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Introduction Despite advances in surgical and anaesthetic techniques, non-cardiac surgery still has a significant mortality. We hypothesised that pre-operative troponin levels might predict post-operative mortality. Methods Patients undergoing elective and urgent/emergency non-cardiac surgery excluding minor procedures were retrospectively assessed for known vascular disease (defined by diagnostic imaging or previous intervention rather than clinical assessment) and vascular risk factors including hypertension, treatment with lipid-modifying agents (irrespective of agent or dose) and chronic lung disease. Pre-operative high-sensitivity troponins and routine pre-operative bloods were recorded. Six- and twelve-month mortality data were collected; independent predictors of mortality and associations between pre-operative patient characteristics and pre-operative troponin were determined. Results 993 patients were assessed; 13% had an elevated pre-operative troponin with 3%>50 ng/L. 825 (83%) were elective patients; 8.6% had an elevated pre-operative troponin. Six-month mortality was 4.2% and 5.9% at twelve months. Elevated pre-operative troponin was associated with higher post-operative mortality; 2.5%, 12.5% and 25% for a troponin 50 ng/L respectively (figure?1). This trend was also evident at twelve months; 3.7%, 16.3% and 37% for the same troponin bands (figure 2). Lipid-modifying agents were independently associated with a lower rate of pre-operative troponin release (HR 0.446 (0.232 – 0.857) p=0.015). Impaired renal function (assessed as a continuous variable), emergency presentation and pre-operative troponin levels were independent predictors of six- and twelve-month mortality with emergency presentation the strongest predictor by hazard ratio (table 1). Age over 75 independently predicted twelve-month mortality only. Conclusion The role of pre-operative troponin monitoring and the prevalence of pre-operative troponin has not previously been established on an all-comer population. Pre-operative troponin level greater than 50 ng/L is an independent predictor of six and twelve-month mortality following non-cardiac surgery in an all-comers cohort although the mechanism of troponin release is not clear. The lower rate of troponin release associated with lipid-modifying medication has been seen in other studies (1). We hypothesise the known anti-inflammatory effects of statins may indicate a systemic inflammatory process responsible for the troponin release rather than unstable coronary disease. Further studies to assess this in the elective population may be useful to target pre-operative interventions. Reference Association between pre-operative statin use and major cardiovascular complications among patients undergoing non-cardiac surgery: the VISION study. ?Berwanger O, Le Manach Y, Suzumura EA, et al. Eur Heart J2016Jan 7;37(2):177?–?85

Objective To estimate the cost-effectiveness of primary angioplasty compared with thrombolysis for acute ST elevation myocardial infarction. Design Cost analysis of UK observational database, incorporated into decision analytical model. Methods Patients receiving treatment within a comprehensive angioplasty service were compared with control patients receiving thrombolysis-based care. The treatment costs and delays to treatment of thrombolysis and angioplasty were estimated. These estimates were then incorporated into an existing model of cost-effectiveness that synthesises evidence from 22 randomised trials to estimate health outcomes measured by quality-adjusted life years (QALYs). Main outcome measures Costs from a health service perspective and outcomes measured as quality adjusted. Results The mean cost of the initial treatment was £3509 for thrombolysis at control sites, £5176 for angioplasty in usual working hours at National Infarct Angioplasty Project sites and an additional £245 if undertaken out of hours. Angioplasty-based care had an incremental cost of £4520 per QALY gained and 0.9 probability of being cost-effective at a threshold of £20 000 per QALY gained. This probability was >0.95 if patients were directly admitted to the cardiac catheter laboratory, 0.75 if admitted via the emergency department or coronary care unit and 0.38 if transferred to the angioplasty centre from another hospital. Conclusions Overall, primary angioplasty-based care is highly likely to be cost-effective at an assumed threshold of £20 000 per QALY gained. It is more likely to be cost-effective if patients are admitted directly to the cardiac catheter laboratory rather than via other hospital departments, or if transferred from another hospital.

Objective: To assess the cost effectiveness of primary angioplasty, compared with medical management with thrombolytic drugs, to achieve reperfusion after acute myocardial infarction ( AMI) from the perspective of the UK NHS. Design: Bayesian evidence synthesis and decision analytic model. Methods: A systematic review was conducted and Bayesian statistical methods used to synthesise evidence from 22 randomised control trials. Resource utilisation was based on UK registry data, published literature and national databases, with unit costs taken from routine NHS sources and published literature. Main outcome measure: Costs from a health service perspective and outcomes measured as quality-adjusted life years (QALYs). Results: For the base case, the incremental cost-effectiveness ratio of primary angioplasty was pound 9241 for each additional QALY, with a probability of being cost effective of 0.90 for a cost-effectiveness threshold of pound 20 000. Results were sensitive to variations in the additional time required to initiate treatment with primary angioplasty. Conclusions: Primary angioplasty is cost effective for the treatment of AMI on the basis of threshold cost-effectiveness values used in the NHS and subject to a delay of up to about 80 minutes. These findings are mainly explained by the superior mortality benefit and the prevention of non-fatal outcomes associated with primary angioplasty for delays of up to this length.

