Time Of Primary Percutaneous Coronary Intervention Research Articles

Endovascular therapeutic hypothermia adjunctive to percutaneous coronary intervention in acute myocardial infarction: realistic simulation as a game changer.

Endovascular therapeutic hypothermia (ETH) reduces the damage by ischemia/reperfusion cell syndrome in cardiac arrest and has been studied as an adjuvant therapy to percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI). New available advanced technology allows cooling much faster, but there is paucity of resources for training to avoid delays in door-to-balloon time (DTB) due to ETH and subsequently coronary reperfusion, which would derail the procedure. The aim of the study was to describe the process for the development of a simulation, training & educational protocol for the multidisciplinary team to perform optimized ETH as an adjunctive therapy for STEMI. We developed an optimized simulation protocol using modern mannequins in different realistic scenarios for the treatment of patients undergoing ETH adjunctive to PCI for STEMIs starting from the emergency room, through the CathLab, and to the intensive care unit (ICU) using the Proteus® Endovascular System (Zoll Circulation Inc™, San Jose, CA, USA). The primary endpoint was door-to-balloon (DTB) time. We successfully trained 361 multidisciplinary professionals in realistic simulation using modern mannequins and sham situations in divisions of the hospital where real patients would be treated. The focus of simulation and training was logistical optimization and educational debriefing with strategies to reduce waste of time in patient's transportation from different departments, and avoiding excessive rewarming during transfer. Afterwards, the EHT protocol was successfully validated in a trial randomizing 50 patients for 18 minutes cooling before coronary recanalization at the target temperature of 32 ± 1.0 ∘C or PCI-only. A total of 35 patients underwent ETH (85.7% [30/35] in 90 ± 15 minutes), without delays in the mean door-to-balloon time for primary PCI when compared to 15 control group patients (92.1 minutes versus 87 minutes, respectively; p = 0.509). Realistic simulation, intensive training and educational debriefing for the multidisciplinary team propitiated feasible endovascular therapeutic hypothermia as an adjuvant therapy to primary PCI in STEMI. gov: NCT02664194.

CCN family member 1 (CCN1) is an early marker of infarct size and left ventricular dysfunction in STEMI patients

Background and aimsCCN family member 1 (CCN1) has recently been proposed as a novel biomarker of myocardial injury, improving prediction of 30-day and one-year mortality following acute coronary syndromes. Among ST-elevation myocardial infarction (STEMI) patients, we evaluated the utility of CCN1 measured immediately before primary percutaneous coronary intervention (PPCI) as a predictor of two earlier endpoints: final myocardial infarct size and post-infarction left ventricular ejection fraction (LVEF). Furthermore, we evaluated the impact of CCN1 on the discriminatory power of the CADILLAC score. MethodsSTEMI patients were obtained from the SPUM-ACS cohort. Serum CCN1 was measured prior to PPCI. Linear regression assessed the association between CCN1, peak creatinine kinase (CK), and post-infarction LVEF. Cox models assessed an association between CCN1 and 30-day all-cause mortality. ResultsCCN1 was measured in 989 patients with a median value of 706.2 ng/l (IQR 434.3–1319.6). A significant correlation between CCN1, myocardial infarct size (peak CK) and LVEF was observed in univariate and multivariate analysis (both p < 0.001). Even among patients with normal classical cardiac biomarker levels at the time of PPCI, CCN1 correlated significantly with final infarct size. CCN1 significantly improved prediction of 30-day all-cause mortality by the CADILLAC score (C-index 0.864, likelihood-ratio chi-square test statistic 6.331, p = 0.012; IDI 0.026, p= 0.050). ConclusionsCompared with classical cardiac biomarkers, CCN1 is potentially the earliest predictor of final myocardial infarct size and post-infarction LVEF. CCN1 improved the discriminatory capacity of the CADILLAC score suggesting a potential role in the very-early risk stratification of STEMI patients.

Relationship between primary percutaneous coronary intervention time of day, infarct size, microvascular obstruction and prognosis in ST-segment elevation myocardial infarction.

