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Significant left main coronary artery disease (LMCAD) occurs in 5–7% of patients undergoing coronary angiography. Patients with LMCAD have a 50% 3-year mortality despite optimal medical therapy. As such, coronary artery bypass grafting (CABG) emerged as the gold standard therapy for the treatment of patients with LMCAD either in isolation or in association with disease elsewhere in the coronary circulation. Advances in stent and adjunctive intracoronary imaging as well as pharmacotherapy has enabled percutaneous coronary intervention (PCI) to challenge CABG in such patients, with a host of randomized and observational studies comparing the safety and efficacy of PCI with CABG. This chapter covers historical data on CABG in LMCAD, compares various PCI techniques with CABG, and finally evaluates the differences in efficacy and safety.

Coronary heart disease is the single most common cause of death in the UK and in Europe, although death rates are declining in most European countries. Hospital mortality rates between non-ST elevation acute coronary syndrome and ST-elevation myocardial infarction are compared, with an examination of the pathophysiology, clinical syndromes, and trials of conservative versus early invasive strategy throughout the chapter. Finally, special subgroups are considered, including those with anaemia and diabetes mellitus.

The majority of this textbook is concerned with the indications for, and applications of, the numerous techniques that interventional cardiologists have at their disposal to assess and treat significant coronary stenosis. However, it is well recognized that atherosclerosis is far from being a discrete pathological process, such that by the time people present with clinically apparent coronary artery disease (CAD), they will often have widespread atheroma throughout their coronary tree. Combined with the reproducible observation that the majority of acute coronary syndromes arise from lesions that were not previously flow-limiting, much research effort has been directed at identifying treatment strategies that will favourably modify all of the patient’s atherosclerotic burden, not just that which can be targeted by percutaneous or surgical revascularization. In this chapter, we focus on the rationale and evidence base supporting the use of statins and renin–angiotensin–aldosterone system inhibition in patients with CAD.

Using the British Cardiovascular Intervention Society percutaneous coronary intervention (PCI) database, temporal trends, predictors, and outcomes of radial access (RA) versus femoral access (FA) for unprotected left main stem percutaneous coronary intervention (LMS-PCI) were studied.Data on arterial access site for LMS-PCI are poorly defined.Data were analyzed from 19,482 LMS-PCI procedures performed in England and Wales between 2007 and 2014. Multivariate logistic regression was used to identify predictors of access site choice and its association with outcomes.The frequency of FA use fell from 77.7% in 2007 to 31.7% in 2014 (p 0.001 for trend). In the most contemporary study years (2012 to 2014), the strongest associates of FA use for unprotected LMS-PCI were renal disease, PCI for restenosis, chronic total occlusion intervention, and female sex. Use of intravascular imaging and chronic anticoagulation were associated with a higher likelihood of RA use. Complexity of the PCI procedure in the RA cohort increased significantly during the study period. Length of stay was shorter (2.6 ± 9.2 vs. 3.6 ± 9.0; p 0.001) and same day discharge greater (43.0% vs. 26.6%; p 0.001) with RA use. After propensity matching, RA use was associated with significant reductions in in-hospital events including access site arterial complications, major bleeding, and major adverse cardiovascular events. Conversion to RA for LMS-PCI was associated with similar reductions in the whole patient cohort. RA use was not associated with lower 12-month mortality.In contemporary practice, the radial artery is the predominant access site for unprotected LMS-PCI, and its use is associated with shorter length of stay, less vascular complications, and less major bleeding than femoral access.

Fractional flow reserve (FFR) is a physiologic measurement of coronary artery perfusion. Studies have demonstrated its benefit in lowering cost and improving outcomes in patients undergoing elective coronary angiography, though follow-up surveys have demonstrated low usage nationwide. We sought to investigate the actual usage in elderly patients undergoing elective coronary angiography. Overall utilization of FFR for elective coronary angiography was 6.3%. Age, sex, race, prior stress testing and region of the country were all statistically significant predictors for FFR use. There still exist many barriers to widespread adoption of this modality, which require further exploration.

INTRODUCTION: There is potential value in testing individual response to P2Y12 inhibitors to predict ischemic and bleeding risk in patients undergoing percutaneous coronary intervention. The aims of this study were: (1) to validate the ability of a novel point of care (POC) assay, thrombelastography (TEG) 6s, to detect changes in adenosine diphosphate (ADP)-induced whole blood clotting in volunteers and patients given clopidogrel using TEG 5000 as a reference and (2) to compare a novel, rapid parameter, area under the curve at 15 minutes (AUC15), with the traditional maximum clot amplitude (MA) in TEG 6s.METHODS: A total of 25 participants were included in whom ADP-induced clotting was measured at 4 time points: (1) 12 healthy volunteers given 600 mg of clopidogrel; (2) 12 patients with ACS given 600 mg of clopidogrel; (3) 1 healthy volunteer given 600 mg of clopidogrel on 5 separate occasions. All samples were tested using conventional TEG 5000 and the new POC TEG 6S, and a new parameter called AUC15 was compared with MA in TEG 6s.RESULTS: (1) TEG 5000 and TEG 6s both detected changes in ADP-induced platelet activation. Bland-Altman analysis demonstrated a good level of agreement between them. (2) For TEG 6S, correlation between MA and the novel AUC15 was strong for both thrombin and ADP channels (R2 = 0.867, R = .936, P < .001), and the AUC15 result was available on average 13.3 minutes earlier.CONCLUSIONS: Thrombelastography 6s is a rapid, easy to use and accurate test of ADP-induced clotting using TEG 5000 as a reference. A novel parameter, AUC15, is a viable, time-saving option for this test and has potential value in personalized P2Y12 inhibitor therapy.

