Urgent Percutaneous Coronary Intervention Research Articles

Clinical characteristics and outcomes in acute myocardial infarction patients aged ≥65 years in Western Romania

Older age is known as a negative prognostic parameter in patients with acute myocardial infarction (AMI). In this study, we aimed to investigate age-related differences in treatment protocols, in-hospital and 1-year mortality. This retrospective observational single-center study enrolled consecutive AMI patients with an urgent percutaneous coronary intervention (PCI) as the main method of myocardial revascularization. The patients divided were divided by age into group I (≥65 years) and group II (<65 years). The primary endpoint was in-hospital mortality, the secondary endpoints were 1-year mortality and rehospitalization rates. Of the 522 admitted with AMI, 476 were enrolled in the study. The mean age was 67 ± 13 years; 62% were men. Group I patients had a significantly lower rate of performed PCI (65% vs. 79%, P < 0.001). 53 patients (12.3%) died during hospitalization, and this proportion was notably higher in the older population (20% vs. 6%, P < 0.0001). The cardiac causes of death were more frequent in group I patients (12% vs. 5.6%, P = 0.016). The multivariate logistic regression selected two variables as independent predictors for the risk of in-hospital death: age ≥65 years (P = 0.0170), and Killip class at admission (P < 0.0001). The 1-year mortality was 3.3%, slightly higher in group I patients (4.8% vs. 1.5%, P = 0.05). In conclusion, patients aged ≥65 years have three times higher in-hospital mortality, but similar 1-year mortality and readmission rates when compared with the younger patients. It is obvious that there is a large potential for improvement of the AMI care in this age group of patients.

Prognostic value of coronary flow capacity assessed by coronary sinus flow obtained by phase contrast cine-magnetic resonance imaging in patients with acute coronary syndrome

Abstract Background The concept of coronary flow capacity (CFC) originated from positron emission tomography has been reported to provide prognostic information. Phase contrast cine-magnetic resonance imaging (PC-CMR) of the coronary sinus (CS) is a promising approach for quantifying global coronary sinus flow (CSF) and global coronary flow reserve (g-CFR) without the need for ionizing radiation, radioactive tracers, or intravascular catheterization. Purpose We evaluated the prognostic value of postprocedural CFC by quantifying CSF using PC-CMR in patients with acute coronary syndrome (ACS) treated with primary or urgent percutaneous coronary intervention (PCI). Methods This study prospectively but nonconsecutively enrolled 569 ACS patients who underwent uncomplicated primary (for ST-segment elevation myocardial infarction (STEMI)) or urgent PCI within 48 hours of symptom onset (for non-ST elevation acute coronary syndrome (NSTE-ACS)). Breath-hold PC-CMR images of CS were acquired to assess absolute CSF at rest and during maximum hyperemia within 30 days after culprit lesion PCI and revascularization of functionally significant non-culprit lesions. The entire cohort was stratified by the CFC according to the thresholds of hyperemic CSF and g-CFR. Impaired CFC was defined as a severely-reduced CFC in the present study. The association of CFC and baseline clinical characteristics with major adverse cardiac events (all-cause death, nonfatal myocardial infarction, hospitalization for congestive heart failure or stroke) was investigated. Results In the final analysis of 502 patients (Male 417 (83.1%), mean age was 67 [58, 73]) and 310 patients (82.3%) with STEMI and 192 patients (38.2%) with NSTE-ACS were studied. In a total cohort, rest and maximal hyperemic CSF and corrected G-CFR were 0.93 [0.68, 1.24] ml/min/g, 2.08 [1.44, 2.77] ml/min/g, and 2.21 [1.58, 3.05], respectively. During a median follow-up of 28 months, MACE occurred in 53 patients (all-cause death: 19, nonfatal myocardial infarction: 16, late revascularization: 59, hospitalization for congestive heart failure: 9, stroke: 9). Cox proportional hazards analysis showed that corrected G-CFR and impaired CFC were both independent predictors of MACE. (hazard ratio (HR), 0.61, 95% confidence interval (CI): 0.45–0.82, p=0.001; HR, 3.51, 95% CI: 1.79–6.86, p≤0.001, respectively). Cardiac event-free survival was significantly worse in patients with impaired CFC (log-rank χ2=22.9, P&amp;lt;0.001). Net reclassification index (NRI) and integrated discrimination improvement (IDI) were both significantly improved when impaired CFC was added to the clinical risk model for predicting MACE. Conclusions In ACS patients successfully revascularized with primary or urgent PCI, CFC categorization stratified by noninvasive PC-CMR provided significant prognostic information independent of infarction size, conventional risk factors and g-CFR. Funding Acknowledgement Type of funding source: None

