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Objective: Percutaneous coronary intervention (PCI) has seen substantial shifts in patient selection in recent years that have increased baseline patient mortality risk. It is unclear to what extent observed changes in mortality are attributable to background mortality risk or the indication and selection for PCI itself. PCI-attributable mortality can be estimated using relative survival, which adjusts observed mortality by that seen in a matched control population. We report relative survival ratios and compare these across different time periods., Methods: National Health Service PCI activity in England and Wales from 2007 to 2014 is considered using data from the British Cardiovascular Intervention Society PCI Registry. Background mortality is as reported in Office for National Statistics life tables. Relative survival ratios up to 1 year are estimated, matching on patient age, sex and procedure date. Estimates are stratified by indication for PCI, sex and procedure date., Results: 549 305 procedures were studied after exclusions for missing age, sex, indication and mortality status. Comparing from 2007 to 2008 to 2013-2014, differences in crude survival at 1 year were consistently lower in later years across all strata. For relative survival, these differences remained but were smaller, suggesting poorer survival in later years is partly due to demographic characteristics. Relative survival was higher in older patients., Conclusions: Changes in patient demographics account for some but not all of the crude survival changes seen during the study period. Relative survival is an under-used methodology in interventional settings like PCI and should be considered wherever survival is compared between populations with different demographic characteristics, such as between countries or time periods., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Background Studies have reported significant reduction in acute myocardial infarction–related hospitalizations during the coronavirus disease 2019 (COVID‐19) pandemic. However, whether these trends are associated with increased incidence of out‐of‐hospital cardiac arrest (OHCA) in this population is unknown. Methods and Results Acute myocardial infarction hospitalizations with OHCA during the COVID‐19 period (February 1–May 14, 2020) from the Myocardial Ischaemia National Audit Project and British Cardiovascular Intervention Society data sets were analyzed. Temporal trends were assessed using Poisson models with equivalent pre–COVID‐19 period (February 1–May 14, 2019) as reference. Acute myocardial infarction hospitalizations during COVID‐19 period were reduced by >50% (n=20 310 versus n=9325). OHCA was more prevalent during the COVID‐19 period compared with the pre–COVID‐19 period (5.6% versus 3.6%), with a 56% increase in the incidence of OHCA (incidence rate ratio, 1.56; 95% CI, 1.39–1.74). Patients experiencing OHCA during COVID‐19 period were likely to be older, likely to be women, likely to be of Asian ethnicity, and more likely to present with ST‐segment–elevation myocardial infarction. The overall rates of invasive coronary angiography (58.4% versus 71.6%; P

BackgroundTranscatheter aortic valve implantation (TAVI) is indicated for patients with aortic stenosis who are intermediate‐high surgical risk. Although all‐cause mortality rates after TAVI are established, survival attributable to the procedure is unclear because of competing causes of mortality. The aim was to report relative survival (RS) after TAVI, which accounts for background mortality risks in a matched general population. Methods and ResultsNational cohort data (n=6420) from the 2007 to 2014 UK TAVI registry were matched by age, sex, and year to mortality rates for England and Wales (population, 57.9 million). The Ederer II method related observed patient survival to that expected from the matched general population. We modelled RS using a flexible parametric approach that modelled the log cumulative hazard using restricted cubic splines. RS of the TAVI cohort was 95.4%, 90.2%, and 83.8% at 30 days, 1 year, and 3 years, respectively. By 1‐year follow‐up, mortality hazards in the >85 years age group were not significantly different from those of the matched general population; by 3 years, survival rates were comparable. The flexible parametric RS model indicated that increasing age was associated with significantly lower excess hazards after the procedure; for example, by 2 years, a 5‐year increase in age was associated with 20% lower excess mortality over the general population. ConclusionsRS after TAVI was high, and survival rates in those aged >85 years approximated those of a matched general population within 3 years. High rates of RS indicate that patients selected for TAVI tolerate the risks of the procedure well.