Whether the time of day of primary percutaneous coronary intervention (pPCI) in patients with ST-segment elevation myocardial infarction (STEMI) is associated with infarct size, microvascular obstruction (MVO), and prognosis is uncertain. We compared infarct size assessed by cardiac MRI (CMR) and clinical outcomes in STEMI patients according to the pPCI time of day from a large, individual patient-data pooled database. We pooled patient-level data from five randomized pPCI trials in which infarct size was measured within 1 month by CMR. Patients were categorized according to the pPCI time of day. Among 1519 patients with STEMI, 794 (52.2%) underwent pPCI between 8:00 h and 15:59 h, 431 (28.4%) between 16:00 h and 23:59 h, and 294 (19.4%) between 24:00 h and 7:59 h. Infarct size was assessed in 1331 patients at a median of 3.0 days (interquartile range 2.0-5.0) after pPCI. Compared with patients who underwent PCI between 8:00 h and 15:59 h, infarct size was not significantly different for patients undergoing PCI from 16:00 h to 23:59 h [adjusted difference -0.7%, 95% confidence interval (CI) -3.1 to 1.7%, P = 0.46] or 24:00 h to 7:59 h (adjusted difference 0.9%, 95% CI -1.2 to 3.1%, P = 0.29). The time of day of pPCI was also unrelated to MVO and the 1-year risks of death or heart failure hospitalization. In this large-scale, individual patient data pooled analysis, no association was found between the time of day of pPCI and infarct size, MVO, or prognosis after STEMI.

Frequency of ST-segment elevation myocardial infarction, non-ST-segment myocardial infarction, and unstable angina: results from a Southwest Chinese Registry.

The burden of cardiovascular disease is predicted to escalate in developing countries. The aim of this study is to assess the characteristics, management strategies and outcomes of the patients with acute coronary syndrome (ACS) who were admitted to hospitals under the chest pain center mode in southwest P. R. China. Adults hospitalized with a diagnosis of ACS were enrolled in the retrospective, observational registry between January 2017 and June 2019 at 11 hospitals in Chengdu, P. R. China. The collected data included the patients' baseline characteristics, clinical management and in-hospital outcomes. After Statistical analysis, (1) A total of 2857 patients with ACS, among which 1482 have ST-segment elevation myocardial infarction (STEMI), 681 have non-STEMI (NSTEMI) and 694 have unstable angina (UA) were enrolled in the study. (2) 61.3% of the ACS patients received reperfusion therapy. More patients with STEMI underwent percutaneous coronary intervention (PCI) compared with NSTEMI/UA patients (80.6% vs. 38.8%, P < 0.001), while thrombolytics were administered in only 1.8% of STEMI patients. (3) The median time from symptoms to hospital was 190 min (IQR 94-468) in STEMI, 283 min (IQR 112-1084) in NSTEMI and 337 min (IQR 97-2220) in UA (P < 0.001), and the door-to-balloon time for primary PCI (pPCI) was 85 min (IQR 55-121) in STEMI. (4) The in-hospital outcomes for STEMI patients included death (8.1%) and acute heart failure (22.6%), while the outcomes for those with NSTEMI and UA were better: death (4.0% and 0.9%, P < 0.001) and acute heart failure (15.3% and 9.9%, P < 0.001). (5) Antiplatelet drugs, lipid-lowering drugs, β-blockers and angiotensin-converting enzyme inhibitors (ACEI) /angiotensin receptor blockers (ARB) were used in about 98.3%, 95.0%, 67.7% and 54.3% of the ACS patients, respectively. Therefore, the management capacity in Chengdu has relatively increased compared with previous studies, but important gaps still exist compared with developed countries, especially regarding the management of the NSTEMI/UA patients.

Does helicopter transport delay prehospital transfer for STEMI patients in rural areas? Findings from the CRAC France PCI registry.

The aim of this study was to analyse delays in emergency medical system transfer of ST-segment elevation myocardial infarction (STEMI) patients to percutaneous coronary intervention (PCI) centres according to transport modality in a rural French region. Data from the prospective multicentre CRAC / France PCI registry were analysed for 1911 STEMI patients: 410 transferred by helicopter and 1501 by ground transport. The primary endpoint was the percentage of transfers with first medical contact to primary percutaneous coronary intervention within the 90 minutes recommended in guidelines. The secondary endpoint was time of first medical contact to primary percutaneous coronary intervention. With helicopter transport, time of first medical contact to primary percutaneous coronary intervention in under 90 minutes was less frequently achieved than with ground transport (9.8% vs. 37.2%; odds ratio 5.49; 95% confidence interval 3.90; 7.73; P<0.0001). Differences were greatest for transfers under 50 km (13.7% vs. 44.7%; P<0.0001) and for primary transfers (22.4% vs. 49.6%; P<0.0001). The median time from first medical contact to primary percutaneous coronary intervention and from symptom onset to primary percutaneous coronary intervention (total ischaemic time) were significantly higher in the helicopter transport group than in the ground transport group (respectively, 137 vs. 103 minutes; P<0.0001 and 261 vs. 195 minutes; P<0.0001). There was no significant difference in inhospital mortality between the helicopter and ground transport groups (6.9% vs. 6.6%; P=0.88). Helicopter transport of STEMI patients was five times less effective than ground transport in maintaining the 90-minute first medical contact to primary percutaneous coronary intervention time recommended in guidelines, particularly for transfer distances less than 50 km.