There have been major changes in the delivery of services to patients with coronary disease over the last two decades. These include primary percutaneous coronary intervention (PCI) for patients with ST-elevation myocardial infarction (STEMI) and an early invasive strategy for those with non-STEMI acute coronary syndromes (ACS). In these settings patients undergo angiography with a view to immediate angioplasty (so-called “follow-on” or “ad-hoc” angioplasty) or early coronary artery bypass grafting (CABG). Chest pain clinics identify patients who need early angiography and these and other elective patients are frequently listed for a potential follow-on procedure. These changes have made revascularisation units more efficient, with greater patient throughput and reduced hospital bed-days. In the United Kingdom they have played a major part in significantly reducing waiting times for procedures. However, this increased efficiency has its challenges. One of the most important is the issue of obtaining informed consent. Decisions should be based on an estimate of the risk of a procedure followed by the risk of the condition as modified by treatment, compared with the risk of the condition on medical treatment alone.1 Estimates of risks and benefits are dependent on a very complex amalgam of many clinical variables and not just the extent of ventricular dysfunction and pattern of coronary disease. The patients cannot be fully advised before coronary angiography but they should at least be introduced to the concepts behind decision-making and the possible outcomes following the angiogram. We perform revascularisation procedures to improve symptoms or improve prognosis. In the emergency setting PCI is usually the first-line approach as it is effective in a situation where the risks of CABG are high. After presenting with a non-STEMI ACS, patients stabilised on medical therapy are willing to undergo angiography as they understand that the effort is to try and prevent …

Background Over the last decade trans-radial access (TRA) has become more common than trans-femoral access (TFA) for Percutaneous Coronary Intervention (PCI) in the UK. Despite studies highlighting the benefits of this transition, there are concerns that the resulting drop in TFA activity has led to operators and centres losing TFA proficiency, compromising the safety and efficacy of procedures where TFA is necessary. Aims To evaluate the impact of each centre’s recent experience of the TFA approach on procedural outcomes in TFA-only procedures. Methods This retrospective cohort study used procedures recorded in the British Cardiovascular Intervention Society (BCIS) PCI audit from 2007 to 2013 in England and Wales. Centres were split into one of three groups depending on the proportion of total procedures undertaken via TFA in 2013, with patient and procedural characteristics for TFA-only procedures observed within these groups over time. By considering each centre’s access site choices in the 12 months prior to procedure date, simply-derived measures were used to capture the ‘recent TFA experience’ of the operating centre for each procedure. The association of these measures on 30-day mortality, after risk-adjustment, were then studied using multiple logistic regression. Results A total of 235,474 procedures were available for analysis. Unadjusted TFA-only mortality in centres who were early-adopters of TRA increased more rapidly than for centres who maintained high TFA activity, and this was driven by higher baseline risk. After case-mix adjustment, recent TFA experience was found to have no effect on 30-day mortality (OR=0.99 per 0.1 increase in recent TFA proportion; CI=0.96 to 1.01; p = 0.220), with similar results when restricting to procedures with low clinical-complexity (OR=0.98 per 0.1 increase in recent femoral proportion; CI=0.95 to 1.01; p = 0.245). Conclusions Poorer TFA outcomes for predominantly high TRA centres are driven by the propensity of these centres to utilise TFA in the highest risk patients. Once differences in case mix are adjusted for, TFA outcomes are similar between high and low radial proportion centres, with no evidence to suggest that increasing unfamiliarity with the TFA technique is detrimental. The outcome gains achieved by the national adoption of TRA is not attenuated by a loss of TFA proficiency, and centres should be encouraged to continue to adopt TRA as the default access site for PCI wherever possible.