Primary percutaneous coronary intervention in nonagenarian patients

Abstract Background Given the continuous increase in life expectancy, elderly patients with ST segment elevation myocardial infarction (STEMI) are becoming a growing proportion of those referred for primary percutaneous coronary intervention (pPCI). However, this population is usually excluded from randomized trials and limited data are available to guide clinical decisions. The aim of this study-level meta-analysis was to describe and analyze the determinants of outcomes in this population. Methods We searched the literature for studies reporting ischemic and hemorrhagic outcomes and/or mortality in nonagenarian patients undergoing pPCI. An analysis of the heterogeneity between studies in outcome reports was performed with I2 test. A univariate meta-regression analysis was conducted to explore the relationship between outcomes of interest and classic cardiovascular risk factors, gender, previous myocardial infarction (MI), MI location, PCI characteristics, hemodynamic instability, vascular access, intra-aortic balloon pump (IABP) and Glycoprotein IIb/IIIa inhibitor (GPI) use. Results Overall, 15 observational studies met our inclusion criteria, with a total of 6787 patients; mean age was 92.4 and 35% were male. The incidence of in-hospital death was 21.3%, 1.4% of our population suffered an in-hospital ischemic stroke and 11.1% faced acute renal failure; in-hospital major bleedings affected 1.7% of the population, but blood-transfusion was needed in 6.9%. Long-term mortality rate was 21.5%. Killip III-IV at admission was related with increased in-hospital mortality (β: 0.2%; p: 0.041), but lower incidence of ARF (β: −0.6%; p: 0.004). Angiographic success was associated with a lower incidence of long-term all-cause mortality (β: −1.7%; p: 0.017) and higher incidence of ARF (β: 1.7%, p&amp;lt;0.001). A higher number of coronary stents implanted was associated with a lower incidence of long-term all-cause mortality (β: −73%; p: 0.01). A higher long-term all-cause mortality was related with male gender (β: 0.9%; p: 0.027) and previous MI (β: 1.5%; p: 0.007). Diabetes was associated with a lower incidence of long-term all-cause mortality (β: −0.8%; p: 0.014) despite a higher incidence of in-hospital blood transfusion (β: 0.5%, p: 0.05), while a history of MI (β: 0.1%; p: 0.049), as well as the use of GPI (β: 0.04) was related with a higher incidence of in-hospital major bleeding. The use of IABP was related with a lower incidence of long-term all-cause death (β: 6.5%; p&amp;lt;0.001) and in-hospital major bleeding (β: −0.4%; p: 0.038). Discussion Our meta-analysis, pooling the largest cohort of nonagenarians undergoing pPCI confirms the feasibility of urgent percutaneous coronary intervention also in this frail population. In particular, although angiographic success increased the incidence of in-hospital ARF, it was associated with a higher long-term survival underling the pivotal role of myocardial reperfusion. Funding Acknowledgement Type of funding source: None

Genetic associations of the origin and predictive estimation of the acute non-ST segment elevation myocardial infarction in patients with metabolic syndrome

Abstract Background and introduction Metabolic syndrome (MS) is a baseline condition that influencesthe management of patients with coronary heart disease (CHD). The assessment of genotyping characteristics in patients with MS with non-ST segment elevation myocardial infarction (nSTEMI) remains a challenge. Purpose To define characteristics of G Protein β3 subunit gene C825T polymorphism; T786C in the eNOS gene and G894T in the eNOS gene in patients with MS after nSTEMI, evaluate the prognostic specificity of genotypes in a study population. Methods The study included 150 patients with CHD and MS. The main group included 99 patients (69.7% males, a mean age of (67.4±0.7 y))with nSTEMI, preserved left ventricular systolic function who underwent urgent percutaneous coronary intervention. The control group included 51 patients with a mean age of (64.6±1.3 y) without the history of previous myocardial infarction and acute cerebrovascular disease. There was no statistically significant difference between gender and age in two groups (p&amp;gt;0.05). The predictive significance of the main group genotypes was estimated with odds ratio and risk ratio of “cumulative point of undesirable effects” (CPUE) and included: cardiovascular death, acute coronary syndrome, repeat revascularization, hospitalization for congestive heart failure. The accuracy of the genotype distribution corresponded to the Hardy-Weinberg equilibrium (p&amp;gt;0.05). The accuracy of the results was analyzed using Student, χ2, Fisher's criteria. Results We received high patient numbers with CC genotype of eNOS:786 gene in the main group (n=19 (19.2%)) as compared with the controls (n=3 (6.2%)) (p&amp;lt;0.05, φ=0.03), with GG genotype of eNOS:894 (p&amp;lt;0.01, χ2=8.0) in the main group (n=59 (59.6%)) as compared with the controls (n=18 (35.3%)), with CC genotype of eNOS:894 in the control group (n=40 (78.4%)) as compared with the main group (n=56 (56.6%)) (p&amp;lt;0.05; χ2=7.0). Patients who were heterozygous for eNOS:894 gene prevailed in the main group (n=30 (30.3%)) as compared with the controls (n=27 (52.9%)) (p&amp;lt;0.01, χ2=7.3). The statistically significant CPUE was more frequent diagnosed in patients with TT genotype of GNβ3:825 (OR=12.00, 95% confidence interval ((CI): 2.8–51.7, p&amp;lt;0.05), CC genotype of eNOS:786 (OR=5.1, 95% CI: 1.3–20.0, p&amp;lt;0.05) and TT genotype of eNOS:894 (OR=8.0, 95% CI: 1.8–35.2, p&amp;lt;0,05). Conclusions 4 practically applicable categories of reviewed genotypes were found: 1) nSTEMI - -protective: CC genotype for GNβ3:825 gene, GT – eNOS:894, 2) nSTEMI – unfavorable: CT–GNβ3:825, CC – eNOS:786 and GG – eNOS:894, 3) CPUE – unfavorable: TT – GNβ3:825, CC – eNOS:786, TT – eNOS:894, and 4) nSTEMI, CPUE-neutral: TT and TC – eNOs:786. CC – eNOS:786 genotype is separated as unfavorable for the development of both nSTEMI and CPUE. More studies are necessary for a personified approach, taken into account the obtained features of genetic associations. Funding Acknowledgement Type of funding source: Public Institution(s). Main funding source(s): Scientific Research Institute - S.V. Ochapovsky Clinic Regional Hospital #1, Krasnodar