BackgroundUp to half of patients undergoing percutaneous coronary intervention have multivessel coronary artery disease (MVD) with conflicting data regarding optimal revascularization strategy in such patients. This paper assesses the evidence for complete revascularization (CR) versus incomplete revascularization in patients undergoing percutaneous coronary intervention, and its prognostic impact using meta‐analysis. Methods and ResultsA search of PubMed, EMBASE, MEDLINE, Current Contents Connect, Google Scholar, Cochrane library, Science Direct, and Web of Science was conducted to identify the association of CR in patients with multivessel coronary artery disease undergoing percutaneous coronary intervention with major adverse cardiac events and mortality. Random‐effects meta‐analysis was used to estimate the odds of adverse outcomes. Meta‐regression analysis was conducted to assess the relationship with continuous variables and outcomes. Thirty‐eight publications that included 156 240 patients were identified. Odds of death (OR 0.69, 95% CI 0.61‐0.78), repeat revascularization (OR 0.60, 95% CI 0.45‐0.80), myocardial infarction (OR 0.64, 95% CI 0.50‐0.81), and major adverse cardiac events (OR 0.63, 95% CI 0.50‐0.79) were significantly lower in the patients who underwent CR. These outcomes were unchanged on subgroup analysis regardless of the definition of CR. Similar findings were recorded when CR was studied in the chronic total occlusion (CTO) subgroup (OR 0.65, 95% CI 0.53‐0.80). A meta‐regression analysis revealed a negative relationship between the OR for mortality and the percentage of CR. ConclusionCR is associated with reduced risk of mortality and major adverse cardiac events, irrespective of whether an anatomical or a score‐based definition of incomplete revascularization is used, and this magnitude of risk relates to degree of CR. These results have important implications for the interventional management of patients with multivessel coronary artery disease.

Background--Retroperitoneal hemorrhage (RH) is a rare bleeding complication of percutaneous coronary intervention, which can result as a consequence of femoral access or can occur spontaneously. This study aims to evaluate temporal changes in RH, its predictors, and clinical outcomes in a national cohort of patients undergoing percutaneous coronary intervention in the United Kingdom. Methods and Results--We analyzed RH events in patients who underwent percutaneous coronary intervention between 2007 and 2014. Multiple logistic regression models were used to identify factors associated with RH and to quantify the association between RH and 30-day mortality and major adverse cardiovascular events. A total of 511 106 participants were included, and 291 in hospital RH events were recorded (0.06%). Overall, rates of RH declined from 0.09% to 0.03% between 2007 and 2014. The strongest independent predictors of RH events were femoral access (odds ratio [OR], 19.66; 95% confidence interval [CI], 11.22-34.43), glycoprotein IIb/IIIa inhibitor (OR, 2.63; 95% CI, 1.99-3.47), and warfarin use (OR, 2.53; 95% CI, 1.07-5.99). RH was associated with a significant increase in 30-day mortality (OR, 3.59; 95% CI, 2.19-5.90) and in-hospital major adverse cardiovascular events (OR, 5.76; 95% CI, 3.71-8.95). A legacy effect was not observed; patients with RH who survived 30 days did not have higher 1-year mortality compared with those without this complication (hazard ratio, 0.97; 95% CI, 0.49-1.91). Conclusions--Our results suggest that RH is a rare event that is declining in the United Kingdom, related to transition to transradial access site utilization, but remains a clinically important event associated with increased 30-day mortality but no long-term legacy effect. [ABSTRACT FROM AUTHOR]

Objectives This study sought to determine the risk factors for post-transcatheter aortic valve replacement (TAVR) dialysis and to determine the impact of pre-TAVR or post-TAVR dialysis on mortality. Background TAVR is now established as an alternative treatment to surgical aortic valve replacement. Data examining the impact of dialysis on outcomes after TAVR are lacking. Methods The UK TAVI (Transcatheter Aortic Valve Implantation) Registry was established to report outcomes on all TAVR procedures performed within the United Kingdom (2007 to 2014). Data were collected prospectively on 6,464 patients with a median follow-up of 625 days. Results The proportion of patients on dialysis before TAVR has remained constant at 1.8%. After TAVR, the proportion of patients newly needing dialysis after TAVR has fallen from 6.1% (2007 to 2008) to 2.3% (2013 to 2014). The risk of new dialysis requirement after TAVR was independently associated with lower baseline renal function, year of procedure, impaired left ventricular function, diabetes, use of an Edwards valve, a nontransfemoral approach, need for open surgery, and moderate-to-severe aortic regurgitation after the procedure. Requirement for new dialysis after TAVR was associated with higher mortality at 30 days (hazard ratio: 6.44; 95% confidence interval: 4.87 to 8.53) and at 4 years (hazard ratio: 3.54; 95% confidence interval: 2.99 to 4.19; p < 0.001 for all) compared with patients without dialysis requirement. Conclusions The proportion of patients needing dialysis after TAVR has decreased over time. Post-TAVR dialysis is associated with increased mortality. Factors identified with dialysis requirement after TAVR require further investigation. [ABSTRACT FROM AUTHOR]

