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Background: In patients with atrial fibrillation (AF) undergoing percutaneous coronary intervention (PCI), selecting an antithrombotic regimen requires balancing risks of ischemic cardiac events, stroke, and bleeding. Methods: We studied 467 patients with AF undergoing PCI in the time period from December 2015 to July 2018 identified via a chart audit by 47 Canadian cardiologists in the CONNECT AF+PCI (the Coordinated National Network to Engage Interventional Cardiologists in the Antithrombotic Treatment of Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) study, to determine patterns of initial antithrombotic therapy selection. Results: The median (25th, 75th percentile) CHADS2 score was 2 (1, 3), and PCI was performed in the setting of acute coronary syndrome in 62.1%. Triple antithrombotic therapy (TAT) was the initial treatment in 62.7%, dual-pathway therapy in 25.7%, and dual antiplatelet therapy in 11.6%, with a temporal increase in use of dual-pathway therapy during the course of the study; median intended TAT duration was 1 (1, 3) month. Compared with patients selected for TAT, patients selected for dual-pathway therapy were less likely to have prior myocardial infarction (35.8% vs 25.8%, P = 0.045) and prior PCI (33.8% vs 23.3%, P = 0.03), and they received shorter total length of stents (38 [23, 56] vs 30 [20, 46] mm, P = 0.03). Patients selected for dual-pathway therapy had a higher prevalence of prior stroke/transient ischemic attack (13.0% vs 23.3%, P = 0.01). There was no difference in prevalence of anemia (21.5% vs 25.8%, P = 0.30). Use of dual-pathway therapy was similar among patients with acute coronary syndrome and those with stable disease (24.1% vs 28.2%, P = 0.32). Conclusions: Approximately one-quarter of AF patients undergoing PCI are treated with dual-pathway therapy in Canadian practice, with its use increasing during the studied period. Patients selected for dual-pathway therapy have less-complex coronary disease history and intervention. Résumé: Introduction: Les patients atteints de fibrillation auriculaire (FA) qui subissent une intervention coronarienne percutanée (ICP) et choisissent un schéma posologique antithrombotique ont besoin de peser les risques d’événements cardiaques d’origine ischémique, d’accidents vasculaires cérébraux et d’hémorragies. Méthodes: Les 467 patients atteints de FA ayant subi une ICP de décembre 2015 à juillet 2018 qui ont fait l’objet de notre étude ont été trouvés lors de la vérification des dossiers par 47 cardiologues canadiens de l’étude CONNECT AF+PCI (Coordinated National Network to Engage Interventional Cardiologists in the Antithrombotic Treatment of Patients With Atrial Fibrillation Undergoing Percutaneous Coronary Intervention) pour déterminer les schémas de sélection du traitement antithrombotique initial. Résultats: Le score CHADS2 médian (25e, 75e percentile) était de 2 (1, 3), et l’ICP avait été réalisée dans le cadre du syndrome coronarien aigu chez 62,1 % des patients. La trithérapie antithrombotique (TTA) était le traitement initial chez 62,7 % des patients, la bithérapie, chez 25,7 % des patients, et la bithérapie antiplaquettaire, chez 11,6 % des patients, mais il y avait une augmentation temporelle dans l’utilisation de la bithérapie durant l’étude; la durée médiane prévue de la TTA était de 1 (1, 3) mois. Comparativement aux patients sélectionnés pour la TTA, les patients sélectionnés pour la bithérapie étaient moins susceptibles d’avoir eu un infarctus du myocarde précédent (35,8 % vs 25,8 %, P = 0,045) et une ICP précédente (33,8 % vs 23,3 %, P = 0,03), et recevaient des endoprothèses de longueur totale plus courte (38 [23, 56] vs 30 [20, 46] mm, P = 0,03). Les patients sélectionnés pour la bithérapie montraient une prévalence plus élevée d’accidents vasculaires cérébraux/accidents ischémiques transitoires (13,0 % vs 23,3 %, P = 0,01). Il n’existait aucune différence dans la prévalence de l’anémie (21,5 % vs 25,8 %, P = 0,30). L’utilisation de la bithérapie était similaire chez les patients atteints d’un syndrome coronarien aigu et chez les patients dont la maladie était stable (24,1 % vs 28,2 %, P = 0,32). Conclusions: Dans la pratique canadienne, environ le quart des patients atteints de FA qui subissent une ICP sont traités par bithérapie, mais durant la période étudiée, son utilisation avait augmenté. Les patients sélectionnés pour la bithérapie ont des antécédents et des interventions liées aux maladies coronariennes moins complexes.

BACKGROUND The Coordinated National Network to Engage Cardiologists in the antithrombotic Treatment of patients with Atrial Fibrillation undergoing Percutaneous Coronary Intervention (CONNECT AF+PCI-I) program provided a snapshot (Nov 2015-Jul 2018) of the antithrombotic management of 467 non-valvular atrial fibrillation (NVAF) patients undergoing PCI in Canada (Bagai et al Can J Cardiol 2018;34:S16). Since then, further randomized clinical trials have supported updated Canadian Cardiovascular Society (CCS) AF and Antiplatelet guideline recommendations for antithrombotic strategies for NVAF and coronary artery disease (CAD) patients undergoing PCI and/or medical management. Thus, an updated quality enhancement assessment in Canadian practice (CONNECT AF+PCI-II) was undertaken. METHODS AND RESULTS By retrospective chart audit (Aug 2018-Dec 2020), 68 cardiologists from 8 provinces identified 626 patients with NVAF. 37% had stable CAD, 56% had an acute coronary syndrome (ACS) and PCI, and 7% had an ACS and were medically managed. Median age was 76 (25th,75th percentiles 69, 83; 87% ≥65 years); 29% female; 38% diabetes; median CHADS2 score 2 (1, 3); median CHA2DS2-VASc score 4 (3, 5); median HAS-BLED score 3 (2, 3). 73% were receiving oral anticoagulation (OAC) before the index ACS/PCI (apixaban 31%, rivaroxaban 24%, dabigatran 6%, edoxaban 2%, warfarin 10%). Initial antithrombotic therapy after the index ACS/PCI was: 53% triple therapy (OAC+dual antiplatelet therapy [DAPT=ASA+P2Y12 receptor inhibitor], 31% OAC+P2Y12 inhibitor, 9% DAPT, 4% OAC+ASA, 2% OAC alone, and CONCLUSION While triple therapy remains the most common initial antithrombotic strategy used in AF patients undergoing PCI and/or admitted with ACS in Canada, treatment duration has shortened over time. Further, more patients are receiving CCS guideline-recommended OAC+ P2Y12 receptor inhibitor post-PCI compared to previously, and OAC monotherapy 1 year post-ACS/PCI.

