Search

Background To date, there have been limited comparisons performed between everolimus-eluting stents (EES) and zotarolimus-eluting stents (ZES) in patients with diabetes mellitus (DM). The objectives of this study was to assess the use of second-generation drug-eluting stents in patients with DM, using optical coherence tomography (OCT) to compare the level of stent coverage of Boston Scientific Promus Element EES compared with Medtronic Resolute Integrity ZES.(Clinicaltrials.gov number NCT02060357). Methods This is a single-centre randomised blinded trials assessing two commercially available stents in 60 patients with diabetes (ZES: n=30, EES: n=30). Patients underwent intracoronary assessment at 6 months with OCT assessing stent coverage, malapposition, neointimal thickness and percentage of in-stent restenosis (ISR). Results Of the 60 patients randomised, 46 patients underwent OCT analysis. There was no difference in baseline characteristics between the two groups. Both Promus Element and Resolute Integrity had low rates of uncovered struts at 6 months with no significant difference between the two groups (2.44% vs 1.24%, respectively; P=0.17). Rates of malapposition struts (3.9% vs 2.5%, P=0.25) and percentage of luminal loss did not differ between stent types. In addition, there was no significant difference in major adverse cardiovascular events (P=0.24) between the stent types. Conclusions This study is the first randomised trial to evaluate OCT at 6 months for ZES and EES in patients with diabetes. Both stents showed comparable strut coverage at 6 months, with no difference in ISR rates at 6 months.

Acute kidney injury (AKI) is a frequent complication of cardiac surgery and usually occurs in patients with preexisting chronic kidney disease (CKD). Remote ischemic preconditioning (RIPC) may mitigate the renal ischemia-reperfusion injury associated with cardiac surgery and may be a preventive strategy for postsurgical AKI. We undertook a randomized controlled trial of RIPC to prevent AKI in 86 patients with CKD (estimated glomerular filtration rate under 60 ml/min per 1.73 m(2)) undergoing coronary artery bypass graft (CABG) surgery. Forty-three patients each were randomized to receive standard care with or without RIPC consisting of three 5-minute cycles of forearm ischemia followed by reperfusion. The primary end point was the development of AKI defined as an increase in serum creatinine concentration over 0.3 mg/dl within 48 h of surgery. Secondary end points included a comparison between the study and control groups of several serum biomarkers of renal injury including cystatin-C, neutrophil gelatinase-associated lipocalin (NGAL), and interleukin-18 (IL-18), and urinary biomarkers including NGAL, IL-18, and kidney injury molecule-1 measured at 6, 12, and 24 h after CABG, and the 72-h serum troponin T concentration area under the curve as a marker of myocardial injury. Clinical and operative characteristics were similar between the preconditioned and control groups. AKI developed in 12 patients in both groups within 48 h of CABG. There were no significant differences between the two groups in the concentrations of any of the serum or urinary biomarkers of renal or cardiac injury after CABG. Thus, RIPC induced by forearm ischemia-reperfusion had no effect on the frequency of AKI after CABG in patients with CKD.

Background The development of acute kidney injury (AKI) after coronary artery bypass graft (CABG) surgery is associated with increased short- and long-term mortality. Whether AKI has a causal relationship with subsequent mortality or whether the development of AKI simply occurs in patients with more comorbidity undergoing more complex procedures remains unresolved. Methods and Results This was an observational cohort study of prospectively collected data from 4694 patients discharged from the hospital after first-time CABG surgery at a tertiary cardiac center between 2003 and 2008. AKI was defined using the Risk, Injury, Failure, Loss, and End stage (RIFLE) criteria, which require at least a 50% increase in serum creatinine. The primary outcome measure was all-cause mortality determined via UK Office of National Statistics. A total of 562 (12.0%) of patients developed AKI after CABG surgery. Patients who developed AKI were older, more likely to be female, and had more comorbidity than patients who did not develop AKI. In a Cox multivariable analysis, the development of AKI was an independent predictor of midterm mortality (hazard ratio, 1.80; 95% confidence interval, 1.50-2.16). Subsequently, a comparison of 562 patients who sustained AKI with 562 propensity score–matched patients who did not sustain AKI was undertaken. After propensity matching, baseline clinical and operative characteristics were similar between both groups. After Cox multivariable analysis of the propensity-matched cohort, AKI remained an independent predictor of midterm mortality (hazard ratio, 1.52; 95% confidence interval, 1.19-1.93). Conclusions The development of AKI after CABG is a serious event associated with worse midterm survival. This excess mortality cannot be explained simply by coexisting comorbidity and surgical complexity.