Interhospital Transfer versus Direct Admission in Patients with Acute ST-Segment Elevation Myocardial Infarction.

There is concern whether patients with ST-segment elevation myocardial infarction (STEMI) who admitted to a percutaneous coronary intervention (PCI) center from interhospital transfer is associated with longer reperfusion time compared with direct admission. We evaluated the reperfusion delays in patients with STEMI who admitted to a primary PCI center through interhospital transfer or direct admission. We retrospectively analyzed 6,494 consecutive STEMI patients admitted between 2011 and 2019. Compared with direct admission ( n = 4,121; 63%), interhospital transferred patients ( n = 2,373) were younger (55 ± 10 vs. 56 ± 10 years, p < 0.001), had similar gender (85.6 vs. 86% male, p = 0.67), greater proportion of off-hour admission (65.2 vs. 48.3%, p < 0.001), less diabetes mellitus (28 vs. 30.8%, p = 0.019), and received more primary PCI (70.5 vs. 48.7%, p < 0.001). Interhospital transferred patients who received primary PCI ( n = 3,677) or fibrinolytic ( n = 238) had longer symptom-to-PCI center admission time (median, 360 vs. 300 minutes, p < 0.001), shorter door-to-device (DTD) time for primary PCI (median, 74 vs. 87 minutes, p < 0.001), and longer total ischemic time (median, 465 vs. 414 minutes, p < 0.001). Logistic regression in interhospital transferred patients showed that delay in door-in-to-door-out (DI-DO) time at the first hospital was strongly associated with prolonged total ischemic time (adjusted odds ratio = 3.92; 95% confidence interval: 3.06-5.04, p < 0.001). This study suggests that although interhospital transferred patients received more primary PCI with shorter DTD time, interhospital transfer creates longer total ischemic time that associates with the delay in DI-DO time at the first hospital that should be improved.

Abstract 375: Improving Door to Balloon Time for Primary Percutaneous Coronary Intervention

Background: In patients with ST-segment-elevation myocardial infarction (MI), timely treatment with primary percutaneous coronary intervention (PPCI) with door-to-balloon (D2B) time &lt;90 minutes is recommended by the current guidelines. Recent study showed continuous association between shortening D2B time to &lt; 60 minutes and reducing mortality risk.D2B time was maintained below the international target of &lt;90 minutes for patients directly arriving to Heart Hospital emergency department (ED) for the last three years. Aim: Our aim is to reduce D2B time for PPCI to reach the new target of &lt; 60 minutes by the end of August 2019. Method: We started our improvement project by understanding the current process and identifying theareas were delay occurred using Safety I concept. Several reasons of delays were identified: Delay in receiving and preparing the patient in ED Several handovers during patient transfer to Cath Lab. Delay in staff arrival to Heart Hospital during the busy traffic after 3:00 pm Back to back procedures during the busy working hours (7:00 am to 3:00 pm) IHI model for improvement was used to test the effectiveness of the suggested changes.Change Concepts: September 2018 - well trained intensive PPCI nurse was assigned daily during the evening and the night shift to manage the patient from ED arrival to the Cath Lab procedure room and from Cath lab following procedure to the destination unit. January 2019 - The role of PPCI nurse extended to all shifts (24 hours) January 2019 - In house Cath lab team (from 3:00 pm to 10 pm) to overcome travel delay during peak traffic hours. August 2019 - Cardiology fellow from the Cath Lab team receives the patient from arrival at ED door. This reduced the time patient spent in the ED. In May 2019 we tried to apply the concept of Safety II: Weekly data for the shortest D2B time compared to the average D2B was posted in the Cath lab and circulated to all staff with the names of the team members involved. This approach allowed us to learn from good experience and share that experience. It also empowered the team to do better in the future cases. Reasons for achieving weekly shortest D2B were collected and analyzed. It has been found that interventionist had made some corrective actions to avoid delay: Many interventionists accept the case based on the ambulance ECG and activate the Cath lab from the field before patient arrived at the ED.o To avoid delay due to difficulty in registration, some interventionists start the procedure without a full registration. Some on call interventionist stayed in the hospital. Results: We achieved our target of reducing D2B time to &lt; 60 minutes before the end of 2019. Conclusion: Door to balloon time for primary percutaneous coronary intervention was successfully reduced to the new &lt;60 minutes target by Integrating of both safety I and Safety II concepts.