BACKGROUND Chronic kidney disease (CKD) increases the risk of adverse outcomes in acute coronary syndrome (ACS). The optimal regimen of dual antiplatelet therapy (DAPT) post percutaneous coronary intervention (PCI) is challenging due to both increased bleeding and thrombotic risks in patients with CKD, particularly since these patients were under-represented in randomized controlled trials. We examined the patterns of DAPT use in ACS patients post PCI stratified by presence of CKD. METHODS AND RESULTS The multi-centre prospective Canadian Observational Antiplatelet Study (COAPT) enrolled patients with an ACS diagnosis from 43 hospitals between December 2011-May 2013. The present study is a subgroup analysis comparing type and duration of DAPT, and associated outcomes among patients with and without CKD defined as eGFR CONCLUSION Patients with CKD had a shorter DAPT duration and were less frequently prescribed potent P2Y12 inhibitors than patients without CKD. Overall, compared with patients without CKD, patients with CKD had higher rates of MACE and similar bleeding rates. However, among those prescribed more potent P2Y12 inhibitors, CKD was associated with more bleeding than those without CKD. Further studies are needed to better define the benefit/risk ratio, and establish a more tailored and evidence-based DAPT regimen for this high-risk patient group.

BACKGROUND Whether polymeric bioresorbable vascular scaffolds (BVS) implantation with transradial approach is feasible and safe is unknown. We compared the feasibility and safety of the transradial approach for BVS delivery with metallic drug-eluting stents (DES). METHODS We identified 118 consecutive patients who underwent BVS implantation and we compared 30-days and 1-year results with 118 matched patients with DES. Patients were matched for age, sex, risk factors and clinical indication. RESULTS Rates of transradial approach were 98% in the BVS group vs 95% in the DES group (P = 0.16) with 5Fr used in 38% and 32% (P = 0.34), respectively. The number of stents was similar in both groups, 2.6 ± 1.5 vs 2.4 ± 1.3 (P = 0.23). Although maximal pressure for stent deployment was identical in both groups (16 ± 3 atm), more lesions were pre-dilated (83% vs 52%, P

Background After myocardial infarction (MI) treated with percutaneous coronary intervention (PCI), guidelines recommend dual antiplatelet therapy (DAPT) with aspirin and an ADP receptor inhibitor (ADPri) for at least 1year. However, whether real-world Canadian practice patterns reflect this recommendation is unknown. Methods We studied 2175 MI patients treated with PCI and discharged from 26 Canadian hospitals between 12/2011 and 05/2013 in the Canadian Observational Antiplatelet sTudy (COAPT). Hierarchical Cox proportional hazard regression modeling was used to determine baseline demographic and clinical factors associated with duration of ADPri therapy post-discharge. Results At index-hospitalization discharge, 1597 (73%) patients were treated with clopidogrel, 220 (10%) with prasugrel, and 358 (17%) with ticagrelor. ADPri was discontinued prior to 1year in 474 (21.8%) patients; discontinuation rates were lowest for patients discharged on prasugrel (17.7%), compared with clopidogrel (22.5%) or ticagrelor (21.0%), (log rank test, p =0.03). In addition to regional variability, factors associated with shorter ADPri duration included older age, low body weight, Killip III/IV heart failure, atrial fibrillation, ticagrelor on discharge, and bare metal stent use, while longer ADPri duration was associated with history of prior MI. Conclusions One in five PCI-treated MI patients did not complete Canadian guideline-recommended 1-year course of ADPri treatment. Premature ADPri discontinuation was most strongly associated with factors that increase the risk of bleeding. Further study is required to assess the clinical implications of premature ADPri discontinuation on patient outcomes.

Background Contemporary use of dual antiplatelet therapy and consistency with guideline recommendations in acute coronary syndrome patients undergoing percutaneous coronary intervention (PCI) have not been well characterized. Methods The COAPT was a prospective, observational, multicenter, longitudinal study of patients with myocardial infarction (MI) undergoing PCI. Baseline characteristics, treatment patterns, processes of care, factors associated with switching to and from novel adenosine diphosphate receptor inhibitors (ADPris), and in-hospital outcomes are described. Results Among 2,179 MI patients undergoing PCI during their index hospitalization, 1,328 (60.9%) had ST elevation. Initial ADPri use included clopidogrel in 1,812 (83.2%), prasugrel in 125 (5.7%), and ticagrelor in 242 (11.1%). At discharge, 1,597 patients (73.4%) were prescribed clopidogrel, 220 (10.1%) prasugrel, and 358 (16.5%) ticagrelor. Switching between ADPri therapies during the index hospitalization occurred in 15.3%, 22.4%, and 25.2% of patients initially started on clopidogrel, prasugrel, and ticagrelor, respectively. Most switches over the 15-month study period occurred during the index admission (16.8% of patients vs 4.4% switches postdischarge). Major adverse cardiovascular events occurred in 7.5% of patients during the index hospitalization. In-hospital bleeding events occurred in 6.0% of patients and most were mild. Conclusions Despite randomized trial evidence and guideline recommendations, only a minority of Canadian MI patients undergoing PCI initially received or were discharged on one of the newer ADPri agents. These findings suggest an opportunity to improve upon the appropriate selection of the ADPris at index hospitalization and discharge in Canadian MI patients undergoing PCI.