A comparison of the safety and effectiveness of prasugrel and clopidogrel in younger population undergoing percutaneous coronary intervention: A retrospective study using a Japanese claims database

BackgroundPrasugrel inhibits platelet aggregation more potently than clopidogrel. In the global phase III trial, prasugrel [loading dose/maintenance dose (LD/MD), 60/10 mg] reduced the incidence of ischemic events but involved a higher risk of hemorrhage than clopidogrel in patients with acute coronary syndromes who were scheduled to undergo percutaneous coronary intervention (PCI). In the Japanese phase III trial for similar patients wherein the prasugrel dose regimen was adjusted (LD/MD, 20/3.75 mg), the efficacy of prasugrel and clopidogrel were comparable to that in the global trial; however, the safety could not be determined due to limited power. Given the strict enrollment criteria, the results of the Japanese phase III trial may not be applicable to routine clinical practice. We compared the safety and effectiveness of prasugrel and clopidogrel in the real-world setting in Japanese patients. MethodsWith an analysis of a large claims database prepared during the post-marketing stages in Japan, we identified patients undergoing PCI and compared the incidence of bleeding and ischemic coronary events between patients who received prasugrel and those receiving clopidogrel. ResultsBetween January 1, 2014 and December 31, 2018, we identified 1977 patients who were scheduled to undergo urgent PCI (urgent PCI cohort) and 1922 who were scheduled to undergo elective PCI (elective PCI cohort). After propensity-score matching, there were no significant differences in the baseline clinical characteristics of the prasugrel and clopidogrel groups in the urgent (n = 1080) and elective PCI (n = 1626) cohorts. In Cox proportional hazard analyses, there were no significant differences in the incidence of bleeding or ischemic coronary events during the median 8-month follow-up in both cohorts. ConclusionsThe safety and effectiveness of prasugrel was comparable to that of clopidogrel in real-world Japanese patients scheduled to undergo PCI.

THE TRICKLING TICKER: A RARE CASE OF INTRAMYOCARDIAL HEMATOMA AFTER PERCUTANEOUS CORONARY INTERVENTION IN CHRONIC TOTAL OCCLUSIONS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Chronic Total Occlusion (CTO) is commonly seen in patients with coronary artery disease (CAD) and is managed medically or with coronary artery bypass grafting (CABG). Some cases with refractory symptoms can be managed with percutaneous coronary intervention (PCI). However, it is associated with complications such as intramyocardial hematoma that can lead to cardiac tamponade. This rare but serious complication can cause fatal outcomes if not recognized early. CASE PRESENTATION: A 60-year-old female presented to our hospital with recurrent substernal chest pain. She had a history of CAD previously managed with CABG. Despite optimal medical therapy and surgical intervention, she reported recurrent symptoms. A left heart catheterization demonstrated CTO for which she underwent PCI to the Right Coronary Artery (RCA). Shortly after the procedure, she developed hypotension requiring ionotropic support. Echocardiogram revealed a hematoma in the free wall of the right atrium surrounded by a complex loculated pericardial effusion which was further confirmed with a Computerized Tomography (CT) scan of the chest. Urgent PCI did not reveal any dye extravasation in the RCA or its branches, ruling out active bleeding. Subsequently, a right heart catheterization was consistent with constrictive physiology without evidence of tamponade. It was decided to conservatively manage the patient without surgical evacuation. The patient had complete resolution of hematoma in the subsequent follow-up visit a month after the procedure. DISCUSSION: CTOs are characterized by complete occlusion of a coronary artery with thrombolysis in myocardial infarction (TIMI) score of 0 or 1, for at least 3 months [1]. Management of CTOs with PCI is associated with a multitude of complications such as coronary perforation, myocardial infarction, need for emergent CABG, and mortality [2]. Perforation of collateral vessels during PCI can lead to the formation of an intramyocardial hematoma. This rare complication has a high risk of mortality as it can potentially cause cardiac tamponade as seen in 0.3% of patients [3]. The majority of these cases present with post-procedural hypotension and hence, an immediate echocardiogram is warranted in such cases. Depending on the stability, an intramural hematoma can be managed conservatively or by surgical decompression. Physicians should be vigilant in suspecting this complication in order to avoid catastrophic outcomes. CONCLUSIONS: Intramyocardial hematoma is a rare and life-threatening complication of PCI in CTO. Urgent evaluation of post-procedural hypotension with an echocardiogram can aid in early diagnosis and prevent fatal outcomes. Reference #1: Stone GW, Kandzari DE, Mehran R, et al. Percutaneous recanalization of chronically occluded coronary arteries: a consensus document: part I. Circulation. 2005;112(15):2364-2372. doi:10.1161/CIRCULATIONAHA.104.481283 Reference #2: Rigger J, Hanratty CG, Walsh SJ. Common and Uncommon CTO Complications [published correction appears in Interv Cardiol. 2019 Feb;14(1):48]. Interv Cardiol. 2018;13(3):121–125. doi:10.15420/icr.2018.10.2 Reference #3: Slootweg AP, Louwerenburg JW, Mecozzi G, Wagenaar LJ, Verhorst PM. Obstructive intramyocardial haematoma after percutaneous coronary intervention. Neth Heart J. 2012;20(9):376–378. doi:10.1007/s12471-011-0163-8 DISCLOSURES: No relevant relationships by Naga Vaishnavi Gadela, source=Web Response No relevant relationships by Sana Hyder, source=Web Response No relevant relationships by Christian Mosebach, source=Web Response

