a first-time coronary angiogram between 1989 and 2017 were identified (n=2 661 245 coronary artery segments in 248 736 patients) and followed until a clinically indicated angiography within 15 years was performed or until death or end of follow-up (April 2018) using SCAAR (Swedish Coronary Angiography and Angioplasty Registry). The stenosis progression and incidence rates were 2.6% and 1.45 (95% CI, 1.43-1.46) per 1000 segment-years, respectively. The greatest progression rate occurred in the proximal and middle segments of the left anterior descending artery. Male sex and diabetes were associated with a 2-fold increase in risk, and nearly 70% of new stenoses occurred in patients with baseline single-vessel disease (hazard ratio, 3.86 [95% CI, 3.69-4.04]). Coronary artery segments in patients with no baseline risk factors had a progression rate of 0.6% and incidence rate of 0.36 (95% CI, 0.34-0.39), increasing to 8.1% and 4.01 (95% CI, 3.89-4.14) per 1000 segment-years, respectively, in patients with ≥4 risk factors. The prognostic impact of risk factors on stenosis progression was greatest in younger patients and women. Conclusions Coronary atherosclerosis progressed slowly but more frequently in the left coronary artery in men and in the presence of traditional risk factors. Coronary artery segments in patients without risk factors had little or no risk of stenosis progression, and the relative impact of risk factors appears to be of greater importance in younger patients and women. These findings help in the understanding the long-term course of coronary atherosclerosis.

Heparin pre-treatment in patients with ST elevation myocardial infarction: a cohort study investigating the effects on coronary artery occlusion, mortality, and bleeding

Abstract Background Unfractionated heparin (UFH) is often administered before arrival at the cath lab in patients with ST-elevation myocardial infarction (STEMI) undergoing percutaneous coronary intervention (PCI). However, large studies regarding the clinical impacts of UFH pre-treatment are scarce. Purpose To investigate if pre-treatment with heparin affects total coronary artery occlusion at angiography, mortality at 30 days, and major bleeding during hospitalization in patients with STEMI undergoing primary PCI. Methods The study population was extracted from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) and consisted of unique patients with a first STEMI event undergoing PCI during the study period 2008 to 2016. Patients receiving UFH pre-treatment were compared with patients not receiving UFH pre-treatment. To obtain relative risks of the outcomes adjusted Poisson regression models with robust standard errors were used. In the adjusted models, we included age, sex, smoking status, year, comorbidities (as specified under tables 1 and 2), and anti-thrombotic treatment (as specified under tables 1 and 2). To obtain absolute risk differences, analyses of propensity score (PS) matched groups were performed. PS was based on the same variables as in the adjusted Poisson regression, and a caliper of 0.02 was used. Results A total of 41,631 patients were included in the study population (median age: 67 years; 71% male), with 16,026 receiving pre-treatment with UFH and 25,605 not receiving UFH pre-treatment. The adjusted Poisson model revealed that UFH pre-treatment was associated with an 11% relative risk reduction of coronary artery occlusion (95% confidence interval (CI): 9%; 12%), and an 13% (95% CI: 2%; 23%) reduced relative risk of mortality. For bleeding, no statistically significant difference was found. In the PS-matched analysis (median age: 67 years, 71% male), the absolute risk differences were for coronary artery occlusion 8.3% (95% CI: 7.1%; 9.5%) in favour of UFH pre-treatment, and for mortality 0.5% (−0.1%; 1.2%), with a modest trend in favour of UFH pre-treatment. For bleeding, no statistically significant difference was found. Conclusion UFH pre-treatment was associated with a reduction in coronary artery occlusion at presentation at the cath lab in patients with STEMI, the number needed to treat being 13, without increasing the risk of bleeding. Regarding mortality, a reduced relative risk was found in the adjusted regression analysis, but the absolute risk difference was small and not statistically significant in the PS-matched analysis. Due to the retrospective study design, residual confounding cannot be excluded. Funding Acknowledgement Type of funding sources: None.

Pretreatment with heparin in patients with ST-segment elevation myocardial infarction: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).