Introduction As coronary perforation (CP) is a rare but serious complication of PCI the current evidence base is limited to small series. Using a national PCI database the incidence, predictors and outcomes of CP during PCI were defined. Methods Data were collected from the BCIS dataset on all PCI procedures performed in England and Wales between 2006 and 2013. Multivariate logistic regressions and propensity scores were used to identify predictors of CP and its association with outcomes. Results 1,762 coronary perforations were recorded from 527,121 PCI procedures (incidence of 0.33%). Patients with CP were more often female or older, with a greater burden of co-morbidity and underwent more complex PCI procedures. Factors independently predictive of CP included age (OR 1.03, 1.02–1.03, p Conclusions Using a national PCI database for the first time the incidence, predictors and outcomes of coronary perforation were conclusively defined. Although CP occurred of PCI rarely it was strongly associated with poor outcomes.

Introduction Primary PCI studies report 3-year mortality rates of 6–7%, but typically lack external validity or are from historical cohorts. To date, no long-term outcome study has accounted for factors other than primary PCI and variables identified at baseline. This is important because long-term survival is more likely to be influenced by factors not associated with the underlying disease or its early management. In the United Kingdom, continuous whole country PCI data are collected through the British Cardiovascular Intervention Society registry and deaths via the Office for National Statistics, providing a unique opportunity to undertake large scale phenotype and intervention-specific research. In order to address the limitations of previous studies, we utilised the UK national cardiovascular and population databases to report relative survival (RS) and excess mortality after PPCI. Methods All individuals in England and Wales with STEMI who received PPCI between 1 st January 2005 and 31 st December 2010 were matched by age, sex, year of procedure and country to English and Welsh population data. Estimates of cumulative relative survival rates (RSRs) and hazard rates were used to calculate expected survival, observed all-cause mortality rate ratios (MRR) and excess mortality rate ratios (EMRR). Crude RS was estimated using the Ederer II method for the whole cohort and cumulative RS estimated by age, sex and biennial year of procedure. Results There was a total of 50,181 STEMI treated by PPCI from 109 hospitals, (mean age (SD) 63.2 (13.1) years, 25.9% female, (total time at risk 94997.5 person years). 6 month, 1 and 5 year RSRs were 93.1%, 92.6% and 90.9% and approached the background rate for patients Conclusions Survival is excellent for young STEMI who receive PPCI. This study highlights long term excess mortality in the elderly and females who could be further stratified for existing and novel therapies to improve cardiovascular outcomes. Relative survival is an accurate, powerful and underused tool that may help identify opportunities to improve longer term cardiovascular outcomes.

Introduction Transcatheter Aortic Valve Implantation (TAVI) is being used increasingly in patients with severe symptomatic Aortic Stenosis (AS). There are few data on length of stay (LOS) in this elderly and co-morbid population. This study evaluates the safety of selective early discharge post TAVI. Methods Data were collected prospectively on all 121 patients who underwent TAVI between 2009 and October 2012. Subjects with severe symptomatic AS were selected for TAVI by the heart team if they had logistic Euroscore >20 and/or were deemed inoperable after direct surgical review. All patients received an Edwards Sapien or Sapien XT valve via transfemoral (n = 89), trans-apical (n = 23) or direct aortic (n = 9) routes. Complications (VARC-2 criteria), LOS and 30 day re-admissions were recorded. Pre-defined minimum LOS was discharge on day 3 post TAVI. Patients were divided into early ( Results Median LOS was 4 days. 40% of patients had been discharged by day 3 post TAVI and 61% by day 4. Transfemoral patients had a significantly shorter median LOS than other routes (3 days vs 6.5 days, p = 0.001). The overall early (30 day) re-admission rate was 10/121 (8.3%). There was no significant difference in re-admissions between the early and delayed discharge groups (9.5% vs 6.4%). There were no deaths between discharge and 30 days and no patients required readmission for PPM. Discussion This study suggests that selective early discharge post TAVI is not associated with higher rates of readmission, sudden death or PPM. Mean LOS of 6 days compares favourably to data from other centres reporting mean LOS of 6.8–15 days. Other studies have recorded readmission rates of between 8–15% so our policy of selective early discharge does not appear to be at a cost of higher readmission. Re-admission rate was lowest in our transfemoral group at 5.6%. Conclusion Selective early discharge following TAVI appears to be safe and is not associated with increased early readmission or delayed complications.