3-years outcome of follow-up of patients with chronic obstructive pulmonary disease successfully treated by percutaneous coronary intervention due to acute coronary syndrome

Aim To evaluate results of three-year follow-up in patients after acute coronary syndrome (ACS) associated with chronic obstructive pulmonary disease (COPD) and to identify predictors for delayed serious cardiovascular adverse (SCVAE) events.Material and methods This prospective cohort study included 119 patients with verified COPD who had ACS after a successful urgent percutaneous coronary intervention and were discharged from the hospital without in-hospital complications. Incidence of and time to SCVAE (cardiovascular death, myocardial infarction, stroke, repeated unscheduled myocardial revascularization) were recorded. SCVAE predictors were identified with the Cox regression by stepwise inclusion of variables into the model.Results SCVAE occurred in 33.6 % of ACS patients with COPD. The high rate of repeated myocardial revascularization mostly contributed to the development of delayed SCVAEs (19.3 % of patients). Independent predictors of SCVAE included the total number of stenoses in major coronary artery branches; ankle-brachial index; glomerular filtration rate calculated with the CKD-EPI equation; frequent COPD exacerbations; functional residual capacity of the lungs; and 6-min walk distance.Conclusion New independent predictors of SCVAE were identified in COPD patients after ACS with percutaneous coronary intervention and stenting, including distance in the 6-min walk test, frequent COPD exacerbations, and functional residual volume of the lungs as an index of pulmonary hyperinflation.

Impact of Coronary Lesion Stability on the Benefit of Emergent Percutaneous Coronary Intervention After Sudden Cardiac Arrest.

Conflicting data exist regarding the benefit of urgent coronary angiogram and percutaneous coronary intervention (PCI) after sudden cardiac arrest, particularly in the absence of ST-segment elevation. We hypothesized that the type of lesions treated (stable versus unstable) influences the benefit derived from PCI. Data were taken between May 2011 and 2014 from a prospective registry enrolling all sudden cardiac arrest in Paris and suburbs (6.7 million inhabitants). Patients undergoing emergent coronary angiogram were included. Decision to perform PCI was left to the discretion of local teams. We assessed the impact of emergent PCI on survival at discharge according to whether the treated lesion was angiographically unstable or stable, and we investigated the predictive factors for unstable coronary lesions. Among 9265 sudden cardiac arrests occurring during the study period, 1078 underwent emergent coronary angiogram (median age: 59.6 years, 78.3% males): 463 (42.9%) had an unstable lesion, 253 (23.5%) only stable lesions, and 362 (33.6%) no significant lesions. Emergent PCI was performed in 478 patients (91.4% of unstable and 21.7% of stable lesions). At discharge, PCI of unstable lesions was associated with twice-higher survival rate compared with untreated unstable lesions (47.9% versus 25.6%, P=0.013), while stable lesions PCI did not improve survival (25.5% versus 26.3%, P=1.00). After adjustment, PCI of unstable coronary lesions was independently associated with improved survival (odds ratio, 2.09 [95% CI, 1.42-3.09], P<0.001), contrary to PCI of stable lesions (odds ratio, 0.92 [95% CI. 0.44-1.87], P=0.824). Angina, initial shockable rhythm, ST-segment elevation, and absence of known coronary artery disease were independent predictors of unstable lesions. Emergent PCI of unstable lesions is associated with improved survival after sudden cardiac arrest, contrary to PCI of stable lesions. Accordingly, early PCI should only be performed in patients with unstable lesions. Four factors (chest pain, ST-elevation, absence of coronary artery disease history, and shockable initial rhythm) could help identify patients with unstable lesions who would, therefore, benefit from emergent coronary angiogram.