ST-elevation Myocardial Infarction and Multivessel Coronary Artery Disease - A Critical Review of Current Practice, Evidence and Meta-analyses.

In recent years, practice and guidelines for patients with ST-elevation myocardial infarction (STEMI) have evolved from a 'culprit-only approach' to complete revascularisation; however, several issues remain, particularly regarding assessment of non-culprit lesions and timing of their revascularisation. Complete revascularisation should be performed in patients presenting with STEMI; however, available studies often present contradictory results regarding the optimal timing of non-culprit lesion percutaneous coronary intervention (PCI). The aim of this review is to provide a practical approach for the assessment of patients presenting with STEMI and multivessel coronary artery disease by analysing randomised trials, meta-analyses and our clinical experience. We recommend multivessel revascularisation at the time of primary PCI for simple cases, while we suggest deferring treatment of complex lesions; the optimal timing of staged PCI should be individualised according to clinical judgement.

Relation of Ratio of Left Ventricular Ejection Fraction to Left Ventricular End-Diastolic Pressure to Long-Term Prognosis After ST-Segment Elevation Acute Myocardial Infarction

Risk stratification of patients with ST-segment elevation acute myocardial infarction (STEMI) is suboptimal. We assessed the prognostic value of the left ventricular ejection fraction to left ventricular end-diastolic pressure (LVEF/LVEDP) ratio in patients with STEMI who underwent primary percutaneous coronary intervention (PPCI). The study included 1,283 patients with STEMI. LVEF and LVEDP were measured at the time of PPCI. The primary outcome was 8-year cardiac mortality. Patients were divided into 3 groups: a group with a LVEF/LVEDP ratio within the first tertile (LVEF/LVEDP ratio <2; n = 437 patients), a group with a LVEF/LVEDP ratio within the second tertile (LVEF/LVEDP ratio 2 to 3; n = 422 patients), and a group with a LVEF/LVEDP ratio within third tertile (LVEF/LVEDP ratio >3; n = 424 patients). There were 109 cardiac deaths during the follow-up: 55 (17.1%), 36 (10.9%), and 18 (6.5%) deaths occurring in patients of the first, second, and third LVEF/LVEDP ratio tertiles, respectively (adjusted hazard ratio = 0.80, 95% confidence interval 0.66 to 0.97, p = 0.022 for 1 unit increment in the LVEF/LVEDP ratio). LVEF/LVEDP ratio (p = 0.035) but not LVEF (p = 0.290) or LVEDP (p = 0.145) alone improved the risk prediction of the models for cardiac mortality (p values show the difference in C-statistics between the models without and with LVEF/LVEDP ratio, LVEF or LVEDP). In conclusion, in patients with STEMI who underwent PPCI, a lower LVEF/LVEDP ratio was independently associated with increased risk of cardiac mortality up to 8 years after PPCI. The LVEF/LVEDP ratio, but not LVEF or LVEDP alone improved predictivity of multivariable models with respect to long-term cardiac mortality.

ST-Elevation Acute Myocardial Infarction in Australia—Temporal Trends in Patient Management and Outcomes 1999–2016

Increased access to reperfusion for ST elevation myocardial infarction (STEMI) has contributed to reduced mortality internationally. We describe temporal trends in pre-hospital care, in-hospital management and outcomes of the STEMI population in Australia. Temporal trends with multiple regression analysis on the management and outcomes of STEMI patients enrolled across 46 Australian hospitals in the Australian cohort of the Global Registry of Acute Coronary Events (GRACE) and the Cooperative National Registry of Acute Coronary Care Guideline Adherence and Clinical Events (CONCORDANCE) between February 1999 and August 2016. 4,110 patients were treated for STEMI, mean age 62.5±13.7years (SD). The median door-to-balloon time of primary percutaneous coronary intervention (PPCI) decreased by 11minutes (p<0.01) although there was no increase in rates of PPCI (p=0.35). Access to non-primary PCI increased by 39% (p<0.01), provisioning of fibrinolysis decreased by 13% (p<0.01) and the median door-to-needle time of 35minutes remained unchanged (p=0.09). Prescription of medical therapies in-hospital remained high, and at discharge there was an increase in prescription of statins (p<0.01); aspirin including antiplatelets (p<0.01), beta blockers (p=0.023) and ACE/ARB (p=0.02). The occurrence of any in-hospital adverse clinical events declined by 78% (p<0.01) albeit, there was no reduction in mortality in-hospital (p=0.84) or within 6 months (p=0.81). Over time, there has been increased access to non-primary PCI; shorter door-to-balloon times for PPCI; less adverse events in-hospital and fewer readmissions for unplanned revascularisation without the realisation of reduced mortality in-hospital or at 6 months. CONCORDANCE Registry ACTRN: 12614000887673.