Objectives The aims of this study were to examine the relationship between body mass index (BMI) and clinical outcomes following percutaneous coronary intervention (PCI) and to determine the relevance of different clinical presentations requiring PCI to this relationship. Background Obesity is a growing problem, and studies have reported a protective effect from obesity compared with normal BMI for adverse outcomes after PCI. Methods Between 2005 and 2013, 345,192 participants were included. Data were obtained from the British Cardiovascular Intervention Society registry, and mortality data were obtained through the U.K. Office of National Statistics. Multiple logistic regression was performed to determine the association between BMI group (<18.5, 18.5 to 24.9, 25 to 30 and >30 kg/m 2 ) and adverse in-hospital outcomes and mortality. Results At 30 days post-PCI, significantly lower mortality was seen in patients with elevated BMIs (odds ratio [OR]: 0.86 [95% confidence interval (CI): 0.80 to 0.93] 0.90 [95% CI: 0.82 to 0.98] for BMI 25 to 30 and >30 kg/m 2 , respectively). At 1 year post-PCI, and up to 5 years post-PCI, elevated BMI (either overweight or obese) was an independent predictor of greater survival compared with normal weight (OR: 0.70 [95% CI: 0.67 to 0.73] and 0.73 [95% CI: 0.69 to 0.77], respectively, for 1 year; OR: 0.78 [95% CI: 0.75 to 0.81] and 0.88 [95% CI: 0.84 to 0.92], respectively, for 5 years). Similar reductions in mortality were observed for the analysis according to clinical presentation (stable angina, unstable angina or non–ST-segment elevation myocardial infarction, and ST-segment elevation myocardial infarction). Conclusions A paradox regarding the independent association of elevated BMI with reduced mortality after PCI is still evident in contemporary U.K. practice. This is seen in both stable and more acute clinical settings. [ABSTRACT FROM AUTHOR]

Background--There are limited data on comparison of contemporary drug-eluting stent (DES) platforms, previous generation DES, and bare-metal stents (BMS) for percutaneous coronary intervention in saphenous vein grafts (SVG). We aimed to assess clinical outcomes following percutaneous coronary intervention to SVG in patients receiving baremetal stents (BMS), first-generation DES, and newer generation DES in a large unselected national data set from the BCIS (British Cardiovascular Intervention Society). Methods and Results--Patients undergoing percutaneous coronary intervention to SVG in the United Kingdom from January 2006 to December 2013 were divided into 3 groups according to stent use: BMS, first-generation DES, and newer generation DES group. Study outcomes included in-hospital major adverse cardiovascular events, 30-day mortality, and 1-year mortality. Patients (n=15 003) underwent percutaneous coronary intervention to SVG in England and Wales during the study period. Of these, 38% received BMS, 15% received first-generation DES, and 47% received second-generation DES. The rates of in-hospital major adverse cardiovascular events were significantly lower in patients treated with secondgeneration DES (odds ratio, 0.51; 95% confidence interval, 0.38-0.68; P<0.001), but not with first-generation DES, compared with BMS-treated patients. Similarly, 30-day mortality (odds ratio, 0.43; 95% confidence interval, 0.32-0.59; P<0.001) and 1-year mortality (odds ratio, 0.60; 95% confidence interval, 0.51-0.71; P<0.001) were lower in patients treated with second-generation DES, but not with first-generation DES, compared with the patients treated with BMS. Conclusions--Patients receiving second-generation DES for the treatment SVG disease have lower rates of in-hospital major adverse cardiovascular events, 30-day mortality, and 1-year mortality, compared with those receiving BMS. [ABSTRACT FROM AUTHOR]

Background: The relationship between procedural volume and prognosis after percutaneous coronary intervention (PCI) remains uncertain, with some studies finding in favor of an inverse association and some against. This UK study provides a contemporary reassessment in one of the few countries in the world with a nationally representative PCI registry.Methods and Results: A nationwide cohort study was performed using the national British Cardiovascular Intervention Society registry. All adult patients undergoing PCI in 93 English and Welsh NHS hospitals between 2007 and 2013 were analyzed using hierarchical modeling with adjustment for patient risk. Of 427 467 procedures (22.0% primary PCI) in 93 hospitals, 30-day mortality was 1.9% (4.8% primary PCI). 87.1% of centers undertook between 200 and 2000 procedures annually. Case mix varied with center volume. In centers with 200 to 399 PCI cases per year, a smaller proportion were PCI for ST-segment-elevation myocardial infarction (8.4%) than in centers with 1500 to 1999 PCI cases per year (24.2%), but proportionally more were for ST-segment-elevation myocardial infarction with cardiogenic shock (8.4% versus 4.3%). For the overall PCI cohort, after risk adjustment, there was no significant evidence of worse, or better, outcomes in lower volume centers from our own study, or in combination with results from other studies. For primary PCI, there was also no evidence for increased or decreased mortality in lower volume centers.Conclusions: After adjustment for differences in case mix and clinical presentation, this study supports the conclusion of no trend for increased mortality in lower volume centers for PCI in the UK healthcare system.Clinical Trial Registration: https://www.clinicaltrials.gov. Unique identifier: NCT02184949. [ABSTRACT FROM AUTHOR]