Current guideline-based recommendations for oral dual-antiplatelet therapy in an acute coronary syndrome (ACS) include the use of newer adenosine diphosphate receptor inhibitor (ADPri) regimens and agents. The Canadian ACS Reflective Program is a multicenter observational quality-enhancement project that compared the use of ADPri therapy in 2 phases (November 2011-March 2013 and April 2013-November 2013) and also compared ADPri use with previous national data from the Canadian Global Registry of Acute Coronary Events (2000-2008). Of 3099 patients with ACS, 30.6% had ST-segment elevation myocardial infarction (STEMI), 52.3% had non-STEMI, and 17% had unstable angina. There was high use of dual-antiplatelet therapy for ≤ 24 hours, with important increases noted when compared with previous national experience (P for trend, < 0.0001). Clopidogrel was the most commonly used ADPri (82.2%), with lower use of the newer agents ticagrelor (9.0%) and prasugrel (3.1%). Ticagrelor and prasugrel use was most frequent in patients with STEMI undergoing percutaneous coronary intervention PCI (34.3%). There was relatively lower use of ADPri therapy at discharge; it was given mainly to patients who did not undergo PCI (68.2%) and to those with non-ST-elevation ACS (82%). When comparing the 2 consecutive phases of data collection in the ACS Reflective, there was an approximate 3- and 2-fold increase in the early and discharge use of the newer ADPri agents, respectively. In conclusion, there has been a temporal increase in ADPri use compared with previous national experience and an increased uptake of newer ADPri agents. Additional work is needed to identify and address barriers limiting optimal implementation of these newer guideline-recommended agents into routine Canadian practice.

ObjectivesThis study sought to determine the efficacy of low rate fluoroscopy at 7.5 frames/s (FPS) versus conventional 15 FPS for reduction of operator and patient radiation dose during diagnostic coronary angiography (DCA) and percutaneous coronary intervention (PCI) via the transradial approach (TRA).BackgroundTRA for cardiac catheterization is potentially associated with increased radiation exposure. Low rate fluoroscopy has the potential to reduce radiation exposure.MethodsPatients undergoing TRA diagnostic angiography ± ad-hoc PCI were randomized to fluoroscopy at 7.5 FPS versus 15 FPS prior to the procedure. Both 7.5 and 15 FPS fluoroscopy protocols were configured with a fixed dose per pulse of 40 nGy. Primary endpoints were operator radiation dose (measured with dosimeter attached to the left side of the thyroid shield in μSievert [μSv]), patient radiation dose (expressed as dose-area product in Gy·cm2), and fluoroscopy time.ResultsFrom October 1, 2012 to August 30, 2013, from a total of 363 patients, 184 underwent DCA and 179 underwent PCI. Overall, fluoroscopy at 7.5 FPS compared with 15 FPS was associated with a significant reduction in operator dose (30% relative reduction [RR], p < 0.0001); and in patient's dose-area product (19% RR; p = 0.022). When stratified by procedure type, 7.5 FPS compared with 15 FPS was associated with significant reduction in operator dose during both DCA (40% RR; p < 0.0001) and PCI (28% RR; p = 0.0011). Fluoroscopy at 7.5 FPS, compared with 15 FPS, was also associated with substantial reduction in patients' dose-area product during DCA (26% RR; p = 0.0018) and during PCI (19% RR; p = 0.13). Fluoroscopy time was similar in 7.5 FPS and 15 FPS groups for DCA (3.4 ± 2.0 min vs. 4.0 ± 4.7 min; p = 0.42) and PCI (11.9 ± 8.4 min vs. 13.3 ± 9.7 min; p = 0.57), respectively.ConclusionsFluoroscopy at 7.5 FPS, compared with 15 FPS, is a simple and effective method in reducing operator and patient radiation dose during TRA DCA and PCI.

ObjectivesTo study the causes of and to develop a risk score for failure of transradial approach (TRA) for percutaneous coronary intervention (PCI).BackgroundTRA-PCI failure has been reported in 5% to 10% of cases.MethodsTRA-PCI failure was categorized as primary (clinical reasons) or crossover failure. Multivariate analysis was performed to determine independent predictors of TRA-PCI failure, and an integer risk score was developed.ResultsFrom January to June 2010, TRA-PCI was attempted in 1,609 (97.3%) consecutive patients, whereas 45 (2.7%) had primary TRA-PCI failure. Crossover TRA-PCI failure occurred in 30 (1.8%) patients. Causes of primary TRA-PCI failure included chronic radial artery occlusion (11%), previous coronary artery bypass graft (27%), and cardiogenic shock (20%). Causes for crossover TRA-PCI failure included: inadequate puncture in 17 patients (57%); radial artery spasm in 5 (17%); radial loop in 4 (13%); subclavian tortuosity in 2 (7%); and inadequate guide catheter support in 2 (7%) patients. Female sex (odds ratio [OR]: 3.2; 95% confidence interval [CI]: 1.95 to 5.26, p < 0.0001), previous coronary artery bypass graft (OR: 6.1; 95% CI: 3.63 to 10.05, p < 0.0001), and cardiogenic shock (OR: 11.2; 95% CI: 2.78 to 41.2, p = 0.0011) were independent predictors of TRA-PCI failure. Risk score values from 0 to 7 predicted a TRA-PCI failure rate from 2% to 80%.ConclusionsIn a high-volume radial center, 2.7% of patients undergoing PCI are excluded from initial TRA on clinical grounds, whereas crossover to femoral approach is required in only 1.8% of the cases. A new simple clinical risk score is developed to predict TRA-PCI failure.