Index of Microcirculatory Resistance at the Time of Primary Percutaneous Coronary Intervention Predicts Early Cardiac Complications: Insights From the OxAMI (Oxford Study in Acute Myocardial Infarction) Cohort.

BackgroundEarly risk stratification after primary percutaneous coronary intervention (PPCI) for ST‐segment–elevation myocardial infarction is currently challenging. Identification of a low‐risk group may improve triage of patients to alternative clinical pathways and support early hospital discharge. Our aim was to assess whether the index of microcirculatory resistance (IMR) at the time of PPCI can identify patients at low risk of early major cardiac complications and to compare its performance against guideline‐recommended risk scores.Methods and Results IMR was measured using a pressure–temperature sensor wire. Cardiac complications were defined as the composite of cardiac death, cardiogenic shock, pulmonary edema, malignant arrhythmias, cardiac rupture, and presence of left ventricular thrombus either before hospital discharge or within 30‐day follow‐up. In total, 261 patients undergoing PPCI who were eligible for coronary physiology assessment were prospectively enrolled. Twenty‐two major cardiac complications were reported. Receiver operating characteristic curve analysis confirmed the utility of IMR in predicting complications and showed significantly better performance than coronary flow reserve, the Primary Angioplasty in Myocardial Infarction II (PAMI‐II), and Zwolle score (P≤0.006). Low microvascular resistance (IMR ≤40) was measured in 159 patients (61%) of the study population and identified all patients who were free of major cardiac complications (sensitivity: 100%; 95% CI, 80.5–100%).Conclusions IMR immediately at the end of PPCI for ST‐segment–elevation myocardial infarction reliably predicts early major cardiac complications and performed significantly better than recommended risk scores. These novel data have implications for early risk stratification after PPCI.

Managing Multivessel Coronary Artery Disease in Patients With ST-Elevation Myocardial Infarction: A Comprehensive Review.

Multivessel coronary artery disease (CAD) is found in up to 60% of the patients presenting with an ST-elevation myocardial infarction (STEMI) and worsens the prognosis proportional to the extent of CAD severity. However, the 2013 American College of Cardiology/American Heart Association STEMI guidelines, based on mostly observational data, had recommended against a routine noninfarct-related artery percutaneous coronary intervention (PCI). After these guidelines were published, a handful of randomized trials became available, and they suggested that PCI of significant lesions in a noninfarct-related artery at the time of primary PCI might result in improved patient outcomes. The incidence of major adverse cardiac events was significantly reduced by 55% at 1 year and 65% at 2 years in patients undergoing angiographically guided PCI of nonculprit vessels at the time of primary PCI, in 2 different randomized trials. Fractional flow reserve-guided PCI of nonculprit vessels in this setting has also been shown to reduce cardiac events by 44% at 1 year. Meta-analyses of both nonrandomized and randomized trials have also suggested that complete revascularization at the time of STEMI significantly improves outcomes, including long-term all-cause mortality. In view of the emerging data, a focused update on primary PCI was published in 2015 and suggested that PCI of noninfarct-related arteries might be considered in selected patients. This article is a comprehensive review of the literature on the treatment of multivessel CAD in patients with STEMI, which provides the reader a critical analysis of the available information to determine the best therapeutic approach.

Complete versus culprit only revascularization in ST-elevation myocardial infarction-a perspective on recent trials and recommendations.