Background—The radial artery is increasingly adopted as the primary access site for cardiac catheterization because of patient preference, lower bleeding rates, cost effectiveness, and reduced risk of mortality in high-risk patient groups. Concerns have been expressed that operators/centers have become increasingly unfamiliar with transfemoral access. The aim of this study was to assess whether a change in access site practice toward transradial access nationally has led to worse outcomes in percutaneous coronary intervention procedures performed through the transfemoral access approach. Methods and Results—Using the British Cardiovascular Intervention Society (BCIS) database, a retrospective analysis of 235 250 transfemoral access percutaneous coronary intervention procedures was undertaken in all 92 centers in England and Wales between 2007 and 2013. Recent femoral proportion and recent femoral volume were determined, and in-hospital vascular complications and 30-day mortality were evaluated. After case-mix adjustment, no independent association was observed between 30-day mortality for cases undertaken through the transfemoral access and center femoral proportion, the risk-adjusted odds ratio for recent femoral proportion was nonsignificant (odds ratio, 0.99; 95% confidence interval, 0.97–1.02; P=0.472 per 0.1 increase in proportion), and similarly recent femoral volume (per 100 procedures) was not found to be significant (odds ratio, 1.00; 95% confidence interval, 0.98–1.01; P=0.869). The in-hospital vascular complication rate was 1.0%, and this outcome was not significantly associated with recent femoral proportion after risk-adjustment (odds ratio, 0.97; 95% confidence interval, 0.94–1.00; P=0.060 per 0.1 increase in proportion). Conclusions—The outcome gains achieved by the national adoption of radial access are not associated with a loss of femoral proficiency, and centers should be encouraged to continue to adopt radial access as the default access site for percutaneous coronary intervention wherever possible in line with current best evidence. [ABSTRACT FROM AUTHOR]

Background--The impact of vascular closure devices (VCDs) via the femoral arterial access site on short-term mortality in patients undergoing percutaneous coronary intervention is currently unknown. Methods and Results--The association between femoral arterial vascular access site management (manual pressure [including external clamp] versus VCD) and 30-day mortality was examined in a national real-world registry of 271 845 patients undergoing percutaneous coronary intervention for elective, non-ST-segment-elevation myocardial infarction and ST-segment-elevation myocardial infarction indications in the United Kingdom between 2006 and 2011. Crude and propensity score-corrected analyses were performed using Cox regression, with additional analyses undertaken in clinically relevant subgroups; 40.1% (n=109 001) of subjects were treated with manual pressure and 59.9% (n=162 844) with VCD. Subjects treated with VCD had fewer comorbidities and were less likely to present with ST-segment-elevation myocardial infarction and cardiogenic shock (P<0.001). Crude 30-day mortality was lower in the group treated with VCD compared with manual pressure (hazard ratio [HR], 0.58; 95% confidence interval [CI], 0.54-0.61; 1.4% versus 2.4%, log rank P<0.0001), findings that were substantially reduced but persisted after propensity score correction (HR, 0.91; 95% CI, 0.86-0.97; 1.8% versus 2.0% versus P<0.001). A more pronounced association of VCD with a reduction in 30- day mortality was evident in females (HR, 0.85; 95% CI, 0.77-0.94; Pinteraction=0.037), presentation with acute coronary syndrome (HR, 0.88; 95% CI, 0.83-0.94; Pinteraction=0.0027), or recent lysis (HR, 0.63; 95% CI, 0.40-1.01; Pinteraction=0.0001). Conclusions--When compared with manual pressure, VCD was associated with a minor short-term (30-day) prognostic benefit after propensity score correction in the global population and clinically relevant subgroups. The potential for residual confounding factors impacting on short-term mortality cannot be excluded, despite the study having measured and balanced all recorded confounder factors. [ABSTRACT FROM AUTHOR]