OBJECTIVES: Diabetes mellitus (DM) and renal impairment (RI) are both independent predictors of mortality after coronary artery bypass graft surgery (CABG). The two conditions often coexist, yet the impact on long-term prognosis after CABG of each factor relative to the other and the two in combination is uncertain. METHODS: We undertook a prospective cohort study of 4869 patients who underwent CABG between 2003 and 2007. The cohort was divided into four groups according to preoperative diabetic status and renal function: patients without either DM or RI (reference group), patients with DM alone, patients with RI alone and patients with both DM and RI. Clinical outcomes were compared between groups. Patients receiving renal replacement therapy were excluded. The primary outcome was 5-year all-cause mortality. RESULTS: The crude 5-year all-cause mortality rate was 9.0% for patients in the reference group, 11.1% for patients with DM alone, 20.3% for patients with RI alone and 28.5% for patients with both DM and RI (P< 0.0001). Five-year survival adjusted for potential confounding factors was significantly worse for patients with DM (hazard ratio (HR) 1.30; 95% confidence interval (CI) 1.06–1.59), patients with RI (HR 1.32; 95% CI 1.08–1.61) and patients with both DM and RI (HR 2.04; 95% CI 1.65–2.53) when compared with patients with neither condition. CONCLUSIONS: Preoperative DM and RI were important predictors of 5-year mortality after CABG. Patients with RI alone had a higher mortality rate than patients with DM alone, but this difference was largely accounted for by age and other comorbidities. The combination of DM and RI doubled the 5-year mortality rate after CABG independently of potential confounding factors.

AIM The aim of this study was to investigate the effects of baseline anaemia on the outcome in patients treated by primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction. METHODS This study was a retrospective cohort study of 2418 patients with ST-elevation myocardial infarction treated by PPCI between January 2004 and August 2010 at a single centre. We investigated the outcome in patients with anaemia compared with that in patients with a normal haemoglobin (Hb) level. Anaemia was defined according to the WHO definition as an Hb level less than 12 g/dl for female individuals and less than 13 g/dl for male individuals. We also calculated hazard ratios using a stratified model according to the Hb level. RESULTS A total of 471 (19%) patients were anaemic at presentation. The anaemic cohort was older (72.2 vs. 62.4 years, P

There are limited data about the effectiveness of primary percutaneous coronary intervention (PPCI) for stent thrombosis treatment. We aimed to evaluate the prevalence and outcomes of PPCI in patients with ST elevation acute myocardial infarction (STEMI) due to stent thrombosis, and comparing the outcomes with patients treated for de novo coronary thrombosis. This was an observational cohort study of 2,935 patients who underwent PPCI from 2003 to 2011 with follow-up for a median of 3.0 years (interquartile range 1.2 to 4.6). The primary end point was the first major adverse cardiac event (MACE) defined as death, nonfatal myocardial infarction, stroke, or target vessel revascularization. Stent thrombosis overall accounted for 6.6% (194 of 2,935) of all STEMIs with a proportion that increased over time (3.3% in 2004 to 9.4% in 2011). A total of 34.5% were early, 30.9% late stent thrombosis, and 34.5% were very late stent thrombosis. Indications for the original intervention were elective in 27.8%, after acute coronary syndrome (non-STEMI or unstable angina) in 21.1%, and after PPCI in 51.1%. Patients with stent thrombosis had higher rates of hypertension, hypercholesterolemia, diabetes, renal dysfunction, and previous myocardial infarction or coronary artery bypass surgery compared with patients with native artery occlusion. MACE rates were higher in patients with stent thrombosis compared with patients with native artery occlusions (40.9%, 95% confidence interval [CI] 31.1 to 50.6 vs 15.1%, 95% CI 12.5 to 18.3; p0.0001). The poor outcome of stent thrombosis was particularly associated with early and late stent thromboses. Very late stent thrombosis appears to be a relatively less serious event, with similar outcomes to native vessel thromboses (MACE very late stent thrombosis 16.5%, 95% CI 8.2 to 28.6 vs native 15.1%, 95% CI 12.5 to 18.3, p = 0.245). In conclusion, stent thrombosis accounts for an increasing proportion of STEMI and is associated with worse outcomes compared with native artery occlusion.