Door-to-balloon (DTB) time is an important metric in primary percutaneous coronary intervention (PCI) for acute ST-segment elevation myocardial infarction to optimize clinical outcomes. The aim of this study was to compare the impact of immediate PCI on culprit lesions in patients with ST-segment elevation myocardial infarctions versus diagnostic angiography followed by PCI on DTB times and procedural data at a high-volume tertiary care radial center. All patients who underwent primary PCI12 hours after symptom onset were studied. Procedural data and all-cause mortality were assessed in all patients. The primary outcome was DTB time. From January 2006 to June 2011, 1,900 patients were included and divided into 2 groups: 562 patients (30%) underwent primary PCI followed by contralateral diagnostic angiography, and 1,338 patients (70%) underwent diagnostic angiography before primary PCI. No significant differences were observed in baseline characteristics. Left anterior descending coronary artery-related ST-segment elevation myocardial infarctions were more often found in patients who underwent PCI first (54% vs 34%, p0.0001). Overall, there was a reduction of 8 minutes in DTB time between patients who underwent PCI first and those who underwent angiography first (32 minutes [interquartile range 24 to 52] vs 40 minutes [interquartile range 30 to 69], respectively, p0.0001). After adjustment, immediate PCI remained an independent predictor of DTB time ≤90 minutes (odds ratio 2.42, 95% confidence interval 1.70 to 3.52, p0.0001). There were no differences in early and late clinical outcomes. In conclusion, a strategy of transradial direct PCI of the infarct-related artery in selected patients before complete coronary angiography was associated with a benefit of 8 minutes in DTB time. Further study is required to determine whether this strategy can favorably affect clinical outcomes.

The association between cardiogenic shock and 1 or1 chronic total occlusion (CTO) in unselected patients presenting with ST-elevation myocardial infarction (MI) (STEMI) has not been characterized.Patients with STEMI referred with or without cardiogenic shock were categorized into no CTO, 1 CTO, and1 CTO. The primary end point was the 30-day mortality.Between 2006 and 2011, 2,020 consecutive patients were included. A total of 141 patients (7%) presented with cardiogenic shock on admission. The prevalence of 1 CTO and1 CTO in a non-infarct-related artery was 23% and 5%, respectively, among patients with shock compared with 6% and 0.5% in patients without shock (P.0001). Independent predictors of cardiogenic shock included left main-related MI (odds ratio [OR] 6.55, 95% CI 1.39-26.82, P = .019), CTO (OR 4.20, 95% CI 2.64-6.57, P.001), creatinine clearance60 mL/min (OR 3.41, 95% CI 2.32-4.99, P.0001), and left anterior descending-related MI (OR 2.20, 95% CI 1.51-3.23, P.0001). Thirty-day mortality was 100% in shock patients with1 CTO, 65.6% with 1 CTO, and 40.2% in patients without CTO (P.0001). After adjustment for left ventricular ejection fraction and renal function, CTO remained an independent predictor for 30-day mortality (hazard ratio [HR] 1.83; 95% CI 1.10-3.01, P = .02).In patients with STEMI, CTO was strongly associated with cardiogenic shock on admission. In this setting, mortality was substantially higher in patients with 1 CTO and exceedingly high in those with1 CTO. The presence of CTO was an independent predictor of early mortality.

The objective of this study was to evaluate the impact of diffuse coronary atherosclerosis on the functional evaluation of moderate coronary lesions in the proximal-mid segment of a coronary artery and its clinical implications. This was a prospective study including 100 consecutive patients with a moderate lesion (45 ± 9% diameter stenosis) in the proximal-mid coronary segment who were evaluated with fractional flow reserve (FFR) measurement. No patient had any other angiographic stenosis distal to the evaluated coronary stenosis. FFR measurements were obtained just distal (~2 to 3 cm) to the lesion (FFR proximal measurement [FFR-PM]) and as distally as possible in the artery (FFR distal measurement [FFR-DM]) after administration of the same dose of intracoronary adenosine. Thirty-nine patients underwent dipyridamole or exercise myocardial single-photon emission computed tomography within 3 months of the FFR study. Mean FFR-PM was significantly higher compared to FFR-DM (0.84 ± 0.08 vs 0.78 ± 0.09, median gradient 0.06, 25th to 75th interquartile range 0.02 to 0.10, p0.0001). FFR-DM was0.75 in 33% of patients with FFR-PM ≥0.75, leading to the decision of revascularization in these patients. Performing FFR measurement in the left main/left anterior descending artery predicted a higher gradient between FFR-DM and FFR-PM (odds ratio 4.58, 95% confidence interval 1.4 to 15.03, p = 0.007). FFR-DM exhibited a better correlation with results of myocardial single-photon emission computed tomography compared to FFR-PM (kappa 0.33 vs 0.22, p0.0001). In conclusion, significant differences between FFR-DM and FFR-PM were observed in patients with moderate coronary stenosis in the proximal-mid segment of a coronary artery, with FFR-DM exhibiting a better correlation with results of noninvasive functional tests. These differences influenced the treatment decision in about 1/3 of patients and highlight the potential clinical relevance of coronary pressure wire positioning for functional evaluation of lesions in the proximal-mid segment of the coronary arteries.

Primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) may be limited by thrombus embolization. Export aspiration catheter (EAC) is a thrombectomy device which may enhance angiographic results, but its impact on clinical outcomes is unclear. This trial objective was to assess the impact of EAC on angiographic and clinical outcomes in patients with STEMI.All STEMI patients undergoing primary or rescue PCI in a tertiary care center were included. Patients were divided in two groups according to the use of the EAC. Patients were followed up prospectively for death, reinfarction, revascularization, or stroke. Thrombolysis In Myocardial Infarction (TIMI) flow in the culprit vessel was assessed before and after PCI.Included in the analysis were 535 patients. EAC was used in 165 patients before angioplasty (Group 1) and 370 patients underwent PCI without thrombus aspiration (Group 2). More patients in Group 1 had initial TIMI flow 0-1 compared to Group 2 (88% vs. 62%, P.001). Proportion of patients with a final TIMI flow 3 was the same in both groups (89.1% vs. 87.6% for Groups 1 and 2, respectively; P=.67). An analysis restricted to patients with initial TIMI flow 0-1 yielded similar results. No difference in clinical outcomes was observed between the two groups (P=.70).Selective use of the EAC based on the judgment of operators results in excellent angiographic and clinical results. Further clinical investigation is needed to definitely answer whether thromboaspiration needs to be performed in all STEMI patients undergoing primary PCI.

Anemia and major bleeding are independent predictors of outcomes after acute coronary syndromes and percutaneous coronary intervention (PCI). Although the transradial approach reduces the incidence of bleeding, the hemoglobin changes after transradial PCI have not been defined. We serially assessed the hemoglobin values before and after transradial PCI and evaluated the effect of hemoglobin changes on outcomes. In the EArly Discharge After Transradial Stenting of CoronarY Arteries (EASY) trial, 1,348 patients underwent transradial PCI. All patients received aspirin, clopidogrel, and a bolus of abciximab before PCI. The hemoglobin values were assessed immediately before and 4 to 6 hours and 12 to 24 hours after PCI. The major adverse cardiac events (death, myocardial infarction, and target vessel revascularization) were assessedor =3 years after PCI. According to the World Health Organization classification, 206 patients (15%) had anemia before PCI and 410 (30%) developed anemia within 24 hours after PCI. A mean hemoglobin decrease of 0.6 +/- 1.0 g/dl occurred within 24 hours after PCI. At 30 days, the major adverse cardiac events were significantly increased when the hemoglobin decrease within 24 hours after PCI was3 g/dl (p = 0.0002). Patients with anemia within 24 hours after PCI had significantly more major adverse cardiac events at 30 days, 6 months, 1 year, and 3 years than patients without anemia (log-rank p = 0.0044). After adjustment for differences in the baseline characteristics, anemia within 24 hours after PCI remained an independent predictor of major averse cardiac events at 3 years (hazard ratio 1.30, 95% confidence interval 1.01 to 1.67, p = 0.045). In conclusion, within 24 hours after transradial PCI with maximal antiplatelet therapy, only a mild hemoglobin decrease was observed. The choice of a hemoglobin decrease3 g/dl after PCI as a cutoff value for current definitions of major bleeding in modern PCI trials appears reasonable. Measures to prevent anemia and blood loss during PCI remain to be further studied.

Objectives The aim of this study was to determine whether a very early imaging strategy improves the prediction of late systolic dysfunction and poor outcomes in ST-segment elevation myocardial infarction (STEMI) compared with traditional predictors. Background Earlier prediction of poor outcomes after STEMI is desirable, because it will allow tailored therapy at the earliest possible time, when benefits might be greatest. Methods One hundred and three patients with acute STEMI were studied by contrast-enhanced cardiovascular magnetic resonance within 12 h of primary angioplasty and at 6 months and followed >2 years. The primary end point was left ventricular (LV) dysfunction, whereas poor outcomes were a key secondary end point. Results Traditional risk factors were only modest predictors of late LV dysfunction. Late gadolinium enhancement (LGE) volume maintained a stronger association to LV ejection fraction change than infarct transmurality, microvascular obstruction, or myocardial salvage during STEMI (p = 0.02). Multivariable logistic regression identified LGE volume during STEMI as the best predictor of late LV dysfunction (odds ratio: 1.36, p = 0.03). An LGE ≥23% of LV during STEMI accurately predicted late LV dysfunction (sensitivity 89%, specificity 74%). The LGE volume provided important incremental benefit for predicting late dysfunction (area under the curve = 0.92, p ≤ 0.03 vs. traditional risk factors). Twenty-three patients developed poor outcomes (1 death, 2 myocardial infarctions, 5 malignant arrhythmias, 4 severe LV dysfunction Conclusions During the hyperacute phase of STEMI, LGE volume provides the strongest association and incremental predictive value for late systolic dysfunction and discerns poor late outcomes.

The 2016 Canadian Cardiovascular Society (CCS) Guidelines for the management of Dyslipidemia recommend to consider a target of

Background In the EASY trial, we have shown the clinical equivalence between abciximab bolus-only and abciximab bolus followed by 12-h infusion in a wide spectrum of patients after percutaneous coronary intervention (PCI). Some reports have suggested better outcomes following intracoronary (IC) abciximab administration compared to intravenous (IV) delivery. We sought to compare cardiac biomarkers release and early and late clinical outcomes after IC or IV abciximab bolus delivery. Methods From 1005 patients randomized in the EASY trial and undergoing transradial coronary stent implantation, 208 received IC abciximab bolus and 797 received IV abciximab bolus. Route of administration was left to operators' discretion. Creatine Kinase-MB, and Troponin-T (Tn-T) were obtained immediately prior to angiography, 4–6 h after PCI and the next day. MACE (death, MI, TVR) rate was evaluated at 30 days, 6 months and 12 months. Results There were more patients with acute coronary syndrome (75% vs 64%, P =0.004) and previous MI (53% vs 42%, P =0.005) in the IC group and more patients with ≥3 dilated sites in the IV group (2% IC vs 7% IV, P =0.03). After PCI, the extent of Tn-T and CK-MB release remained comparable in both groups. The MACE rate was 2% in both groups at 30 days, 9% in IC bolus vs 5% in IV bolus ( P =0.04) at 6 months and 10% in IC bolus vs 9% in IV bolus ( P =0.50) at 12 months. By multivariate analysis, IC abciximab bolus was not associated with better outcomes at 12 months compared to IV bolus (HR 1.07, 95% CI 0.82–1.35, P =0.62). Conclusion Compared to IV abciximab administration, IC abciximab was not associated with less cardiac biomarkers release or better clinical outcomes after uncomplicated transradial PCI. Further studies are required in clinical scenarios including patients with higher thrombotic burden and/or occluded vessels as in primary and rescue PCI.