The presence of multivessel coronary artery disease (CAD) is strongly associated with higher 30-day mortality, reduced myocardial reperfusion success, reinfarction, and occurrence of major adverse cardiac events (MACE) at 1 year compared with single-vessel CAD. Despite higher morbidity and mortality in patients with ST-elevation myocardial infarction (STEMI) and coexistent multivessel CAD, major guidelines recommended against percutaneous coronary intervention (PCI) on non-culprit lesions at the time of primary PCI in patients with STEMI who are hemodynamically stable. The presence of multivessel CAD often poses a therapeutic dilemma for interventional cardiologists. A few larger scale randomized controlled trials (RCTs) and meta-analyses have been conducted. The conclusions regarding multivessel PCI generally trend towards lower risk of MACE, repeat revascularization, with similar risks of recurrent myocardial infarction (MI) and mortality. However, none of the RCTs were adequately powered for hard outcomes of death and MI.

Not So Fast: Complete Revascularization of the ST-Segment-Elevation Myocardial Infarction Patient Is Not Yet Proven.

Opposing Viewpoint, see p 1571 In most advanced healthcare systems, primary percutaneous coronary intervention (PPCI) has replaced thrombolysis as the optimal therapy for patients presenting with ST-segment–elevation acute myocardial infarction (STEMI). The frequent discovery of nonculprit vessel lesions during this index revascularization has fueled enthusiasm among interventional cardiologists to implant additional stents at the time of PPCI. The potential for cost saving by preventing an additional second procedure, reductions in inpatient stay, and even mortality benefits from immediate complete revascularization have been hypothesized. Determining whether this approach is a rational extension of the index emergency revascularization procedure or a costly and potentially hazardous extrapolation of the benefits of coronary stents has sparked considerable debate. Disease in the nonculprit vessel in patients with STEMI is common; it is present in up to 60% of patients and, predictably, its presence is associated with worse outcomes.1 A pooled meta-analysis of 40 280 patients published in 2011 suggested that staged percutaneous coronary intervention (PCI) of nonculprit lesions yielded superior short- and long-term outcomes in comparison with culprit lesion–only treatment, whereas multivessel PCI resulted in worse outcomes to culprit-only PCI or staged PCI.1 Because this retrospective analysis is subject to confounding (multivessel PCI performed preferentially for cardiogenic shock), 3 …

Invasive Assessment of the Coronary Microcirculation in Reperfused ST-Segment-Elevation Myocardial Infarction Patients: Where Do We Stand?

For patients presenting with an acute ST-segment-elevation myocardial infarction, the most effective therapy for reducing myocardial infarct size and preserving left ventricular systolic function is primary percutaneous coronary intervention (PPCI). However, mortality and morbidity remain significant. This is partly attributed to the development of microvascular obstruction, which occurs in around 50% of ST-segment-elevation myocardial infarction patients post-PPCI, and it is associated with adverse left ventricular remodeling and worse clinical outcomes. Although microvascular obstruction can be detected by cardiac imaging techniques several hours post-PPCI, it may be too late to intervene at that time. Therefore, being able to predict the development of microvascular obstruction at the time of PPCI may identify high-risk patients who might benefit from further adjuvant intracoronary therapies, such as thrombolysis, vasodilators, glycoprotein IIb/IIIa inhibitors, and anti-inflammatory agents that may reduce microvascular obstruction. Recent studies have shown that invasive coronary physiology measurements performed during PPCI can be used to assess the coronary microcirculation. In this article, we provide an overview of the various invasive methods currently available to assess the coronary microcirculation in the setting of ST-segment-elevation myocardial infarction, and how they could potentially be used in the future for tailoring therapies to those most at risk.

Coronary Catheterization and Percutaneous Coronary Intervention in China: 10-Year Results From the China PEACE-Retrospective CathPCI Study.