Unfractionated heparin (UFH) is frequently administered before percutaneous coronary intervention (PCI) in patients with ST-segment elevation myocardial infarction (STEMI). The aim of the study was to investigate if pretreatment with UFH prior to arrival at the catheterisation laboratory affects coronary artery occlusion, mortality, and in-hospital major bleeding in patients with STEMI undergoing PCI. Patients with a first STEMI event undergoing PCI between 2008 and 2016 were extracted from the Swedish Coronary Angiography and Angioplasty Registry. Risk ratios for UFH pretreatment versus no pretreatment regarding coronary artery occlusion at presentation in the catheterisation laboratory, 30-day mortality, and bleeding were obtained using adjusted Poisson regression models with robust standard errors. Analyses of propensity score (PS)-matched groups were performed to obtain absolute risk differences. In all, 41,631 patients were included, 16,026 (38%) with and 25,605 (62%) without UFH pretreatment. Adjusted risk ratios were 0.89 (95% confidence interval [CI]: 0.87 to 0.90) for coronary artery occlusion, 0.87 (0.77 to 0.99) for mortality, and 1.01 (0.86 to 1.18) for bleeding. In the PS-matched analyses, the absolute risk differences were -0.087 (-0.074 to -0.099) for coronary artery occlusion, -0.011 (-0.017 to -0.0041) for mortality, and 0 (-0.0052 to 0.0052) for bleeding. Pretreatment with UFH was associated with a reduction in coronary artery occlusion among patients with STEMI, with a number needed to treat (NNT) of 12, without increasing the risk of major in-hospital bleeding. Regarding mortality, a reduction was found with UFH pretreatment, with an NNT of 94, but this effect was not robust over all sensitivity analyses and residual confounding cannot be excluded.

Risk of coronary stenosis after adjuvant radiotherapy for breast cancer

PurposeAdjuvant radiotherapy (RT) for breast cancer is associated with an increased risk of ischemic heart disease. We examined the risk of coronary artery stenosis in a large cohort of women with breast cancer receiving adjuvant RT.MethodsA cohort of women diagnosed with breast cancer between 1992 and 2012 in three Swedish health care regions (n = 57,066) were linked to the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) to identify women receiving RT who subsequently underwent a percutaneous coronary intervention (PCI) due to coronary stenosis. Cox regression analyses were performed to examine risk of a coronary intervention and competing risk analyses were performed to calculate cumulative incidence.ResultsA total of 649 women with left-sided breast cancer and 494 women with right-sided breast cancer underwent a PCI. Women who received left-sided RT had a significantly higher risk of a PCI in the left anterior descending artery (LAD) compared to women who received right-sided RT, hazard ratio (HR) 1.44 (95% confidence interval [CI] 1.21–1.77, p < 0.001). For the proximal, mid, and distal LAD, the HRs were 1.60 (95% CI 1.22–2.10), 1.38 (95% CI 1.07–1.78), and 2.43 (95% CI 1.33–4.41), respectively. The cumulative incidence of coronary events at 25 years from breast cancer diagnosis were 7.0% in women receiving left-sided RT and 4.4% in women receiving right-sided RT.ConclusionImplementing and further developing techniques that lower cardiac doses is important in order to reduce the risk of long-term side effects of adjuvant RT for breast cancer.

Trends in Clinical Practice and Outcomes After Percutaneous Coronary Intervention of Unprotected Left Main Coronary Artery.

BackgroundThe use of percutaneous coronary intervention (PCI) to treat unprotected left main coronary artery disease has expanded rapidly in the past decade. We aimed to describe nationwide trends in clinical practice and outcomes after PCI for left main coronary artery disease.Methods and ResultsPatients (n=4085) enrolled in the SCAAR (Swedish Coronary Angiography and Angioplasty Registry) as undergoing PCI for left main coronary artery disease from 2005 to 2017 were included. A count regression model was used to analyze time‐related differences in procedural characteristics. The 3‐year major adverse cardiovascular and cerebrovascular event rate defined as death, myocardial infarction, stroke, and repeat revascularization was calculated with the Kaplan‐Meier estimator and Cox proportional hazard model. The number of annual PCI procedures grew from 121 in 2005 to 589 in 2017 (389%). The increase was greater for men (479%) and individuals with diabetes (500%). Periprocedural complications occurred in 7.9%, decreasing from 10% to 6% during the study period. A major adverse cardiovascular and cerebrovascular event occurred in 35.7% of patients, falling from 45.6% to 23.9% (hazard ratio, 0.56; 95% CI, 0.41–0.78; P=0.001). Radial artery access rose from 21.5% to 74.2% and intracoronary diagnostic procedures from 14.0% to 53.3%. Use of bare‐metal stents and first‐generation drug‐eluting stents fell from 19.0% and 71.9%, respectively, to 0, with use of new‐generation drug‐eluting stents increasing to 95.2%.ConclusionsRecent changes in clinical practice relating to PCI for left main coronary artery disease are characterized by a 4‐fold rise in procedures conducted, increased use of evidence‐based adjunctive treatment strategies, intracoronary diagnostics, newer stents, and more favorable outcomes.