Efficacy and safety of trimetazidine after percutaneous coronary intervention (ATPCI): a randomised, double-blind, placebo-controlled trial

Angina might persist or reoccur despite successful revascularisation with percutaneous coronary intervention (PCI) and antianginal therapy. Additionally, PCI in stable patients has not been shown to improve survival compared with optimal medical therapy. Trimetazidine is an antianginal agent that improves energy metabolism of the ischaemic myocardium and might improve outcomes and symptoms of patients who recently had a PCI. In this study, we aimed to assess the long-term potential benefits and safety of trimetazidine added to standard evidence-based medical treatment in patients who had a recent successful PCI. We did a randomised, double-blind, placebo-controlled, event-driven trial of trimetazidine added to standard background therapy in patients who had undergone successful PCI at 365 centres in 27 countries across Europe, South America, Asia, and north Africa. Eligible patients were aged 21-85 years and had had either elective PCI for stable angina or urgent PCI for unstable angina or non-ST segment elevation myocardial infarction less than 30 days before randomisation. Patients were randomly assigned by an interactive web response system to oral trimetazidine 35 mg modified-release twice daily or matching placebo. Participants, study investigators, and all study staff were masked to treatment allocation. The primary efficacy endpoint was a composite of cardiac death; hospital admission for a cardiac event; recurrence or persistence of angina requiring an addition, switch, or increase of the dose of at least one antianginal drug; or recurrence or persistence of angina requiring a coronary angiography. Efficacy analyses were done according to the intention-to-treat principle. Safety was assessed in all patients who had at least one dose of study drug. This study is registered with the EU Clinical Trials Register (EudraCT 2010-022134-89). From Sept 17, 2014, to June 15, 2016, 6007 patients were enrolled and randomly assigned to receive either trimetazidine (n=2998) or placebo (n=3009). After a median follow-up of 47·5 months (IQR 42·3-53·3), incidence of primary endpoint events was not significantly different between the trimetazidine group (700 [23·3%] patients) and the placebo group (714 [23·7%]; hazard ratio 0·98 [95% CI 0·88-1·09], p=0·73). When analysed individually, there were no significant differences in the incidence of the components of the primary endpoint between the treatment groups. Similar results were obtained when patients were categorised according to whether they had an elective or urgent PCI. 1219 (40·9%) of 2983 patients in the trimetazidine group and 1230 (41·1%) of 2990 patients in the placebo group had serious treatment-emergent adverse events. Frequencies of adverse events of interest were similar between the groups. Our results show that the routine use of oral trimetazidine 35 mg twice daily over several years in patients receiving optimal medical therapy, after successful PCI, does not influence the recurrence of angina or the outcome; these findings should be taken into account when considering the place of trimetazidine in clinical practice. However, the long-term prescription of this treatment does not appear to be associated with any statistically significant safety concerns in the population studied. Servier.

Inflammatory Conditions in Acute Coronary Syndrome Patients Treated with Percutaneous Coronary Intervention of Saphenous Vein Graft.

The study aimed to evaluate the inflammatory blood parameters in acute coronary syndrome (ACS) patients with a history of coronary artery bypass graft (CABG) and treated with percutaneous coronary intervention (PCI) of saphenous vein graft (SVG). A total of 347 patients who underwent urgent SVG PCI with the diagnosis of ACS were included in the study. After the application of exclusion criteria, 79 patients were allocated into two groups, namely, successful PCI ( n = 59) and unsuccessful PCI ( n = 20), and included in the statistical analysis. Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) levels were significantly higher in patients with unsuccessful SVG PCI. In the logistic regression analysis, PLR, C-reactive protein, and diabetes mellitus emerged as independent factors associated with unsuccessful SVG PCI. The area under the curve for PLR was 0.70 (95% confidence interval: 0.55-0.85, p = 0.006). The cut-off value of PLR (128.99) was associated with 70.0% sensitivity and 69.5% specificity. Elevated inflammatory status is associated with unsuccessful PCI of SVG in ACS patients. Increased PLR levels on admission is an independent predictor of this situation. This cheap and simple marker can help us to predict unsuccessful SVG PCI in ACS patients.

Pre-percutaneous Coronary Intervention Pericoronary Adipose Tissue Attenuation Evaluated by Computed Tomography Predicts Global Coronary Flow Reserve After Urgent Revascularization in Patients With Non-ST-Segment-Elevation Acute Coronary Syndrome.