It is unclear how comorbidity influences rates and causes of unplanned readmissions following percutaneous coronary intervention (PCI). We analyzed patients in the Nationwide Readmission Database who were admitted to hospital between 2010 and 2014. The comorbidity burden as defined by the Charlson Comorbidity Index (CCI). Primary outcomes were 30-day readmission rates and causes of readmission according to comorbidity burden. A total of 2,294,346 PCI procedures were included the analysis. The patients in CCI = 0, 1, 2 and ≥3 were 842,272(36.7%), 701,476(30.6%), 347,537(15.1%) and 403,061(17.6%), respectively. 219,227(9.6%) had an unplanned readmission within 30 days and rates by CCI group were 6.6%, 8.6%, 11.4% and 15.9% for CCI groups 0, 1, 2 and ≥3, respectively. The CCI score was also associated with greater cost (cost of index PCI for not readmitted vs readmitted was CCI = 0 $21,257 vs $19,764 and CCI ≥ 3 $26,736 vs $27,723). Compared to patients with CCI = 0, greater CCI score was associated with greater independent odds of readmission (CCI = 1 OR 1.25(1.22–1.28), p

Background— There is wide variation in survival rates from out-of-hospital cardiac arrest (OHCA) and overall survival remains poor. There is an expert consensus that early reperfusion therapy in ST-elevation reduces mortality. The management of patients without ST-elevation, however, is controversial. Methods and Results— The Myocardial Ischaemia National Audit Project database is a national registry of all hospital admissions in England and Wales treated as an acute coronary syndrome (ACS). We examined temporal trends, over a 5-year period, of OHCAs identified by Myocardial Ischaemia National Audit Project, admitted to hospital and treated as ACS, the interventional management of these patients and clinical outcomes. Four hundred ten thousand four hundred sixty-two patients were admitted to hospital in England and Wales with ACS. Of these, 9421 presented with OHCA (2.30%). There was an increase in OHCA cases as a proportion of ACS between 2009 and 2013 (1.79% in 2009 versus 2.74% in 2013; P trend P trend P P Conclusions— This observational study showed that selection for coronary angiography±percutaneous coronary intervention was associated with reduced mortality in OHCA patients diagnosed with ACS. These data support the need for a randomized controlled trial.

Background: Transradial access (TRA) for percutaneous coronary intervention (PCI) is associated with a reduced risk of mortality compared with transfemoral access, access site–related bleeding complications, and shorter length of stay. The budget impact from a healthcare system that has largely transitioned to TRA for PCI has not been previously published. Methods and Results: Data from 323 656 patients undergoing PCI between 2010 and 2014 were obtained from the British Cardiovascular Intervention Society database. Costs for TRA and transfemoral access PCI were estimated based on procedure cost, length of stay, and differences in the rates of complications (major bleeding and vascular complications). In the base case, a propensity-matched data set between transfemoral access and TRA was used to directly compare the cost per PCI, whereas in the real-world analysis, the full data set was used. Across all indications and all years, TRA offered an average cost saving of £250.59 per procedure (22% reduction) versus transfemoral access with the majority of cost saving derived from reduced length of stay (£190.43) rather than direct costs of complications (£3.71). In the real-world analysis, adoption of TRA was estimated to have provided cost savings of £13.31 million across England between 2010 and 2014; however, if operators in all regions had adopted TRA at the rate of the region with the highest utilization, cost savings of £33.40 million could have been achieved. Conclusions: The transition to TRA in England has been associated with significant cost savings across the national healthcare system, in addition to the well-established clinical benefits.

Thomas Hobson was a livery stable owner in Cambridge, England, in the 17th century who had an extensive stable of over 40 horses and ran a thriving horse rental business. His customers believed that, on entry, they would be given their choice of mounts, when in fact he offered them no choice: Hobson required that all his customers choose the horse in the stall closest to the door or have no horse at all. Literally, they had no choice but Hobson’s choice. Similarly, in percutaneous coronary intervention (PCI), adjunctive pharmacotherapy with platelet inhibitors and anticoagulant regimes have improved clinical outcomes through a reduction in ischemic events, including stent thrombosis,1–3 albeit at the expense of increased bleeding complications.4 Although the delivery of antiplatelet agents and anticoagulant regimes can be personalized at an individual patient level in an attempt to balance the reduction in ischemic risk while minimizing the increased risk of major bleeding, like Hobson’s choice in the 17th century, there is currently no option to avoid these agents altogether in PCI in patients with high bleeding risk. Thus, in general, it is either antiplatelet inhibition or no PCI—a 21st century interventional cardiologist’s manifestation of Hobson’s choice. See Article by Groves et al Thrombocytopenia is not uncommon in patients undergoing PCI with a reported prevalence of around 6% in a pooled analysis of the ACUITY trial (Acute Catheterization and Urgent Intervention Triage Strategy) and HORIZONS-AMI trial (The Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction),5 with ≤7% of elective patients6 and 13% of patients with acute coronary syndrome (ACS) developing new thrombocytopenia during their hospitalization.7 Patients with thrombocytopenia tend to be older,5 …