The use of coronary catheterization and percutaneous coronary intervention (PCI) is increasing in China, but, to date, there are no nationally representative assessments of the quality of care and outcomes in patients undergoing these procedures. To assess the quality of care and outcomes of patients undergoing coronary catheterization and PCI in China. In a clinical observational study (China PEACE [Patient-Centered Evaluative Assessment of Cardiac Events]-Retrospective CathPCI Study), we used a 2-stage, random sampling strategy to create a nationally representative sample of 11 241 patients undergoing coronary catheterization and PCI at 55 urban Chinese hospitals in calendar years 2001, 2006, and 2011. Data analysis was performed from July 11, 2014, to November 20, 2015. Patient characteristics, treatment patterns, quality of care, and outcomes associated with these procedures and changes over time. Of the 11 241 patients included in the study, the samples included, for 2001, 285 women (weighted percentage, 28.6%); for 2006, 826 women (weighted percentage, 32.2%), and for 2011, 2588 women (weighted percentage, 35.7%). Mean (SD) ages were 58 (8), 60 (11), and 61 (11) years, respectively. Between 2001 and 2011, estimated national rates of hospitalizations for coronary catheterization increased from 26 570 to 452 784 and for PCI, from 9678 to 208 954 (17-fold and 21-fold), respectively. More than half of stable patients undergoing coronary catheterization had nonobstructive coronary artery disease; this amount did not change significantly over time (2001: 60.3% [95% CI, 56.1%-64.5%]; 2011: 57.5% [95% CI, 55.8%-59.3%], P = .05 for trend). The proportion of PCI procedures performed via radial approach increased from 3.5% (95% CI, 1.7%-5.3%) in 2001 to 79.0% (95% CI, 77.7%-80.3%) in 2011 (P < . 001 for trend). The use of drug-eluting stents (DESs) increased from 18.0% (95% CI, 14.2%-21.7%) in 2001 to 97.3% (95% CI, 96.9%-97.7%) in 2011 (P < .001 for trend) largely owing to increased use of domestic DESs. The median length of stay decreased from 14 days (interquartile range [IQR], 9-20) in 2001 to 10 days (IQR, 7-14) in 2011 (P < .001 for trend). In-hospital mortality did not change significantly, but both adjusted risk of any bleeding (odds ratio [OR], 0.53 [95% CI, 0.36-0.79], P < .001 for trend) and access bleeding (OR, 0.23 [95% CI, 0.12-0.43], P < .001) were decreased between 2001 and 2011. The medical records lacked documentation needed to calculate commonly used process metrics including door to balloon times for primary PCI and the prescription of evidence-based medications at discharge. Although the use of catheterization and PCI in China has increased dramatically, we identified critical quality and documentation gaps that represent opportunities to improve care. Our findings can serve as a foundation to guide future quality improvement initiatives in China.

Impact of the Residual SYNTAX Score on Outcomes of Revascularization in Patients with ST-Segment Elevation Myocardial Infarction and Multivessel Disease.

Primary percutaneous coronary intervention (P-PCI) has become the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI) when performed by an experienced team in a timely manner. However, no consensus exists regarding the management of multivessel coronary disease detected at the time of P-PCI.AIMThe aim of this study was to evaluate the use of the residual SYNTAX score (rSS) following a complete vs. culprit-only revascularization strategy in patients with STEMI and multivessel disease (MVD) to quantify the extent and complexity of residual coronary stenoses and their impact on adverse ischemic outcomes.METHODSBetween October 1, 2012, and November 30, 2013, we enrolled 120 consecutive STEMI patients with angiographic patterns of multivessel coronary artery disease (CAD) who had a clinical indication to undergo PCI. The patients were subdivided into those who underwent culprit-only PCI (60 patients) and those who underwent staged-multivessel PCI during the index admission or who were staged within 30 days of the index admission (60 patients). Both the groups were well matched with regard to clinical statuses and lesion characteristics. Clinical outcomes at one year were collected, and the baseline SYNTAX score and rSS were calculated.RESULTSThe mean total stent length (31.07 ± 12.7 mm vs. 76.3 ± 14.1 mm) and the number of stents implanted per patient (1.34 ± 0.6 vs. 2.47 ± 0.72) were higher in the staged-PCI group. The rSS was higher in the culprit-only PCI group (9.7 ± 5.7 vs. 1.3 ± 1.99). The angiographic and clinical results after a mean follow-up of 343 ± 75 days demonstrated no significant difference in the occurrence of in-hospital Major Adverse Cardiac and Cerebrovascular Events (MACCE) between both the groups (6.7% vs. 5%, P = 1.000). However, patients treated with staged PCI with an rSS ≤8 had significant reductions in one-year MACCE (10.7% vs. 30.5%, P = 0.020*), death/Myocardial infarction (MI)/Cerebrovascular accident (CVA) (5% vs. 13.8%, P = 0.016*), and repeat revascularization (4.8% vs. 25%, P = 0.001*). We found that culprit-only, higher GRACE risk scores at discharge and an rSS >8 were independent predictors of MACCE at one year.CONCLUSIONSStaged PCI that achieves reasonable complete revascularization (rSS ≤8) improves mid-term survival and reduces the incidence of repeat PCI in patients with STEMI and MVD. Nonetheless, large-scale randomized trials are required to establish the optimal revascularization strategy for these high-risk patients.