BackgroundImpaired global coronary flow reserve (g‐CFR) is related to worse outcomes. Inflammation has been postulated to play a role in atherosclerosis. This study aimed to evaluate the relationship between pre‐procedural pericoronary adipose tissue inflammation and g‐CFR after the urgent percutaneous coronary intervention in patients with first non–ST‐segment–elevation acute coronary syndrome.Methods and ResultsPhase‐contrast cine‐magnetic resonance imaging was performed to obtain g‐CFR by quantifying coronary sinus flow at 1 month after percutaneous coronary intervention in a total of 116 first non–ST‐segment–elevation acute coronary syndrome patients who underwent pre‐percutaneous coronary intervention computed tomography angiography. On proximal 40‐mm segments of 3 major coronary vessels on computed tomography angiography, pericoronary adipose tissue attenuation was assessed by the crude analysis of mean computed tomography attenuation value. The patients were divided into 2 groups with and without impaired g‐CFR divided by the g‐CFR value of 1.8. There were significant differences in age, culprit lesion location, N‐terminal pro‐B‐type natriuretic peptide levels, high‐sensitivity C‐reactive protein (hs‐CRP) levels, mean pericoronary adipose tissue attenuation between patients with impaired g‐CFR and those without (g‐CFR, 1.47 [1.16, 1.68] versus 2.66 [2.22, 3.28]; P<0.001). Multivariable logistic regression analysis revealed that age (odds ratio [OR], 1.060; 95% CI, 1.012–1.111, P=0.015) and mean pericoronary adipose tissue attenuation (OR, 1.108; 95% CI, 1.026–1.197, P=0.009) were independent predictors of impaired g‐CFR (g‐CFR <1.8).ConclusionsMean pericoronary adipose tissue attenuation, a marker of perivascular inflammation, obtained by computed tomography angiography performed before urgent percutaneous coronary intervention, but not hs‐CRP, a marker of systemic inflammation was significantly associated with g‐CFR at 1‐month after revascularization. Our results may suggest the pathophysiological mechanisms linking perivascular inflammation and g‐CFR in patients with non–ST‐segment–elevation acute coronary syndrome.

Ticagrelor and the risk of Staphylococcus aureus bacteraemia and other infections.

To investigate the 1-year risks of Staphylococcus aureus bacteraemia (SAB), sepsis, and pneumonia in patients who underwent percutaneous coronary intervention and were treated with ticagrelor vs. clopidogrel. In this nationwide observational cohort study, 26606 patients who underwent urgent or emergent percutaneous coronary intervention (January 2011-December 2017) and initiated treatment with ticagrelor [N = 20073 (75.5%); median age 64 years (25th-75th percentile 55-72 years); 74.8% men] or clopidogrel [N = 6533 (24.5%); median age 68 years (25th-75th percentile 58-77 years); 70.2% men] were identified using Danish nationwide registries. The 1-year standardized absolute risks of outcomes was calculated based on cause-specific Cox regression models, and average treatment effects between treatment groups were obtained as standardized differences in absolute 1-year risks. The absolute 1-year risk of SAB was 0.10% [95% confidence interval (CI), 0.05-0.15%] in the ticagrelor group and 0.29% (95% CI, 0.17-0.42%) in the clopidogrel group. Compared with clopidogrel, treatment with ticagrelor was associated with a significantly lower absolute 1-year risk of SAB [absolute risk difference -0.19% (95% CI, -0.32% to -0.05%), P value 0.006]. Likewise, treatment with ticagrelor was associated with a significantly lower absolute 1-year risk of sepsis [0.99% (95% CI, 0.83-1.14%) vs. 1.49% (95% CI, 1.17-1.80%); absolute risk difference -0.50% (95% CI, -0.86% to -0.14%), P value 0.007] and pneumonia [3.13% (95% CI, 2.86-3.39%) vs. 4.56% (95% CI, 4.03-5.08%); absolute risk difference -1.43% (95% CI, -2.03% to -0.82%), P value < 0.001] compared with clopidogrel. Treatment with ticagrelor was associated with a significantly lower 1-year risk of SAB, sepsis, and pneumonia compared with clopidogrel.

Inferior ST-Elevation Myocardial Infarction Presenting When Urgent Primary Percutaneous Coronary Intervention Is Unavailable: Should We Adhere to Current Guidelines?

The pivotal studies that led to the recommendations for emergent reperfusion therapy for ST-elevation myocardial infarction (STEMI) were conducted for the most part over 25 years ago. At that time, contemporary standard treatments including aspirin, statin, and even anticoagulation were not commonly used. The 2013 American College of Cardiology Foundation (ACCF)/American Heart Association (AHA) guidelines and the 2017 European Society of Cardiology guidelines give a class I recommendation (with the level of evidence A) for primary percutaneous coronary intervention (pPCI) in patients with STEMI and ischemic symptoms of less than 12 h. However, if the patient presents to a hospital without pPCI capacity, and it is anticipated that pPCI cannot be performed within 120 min of first medical contact, fibrinolytic therapy is indicated (if there are no contraindications) (class I indication, level of evidence A). Our review of the pertinent literature shows that the current recommendation for inferior STEMI is based on the level of evidence lower than A. We can consider level B even C, supporting the recommendation for fibrinolytic therapy if pPCI is not available for inferior STEMI.