Background--Transradial access is associated with reduced access site-related bleeding complications and mortality post percutaneous coronary intervention. The objective of this study is to examine the relationship between access site practice and clinical outcomes and how this may be influenced by operator and center experience/expertise. Methods and Results--The influence of operator and center experience/expertise was studied on 30-day mortality, in-hospital major adverse cardiovascular events (a composite of in-hospital mortality and in-hospital myocardial infarction and target vessel revascularization) and in-hospital major bleeding based on access site adopted (radial versus femoral). Operator/center experience/expertise were defined by both total volume and transradial access proportion. A total of 164 395 procedures between 2012 and 2013 in the National Health Service in England and Wales were analyzed. After case-mix adjustment, transradial access was associated with an average odds reduction of 39% for 30-day mortality compared with transfemoral access (odds ratio, 0.61; 95% confidence interval, 0.55- 0.68; P<0.001). The magnitude of this risk reduction was modified by increases in total procedural volume and radial proportion at the operator level (odds ratio reduction of 11% per 100 extra procedures, 95% confidence interval, 3%-19%; odds ratio reduction of 6% per 10%-point increase in radial proportion, 95% confidence interval, 1%-11%) with no significant impact of operator radial volume, center total volume, center radial volume, and center radial proportion. Conclusions--The lower mortality associated with transradial access adoption relates to both the total procedural volume and the proportion of procedures undertaken radially by operator, with operators undertaking the greatest proportion of their procedures radially having the largest relative reduction in mortality risk. [ABSTRACT FROM AUTHOR]

Objectives This study used a large national cohort to examine patterns of thrombectomy use in ST-segment elevation myocardial infarction (STEMI) and the relationship to mortality. Background The impact of coronary thrombectomy on mortality in STEMI has not been definitively established. Published trial data have been insufficiently powered to address this. Methods The U.K. national registry was used to study 98,176 patients treated with primary percutaneous coronary intervention (PCI), between January 1, 2006, and December 31, 2013. Patients were grouped on the basis of whether they received thrombectomy or not; subgroups of simple (manual aspiration) and complex (mechanical) thrombectomy were also evaluated. The primary endpoint was 30-day mortality. The principal adjusted analysis used propensity score matching (PSM). A sensitivity analysis was performed using logistic regression controlled for the propensity score. Results Thrombectomy use markedly increased in the United Kingdom between 2008 and 2010 but plateaued thereafter at slightly below 50% of all primary PCI cases. No significant mortality difference was seen, in adjusted analyses, between the overall thrombectomy group and the no thrombectomy group, at 30 days or 1 year (at 30 days, PSM average treatment effect [ATE] coefficient 0.0028, 95% confidence interval: −0.0048 to 0.0104; p = 0.47). Likewise, no difference was seen between the simple (manual) thrombectomy versus no thrombectomy, at either time point (at 30 days, PSM ATE coefficient 0.0007, 95% confidence interval: −0.0049 to 0.0063; p = 0.80). By contrast, the complex (mechanical) thrombectomy group demonstrated a significantly higher mortality than the no thrombectomy group at 1-year follow-up (PSM ATE coefficient 0.0434, 95% confidence interval: 0.0081 to 0.0786; p = 0.017). Conclusions Coronary thrombectomy was not associated with lower mortality in primary PCI for STEMI when used in our large all-comer cohort in a selective manner on the basis of physician judgment. These findings are consistent with other negative clinical outcomes in recent large randomized controlled trials studying routine manual thrombectomy in primary PCI. [ABSTRACT FROM AUTHOR]

OBJECTIVES: This study sought to define the prevalence and prognostic impact of blood transfusions in contemporary percutaneous coronary intervention (PCI) practice. BACKGROUND: Although the presence of anemia is associated with adverse outcomes in patients undergoing PCI, the optimal use of blood products in patients undergoing PCI remains controversial. METHODS: A search of EMBASE and MEDLINE was conducted to identify PCI studies that evaluated blood transfusions and their association withmajor adverse cardiac events (MACE) andmortality. Two independent reviewers screened the studies for inclusion, and data were extracted from relevant studies. Random effects meta-analysis was used to estimate the risk of adverse outcomes with blood transfusions. Statistical heterogeneity was assessed by considering the I² statistic. RESULTS: Nineteen studies that included 2,258,711 patients with more than 54,000 transfusion events were identified (prevalence of blood transfusion 2.3%). Crude mortality rate was 6,435 of 50,979 (12.6%, 8 studies) in patients who received a blood transfusion and 27,061 of 2,266,111 (1.2%, 8 studies) in the remaining patients. Crude MACE rates were 17.4% (8,439 of 48,518) in patients who had a blood transfusion and 3.1% (68,062 of 2,212,730) in the remaining cohort. Meta-analysis demonstrated that blood transfusion was independently associated with an increase in mortality (odds ratio: 3.02, 95% confidence interval: 2.16 to 4.21, I² = 91%) and MACE (odds ratio: 3.15, 95% confidence interval: 2.59 to 3.82, I² = 81%). Similar observations were recorded in studies that adjusted for baseline hematocrit, anemia, and bleeding. CONCLUSIONS: Blood transfusion is independently associated with increased risk of mortality and MACE events. Clinicians should minimize the risk for periprocedural transfusion by using available bleeding-avoidance strategies and avoiding liberal transfusion practices. [ABSTRACT FROM AUTHOR]