Short- and Long-Term Clinical Outcomes for Patients With Takotsubo Syndrome and Patients With Myocardial Infarction: A Report From the Swedish Coronary Angiography and Angioplasty Registry.

BackgroundTakotsubo syndrome (TS) is a potentially life‐threatening acute cardiac syndrome with a clinical presentation similar to myocardial infarction and for which the natural history, management, and outcome remain incompletely understood. Our aim was to assess the relative short‐term mortality risk of TS, ST‐segment–elevation myocardial infarction (STEMI), and non‐STEMI (NSTEMI) and to identify predictors of in‐hospital complications and poor prognosis in patients with TS.Methods and ResultsThis is an observational cohort study based on the data from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry). We included all patients (n=117 720) who underwent coronary angiography in Sweden attributed to TS (N=2898 [2.5%]), STEMI (N=48 493 [41.2%]), or NSTEMI (N=66 329 [56.3%]) between January 2009 and February 2018. We compared patients with TS to those with NSTEMI or STEMI. The primary end point was all‐cause mortality at 30 days. Secondary outcomes were acute heart failure (Killip Class ≥2) and cardiogenic shock (Killip Class 4) at the time of angiography. Patients with TS were more often women compared with patients with STEMI or NSTEMI. TS was associated with unadjusted and adjusted 30‐day mortality risks lower than STEMI (adjusted hazard ratio [adjHR], 0.60; 95% CI, 0.48–0.76; P<0.001), but higher than NSTEMI (adjHR, 2.70; 95% CI, 2.14–3.41; P<0.001). Compared with STEMI, TS was associated with a similar risk of acute heart failure (adjHR, 1.26; 95% CI, 0.91–1.76; P=0.16) but a lower risk of cardiogenic shock (adjHR, 0.55; 95% CI, 0.34–0.89; P=0.02). The relative 30‐day mortality risk for TS versus STEMI and NSTEMI was higher for smokers than nonsmokers (adjusted P interaction STEMI=0.01 and P interaction NSTEMI=0.01).ConclusionsThe 30‐day mortality rate in TS was higher than in NSTEMI but lower than STEMI despite a similar risk of acute heart failure in TS and STEMI. Among patients with TS, smoking was an independent predictor of mortality.

Long-term mortality in patients with ischaemic heart failure revascularized with coronary artery bypass grafting or percutaneous coronary intervention: insights from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).

Aims To compare coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for treatment of patients with heart failure due to ischaemic heart disease.Methods and results We analysed all-cause mortality following CABG or PCI in patients with heart failure with reduced ejection fraction and multivessel disease (coronary artery stenosis >50% in ≥2 vessels or left main) who underwent coronary angiography between 2000 and 2018 in Sweden. We used a propensity score-adjusted logistic and Cox proportional-hazards regressions and instrumental variable model to adjust for known and unknown confounders. Multilevel modelling was used to adjust for the clustering of observations in a hierarchical database. In total, 2509 patients (82.9% men) were included; 35.8% had diabetes and 34.7% had a previous myocardial infarction. The mean age was 68.1 ± 9.4 years (47.8% were >70 years old), and 64.9% had three-vessel or left main disease. Primary designated therapy was PCI in 56.2% and CABG in 43.8%. Median follow-up time was 3.9 years (range 1 day to 10 years). There were 1010 deaths. Risk of death was lower after CABG than after PCI [odds ratio (OR) 0.62; 95% confidence interval (CI) 0.41–0.96; P = 0.031]. The risk of death increased linearly with quintiles of hospitals in which PCI was the preferred method for revascularization (OR 1.27, 95% CI 1.17–1.38, Ptrend < 0.001).Conclusion In patients with ischaemic heart failure, long-term survival was greater after CABG than after PCI.

Outcome of PCI with Xience versus other commonly used modern drug eluting stents: A SCAAR report.