Aim Primary percutaneous coronary intervention (PPCI) produces more effective coronary reperfusion and allows immediate risk stratification compared with fibrinolysis. We investigated the safety and feasibility of very early discharge at 2 days following PPCI in selected low-risk cases. Methods This was a prospective observational cohort study of 2779 patients who underwent PPCI between 2004 and 2011. Patients meeting the following criteria were deemed suitable for very early discharge; TIMI III flow, left ventricle (LF) ejection fraction >40%, and rhythmic and haemodynamic stability out to 48 h. Higher-risk patients who did not fulfil these criteria were discharged later according to physician preference. All patients were offered outpatient review by a multidisciplinary team. Endpoints included 30 day readmission rates and major adverse cardiac events (MACE) out to a median of 2.8 years (IQR range: 1.3–4.4 years). Results 1309 (49.3%) PPCI patients met very early discharge criteria, of whom 1117 (85.3%) were actually discharged at 2 days. 620 (23.4%) were discharged at 3 days, and 916 (34.5%) >3 days after admission (median 5, IQR: 4–8) days). Patients discharged at 2 days were younger, and had lower rates of diabetes, renal dysfunction, multivessel coronary artery disease, previous myocardial infarction, and previous coronary artery bypass surgery, compared with patients discharged later. 30-day readmission rates for non-MACE events were 4.8%, 4.9% and 4.6% for patients discharged 2 days, 3 days and >3 days after admission, respectively. MACE rates were lowest in patients discharged at 2 days (9.6%, 95% CI 4.7% to 16.6%) compared with patients discharged at 3 days (12.3% 95% CI 6.0% to 19.2%) and >3 days (28.6% 95% CI 22.9% to 34.7%, p Conclusions Our data suggest that discharge of low-risk patients 2 days after successful PPCI is feasible and safe. Over 40% of all patients with ST-elevation myocardial infarction may be suitable for early discharge with important implications for healthcare costs.

To compare short and medium-term prognosis in South Asian and Caucasian patients undergoing percutaneous coronary intervention (PCI) to determine if there are ethnic differences in case death rates.Retrospective cohort study.A cardiology referral centre in east London.9771 patients who underwent PCI from October 2003 to December 2007 of whom 7966 (81.5%) were Caucasian and 1805 (18.5%) were South Asian.In-hospital major adverse cardiac events (MACE; death, myocardial infarction, stroke and target vessel revascularisation), subsequent revascularisation rates (PCI and coronary artery bypass grafting; CABG) and all-cause mortality during a median follow-up of 2.5 years (range 1.5-3.6 years).South Asian patients were younger than Caucasian patients (59.69±0.27 vs 64.69±0.13 years, p0.0001), and more burdened by cardiovascular risk factors, particularly type II diabetes mellitus (45.9%±1.2% vs 15.7%±0.4%, p0.0001). The in-hospital rates of MACE were similar for South Asians and Caucasians (3.5% vs 2.8%, p=0.40). South Asians had higher rates of clinically driven PCI for restenosis and subsequent CABG, although Kaplan-Meier estimates of all-cause mortality showed no significant differences; this was regardless of whether PCI was performed post-acute coronary syndrome or as an elective procedure. The adjusted hazard of death for South Asians compared with Caucasians was 1.00 (95% CI 0.81 to 1.23).In this large PCI cohort, the in-hospital and longer-term mortality of South Asians appeared no worse than that of Caucasians. South Asians had higher rates of restenosis and CABG during follow-up. Data suggest that the excess coronary mortality for South Asians compared with Caucasians is not explained by differences in case-fatality rates.