Successful Percutaneous Coronary Intervention Using Intravascular Ultrasound-Guided Rewiring Technique in a Case of Spontaneous Coronary Artery Dissection Involving Left Main Bifurcation

We herein describe a 49-year-old woman without significant cardiovascular risk factors who was transferred to our hospital with sudden onset of chest pain. The patient was diagnosed with non-ST-elevation acute myocardial infarction, and coronary angiography revealed a dissection at the proximal site of the left anterior descending artery (LAD) extending from the left main trunk (LMT) suggestive of spontaneous coronary artery dissection (SCAD). Because coronary flow was impaired after contrast injection and the patient had chest pain with ST elevation, urgent percutaneous coronary intervention was performed. The first guide wire was initially introduced from the LMT to the distal LAD, but intravascular ultrasound (IVUS) imaging revealed that the guide wire had passed through the true lumen of the left coronary artery ostium, false lumen at the ostium of the left circumflex artery, and true lumen of the distal LAD. We then reinserted another guide wire using an IVUS-guided rewiring technique from the true lumen of the LMT to the distal LAD. Finally, a drug-eluting stent was deployed to cover the dissected segment, and final coronary angiography revealed acceptable results with a patent left circumflex artery. This case report highlights that physicians should consider SCAD among the differential diagnoses in patients presenting with acute coronary syndrome, particularly in young women. In the present case, IVUS played a pivotal role in not only detecting the arterial dissection but also correctly introducing the guide wire into the true lumen.

Comparison of Patient-Reported vs Physician-Estimated Angina in Patients Undergoing Elective and Urgent Percutaneous Coronary Intervention

This cohort study assesses the use of patient-reported vs physician-estimated angina in patients undergoing percutaneous coronary intervention.

243Reviewing electronic health records with the use of natural language processing to determine the prognostic impact of AF and anticoagulation therapy in patients undergoing PCI

Abstract Introduction Between 10-15% of patients undergoing percutaneous coronary intervention (PCI) have a history of atrial fibrillation (AF), and require both oral anticoagulant (OAC) as well as antiplatelet therapy following PCI. However this combination puts the patient at a high risk of serious or fatal bleeding complications. Using big data from electronic health records (EHR) provides the unique opportunity to observe to what extent AF and anticoagulant therapy affect the outcome of patients undergoing PCI in routine clinical practice. Purpose We analysed whether a history of AF and the use of OAC upon discharge was independently associated with short-term, mid-term and long-term mortality in large single institution cohort of patients undergoing PCI. Methods This retrospective EHR study was approved by the institutional review board and data privacy officer. The study population comprised all patients undergoing either planned or urgent PCI between 2012 and 2018. SNOMED time coded past and current medical diagnosis, procedures and drug therapy were extracted from the medical correspondence using natural language processing, procedural characteristics were obtained from the PCI database, and hospital admission data, billing cost, length of stay and vital status were added from the hospital administrative software. Vital status was obtained in all patients. The independent predictors of mortality were analysed using a stepwise multivariate logistic linear regression analysis, with automated forward selection of variables. For each variable the odds ratio with confidence intervals were derived from the regression model. The validity of the model was tested with the Hosmer and Lemeshow test. Results During a 6 year period 5223 patients were identified who underwent a total of 6854 PCI’s, of which 74% were men with a median age of 71 years. At the time of PCI, 256 patients had AF and were not treated with OAC, 549 patients had AF and were treated with OAC, 284 patients developed AF during follow up and 5765 were in sinus rhythm. Patients with a history of AF or ensuing AF were older, more often had multivessel coronary disease, a history of CABG and MI, renal failure, diabetes mellitus and a lower ejection fraction. AF was found to be a strong independent predictor of mortality at 30 days (OR: 2,8), 120 days (OR: 2), 1 year (OR: 1,9) and 5 years (OR: 1,7) following PCI. By contrast OAC was associated with lower odds ratios of mortality at 30 days (OR: 0,4), 120 days (OR: 0,4), 1 year (OR: 0,7) and 5 years (OR: 0,7). Also the occurence of AF post PCI was linked with an increased mortality Conclusions In this large data set of patients undergoing PCI in routine clinical practice, a history of AF was independently associated with increased short-term, mid-term and long-term mortality. On the other hand, OAC was associated with improved short-term, mid-term and long-term mortality survival following PCI. Abstract Figure.

Invasive strategy for COVID patients presenting with acute coronary syndrome: The first multicenter Italian experience.