Introduction In high-risk patients with severe symptomatic aortic stenosis (AS) surgical AVR (sAVR) or Transcatheter Aortic Valve Implanation (TAVI) are established treatment options. Rates of permanent pacemaker (PPM) insertion post TAVI are dependent on valve type and vary from22.5% for Medtronic CoreValve to 5.9% for the Edwards heart valve system. We examined PPM rates in a real world registry of 136 consecutive TAVI patients to explore pre-TAVI and post-TAVI PPM implantation rates. We also used a comparator group of patients who underwent sAVR following heart team evaluation. Method Our unit is a regional referral centre with a catchment population of 1.5 million. Data was collected prospectively on all patients with severe symptomatic AS assessed in our TAVI heart team MDT (between 2009–2012). TAVI indications were either logistic Euroscore >20% or inoperable status as judged by direct surgical review and heart team discussion. PPMs were implanted prior to TAVI if patients had class I or II indications for pacing. The Edwards Sapien or Sapien XT heart-valve system was used in all TAVI procedures. Prospectively collected data included: co-morbidities, logistic Euroscore, and incidence of urgent/emergency PPM implantation post procedure. Results 136 patients underwent TAVI and 59 underwent sAVR following heart team review. TAVI patients were older and higher risk than sAVR patients (mean age 82 ± 7 vs 80yrs; mean log Euroscore 25 ± 13% vs 15 ± 9.7 %). Patients with existing PPM at baseline in the TAVI and sAVR cohort were 6.6% (n = 9) and 3.4% (n = 2), respectively. Six (4.4%) patients had a PPM electively implanted pre TAVI after heart team review. The incidence of PPM insertion following TAVI and sAVR was 3.7% (n = 5) and 5.1% (n = 3), respectively. In the TAVI cohort, three patients had PPM implanted peri-procedure and two were implanted within five days. sAVR patients had their PPM implanted electively at a mean 118 days post procedure. Conclusion/Implications Standard indications for PPM insertion in elderly patients pre-TAVI are common. Our post TAVI pacing rates are low and compare favourably to those seen in tightly controlled clinical trials. Requirement for PPM insertion post TAVI is also similar to sAVR.

At the European Society for Cardiology annual meeting in Stockholm at the end of August 2010, the new joint European Society of Cardiology (ESC) and European Association for Cardiothoracic Surgery (EACTS) guidelines on myocardial revascularisation were published online.1 These are a completely new set of guidelines which incorporate the 2006 percutaneous coronary intervention (PCI) guidelines on the management of stable angina pectoris2 and also contain important differences reflecting advances in the clinical management of ischaemic heart disease and advocating a more formal multidisciplinary approach to intervention in such patients. In contrast to previous guidelines for interventions in coronary artery disease produced independently by the cardiology and cardiac surgery communities, the new ESC/EACTS collaborative effort recognises the need for cohesive guidelines applicable to the management of the entire spectrum of coronary artery disease. While less severe disease can be adequately treated by lifestyle changes and optimal medical therapy, more severe disease may additionally require intervention by stenting or surgery. Accordingly, the writing committee, which was co-chaired by a cardiologist and a surgeon, consisted of 25 members in total and included nine non-interventional cardiologists, eight interventional cardiologists and eight cardiac surgeons. This is in marked contrast to the previous ESC guidelines task force which included a single cardiac surgeon among its 16 members.2 It should also be noted that the guidelines were produced without any commercial sponsorship from the pharmaceutical or interventional or surgical device industry, who are all powerful players in the cardiovascular arena. After several revisions, the guidelines were approved by the external reviewers from the respective societies. The ESC guidelines are based on a ‘comprehensive review of the published evidence’3 with a ‘formal meta-analysis at the beginning of the writing phase’.4 However, it has also to be acknowledged that, as with all guidelines, some …

Cardiac catheterisation and angiography uses ionising radiation and therefore produces a radiation dose to the patient and to the operating staff. The dose to the patient can be measured using thermoluminescent dosemeters placed on the skin or by using a large-area detector attached to the x ray tube to measure the dose–area product (DAP) for the incident x ray beam (DAP meter). The DAP is particularly useful for assessing and comparing the radiation dose from screening procedures. It provides a more useful indication of the overall patient exposure than measurement of surface dose at particular locations. The dose measurement is used either as a surrogate for radiation risk or as a step in actually estimating the risk. Published factors allow conversion of the DAP to effective dose, a derived quantity in which doses to different organs or tissues are weighted according to their radiosensitivity and summed to give a risk-related dose quantity.1–5 UK legislation does not give dose limits for patients undergoing medical diagnostic exposures, but requires adherence to the “as low as reasonably practicable” principle, and comparison of doses with diagnostic reference levels for common procedures. Published data for patient exposure, absorbed dose, effective dose and risk of malignancy from the different specific diagnostic cardiac catheterisation procedures are incomplete, and there are no national diagnostic reference levels for individual procedures. We undertook this study with the aim of establishing local patient doses for six different diagnostic cardiac catheterisation procedures …