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Near-infrared spectroscopy (NIRS) intravascular ultrasound imaging can detect lipid-rich plaques (LRPs). LRPs are associated with acute coronary syndromes or myocardial infarction, which can result in revascularisation or cardiac death. In this study, we aimed to establish the relationship between LRPs detected by NIRS-intravascular ultrasound imaging at unstented sites and subsequent coronary events from new culprit lesions.

Use of bivalirudin has been associated with a reduction in the incidence of bleeding in patients undergoing percutaneous coronary intervention. Patients with chronic kidney disease, a known predictor of post–percutaneous coronary intervention bleeding, are under-represented in clinical trials.

Prasugrel is a recently approved thienopyridine for use in patients with acute coronary syndromes undergoing percutaneous coronary intervention. There are no data on contemporary use of prasugrel in routine clinical practice.

The safety of glycoprotein (GP) IIb/IIIa inhibitors has been well documented in clinical trials. Although these trials have included a broad patient population, the strict enrollment criteria may have resulted in exclusion of patients at a higher risk of bleeding complications. The authors conducted a retrospective chart review of 1020 consecutive patients who received GP IIb/IIIa inhibitors and underwent percutaneous coronary intervention in a large community hospital. They used Thrombolysis in Myocardial Infarction (TIMI) criteria to define major or minor bleeding complications. Bleeding complications developed in 214 (21%) patients, with major bleeding in 89 (9%). Univariate predictors of bleeding were older age, lower body weight, elevated serum creatinine, higher activated partial thromboplastin time (aPTT) level, history of diabetes mellitus (DM), peripheral vascular disease (PVD), congestive heart failure (CHF), and emergency procedure for acute myocardial infarction (AMI). Multivariate predictors of major bleeding were PVD (20% in bleeding group vs 11% in nonbleeders, odds ratio [OR] = 1.8, 95% confidence interval [CI] = 1.2–2.6, P< .004), age (68 ± 2 years, 95% CI = 66–70 in bleeding group vs 63 ± 13 years, 95% CI = 61.2–63 in nonbleeders, P< .001), and higher aPTT level (66 ± 27 seconds, 95% CI = 63–70 in bleeding group vs 53 ± 28 seconds, 95% CI = 51–56 in nonbleeders, P< .001). The risk of bleeding in the large community hospital setting may be higher than in randomized clinical trials. This increased risk is associated with higher hospitalization costs. Recognition of predictors of bleeding should further enhance the safety of these antiplatelet agents.

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Objective:To evaluate the association of hospital and operator chronic total occlusion (CTO) percutaneous coronary interventions (PCI) volume with success rates and outcomes of patients undergoing CTO-PCI.Background:Few data exist for the association of CTO procedural volume and outcomes for CTO-PCI.Methods:We analyzed data from the Blue Cross Blue Shield Cardiovascular Consortium (BMC2) registry in Michigan (2010-2017) to evaluate the association of hospital and operator volumes with procedural success rates and outcomes of patients undergoing CTO PCI volumes. CTO PCI was defined as PCI of a 100% occluded major coronary artery presumed to be at least >3 months old.Results:Among 210,172 patients enrolled in the registry, 7,389 CTO PCIs were attempted with success rate of 53%. CTO-PCI success increased with hospital volume and was significantly higher in low volume operators at high volume centers than low volume operators at low volume hospitals (Figure 1). Major adverse events and death showed an inverse relationship with volume with highest mortality for CTO-PCI by low volume operators at low volume centers and lowest for high volume operators at high-volume centers (Figure 2).Conclusions:Operator and hospital CTO-PCI volumes were directly related to procedural success and inversely to death among patients undergoing CTO-PCIs. Low volume operators at high volume centers had significantly higher success and lower death rates compared with low volume operators at low volume centers. These data suggested that oversight of CTO-PCIs at low volume centers by high volume operators has the potential for improving the success rates and outcomes of CTO-PCIs at such hospitals.

Background:Interventions on CTO have been shown to be associated with improvement in angina. Previous data from registries have shown increased risk of adverse cardiac events for CTO compared with non-CTO PCI.Methods:To study the uptake and outcomes of CTO-PCI in Michigan, we evaluated all patients (excluding those with STEMI) enrolled in Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) registry (2010-2017). CTO PCI was defined as PCI of a 100% occluded major coronary artery presumed to be >3 months old.Results:Among 210,172 patients in the BMC2 registry, 7,389 CTO PCIs were attempted with 3,947 (53%) achieving post-PCI TIMI 3 flow. Overall the proportion of CTO-PCI among all PCI procedures increased over the study period (2.7%-2010 to 4.5%-2017). Pre-PCI assessment for ischemia was performed in 47% of patients and remained similar over time, Angina class <2 was present in a quarter of patients. Major complications occurred in 245 patients (3.3%) and included death in 106 (1.4%), post procedural stroke in 27 (0.4%), cardiac tamponade in 35 (0.5%) and urgent CABG in 95 patients (1.3%). Procedural success (defined as TIMI 3 flow without MACE and <50% residual stenosis) improved modestly (45%-2010 to 55%-2017 (p for trend <0.001, Figure). However, hospital death and MACE for CTO-PCI remained unchanged over the study period (p for trends 0.247 and 0.859) (Figure). These events were lowest for stable angina and highest in NSTE patients undergoing CTO-PCI.Conclusions:Performance of CTO-PCI in Michigan has increased over time. While the success rate of CTO-PCI has increased modestly, procedural MACE or death have remained steady over the study period. With expected increased in the performance of CTO PCIs, our data suggested room for improvement in the selection and functional assessment of patients undergoing CTO-PCI before subjecting them to the increased risk of this procedure.

Background:The National Cardiogenic Shock Initiative (NCSI) is a single-arm, prospective, multicenter study to assess clinical outcomes associated with early mechanical circulatory support (MCS) in patients presenting with acute myocardial infarction and cardiogenic shock (AMICS) treated with percutaneous coronary intervention (PCI).Methods:From July 2016 to May 2019, patients who presented with AMICS to the 65 participating hospitals were included in the study and were treated using a standard protocol with invasive hemodynamic monitoring, early MCS and PCI. Patients were stratified based on the age and 4 cohorts were generated: <50, 50-59, 60-69, and >=70 years old.Results:A total of 213 patients were included, 28 were <50 years old, 55 were 50 to 59 years old, 58 were 60 to 69 years old, and 73 were >=70 years old. There was significantly difference in mortality among groups; using patients younger than 50 years old as the reference (35.6% mortality), the mortality for patients aged 50 to 59 was 25.5% (OR: 9.22 p=0.037), 34.5% for patients 60 to 69 years old (OR: 14.2, p=0.012), and 42.5% for patients 70 years or older (OR: 19.2, p=0.004). A lactic acid greater than 4 mmol/dl was associated with higher mortality in older cohorts.There was no significant difference in the rates of acute kidney injury among cohorts. Patients in the younger cohorts required additional support and had longer length of stay when compared to the older cohorts. Radial access was less commonly used in patients older than 70 years old (13.7%) and more common in younger than 50 years old (28.6%).Conclusion:The odds of inpatient mortality is proportional to the patient age group, which could be as high as 20 times higher for patients 70 years and older, 14 times higher in patients 60 to 69 years old, and 9 times higher in patients 50 to 59 years old, when compared with patients younger than 50 years old. There is a cumulative risk with age and a lactic acid greater than 4 mmol/dl to predict mortality in AMICS.