The objectives of this study were to evaluate the usefulness of fractional flow reserve (FFR) measurements to guide the clinical decision in patients with intermediate left main coronary artery (LMCA) stenosis and to determine the predictors of major adverse cardiac events (MACE) -- cardiac death, myocardial infarction, coronary revascularization -- in such cases; 142 consecutive patients with intermediate LMCA stenosis (mean percent diameter stenosis 42 +/- 13%) were included. All patients underwent FFR measurement after intracoronary administration of adenosine at a doseor =30 microg. The clinical decisions were based on FFR as follows: coronary revascularization was recommended if FFR was0.75, medical treatment if FFR was0.80, and individualized decision based on additional clinical data if FFR was between 0.75 and 0.80. Mean FFR was 0.81 +/- 0.09 after the administration of 176 +/- 99 microg of adenosine. Based on FFR results, 60 patients (42%) underwent coronary revascularization, and 82 patients (58%) received medical treatment. At 14 +/- 11 months follow-up, the incidence of MACE related to the LMCA stenosis was 13% in the medical treatment group and 7% in the revascularization group (p = 0.27). The incidence of cardiac death or myocardial infarction was 6% in the medical treatment group and 7% in the revascularization group (p = 0.70). In the medical treatment group, with MACE had received a lower dose of intracoronary adenosine (86 +/- 57 vs 167 +/- 102 microg; odds ratio 1.39 for each decrease of 30 microg of intracoronary adenosine, 95% confidence interval 1.02 to 1.89) and more frequently had diabetes (55% vs 21%; odds ratio 4.40, 95% confidence interval 1.17 to 16.42). In conclusion, FFR measurement is helpful in guiding the decision whether to revascularize patients with intermediate LMCA stenosis. However, patients with diabetes remain at higher risk, and higher doses than previously recommended of intracoronary adenosine might have to be used in the evaluation of LMCA stenosis.

Background Long-term clinical follow-up has shown a significant benefit after percutaneous coronary intervention (PCI) for abciximab bolus followed by 12-hour infusion over placebo or bolus-only. With contemporary techniques and clopidogrel pretreatment, it is unknown whether the 12-hour infusion is still associated with a clinical benefit. The purpose of this study is to compare 6- and 12-month clinical outcomes in patients treated after PCI with abciximab bolus-only and abciximab bolus followed by 12-hour infusion. Methods After a bolus of abciximab (0.25 mg/kg) and uncomplicated transradial coronary stenting, 1,005 patients were randomized either to same-day discharge and no infusion of abciximab (bolus-only group, n=504) or to overnight hospitalization and 12 hours (0.125 μg/[kg min]) of abciximab infusion (bolus + infusion group, n=501). The rate of major adverse cardiovascular events (MACE) was evaluated at 30 days, 6 months, and 12 months. Results At 30 days, the rate of MACE including death, myocardial infarction, and target vessel revascularization was similar in the 2 groups: 1.4% in the bolus-only group versus 1.8% in the bolus + infusion group ( P = .63). At 6 months, the MACE rate was 5.6% in the 2 randomized groups. At 12 months, the MACE rate was also similar in both groups: 8.7% in the bolus-only group and 9.2% in the bolus + infusion group (hazard ratio 0.97, 95% CI 0.79-1.20, P = .80). Similar efficacy was also observed in several subgroups including higher-risk patients such as those with elevated troponin T before PCI. Conclusions In patients pretreated with clopidogrel and undergoing uncomplicated coronary artery stenting, there is no difference in the 6- and 12-month outcomes between patients treated with abciximab bolus-only versus those treated with bolus + infusion, a finding consistent with the initial 30-day outcomes.

Outpatient practice after percutaneous coronary intervention (PCI) is gaining momentum due to constantly optimizing results. Furthermore, the availability of limited beds to handle the large volume of coronary interventions also promotes outpatient practice. The present report relates the current experience with same-day discharge and defines persisting challenges in promoting accelerated in-hospital turnover. Since the mid-1990s, there have been several reports on same-day discharge following uncomplicated procedures. Overall, the success of outpatient PCI practice is based on a few technological and pharmacological advances. First, the systematic use of stents and potent antiplatelet agents have revolutionized the acute success rates of PCI by virtually eliminating the risks of acute vessel closure within the first 24 h following a successful procedure. Second, the miniaturization of catheter sizes has also simplified access site management, accelerated ambulation time and limited the risks of puncture site bleeding. In this regard, the transradial approach initially described in Canada and later popularized in Europe has transformed the acute care of patients after PCI. Today, however, the practice of transradial PCI still varies largely from country to country. From the literature review, it appears that after a short period of observation (4 h to 6 h), the majority of eligible patients who have undergone uncomplicated coronary stenting can be discharged on the same day. Whereas implementation of same-day discharge to referring centres is simple, home discharge requires the development of structured outpatient programs with dedicated resources to assist the patient and family with short-term logistics, to provide reassurance, to serve as a ‘safety net’ and, lastly, to promote medication compliance and cardiovascular risk factor management. Further studies are required to better define the cost-minimization effects of outpatient PCI practice, as well as patient perception of fast-track PCI. It is proposed that outpatient PCI will likely continue to expand over the next decade.