Background: Nonsurgical centers (NSC) contribute significantly to the capacity of overall percutaneous coronary intervention (PCI) in the United Kingdom. Although previous studies have demonstrated similar PCI outcomes in surgical centers (SC) versus NSC, it is unknown whether this applies to more complex procedures such as left main stem (LMS) PCI. We compared patient characteristics and outcomes of LMS PCI performed across SC and NSC in England and Wales. Methods: A retrospective analysis of procedures between January 2006 and March 2020 was performed using the British Cardiovascular Intervention Society database and stratified according to the surgical status of the center. The primary outcomes assessed were in-hospital major adverse cardiovascular and cerebrovascular events, all-cause mortality, and Bleeding Academic Research Consortium stage 3 to 5 bleeding. Results: Forty thousand seven hundred forty-four patients underwent LMS PCI during the period, of which 13 922 (34.2%) had their procedure performed at an NSC. The proportion of LMS PCI performed in NSC increased >2-fold (15.9% in 2006 to 36.7% in 2020). There was no association between surgical cover location and in-hospital mortality (odds ratio, 0.92 [95% CI, 0.69–1.22]), in-hospital major adverse cardiovascular and cerebrovascular events (odds ratio, 1.00 [95% CI, 0.79–1.25]), or emergency coronary artery bypass graft surgery (odds ratio, 1.00 [95% CI, 0.95–1.06]). NSC had lower Bleeding Academic Research Consortium 3 to 5 bleeding complications (odds ratio, 0.53 [95% CI, 0.34–0.82]). Conclusions: There has been an increase in LMS PCI volumes at NSC, particularly elective LMS PCI. LMS PCI performed at NSC was not associated with increased mortality, in-hospital major adverse cardiovascular and cerebrovascular events, or emergency coronary artery bypass graft surgery, despite higher disease complexity. [ABSTRACT FROM AUTHOR]