Objective: To define the 99th percentile of high sensitivity cardiac troponin I (hs-cTnI) concentration for a hospital population. Design: Prospective study of 20,000 consecutive patients undergoing blood sampling for any reason at a large teaching hospital. Setting: University Hospital Southampton NHS Trust (UHS). Participants: 20,000 consecutive individuals, inpatient or outpatient, undergoing blood tests at UHS for any clinical reason. Hs-cTnI concentrations (Beckman Coulter Access AccuTnI 3 assay) were nested for analysis in all cases except those in whom the supervising physician had requested hs-cTnI for clinical reasons. Main outcome measures: Distribution of hs-cTnI concentrations of all study patients. Results: The 99th percentile of hs-cTnI for the whole population (n=20,000) was 296 ng/L, compared to a manufacturer quoted 99th percentile of 40 ng/L (currently used clinically as the "upper limit of normal", ULN). In 1 in 20 (5.4%, n=1080) of the total population hs-cTnI concentrations were above 40 ng/L. After exclusion of individuals diagnosed with an acute myocardial infarction (AMI) (n=122), or those in whom troponin was requested (n=1707), the 99th percentile of the remainder (n=18,171) was 189 ng/L. The 99th percentile for inpatients (n=4759) and outpatients (n=9280) was 563 ng/L and 65 ng/L, respectively. Patients from the emergency department (n=3706) had a 99th percentile of 215 ng/L, with 6.1% (n=491) above the quoted ULN. 39% (n=48) of all individuals from the critical care units (n=123) and 15.7% (n=87) of all medical inpatients had a hs-cTnI concentration above the quoted ULN. Conclusions: In 20,000 consecutive patients undergoing a blood test for any reason at this hospital 1 in 20 have a hs-cTnI above the manufacturer quoted ULN. These data highlight the need for clinical staff to interpret hs-cTnI concentrations carefully, particularly when applying the manufacturer's ULN to diagnose AMI. The use of hs-cTn to diagnose AMI in any patient without a typical history may be flawed. Funding Statement: Unrestricted Research Grant – Beckman Coulter Declaration of Interests: M. Mariathas – none declared, R. Allan – none declared, B. Olechowski – none declared, S. Ramamoorthy – none declared, M. Azor – none declared, Z. Nicholas – none declared, A. Calver – none declared, S. Corbett – none declared, M. Mahmoudi – none declared, J. Rawlins – none declared, I. Simpson – none declared, J. Wilkinson – none declared, C. Kwok- none declared, M. Mamas- none declared, P. Cook – none declared, N. Curzen – unrestricted research grants from: Boston Scientific; Haemonetics; Heartflow; Beckmann Coulter. Speaker fees/consultancy from: Haemonetics, Abbot Vascular; Heartflow; Boston Scientific. Travel sponsorship – Biosensors, Abbot, Lilly/D-S; St Jude Medical, Medtronic. Ethics Approval Statement: This research project was undertaken according to the principles of Good Clinical Practice and the Declaration of Helsinki. The study was approved by the local ethical committee who then referred it to the Health Research Authority (HRA) UK for further approval (Rec reference: 17/SC/0042, IRAS project ID: 215262). The method did not require knowledge or consent from patients.

Patient outcome following percutaneous coronary intervention (PCI) is predominantly determined by three factors: clinical presentation, comorbidities, and decision-making process before, during, and after the PCI procedure. In order to justify any intervention, there needs to be reason to think that this will result in either (a) an improvement of symptoms, or (b) an improvement in prognosis, or (c) both. For the interventionalist, the skillful application of modern diagnostic tools and reference to the appropriate evidence base can facilitate delivery of optimal patient care. Coronary angiography has been used as a diagnostic tool for more than half a century. However, it is now well established that coronary angiography alone has important flaws and, in particular, can correlate poorly with the functional importance of a stenosis within the epicardial arteries. Further, the evidence base increasingly points to lesion-level ischemia as our target for revascularization. The availability of invasive physiological lesion assessment has revolutionized our ability to define with precision the presence or absence of lesion-level ischemia. The aim of this chapter is to review the evidence for and the expanding role of physiological lesion assessment in our everyday interventional practice.

Objective MicroRNAs (miRNAs) may serve as potential biomarkers in a variety of pathologies. The aim of this study was to determine whether miRNAs could serve as blood-based markers of isolated coronary artery calcification (CAC) defined as CAC in the absence of an underlying metabolic abnormality. Methods 24 age-matched and sex-matched patients who had been referred for elective CT coronary calcium score and angiography as part of investigation for cardiac chest pain were recruited. Peripheral venesection was performed and an Agatston calcium score was derived from the CT coronary angiogram using default software. RNA was extracted using the LeukoLOCK Total RNA Isolation System for Toray’s microarray analysis and quantitative reverse transcription PCR (qRT-PCR). Results The patients were well matched for age, sex and conventional risk factors for coronary artery disease. Microarray analysis identified lower expression of miRNA-138-2-3p, miRNA-1181, miRNA-6816-3p and miRNA-8059 in patients with coronary artery calcium score (CACS)=0 vs CACS>100. qRT-PCR confirmed significant downregulation of miRNA-8059 in patients with CACS>100 (CACS=0 vs CACS>100; P=0.03). Conclusion miRNA-8059 may serve as a peripheral blood-based biomarker for the presence of CAC, as well as provide a platform for studying the pathophysiological basis of isolated CAC. Trial registration number NCT01992848; Results.