This study determined the safety of deferring coronary revascularization based on a fractional flow reserve (FFR) valueor = 0.75 in a series of consecutive unselected coronary patients with moderate coronary lesions, including patients with unstable angina, myocardial infarction (MI), and/or positive noninvasive test findings. The study included 201 consecutive coronary patients (mean age 62 +/- 10 years; 65% men) with 231 lesions evaluated by FFR measurement for which revascularization was deferred based on a FFR valueor = 0.75. Lesions associated with a positive noninvasive test result were those located in an artery supplying a myocardial territory in which myocardial ischemia was demonstrated by a noninvasive test. Cardiac events (cardiac death, MI, revascularization) and Canadian Cardiovascular Society angina class were evaluated at follow-up. Indications for coronary angiography included unstable angina or MI (62%), stable angina (30%), or atypical chest pain (8%). Forty-four patients (22%) hador = 1 coronary lesion associated with a positive noninvasive test result in which FFR was evaluated. Mean FFR value was 0.87 +/- 0.06 and mean lesion percent diameter stenosis was 41 +/- 8%. At 11 +/- 6 months of follow-up, cardiac events occurred in 20 patients (10%), and no significant differences were observed between patients with unstable angina or MI and those with stable angina (9% vs 13%, p = 0.44) or between patients with and without lesions associated with positive noninvasive test results (9% vs 10%, p = 1.00). At the end of follow-up, 88% of patients were asymptomatic in angina class 0 or I, with no differences across various groups. In conclusion, these results suggest that patients with moderate coronary lesions can be safely managed without revascularization on the basis of FFR measurements, irrespective of clinical presentation and/or presence of positive noninvasive test results.

Although randomized trials have clearly demonstrated the clinical efficacy with regimens of platelet glycoprotein IIb/IIIa antagonists that result in >80% inhibition of baseline platelet aggregation in percutaneous coronary intervention (PCI), there are no data available concerning the optimal duration of infusion of these agents. In an era when the length of hospitalization has a major impact on health care costs, the determination of the optimal duration of the infusion of these drugs after PCI is of great relevance. The investigators therefore sought to determine the optimal length of the infusion of eptifibatide after PCI by analyzing the outcomes of patients enrolled in the Enhanced Suppression of the Platelet IIb/IIIa Receptor With Integrilin Therapy trial who were randomized to treatment with eptifibatide.

Because of its potential for antigenicity, theoretical concerns related to readministration of abciximab have been raised. We conducted the ReoPro Readministration Registry to assess the efficacy and safety of abciximab readministration. A total of 1,342 patients who underwent percutaneous coronary intervention and who received abciximab for at least a second time were recruited. Safety end points were hypersensitivity reactions, major bleeding, and thrombocytopenia (TCP). Human antichimeric antibody (HACA) titers were determined before and after readministration. Procedural success was 98% and was not influenced by the number of courses of abciximab or the presence of HACA. There were no cases of anaphylaxis. There were 5 minor allergic reactions, none of which required termination of the infusion. Clinically significant bleeding occurred in 31 patients (2.3%), including 1 (0.07%) with intracranial hemorrhage. TCP (

s S7 INTRODUCTION: The elderly represent an increasing proportion of patients with acute coronary syndromes (ACS) that are at high risk of mortality and recurrent admissions. According to Statistics Canada, Nova Scotia’s demographic structure comprises the largest proportion of elderly in Canada with an extensive burden of coronary disease such that over one third of ACS occur in patients >75 years. The purpose of this study is to evaluate temporal trends in the management and outcomes of elderly patients in Nova Scotia with non-ST elevation myocardial infarction (NSTEMI), the commonest form of ACS. METHODS: Data were obtained from the Cardiovascular Health Nova Scotia database for all patients admitted with NSTEMI between January 1, 1999 and December 31, 2011. Patients 75 years were defined as elderly and compared to those

adenosine diphosphate (ADP) receptor inhibitors (ticagrelor, prasugrel), ischemic outcomes and bleeding risks of Canadian patients with myocardial infarction (MI) undergoing percutaneous coronary intervention (PCI) in routine practice have not been fully characterized. METHODS: COAPT is a prospective, multicenter, longitudinal, observational cohort study describing Canadian treatment patterns of ADP receptor inhibitor (ADPri) therapy and its association with patient and treatment characteristics, over a 15-month period, in patients with ST elevation (STEMI) and non-ST elevation MI (NSTEMI) undergoing PCI. We investigated the patterns of use of ADPri therapy in-hospital and longer-term ischemic and bleeding events in this population. For this interim analysis (follow-up to be completed in Q3 2014), major adverse cardiovascular events (MACE: death, MI, stroke, urgent revascularization, stent thrombosis, cardiogenic shock, and new or worsening congestive heart failure [CHF]) and moderate/severe bleeding were identified during prospective follow-up. RESULTS: Between December 2011 andMay 2013, 2134 patients (61% STEMI), were enrolled from 26 PCI hospitals. Patient characteristics are shown in Table 1. Aspirin was given to 93% of patients on initial presentation (median dose 160 mg). Discharge ADPri therapy was clopidogrel (73%), ticagrelor (17%), and prasugrel (10%); 2.3% received oral anticoagulation at discharge. Inhospital MACE occurred in 11.1% of patients, including death (0.1%), MI (6.9%), stroke (0.2%), urgent revascularization (4.6%), stent thrombosis (0.7%), cardiogenic shock (1.0%), and new or worsening CHF (3.7%). During a mean follow-up of 11.7 months, MACE occurred in 6% of patients after discharge. Figure 1 shows the percentage of patients with cardiovascular events by discharge ADPri therapy. Moderate/severe bleeding was reported in 1.4% of patients in-hospital and 5% after discharge. Most frequent sites of bleeding were nose (6.8%), gastrointestinal (3.2%), hematoma/ vascular access site (3.8%), and urinary tract (1.7%). Approximately 1.0% received a blood transfusion, and 0.6% underwent a surgical procedure for bleeding. ADPri were switched, interrupted, or discontinued due to concomitant oral anticoagulants in 0.6%, 0.1%, or 0.6%, respectively. Overall, 1.6% required stopping the ADPri. CONCLUSION: In this observational study where newer ADPri therapies were prescribed to onlyw27% of patients at discharge, MACE occurred in 6% and moderate/severe bleeding occurred in 5% of patients in the year post-discharge. In accordance with the 2012 Updated Canadian Cardiovascular Society Antiplatelet Therapy Guideline recommendations for the year following discharge, there may be an opportunity to further reduce MACE with greater use of newer ADPri agents. Eli Lilly Canada Inc.