ObjectiveTo report our initial experience of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2)/acute coronary syndrome (ACS) patients undergoing standard of care invasive management.BackgroundThe rapid diffusion of the SARS‐CoV‐2 together with the need for isolation for infected patients might be responsible for a suboptimal treatment for SARS‐CoV‐2 ACS patients. Recently, the group of Sichuan published a protocol for COVID/ACS infected patients that see the thrombolysis as the gold standard of care.MethodsWe enrolled 31 consecutive patients affected by SARS‐COV‐2 admitted to our emergencies room for suspected ACS.ResultsAll patients underwent urgent coronary angiography and percutaneous coronary intervention (PCI) when required except two patients with severe hypoxemia and unstable hemodynamic condition that were conservatively treated. Twenty‐one cases presented diffuse ST‐segment depression while in the remaining cases anterior and inferior ST‐elevation was present in four and six cases, respectively. PCI was performed in all cases expect two that were diagnosed as suspected myocarditis because of the absence of severe coronary disease and three with apical ballooning at ventriculography diagnostic for Tako‐Tsubo syndromes. Two patients conservatively treated died. The remaining patients undergoing PCI survived except one that required endotracheal intubation (ETI) and died at Day 6. ETI was required in five more patients while in the remaining cases CPAP was used for respiratory support.ConclusionsUrgent PCI for ACS is often required in SARS‐CoV‐2 patients improving the prognosis in all but the most advanced patients. Complete patient history and examination, routine ECG monitoring, echocardiography, and careful evaluation of changes in cardiac enzymes should be part of the regular assessment procedures also in dedicated COVID positive units.

Non-Vitamin K Oral Anticoagulants (NOAC) Versus Vitamin K Antagonists (VKA) for Atrial Fibrillation with Elective or Urgent Percutaneous Coronary Intervention: A Meta-Analysis with a Particular Focus on Combination Type.

Background: Our study aims to perform a meta-analysis of benefits and risks associated with the use of non-vitamin K oral anticoagulants (NOAC) versus vitamin K antagonists (VKA) in patients with a percutaneous coronary intervention (PCI) with a particular focus on the combination type: dual vs. dual antithrombotic therapy (DAT: NOAC + single antiplatelet therapy (SAPT) vs. DAT: VKA + SAPT), dual vs. triple antithrombotic therapy (DAT: NOAC + SAPT vs. TAT: VKA + dual antiplatelet therapy (DAPT)) or triple vs. triple antithrombotic therapy (TAT: NOAC+DAPT vs. TAT: VKA+DAPT). Methods: PubMed, EMBASE, and Cochrane databases were searched to identify randomized controlled trials comparing antithrombotic regimens. Four randomized studies (n = 10.969; PIONEER AF-PCI, RE-DUAL PCI, AUGUSTUS, and ENTRUST-AF PCI) were included. The primary outcome was the composite of major bleeding defined by the International Society on Thrombosis and Hemostasis (ISTH) and clinically relevant bleeding requiring medical intervention (CRNM). Secondary outcomes included all-cause mortality, major adverse cardiovascular events (MACE), myocardial infarction (MI), stroke, and stent thrombosis (ST). Results: Combination strategies with NOACs were associated with reduced risk of major bleeding events across different combination strategies as compared to VKA, with the most significant risk reduction when DAT was compared with TAT, namely DAT with NOAC + SAPT was associated with a 37% relative risk reduction (RRR) of major bleeding events as compared to TAT with VKA + DAPT (RR 0.63; 95% CI, 0.50–0.80). The reduction of major bleeding risks is a class effect of NOACs. Combination strategies of NOACs vs. VKAs resulted in a comparable risk of MACE, MI, stroke, ST, or death. Conclusions: Antithrombotic combinations of NOACs (as DAT or TAT) are safer than VKAs with respect to bleeding risk and result in a satisfactory efficacy with no increase of ischemic or thrombotic events in patients undergoing PCI.

Is myocardial revascularization really necessary in patients with ≥50% but

The aim of this study is to evaluate the immediate and mid-term effects of omitting coronary artery bypass grafting in patients with moderate coronary artery stenosis who have a primary indication for valvular surgery. We included 77 consecutive patients admitted to our Institution for aortic or mitral valve surgery between June 2012 and June 2017 in whom a de novo diagnosis of ≥50%, but <70% coronary stenosis was made. In this cohort, the myocardial revascularization was omitted. All these patients were free from angina and ischaemia on echo and ECG. There were no in-hospital deaths. In only 1 patient, acute myocardial infarction occurred postoperatively, which was immediately treated by percutaneous coronary intervention (PCI). The 6-year overall survival was 94.7 ± 2.59%. At 6 years, no cardiac deaths were recorded. At follow-up, 4 patients underwent elective PCI after a positive stress myocardial perfusion test. Only 1 patient underwent urgent PCI due to acute coronary syndrome. At 6 years, the cumulative incidence function of PCI, with death as competing risk, was 8 ± 3.9%. In our experience, moderate coronary stenosis, occasionally discovered at the time of valvular heart surgery, can be safely overlooked and do not need any further treatment at follow-up in the majority of cases. Our results open up the opportunity to apply this 'intentional omission strategy' in different situations, such as minimally invasive heart surgery, percutaneous procedures and complex patients.

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

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