We have read with interest the paper by Collinson et al ,1 and we are grateful for an opportunity to respond to their comments, especially those that relate to our recent BMJ paper describing the Is the current threshold for diagnosing raised highly sensitive troponin apparopriate for a hospital population? (CHARIOT) study.2 The use of more sensitive troponin assays in UK hospitals is now universal. The frontline clinical staff who request and then interpret the test belong to a wide range of clinical specialties. The concept for CHARIOT emerged out of our observations that there was an important mismatch in actual clinical practice between the extremely precise guidelines that lay out how these assays should be employed to rule out myocardial infarction (MI), or diagnose MI or myocardial injury, and their actual use. Specifically, there are important and widespread misconceptions about how troponin values should be or can be interpreted. First, that the manufacturer-provided 99th centile value for their assay represents a binary ‘upper limit of normal’ for a hospital population. Second, that a single troponin result above that 99th centile represents an ‘acute coronary syndrome’ diagnosis, regardless of whether there is an appropriate accompanying history. Third, that the general awareness that type 2 MI and myocardial injury are common, distinct clinical entities from type 1 MI, both pathophysiologically and in terms of appropriate management algorithms, …

BackgroundThe sensitivity and specificity of the subcutaneous implantable cardioverter defibrillator (S-ICD) pre-implant screening tool required clinical evaluation.MethodsBipolar vectors were derived from electrodes positioned at locations similar to those employed for S-ICD sensing and pre-implant screening electrodes, and recordings collected through 80-electrode PRIME®-ECGs, in six different postures, from 40 subjects (10 healthy controls, and 30 patients with complex congenital heart disease (CCHD); 10 with Tetralogy of Fallot (TOF), 10 with single ventricle physiology (SVP), and 10 with transposition of great arteries (TGA)). The resulting vectors were analysed using the S-ICD pre-implant screening tool (Boston Scientific) and processed through the sensing algorithm of S-ICD (Boston Scientific). The data were then evaluated using 2 × 2 contingency tables. Fisher exact and McNemar tests were used for a comparison of the different categories of CCHD, and p < 0.05 vs. controls considered to be statistically significant.Results57% of patients were male, mean age of 36.3 years. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the S-ICD screening tool were 95%, 79%, 59% and 98%, respectively, for controls, and 84%, 79%, 76% and 86%, respectively, in patients with CCHD (p = 0.0001).ConclusionThe S-ICD screening tool was comparatively more sensitive in normal controls but less specific in both CCHD patients and controls; a possible explanation for the reported high incidence of inappropriate S-ICD shocks. Thus, we propose a pre-implant screening device using the S-ICD sensing algorithm to minimise false exclusion and selection, and hence minimise potentially inappropriate shocks.

Despite the clinical effectiveness of coronary artery stenting, percutaneous coronary intervention or "stenting" is not free of complications. Stent malapposition (SM) is a common feature of "stenting" particularly in challenging anatomy, such as that characterized by long, tortuous and bifurcated segments. SM is an important risk factor for stent thrombosis and recently it has been associated with longitudinal stent deformation. SM is the result of many factors including reference diameter, vessel tapering, the deployment pressure and the eccentric anatomy of the vessel. For the purpose of the present paper, virtual multi-folded balloon models have been developed for simulated deployment in both constant and varying diameter vessels under uniform pressure. The virtual balloons have been compared to available compliance charts to ensure realistic inflation response at nominal pressures. Thereafter, patient-specific simulations of stenting have been conducted aiming to reduce SM. Different scalar indicators, which allow a more global quantitative judgement of the mechanical performance of each delivery system, have been implemented. The results indicate that at constant pressure, the proposed balloon models can increase the minimum stent lumen area and thereby significantly decrease SM.

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 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.

Transcatheter aortic valve implantation (TAVI) was first used in clinical practice in 2002. Since 2002, there has been a rapid increase in TAVI activity in patients with symptomatic severe aortic stenosis. This has been supported by systematic randomized data comparing TAVI against the gold standard treatment for the last 50 years’ surgical aortic valve replacement. TAVI is now currently a recommended therapeutic intervention in the treatment of severe aortic stenosis patients who are deemed either high risk or inoperable. The indications for TAVI continue to expand. Within this review we will focus on the current guidelines for TAVI, the evidence for it, the complications of TAVI, postprocedure care, the technology available to clinicians now and finally the future perspectives for TAVI.

The introduction of the highly sensitive troponin (hs-trop) assays into clinical practice has allowed for the more rapid diagnosis or exclusion of type 1 myocardial infarctions (T1MI) by clinicians, in addition type 2 myocardial infarctions (T2MI) are now more frequently detected. Tachyarrhythmias are one of the common causes of T2MI, the medium and long term outcome for this cohort of T2MI is yet to be clarified.Retrospective review of consecutive patients admitted with a diagnosis of either (a) non ST-elevation myocardial infarction (NSTEMI) or (b) tachyarrhythmia was performed. Data were collected on patient demographics and investigations. Patient mortality status was recorded through the Personal Demographics Service (PDS) via NHS Digital.A total of 704 patients were eligible for inclusion to the study. 264 patients were included in the study with a final discharge diagnosis of NSTEMI and 440 patients with a final discharge diagnosis of tachyarrhythmia. There was a significantly higher peak troponin in NSTEMI patients compared to the tachyarrhythmia troponin positive group (4552ng/L vs 571ng/L, p0.001). Mortality was significantly higher in the troponin positive tachyarrhythmia patients than the troponin negative patients (54 vs 34, 26.2% vs 14.5%, log rank p=0.003), furthermore, the mortality of NSTEMI and troponin positive tachyarrhythmia patients was similar (55 vs 54, 20.8% vs 26.2%, log rank p=0.416). Only one patient (0.14%) was given a formal diagnosis of T2MI.These data suggest that troponin positive tachyarrhythmia is not a benign diagnosis, and has a mortality rate similar to NSTEMI. Formal labeling as T2MI is rare in real life practice. More investigation into the detection and management of T2MI and troponin positive arrhythmia patients is now warranted.