Objectives This study sought to determine mortality rates among cardiogenic shock (CGS) patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome in the contemporary treatment era and to determine predictors of mortality. Background It is unclear whether recent advances in pharmacological and interventional strategies have resulted in further improvements in short- and long-term mortality and which factors are associated with adverse outcomes in patients presenting with CGS and undergoing PCI in the setting of acute coronary syndrome. Methods This study analyzed prospectively collected data for patients undergoing PCI in the setting of CGS as recorded in the BCIS (British Cardiovascular Intervention Society) PCI database. Results In England and Wales, 6,489 patients underwent PCI for acute coronary syndrome in the setting of CGS. The mortality rates at 30 days, 90 days, and 1 year were 37.3%, 40.0%, and 44.3%, respectively. On multiple logistic regression analysis, age (for each 10-year increment of age: odds ratio [OR]: 1.59, 95% confidence interval [CI]: 1.51 to 1.68; p < 0.0001), diabetes mellitus (OR: 1.47, 95% CI: 1.28 to 1.70; p < 0.0001), history of renal disease (OR: 2.03, 95% CI: 1.63 to 2.53; p < 0.0001), need for artificial mechanical ventilation (OR: 2.56, 95% CI: 2.23 to 2.94; p < 0.0001), intra-aortic balloon pump use (OR: 1.57, 95% CI: 1.40 to 1.76; p < 0.0001), and need for left main stem PCI (OR: 1.90, 95% CI: 1.62 to 2.23; p < 0.0001) were associated with higher mortality at 1 year. Conclusions In this large U.K. cohort of patients undergoing PCI in the context of CGS, mortality remains high in spite of the use of contemporary PCI strategies. The highest mortality occurs early, and this time period may be a particular target of therapeutic intervention. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to compare baseline characteristics and medium-term prognosis in South Asian and Caucasian patients undergoing percutaneous coronary intervention (PCI). Background: It is unclear whether South Asians undergoing PCI have worse outcomes than Caucasians. Methods: We performed a retrospective analysis of 279,256 patients undergoing PCI from 2004 to 2011 from the British Cardiovascular Intervention Society national database, of whom 259,318 (92.9%) were Caucasian and 19,938 (7.1%) were South Asian (South Asian includes patients of Pakistani, Indian, Bangladeshi, or Sri Lankan ethnic origin). The main outcome measures were in-hospital major adverse cardiac and cerebrovascular events and all-cause mortality during a median follow-up of 2.8 years (interquartile range: 1.5 to 4.5 years). Results: South Asians were younger (59.69 ± 0.27 years vs. 64.69 ± 0.13 years, p > 0.0001); more burdened by cardiovascular risk factors, particularly diabetes mellitus (42.1 ± 1.2% vs. 15.4 ± 0.4%, p > 0.0001); and more likely to have multivessel coronary disease than Caucasians. In-hospital rates of major adverse cardiac and cerebrovascular events were similar for South Asians and Caucasians (3.5% vs. 2.8%, p = 0.40). Unadjusted Kaplan-Meier estimates of all-cause mortality showed better survival for South Asians compared with Caucasians, after PCI for either acute myocardial infarction or angina. Age-adjusted analysis revealed increased mortality (hazard ratio: 1.24; 95% confidence interval: 1.18 to 1.30), but after adjustment for the substantial variation in baseline risk factors including diabetes, there was no significant difference between South Asians and Caucasians (hazard ratio: 0.99; 95% confidence interval: 0.94 to 1.05). Conclusions: In this large, contemporary cohort of patients treated by PCI, South Asians were younger but had more extensive disease and major risk factors, particularly diabetes. However, after correcting for these differences, in-hospital and medium-term mortality of South Asians was no worse than that of Caucasians. This suggests that in South Asians, the high prevalence of diabetes exerts an adverse influence on mortality, but ethnicity itself is not an independent predictor of outcome. [Copyright &y& Elsevier]