BACKGROUND: There are limited data on the contemporary use of ADP receptor inhibitors (ADPri) in Canadian patients with myocardial infarction. The frequency and the reasons for switching between these agents merits further investigation. METHODS: COAPT is a prospective, multicenter, longitudinal, observational, cohort study describing Canadian treatment patterns of ADPri therapy and its association with patient and treatment characteristics, over a 15-month period, in patients with ST elevation (STEMI) and non-ST elevation myocardial infarction (NSTEMI) undergoing PCI. We investigated the patterns of use of ADPri therapy during the index hospitalisation and for a median 15 months after discharge. RESULTS: Between December 2011 and May 2013, 2179 patients were enrolled from 26 PCI hospitals across Canada. In STEMI patients, the initial ADPri prescribed was clopidogrel in 79.4%, prasugrel in 8.1% and ticagrelor in 12.5%. For NSTEMI patients, clopidogrel was the initial ADPri in 89.0%, prasugrel in 2.0% and ticagrelor in 9.0%. During index hospitalization, switching between ADPri occurred in 15.3%, 22.4%, and 25.2% of patients initially treated with clopidogrel, prasugrel, and ticagrelor, respectively. Some patients, after an initial change in therapy, were switched back to their original ADPri. At discharge, 73.4% were prescribed clopidogrel, 10.1% prasugrel and 16.5% ticagrelor. The Figure describes discharge ADPri according to initial ADPri prescribed. During follow-up, additional switches occurred in 2.8%, 8.2% and 9.5%, respectively. Factors associated with switching include renal disease, STEMI presentation, living in Quebec, initial prescription by an interventional cardiologist, and university education (Table). Patients older than 75 years, transferred from another site, living in Western Canada and those initiated on clopidogrel were less likely to be switched. Out of 54 switches from prasugrel, 6 were because of the need for oral anticoagulant, 6 because of an ischemic or adverse event (AE), 1 could not afford the medication, 1 underwent surgery and 40 for other reasons not related to AE. In 82 patients switched from ticagrelor, 1 was because of the need for oral anticoagulant, 4 because of an ischemic or adverse event, 4 for personal reason, 2 because of planned CABG and 71 because of physician’s decision not related to AE. CONCLUSION: During the study period, nearly 80% of MI patients undergoing PCI were initially treated with clopidogrel despite recommendations from the 2012 Updated Canadian Cardiovascular Society Antiplatelet Guidelines encouraging the preferential use of newer agents. These findings suggest an opportunity to improve upon adherence to guideline-recommended treatment patterns for STEMI and NSTEMI.

INTRODUCTION: Mild therapeutic hypothermia (TH) has been found effective in improving neurological prognosis of comatose patient after cardiac arrest (CA). Delay in initiating TH has been associated with poor neurological outcomes. Cardiac catheterization (CC) is often performed in patients with CA. The impact of CC on timing of TH and the ideal timing of CC in patients with CA need further evaluation. METHOD: We conducted a retrospective study including all patients who underwent TH after CA between November 1st 2009 and October 20th 2012 in a tertiary care center with PCI facilities. Patients were separated in two groups based on delay of initiation of TH from CA ( 180 min). We identified factors associated with delay in initiating TH using logistic regression. RESULTS: Forty-two patients underwent TH during the study period. Two patients were excluded because of missing values. Selected patient characteristics are shown in the Table. TH was initiated in the referral hospital in 5 (12%) patients. Median time of initiation of TH from CA was 205 (169, 297) minutes. Performing imaging tests before cooling was associated with delayed initiation of TH: cardiac ultrasound (329 222 versus 204 82 minutes; p 1⁄4 0.01), computerized tomography scan (309 208 versus 202 77 minutes; p 1⁄4 0.02). On average, initiation of TH was delayed for 61 min in patients undergoing CC first when compared to patients who were cooled first (268 min vs 207 min). After exclusion of patients in whom TH was initiated in the referral hospital, factors independently associated with delay in initiation of TH of> 180 min were: presentation during daytime (p1⁄40.002), being transferred from a referral hospital (p1⁄40.04) and undergoing CC before TH (p1⁄40.06). TH was initiated immediately prior to CC in 6 patients. Time to reach target temperature was longer in these patients compared to other patients (215 min vs 128 min; p1⁄40.03). No ischemic complication was reported in patients undergoing PCI during TH. Overall, inhospital mortality was 50%. In survivors, neurological outcome was good (CPC 1 or 2) in 17 out of 20 patients. CONCLUSION: In this single-center registry of patients sustaining a CA, CC was associated with a substantial delay in initiation of TH. Cooling at the time of CC was feasible and while it lengthens the time to reach target temperature, it was not associated with adverse ischemic outcomes.