This study aimed to examine the 30-day unplanned readmissions rate, predictors of readmission, causes of readmissions, and clinical impact of readmissions after percutaneous coronary intervention (PCI).Unplanned rehospitalizations following PCI carry significant burden to both patients and the local health care economy and are increasingly considered as an indicator of quality of care.Patients undergoing PCI between 2013 and 2014 in the U.S. Nationwide Readmission Database were included. Incidence, predictors, causes, and cost of 30-day unplanned readmissions were determined.A total of 833,344 patients with PCI were included, of whom 77,982 (9.3%) had an unplanned readmission within 30 days. Length of stay for the index PCI was greater (4.7 vs. 3.9 days) and mean total hospital cost ($23,211 vs. $37,524) was higher for patients who were readmitted compared with those not readmitted. The factors strongly independently associated with readmissions were index hospitalization discharge against medical advice (odds ratio [OR]: 1.91; 95% confidence interval [CI]: 1.65 to 2.22), transfer to short-term hospital for inpatient care (OR: 1.62; 95% CI: 1.38 to 1.90), discharge to care home (OR: 1.57; 95% CI: 1.51 to 1.64), and chronic kidney disease (OR: 1.50; 95% CI: 1.44 to 1.55). Charlson Comorbidity Index score (OR: 1.28; 95% CI: 1.27 to 1.29) and number of comorbidities (OR: 1.18; 95% CI: 1.17 to 1.18) were independently associated with unplanned readmission. The majority of readmissions were due to noncardiac causes (56.1%).Thirty-day readmissions after PCI are relatively common and relate to baseline comorbidities and place of discharge. More than one-half of the readmissions were due to noncardiac causes.

We thank Dr Uretsky et al for suggesting to check for potential differences in baseline characteristics and—more importantly—in outcome between patients with and patients without post-percutaneous coronary intervention fractional flow reserve (post-PCI FFR) measurements.1 It is indeed likely that procedural characteristics, not captured by the case record form, may have influenced the operator to decide to perform or not to perform the final FFR measurements. Checking for these differences in outcome might increase the generalizability of the conclusions. We will therefore perform this analysis in …

Background— The predictive value of fractional flow reserve (FFR) measured immediately after percutaneous coronary intervention (PCI) with drug-eluting stent placement has not been prospectively investigated. We investigated the potential of post-PCI FFR measurements to predict clinical outcome in patients from FAME 1 and 2 trials (Fractional Flow Reserve or Angiography for Multivessel Evaluation). Methods and Results— All patients of FAME 1 and FAME 2 who had post-PCI FFR measurement were included. The primary outcome was vessel-oriented composite end point at 2 years, defined as vessel-related cardiovascular death, vessel-related spontaneous myocardial infarction, and ischemia-driven target vessel revascularization. Eight hundred thirty-eight vessels in 639 patients were analyzed. Baseline FFR values did not differ between vessels with versus without vessel-oriented composite end point (0.66±0.11 versus 0.63±0.14, respectively; P =0.207). Post-PCI FFR was significantly lower in vessels with vessel-oriented composite end point (0.88±0.06 versus 0.90±0.06, respectively; P =0.019). Comparing the 2-year outcome of lower and upper tertiles of post-PCI FFR significant difference was found favoring upper tertile in terms of overall vessel-oriented composite end point (9.2% versus 3.8%, respectively; hazard ratio, 1.46; 95% confidence interval, 1.02–2.08; P =0.037) and target vessel revascularization (7.0% versus 2.4%, respectively; hazard ratio, 1.59; 95% confidence interval, 1.03–2.46; P =0.037). When adjusted to sex, hypertension, diabetes mellitus, target vessel, serial stenosis, and baseline percentage diameter stenosis, a strong trend was preserved in terms of target vessel revascularization (harzard ratio, 1.55; 95% confidence interval, 0.97–2.46; P =0.066), favoring the upper tertile. Post-PCI FFR of 0.92 was found to have the highest diagnostic accuracy; however, the positive likelihood ratio remained low ( Conclusions— A higher post-PCI FFR value is associated with a better vessel-related outcome. However, its predictive value is too low to advocate its use as a surrogate clinical end point.

We describe the case of a 45-year-old woman presenting with troponin positive cardiac-sounding chest pain. An initial emergency angiogram demonstrated two vessel coronary disease, including a distal right coronary artery occlusion. No percutaneous coronary intervention was performed and the patient was treated medically. At re-presentation with further pain a few days later, coronary angiography demonstrated no significant coronary lesions. After consideration of other multisystem symptoms and raised eosinophil count, the patient was diagnosed with eosinophilic granulomatosis with polyangiitis (formerly known as Churg-Strauss syndrome) presenting with coronary arteritis. This case should remind physicians to be vigilant and to consider non-atherosclerotic causes of acute coronary syndrome presentation, which should not always result in a stent.

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.