To analyze the clinical outcome of percutaneous coronary intervention (PCI) using the Xience drug eluting stent (DES) versus other modern DES. This retrospective study based on the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) analyzed the outcome of PCI using Xience versus other commonly used modern DES, 2007 to 2017. The primary outcome measure was a combination of all-cause death, myocardial infarction (MI) and revascularisation with PCI. Angiographical outcome measures were in-stent restenosis (ISR) and stent thrombosis (ST). Rates of the primary outcome measure for Xience and other DES were 31.9% and 28.2% respectively, adjusted hazard ratio (HR) 0.99 (95% CI 0.95-1.03). Crude rates of ISR were 2.9% versus 2.1% over 4.3 and 2.9 years respectively, adjusted HR 0.93 (95% CI 0.81-1.06). Crude rates of ST were 0.9% versus 0.7%, adjusted HR 1.07 (95% CI 0.82-1.39). Results were consistent in all sensitivity analyses. This nationally complete, real-world study confirms that Xience is a safe and effective DES with low-event rates of ISR and ST. Compared with a control group containing a large proportion of thinner strut stents and absorbable polymers, Xience exhibits similar results in all important clinical endpoints.

The association of mode of location activity and mobility with acute coronary syndrome: a nationwide ecological study.

BackgroundWe aimed to study the effect of social containment mandates on ACS presentation during COVID‐19 pandemic using location activity and mobility data from mobile phone map services.MethodsWe conducted a cross‐sectional study using data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) including all ACS presentations during the pandemic until 7 May 2020. Using a count regression model, we adjusted for day of the week, daily weather and incidence of COVID‐19.ResultsA 10% increase in activity around areas of residence was associated with 38% lower rates of ACS hospitalizations, whereas increased activity relating to retail and recreation, grocery stores and pharmacies, workplaces and mode of mobility was associated with 10‐20% higher rates of ACS hospitalizations.ConclusionGovernment policy regarding social containment mandates has important public health implications for medical emergencies such as ACS and may explain the decline in ACS presentations observed during COVID‐19 pandemic.

Long-term survival in patients with coronary artery disease undergoing percutaneous coronary intervention with or without intracoronary pressure wire guidance: a report from SCAAR

Abstract Background Intracoronary pressure wire measurements of fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR) provide decision-making guidance during percutaneous coronary intervention (PCI). However, limited data exist on the impact of FFR/iFR on long-term clinical outcomes in patients with stable angina, unstable angina (UA)/non-ST-segment elevation myocardial infarction (NSTEMI), or STEMI. Methods We used data from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) on all patients in Sweden undergoing PCI (with or without FFR/iFR guidance) for stable angina, UA/NSTEMI, or STEMI between January 2005 and March 2018. The primary endpoint was all-cause mortality and the secondary endpoints were stent thrombosis or restenosis and periprocedural complications. The primary model was multilevel Cox proportional-hazards regression using an instrumental variable (IV) to adjust for known and unknown confounders with treating hospital as a treatment-preference instrument. The following variables were entered into Cox proportional-hazards regression in addition to the IV: age, sex, diabetes, indication for PCI, severity of coronary disease, smoking status, hypertension, hyperlipidemia, previous myocardial infarction, previous PCI, previous coronary artery bypass graft, type of stent. Results In total, 151,001 patients underwent PCI: 31,514 (20.9%) for stable angina, 74,982 (49.6%) for UA/NSTEMI, and 44,505 (29.5%) for STEMI. Of these, FFR/iFR guidance was used in 11,433 patients (7.6%): 5029 (44.0%) with stable angina, 5989 (52.4%) with UA/NSTEMI, and 415 (3.6%) with STEMI; iFR was used in 1156 (10.1%) of these patients. After a median follow-up of 1784 (range 1–4824) days, the FFR/iFR group had lower adjusted risk estimates for all-cause mortality [hazard ratio (HR) 0.79; 95% confidence interval (CI) 0.69–0.91; P=0.001] and stent thrombosis and restenosis (HR 0.13; 95% CI 0.09–0.19; P&amp;lt;0.001). The number of periprocedural complications did not differ significantly between the groups (odds ratio 0.69; 95% CI 0.30–1.55; P=0.368). There was no interaction between FFR/iFR and indication for PCI. We found no difference between FFR and iFR (HR 1.12; 95% CI 0.90–1.59; P=0.216). Conclusions In this observational study, the use of FFR/IFR was associated with a lower risk of long-term mortality in patients undergoing PCI for stable angina, UA/NSTEMI, or STEMI. Our study supports the current European and American guidelines for the use of FFR/iFR during PCI and shows that intracoronary pressure wire guidance has prognostic benefit in patients with stable angina as well as in patients with the acute coronary syndrome. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): Heart and Lung Foundation, ALF Västra Götaland, Swedish Scientific Council