Supplemental Digital Content is available in the text. Background: Patients with complex high-risk coronary anatomy, such as those with a last remaining patent vessel (LRPV), are increasingly revascularized with percutaneous coronary intervention (PCI) in contemporary practice. There are limited data on the outcomes of these high-risk procedures. Methods: We analyzed a large longitudinal PCI cohort (2007–2014, n=501 841) from the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing patients into 2 groups; LRPV group (n=2432) and all other PCI groups (n=506 691). Results: Patients in the LRPV PCI group were older, had more comorbidities, and higher prevalence of moderate-severe left ventricular systolic dysfunction. Mortality was higher in the LRPV PCI group during hospital admission (12 % versus 1.5 %, P <0.001), at 30 days (15% versus 2%, P <0.001), and at one-year (24% versus 5%, P <0.001). In a propensity score matching analysis the adjusted risk of mortality during index admission (odds ratio, 2.05 [95% CI, 1.65–2.44], P <0.001), at 30 days (odds ratio, 2.13 [95% CI, 1.78–2.5], P <0.001), at 1 year (odds ratio, 1.81 [95% CI, 1.59–2.03], P <0.001), and in-hospital major adverse cardiovascular events (odds ratio, 1.8 [95% CI, 1.42–2.19], P <0.001) were higher in LRPV PCI group as compared to control group. In sensitivity analyses, similar clinical outcomes were observed irrespective of which major epicardial coronary artery was treated. Conclusions: In this contemporary cohort, patients who had PCI to their LRPV had a higher-risk profile and more adverse clinical outcomes, irrespective of the vessel treated. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text. Background: The relationship between operator volume and survival after unprotected left main stem percutaneous coronary intervention (uLMS-PCI) is poorly defined. Methods: Data from the British Cardiovascular Intervention Society national PCI database were analyzed for all uLMS-PCI procedures performed in England and Wales between 2012 and 2014 and 4 quartiles of annualized uLMS-PCI volume (Q1–Q4) generated. Individual logistic regressions were performed for 12-month mortality to quantify the independent association between operator quartile and outcomes. Results: In total, 6724 uLMS-PCI procedures were analyzed with a negatively skewed distribution and an annualized median of 3 procedures per year. Operator volume ranged from 1 to 54 uLMS-PCI procedures/year. Within Q1, 347 operators performed a median of 2 procedures/year (interquartile range, 1–3); in Q2, 134 operators performed a median of 5 procedures/year (interquartile range, 4–6); in Q3, 59 operators performed a mean of 10 procedures/year (interquartile range, 8–12); and in Q4, 29 operators performed a mean of 21 procedures/year (interquartile range, 17–29). Higher volume operators undertook uLMS-PCI in patients with greater comorbid burden and performed more complex procedures compared with lower operator volumes. Adjusted in-hospital survival (odds ratio, 0.39 [95% CI, 0.24–0.67]; P <0.001), in-hospital major adverse cardiac and cerebral events (odds ratio, 0.41 [95% CI, 0.27–0.62]; P <0.001), and 12-month survival (odds ratio, 0.54 [95% CI, 0.39–0.73]; P <0.001) were lower in Q4 operators compared with Q1 operators. A close association between operator volume/case and superior 12-month survival was observed (P <0.001). The lower volume threshold of minimum operator uLMS-PCI volume associated with improved survival was ≥16 cases/year. Conclusions: These data suggest that operator volume is an important factor in determining outcome after uLMS-PCI. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text. Background: There are limited data on outcomes of patients with previous coronary artery bypass graft (CABG) presenting with non–ST-segment–elevation myocardial infarction undergoing percutaneous coronary intervention (PCI). We compare clinical characteristics and outcomes in non–ST-segment–elevation myocardial infarction patients undergoing PCI with or without prior CABG surgery in a national cohort. Methods and Results: We identified 205 039 patients with non–ST-segment–elevation myocardial infarction who underwent PCI between 2007 and 2014 in the British Cardiovascular Intervention Society database. Clinical, demographic, procedural, and outcome data were analyzed by dividing into 3 groups: group 1, PCI in native coronary arteries and no prior CABG (n=186 670); group 2, PCI in native arteries with prior CABG (n=8825); group 3, PCI in grafts (n=9544). Patients in group 2 and 3 were older and had more comorbidities and higher mortality at 30 days (group 2, 2.6% and group 3, 1.9%) and 1 year (group 2, 8.29% and group 3, 7.08%) as compared with group 1 (1.7% and 4.87%). After multivariable analysis, no significant difference in outcomes was observed in 30-days mortality (odds ratio; group 2=0.87 [CI, 0.69–1.80; P =0.20], group 3=0.91 [CI, 0.71–1.17; P =0.46]), in-hospital major adverse cardiovascular event (odds ratio: group 2=1.08 [CI, 0.88–1.34; P =0.45], group 3=0.97 [CI=0.77–1.23; P =0.82]), and in-hospital stroke (odds ratio: group 2=1.37 [CI, 0.71–2.69; P =0.35], group 3=1.13 [CI, 0.55–2.34; P =0.73]; group 1=reference). Conclusions: Patients with prior CABG are presenting with non–ST-segment–elevation myocardial infarction and treated with PCI had more comorbid illnesses, but once these differences were adjusted for, prior CABG did not independently confer additional risk of mortality and major adverse cardiovascular event. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text. Background: Enabling strategies (ESs) are increasingly used during percutaneous coronary intervention for chronic total occlusive disease (CTO-PCI), enhancing procedural success. Using the British Cardiovascular Society dataset, we examined changes in the use of ESs and procedural/clinical outcomes for CTO-PCI. Methods and Results: ESs were defined as intravascular ultrasound, rotational/laser atherectomy, dual arterial access, use of microcatheters, penetration catheters or CrossBoss, and procedures categorized by number of ESs used. Data were analysed on all elective CTO-PCI procedures performed in England and Wales between 2006 and 2014. Multivariable logistic regression was used to identify predictors of procedural success. During 28 050 CTO-PCIs, there were significant temporal increases in ES use. There was a stepwise increase in CTO success with increased ES use, with 83.8% of cases successful where ≥3 ESs were used. Overall, CTO-PCI success rate for the whole cohort increased from 55.4% in 2006 to 66.9% in 2014 (P <0.001), but the greatest increase in procedural success was associated with ≥3 ES use. In multivariable analysis, any ES use and the number of ESs used were predictive of procedural success. Coronary perforation increased from 1.2% with zero ES use to 4.0% with ≥3 (P <0.001). After adjustment, although arterial complication, in-hospital bleeding, in-hospital mortality, and major adverse cardiovascular or cerebrovascular events remained more likely with ES use, 30-day mortality was not significantly different between groups. Conclusions: ES use during CTO-PCI was associated with significant improvements in CTO-PCI success. ES use was associated with increased procedural complications and in-hospital major adverse cardiovascular events, but not with 30-day mortality. [ABSTRACT FROM AUTHOR]