3 Outcomes following Primary Percutaneous Coronary Intervention in Patients with multi-vessel Coronary Artery Disease in the Modern Era

Background The optimal timing of non-culprit lesion PCI in ST elevation myocardial infarction (STEMI) patients with multi-vessel coronary artery disease (MVD) treated primary percutaneous coronary intervention (PPCI) remains uncertain. Aim To assess early ( Methods After excluding patients with cardiogenic shock and those with previous CABG, a total of 3486 PPCI-treated STEMI at two tertiary centres were included in this study. Patients were divided into 3 groups according to their MVD status and the number of coronary arteries treated at time of PPCI: 1) single vessel disease (SVD, n = 2164); 2) culprit-only multi-vessel disease (CO-MVD, n = 790); and 3) multi-vessel PCI MVD disease (MVPCI-MVD, n = 193) group. Results Patients in SVG group were younger and were less likely to have previous history diabetes mellitus, hypertension, previous MI or CVA proportion of females compared to other groups. Overall one year emergency rePCI rate was 2.9%. One year emergency rePCI was significantly higher in CO-MVD group (7.5%) compared to SVD group (1.4%) and MVPCI-MVD group (2.1%). Overall 30-day and late mortality rates were 3.7% and 3.2%, respectively. Compared to SVG, both multi-vessel groups were associated with increased 30-day mortality; with adjusted odds ratios (95% confidence interval [CI]) of 1.69 (1.11–2.57) in CO-MVD and 1.78 (0.92–3.43) in MVPCI-MVD group, but not with late mortality; with hazard ratios (95% CI) of 1.01 (0.65–1.56) in CO-MVD and 0.88 (0.42–1.86) in MVPCI-MVD. Overall 30-day and late emergency PCI rates were 1.2% and 1.7%, respectively. Compared to SVD group, Conclusions In this large observational study of unselected PPCI-treated patients, MVD was associated with increased 30-day mortality but not with mortality beyond 30 days. Furthermore, rate of emergency repeat PCI was highest in CO-MVD compared to other groups.

Randomized Trial of Complete Versus Lesion-Only Revascularization in Patients Undergoing Primary Percutaneous Coronary Intervention for STEMI and Multivessel Disease: The CvLPRIT Trial

BackgroundThe optimal management of patients found to have multivessel disease while undergoing primary percutaneous coronary intervention (P-PCI) for ST-segment elevation myocardial infarction is uncertain. ObjectivesCvLPRIT (Complete versus Lesion-only Primary PCI trial) is a U.K. open-label randomized study comparing complete revascularization at index admission with treatment of the infarct-related artery (IRA) only. MethodsAfter they provided verbal assent and underwent coronary angiography, 296 patients in 7 U.K. centers were randomized through an interactive voice-response program to either in-hospital complete revascularization (n = 150) or IRA-only revascularization (n = 146). Complete revascularization was performed either at the time of P-PCI or before hospital discharge. Randomization was stratified by infarct location (anterior/nonanterior) and symptom onset (≤3 h or >3 h). The primary endpoint was a composite of all-cause death, recurrent myocardial infarction (MI), heart failure, and ischemia-driven revascularization within 12 months. ResultsPatient groups were well matched for baseline clinical characteristics. The primary endpoint occurred in 10.0% of the complete revascularization group versus 21.2% in the IRA-only revascularization group (hazard ratio: 0.45; 95% confidence interval: 0.24 to 0.84; p = 0.009). A trend toward benefit was seen early after complete revascularization (p = 0.055 at 30 days). Although there was no significant reduction in death or MI, a nonsignificant reduction in all primary endpoint components was seen. There was no reduction in ischemic burden on myocardial perfusion scintigraphy or in the safety endpoints of major bleeding, contrast-induced nephropathy, or stroke between the groups. ConclusionsIn patients presenting for P-PCI with multivessel disease, index admission complete revascularization significantly lowered the rate of the composite primary endpoint at 12 months compared with treating only the IRA. In such patients, inpatient total revascularization may be considered, but larger clinical trials are required to confirm this result and specifically address whether this strategy is associated with improved survival. (Complete Versus Lesion-only Primary PCI Pilot Study [CvLPRIT]; ISRCTN70913605)

TCT-328 FFR-guided complete revascularization during primary PCI: Preliminary data from the COMPARE ACUTE trial

Current guidelines deem percutaneous coronary intervention (PCI) of a non-infarct related artery (n-IRA) at the time of primary PCI (pPCI). This approach is being challenged by recent studies, which show benefits of complete rather than culprit vessel-only revascularization at the time of pPCI.