Good long-term survival of Icelandic women following acute myocardial infarction

Abstract Background Mortality from coronary artery disease has decreased considerably in recent decades in Western societies, but less in women compared with men. Possible explanations for this difference include delayed medical attention, atypical presenting symptoms and also a higher incidence of myocardial infarction with non-obstructive coronary arteries in women. In addition, recent studies suggest that women with acute myocardial infarction (AMI) are less likely to receive treatment according to guidelines, which results in worse prognosis for women. Iceland is listed as one of the most gender-equal countries in the world and we hypothesised that this may reduce the gender gap in treatment and survival following AMI. Purpose The aim of this nationwide study was to compare clinical characteristics and treatment of men and women with AMI, identify independent risk factors for long-term mortality and estimate the impact of gender on relative survival. Methods This was a retrospective cohort study on all patients in Iceland with STEMI (2008–2018) and NSTEMI (2013–2018) who had obstructive coronary artery disease on coronary angiography. Information about patients and angiography results and treatment were obtained from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR) and electronic health records. Data for all-cause mortality was extracted through linkage with Statistics Iceland and survival was estimated with Kaplan-Meier method and Cox regression analysis used to identify significant risk factors for long-term mortality. Excess mortality from the AMI episode was estimated by comparing the survival with age- and gender-matched population in Iceland in 30-day intervals. Results A total of 1345 STEMI patients (24% women) and 1249 NSTEMI patients (24% women) were evaluated. Women with both STEMI (mean age: 71±11. vs. 67±12) and NSTEMI (mean age: 69±13 vs. 62±12) were older and less likely to have a cardiovascular history. There was no gender difference in the extent of coronary artery disease or treatment. Whilst long-term survival for women following STEMI (A) was lower, female gender was not found to be an independent risk factor for mortality after adjusting for age and comorbidities (HR 0.98, 95%-CI: 0.75–1.29). The survival after NSTEMI was similar between genders (B) and female gender was a protective prognostic factor (HR 0.67, 95% CI: 0.46–0.97). There was an excess 30-day mortality following STEMI (C) and NSTEMI (D) for both women and men compared to the matched Icelandic population, but thereafter the mortality rate was similar. Conclusion Our findings indicates that women and men in Iceland receive comparable treatment for AMI, including invasive treatment. Prognosis following NSTEMI is better in women. Higher early mortality after STEMI may be caused by delays in presentation and diagnosis as well as older age of women because female gender was not a significant risk factor for mortality. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): University hospital of Iceland, 4 weeks research leave

Clinical outcomes with unselected use of an ultrathin-strut sirolimus-eluting stent: a report from the Swedish Coronary Angiography and Angioplasty Registry (SCAAR).

The aim of this study was to assess the real-world clinical performance of a sirolimus-eluting ultrathin-strut drug-eluting stent (DES) (Orsiro) in a large nationwide cohort of patients undergoing percutaneous coronary intervention (PCI). From the Swedish Coronary Angiography and Angioplasty Registry, the two-year outcomes of 4,561 patients implanted with Orsiro (Orsiro group) and 69,570 receiving other newer-generation DES (n-DES group) were analysed. The rate of definite stent thrombosis was low in both groups (0.67% and 0.83% for Orsiro and n-DES, respectively; adjusted hazard ratio [HR] 0.90, 95% confidence interval [CI]: 0.55-1.46, p-value 0.66). Restenosis was also infrequent (1.5% vs 2.0% with Orsiro and n-DES, adjusted HR 0.81, 95% CI: 0.63-1.03, p-value=0.09). The risk of target lesion revascularisation by PCI was lower in the Orsiro group (1.6% vs 2.3%, adjusted HR 0.75, 95% CI: 0.60-0.94, p-value=0.013). All-cause mortality and myocardial infarction did not show a statistically significant difference between the two groups (mortality of 7.5% in both groups, adjusted HR 0.99, 95% CI: 0.72-1.35, p-value=0.94; 6.0% vs 5.2% for myocardial infarction, adjusted HR 1.19, 95% CI: 1.00-1.43, p-value=0.06). In a nationwide scenario, the use of a sirolimus-eluting ultrathin-strut DES portended favourable clinical outcomes.