Background\ud The assessment of patients presenting with angina using invasive angiography alone is imperfect. By contrast, fractional flow reserve (FFR) allows for assessment of lesion-specific ischemia, which is predictive of clinical outcome. A series of studies has demonstrated that the availability of FFR data at the time of diagnostic angiography leads to significant differences in the management of those patients.\ud \ud Hypothesis: The objective of this paper is to assess the consistency in the difference in management resulting from an FFR-directed versus and angiogram-directed strategy in appropriate observational and randomized trials.\ud \ud Methods\ud A methodical search was made using MEDLINE, Current Contents Connect, Google Scholar, EMBASE, Cochrane library, PubMed, Science Direct, and Web of Science.\ud \ud Results\ud Eight studies were identified using the eligibility criteria. A total of 2468 patients were recommended to have optimal medical therapy (OMT) alone after initial angiographic assessment but, after FFR results were available, a total of 716 (29.0%) were referred for revascularization (PCI 626 patients [25.36%]; CABG 90 patients [3.64%]). Similarly, 3766 patients were originally committed to PCI after initial angiography: of these 1454 patients (38.61%) were reconsidered to be suitable for OMT alone and 71 individuals (1.8%) were deemed suitable for CABG after FFR data were available. Further, of 366 patients referred for CABG based on angiographic data, the availability of FFR data changed the final decision to OMT alone in 65 patients (17.76%) and PCI in 51 patients (13.9%). Overall, the angiogram-derived management was changed in 22%–48% of these study populations when FFR data were available.\ud \ud Conclusions\ud Some use of FFR during coronary angiography alters the angiogram-directed management in a remarkably consistent manner. These data suggest that routine use of FFR at the diagnostic angiogram would improve patient care.

Objectives The goal of this study was to report outcomes from percutaneous coronary intervention (PCI) to an unprotected left main stem (UPLMS) stenosis according to presenting syndrome, including ST-segment elevation myocardial infarction (STEMI), non–ST-segment elevation acute coronary syndrome (NSTEACS), and chronic stable angina (CSA). Background There are no published whole-country data concerning patient outcomes following PCI to UPLMS. Methods This study is a prospective national cohort study using data from the British Cardiovascular Intervention Society (BCIS) registry from January 1, 2005, through December 31, 2010. Results Of 5,065 patients having PCI to an UPLMS, 784 (15.5%) presented with STEMI, 2,381 (47.0%) with NSTEACS, and 1,900 (37.5%) with CSA. Crude 30-day and 1-year mortality rates were STEMI: 28.3% and 37.6%, NSTEACS: 8.9% and 19.5%, and CSA: 1.4% and 7.0%, respectively. Unadjusted in-hospital major adverse cardiovascular and cerebrovascular event rates were STEMI: 26.6%, NSTEACS: 6.6%, and CSA: 3.3%. Risk of 30-day mortality was much greater for STEMI and NSTEACS patients than CSA (STEMI adjusted odds ratio [aOR]: 29.45, 95% confidence interval [CI]: 19.37 to 44.80, NSTEACS aOR: 6.45, 95% CI: 4.27 to 9.76). More than 40% of patients presenting with STEMI had cardiogenic shock, in whom mortality was higher than in STEMI cases without shock (30 days: 52.0% vs. 11.7%, 1 year: 61.1% vs. 20.9%). Radial access, compared with the femoral approach, was associated with a lower risk of 30-day mortality (STEMI aOR: 0.37, 95% CI: 0.21 to 0.62; NSTEACS aOR: 0.66, 95% CI: 0.45 to 0.97). Conclusions More than one-half of the patients who received UPLMS PCI were acute where outcomes were much worse than elective cases. Cardiogenic shock is common in STEMI patients, of whom more than one-half die at 30 days. The radial approach was associated with reduced early mortality in acute cases.

Background— The use of coronary angiography (CA) for diagnosis and management of chest pain (CP) has several flaws. The assessment of coronary artery disease using fractional flow reserve (FFR) is a well-validated technique for describing lesion-level ischemia and improves clinical outcome in the context of percutaneous coronary intervention. The impact of routine FFR at the time of diagnostic CA on patient management has not been determined. Methods and Results— Two hundred patients with stable CP underwent CA for clinical indications. The supervising cardiologist (S.C.) made a management plan based on CA (optimal medical therapy alone, percutaneous coronary intervention, coronary artery bypass grafting, or more information required) and also recorded which stenoses were significant. An interventional cardiologist then measured FFR in all patent coronary arteries of stentable diameter (≥2.25 mm). S.C. was then asked to make a second management plan when FFR results were disclosed. Overall, after disclosure of FFR data, management plan based on CA alone was changed in 26% of patients, and the number and localization of functional stenoses changed in 32%. Specifically, of 72 cases in which optimal medical therapy was recommended after CA, 9 (13%) were actually referred for revascularization with FFR data. By contrast, of 89 cases in whom management plan was optimal medical therapy based on FFR, revascularization would have been recommended in 25 (28%) based on CA. Conclusions— Routine measurement of FFR at CA has important influence both on which coronary arteries have significant stenoses and on patient management. These findings could have important implications for clinical practice. Clinical Trial Registration— URL: http://www.clinicaltrial.gov . Unique identifier: NCT01070771.

Objectives The aim of this study was to determine whether drug-eluting stents (DES) are superior to bare-metal stents (BMS) in octogenarian patients with angina. Background Patients ≥80 years of age frequently have complex coronary disease warranting DES but have a higher risk of bleeding from prolonged dual antiplatelet therapy. Methods This multicenter randomized trial was conducted in 22 centers in the United Kingdom and Spain. Patients ≥80 years of age underwent stent placement for angina. The primary endpoint was a 1-year composite of death, myocardial infarction, cerebrovascular accident, target vessel revascularization, or major hemorrhage. Results In total, 800 patients (83.5 ± 3.2 years of age) were randomized to BMS (n = 401) or DES (n = 399) for treatment of stable angina (32%) or acute coronary syndrome (68%). Procedural success did not differ between groups (97.7% for BMS vs. 95.4% for DES; p = 0.07). Thirty-eight percent of patients had ≥2-vessel percutaneous coronary intervention, and 66% underwent complete revascularization. Patients who received BMS had shorter stent implants (24.0 ± 13.4 mm vs. 26.6 ± 14.3 mm; p = 0.01). Rates of dual antiplatelet therapy at 1 year were 32.2% for patients in the BMS group and 94.0% for patients in the DES group. The primary endpoint occurred in 18.7% of patients in the BMS group versus 14.3% of patients in the DES group (p = 0.09). There was no difference in death (7.2% vs. 8.5%; p = 0.50), major hemorrhage (1.7% vs. 2.3%; p = 0.61), or cerebrovascular accident (1.2% vs. 1.5%; p = 0.77). Myocardial infarction (8.7% vs. 4.3%; p = 0.01) and target vessel revascularization (7.0% vs. 2.0%; p = 0.001) occurred more often in patients in the BMS group. Conclusions BMS and DES offer good clinical outcomes in this age group. DES were associated with a lower incidence of myocardial infarction and target vessel revascularization without increased incidence of major hemorrhage. (Xience or Vision Stent–Management of Angina in the Elderly [XIMA]; ISRCTN92243650 )

Objectives The goal of this study was to evaluate the pharmacodynamic effects of switching patients from ticagrelor to prasugrel. Background Clinicians may need to switch between more potent P2Y12 inhibitors because of adverse effects or switch to the use of a once-daily dosing regimen due to compliance issues. Methods After a 3- to 5-day run-in phase with a ticagrelor 180-mg loading dose (LD) followed by a ticagrelor 90-mg twice-daily maintenance dose (MD), aspirin-treated patients (N = 110) with stable coronary artery disease were randomized to continue ticagrelor or switch to prasugrel 10-mg once-daily MD, with or without a 60-mg LD. Pharmacodynamic assessments were defined according to P2Y12 reaction unit (PRU) (P2Y12 assay) and platelet reactivity index (vasodilator-stimulated phosphoprotein phosphorylation assay) at baseline (before and after the run-in phase) and 2, 4, 24, and 48 h and 7 days after randomization. Results Platelet reactivity was significantly greater at 24 and 48 h after switching to prasugrel versus continued therapy with ticagrelor, although to a lesser extent in those receiving an LD. Mean PRU remained significantly higher in the combined prasugrel groups versus the ticagrelor group (least-squares mean difference: 46 [95% confidence interval 25 to 67]) and did not meet the primary noninferiority endpoint (upper limit of the confidence interval ≤45), although PRU in the prasugrel cohort was lower at 7 days than at 24 or 48 h. Accordingly, rates of high on-treatment platelet reactivity were higher at 24 and 48 h in both prasugrel groups. At 7 days, there was no difference in high on-treatment platelet reactivity rate between the combined prasugrel and ticagrelor groups. Conclusions Compared with continued ticagrelor therapy, switching from ticagrelor to prasugrel therapy was associated with an increase in platelet reactivity that was partially mitigated by the administration of an LD.

In percutaneous coronary intervention (PCI), stent malapposition is a common complication often leading to stent thrombosis (ST). More recently, it has also been associated with longitudinal stent deformation (LSD) normally occurring through contact of a post balloon catheter tip and the protruding malapposed stent struts.The aim of this study was to assess the longitudinal integrity of first and second generation drug eluting stents in a patient specific coronary artery segment and to compare the range of variation of applied loads with those reported elsewhere. We successfully validated computational models of three drug-eluting stent designs when assessed for longitudinal deformation. We then reconstructed a patient specific stenosed right coronary artery segment by fusing angiographic and intravascular ultrasound (IVUS) images from a real case. Within this model the mechanical behaviour of the same stents along with a modified device was compared. Specifically, after the deployment of each device, a compressive point load of 0.3 N was applied on the most malapposed strut proximally to the models. Results indicate that predicted stent longitudinal strength (i) is significantly different between the stent platforms in a manner consistent with physical testing in a laboratory environment, (ii) shows a smaller range of variation for simulations of in vivo performance relative to models of in vitro experiments, and (iii) the modified stent design demonstrated considerably higher longitudinal integrity. Interestingly, stent longitudinal stability may differ drastically after a localised in vivo force compared to a distributed in vitro force.

The Selvester score is an effective means for estimating the extent of myocardial scar in a patient from lowcost ECG recordings. Automation of such a system is deemed to help implementing low-cost high-volume screening mechanisms of scar in the primary care. This article describes, for the first time to the best of our knowledge, an automated implementation of the updated Selvester scoring system for that purpose, where fractionated QRS morphologies and patterns are identified and classified using a novel Stationary Wavelet Transform (SWT) based fractionation detection algorithm. This stage informs the two principal steps of the updated Selvester scoring scheme - the confounder classification and the point awarding rules. The complete system is validated on 51 ECG records of patients detected with ischemic heart disease. Validation has been carried out using manually detected confounder classes and computation of the actual score by expert cardiologists as the ground truth. Our results show that as a stand-alone system it is able to classify different confounders with 94.1% accuracy whereas it exhibits 94% accuracy in computing the actual score. When coupled with our previously proposed automated ECG delineation algorithm, that provides the input ECG parameters, the overall system shows 90% accuracy in confounder classification and 92% accuracy in computing the actual score and thereby showing comparable performance to the stand-alone system proposed here, with the added advantage of complete automated analysis without any human intervention.

Introduction: There remains considerable heterogeneity in the management of significant lesions in non culprit coronary arteries in STEMI patients undergoing primary percutaneous coronary intervention (PPCI). Three recent randomised trials have shown clinical outcome benefit in a complete revascularisation approach when compared to PPCI of the culprit artery alone. By contrast, observational data suggest that an aggressive complete revascularisation may not confer clinical benefit and may, in some cases, be harmful.Areas covered: In this review we discuss the three recent randomised trials that have advocated a complete revasculariation approach in addition to data available from registries.Expert commentary: An adequately powered, randomised controlled trial is required to answer the question of whether complete revascularisation in STEMI patients is beneficial and, if so, whether it should be ischaemia directed and whether it should be at the index procedure or staged.

Background Up 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 Results A 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 . Conclusion CR 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.

Although the predictors and outcomes of radial versus femoral access are well defined for unselected PCI procedures and certain sub-groups, there are few data for patients undergoing left main stem percutaneous coronary intervention (LMS-PCI). The aim of the present study was to address these

[Tomaniak, Mariusz; Chang, Chun-Chin; Onuma, Yoshinobu] Erasmus MC, Thorax Ctr, Dept Intervent Cardiol, Rotterdam, Netherlands. [Tomaniak, Mariusz; Chang, Chun-Chin; Onuma, Yoshinobu] Med Univ Warsaw, Dept Cardiol 1, Warsaw, Poland. [Chichareon, Ply; Kogame, Norihiro; Modolo, Rodrigo; Takahashi, Kuniaki] Acad Med Ctr, Amsterdam, Netherlands. [Klimczak, Dominika] Med Univ Warsaw, Dept Immunol Transplant Med & Internal Dis, Div Heart Failure & Cardiac Rehabil, Warsaw, Poland. [Komiyama, Hidenori; Rademaker-Havinga, Tessa] Cardialysis, Rotterdam, Netherlands. [Curzen, Nick] Univ Hosp Southampton, Southampton, Hants, England. [Haude, Michael] Lukaskrankenhaus Neuss, Neuss, Germany. [Hamm, Christian] Kerckhoff Clin, Bad Nauheim, Germany. [Steg, Philippe Gabriel] Grp Hosp Bichat Claude Bernard, Paris, France. [Juni, Peter] Univ Toronto, Toronto, ON, Canada. [Vranckx, Pascal] Hartctr Hasselt, Hasselt, Belgium. [Valgimigli, Marco] Inselpsital, Swiss Cardiovasc Ctr, Bern, Switzerland. [Windecker, Stephan] Univ Bern, Bern Univ Hosp, Inselspital, Bern, Switzerland. [Anderson, Richard] Univ Hosp Wales, Cardiff, S Glam, Wales. [Serruys, Patrick] Imperial Coll, London, England.

International guidelines recommend that for non–ST-segment elevation acute myocardial infarction (NSTEMI), the timing of an invasive strategy (IS) is a function of the patient’s baseline risk. The extent to which this is delivered across and within health care systems is unknown. Data were

Availability of cardiac catheterization facilities at the admitting hospitals is an important determinant of receipt of invasive cardiac procedures such as coronary angiography (CA) and percutaneous coronary intervention (PCI). This study evaluates the receipt of invasive cardiac procedures and

There is limited data around temporal changes in clinical characteristics of patients admitted with Non-ST elevation acute myocardial infarction (NSTEMI) receiving invasive coronary angiography (CA) at different time points and clinical outcomes. This study aims to investigate the temporal trends in

In this paper, we address the problem of detecting the presence of a myocardial scar from the standard electrocardiogram (ECG)/vectorcardiogram (VCG) recordings, giving effort to develop a screening system for the early detection of the scar in the point-of-care. Based on the pathophysiological implications of scarred myocardium, which results in disordered electrical conduction, we have implemented four distinct ECG signal processing methodologies in order to obtain a set of features that can capture the presence of the myocardial scar. Two of these methodologies are: 1) the use of a template ECG heartbeat, from records with scar absence coupled with wavelet coherence analysis and 2) the utilization of the VCG are novel approaches for detecting scar presence. Following, the pool of extracted features is utilized to formulate a support vector machine classification model through supervised learning. Feature selection is also employed to remove redundant features and maximize the classifier's performance. The classification experiments using 260 records from three different databases reveal that the proposed system achieves 89.22% accuracy when applying tenfold cross validation, and 82.07% success rate when testing it on databases with different inherent characteristics with similar levels of sensitivity (76%) and specificity (87.5%).

Acute ST-segment elevation myocardial infarction (STEMI) is a dynamic, thrombus-driven event. As understanding of its pathophysiology has improved, the central role of platelets in initiation and orchestration of this process has become clear. Key components of STEMI include formation of occlusive thrombus, mediation and ultimately amplification of the local vascular inflammatory response resulting in increased vasoreactivity, oedema formation, and microvascular obstruction. Activation, degranulation, and aggregation of platelets are the platforms from which these components develop. Therefore, prompt, potent, and predictable antithrombotic therapy is needed to optimise clinical outcomes after primary percutaneous coronary intervention. We review present pharmacological and mechanical adjunctive therapies for reperfusion and ask what is the optimum combination when primary percutaneous coronary intervention is used as the mode of revascularisation in patients with STEMI.