Aims The CARDia (Coronary Artery Revascularization in Diabetes) trial compared coronary artery bypass grafting (CABG) and optimal percutaneous coronary intervention (PCI) in diabetic patients with multivessel coronary disease. Patients enrolled had symptoms of myocardial ischaemia. As symptom assessment is flawed in diabetic patients, a substudy was undertaken to compare the extent to which these revascularization strategies alter reversible ischaemia. Methods and results Seventy-one patients underwent stress echo at baseline and at 6 months. A 17-segment echocardiographic wall motion score index (WMSI) was assigned at baseline [WMSI(pre)] and at 6 months [WMSI(post)]. An overall score defined the difference: WMSI( ∂ ) = WMSI(pre) − WMSI(post). Of 71 patients recruited, 42 underwent PCI and 29 CABG. Mean WMSI(pre) in the PCI group was 1.63 and mean WMSI(post) was 1.32. Mean WMSI(pre) in the CABG group was 1.69 and mean WMSI(post) was 1.46. The PCI WMSI( ∂ ) was 0.31 and CABG WMSI( ∂ ) was 0.23 ( P = 0.8). Of 42 PCI patients, 39 demonstrated ischaemia at baseline. At 6 months 31 had improvements in ischaemia (79%), 5 showed no improvement, and 3 ischaemia worsened. Of 29 CABG patients, 23 demonstrated ischaemia at baseline. At 6 months, 20 had improvements in ischaemia (87%), 2 had no improvement, and in 1 ischaemia worsened. No difference was seen in the number of patients with improvements in reversible ischaemia between PCI and CABG [79 vs. 87%, ( P = 0.9)]. Conclusion Optimal revascularization in diabetic patients with multivessel disease remains controversial. This subset analysis of the CARDia trial suggests both PCI and CABG achieve similar improvement in reversible ischaemia.

Objectives The purpose of this study was to compare the safety and efficacy of percutaneous coronary intervention (PCI) with stenting against coronary artery bypass grafting (CABG) in patients with diabetes and symptomatic multivessel coronary artery disease.Background CABG is the established method of revascularization in patients with diabetes and multivessel coronary disease, but with advances in PCI, there is uncertainty whether CABG remains the preferred method of revascularization.Methods The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), and stroke, and the main secondary outcome included the addition of repeat revascularization to the primary outcome events. A total of 510 diabetic patients with multivessel or complex single-vessel coronary disease from 24 centers were randomized to PCI plus stenting (and routine abciximab) or CABG. The primary comparison used a noninferiority method with the upper boundary of the 95% confidence interval (CI) not to exceed 1.3 to declare PCI noninferior. Bare-metal stents were used initially, but a switch to Cypher (sirolimus drug-eluting) stents (Cordis, Johnson & Johnson, Bridgewater, New Jersey) was made when these became available.Results At 1 year of follow-up, the composite rate of death, MI, and stroke was 10.5% in the CABG group and 13.0% in the PCI group (hazard ratio [HR]: 1.25, 95% CI: 0.75 to 2.09; p = 0.39), all-cause mortality rates were 3.2% and 3.2%, and the rates of death, MI, stroke, or repeat revascularization were 11.3% and 19.3% (HR: 1.77, 95% CI: 1.11 to 2.82; p = 0.02), respectively. When the patients who underwent CABG were compared with the subset of patients who received drug-eluting stents (69% of patients), the primary outcome rates were 12.4% and 11.6% (HR: 0.93, 95% CI: 0.51 to 1.71; p = 0.82), respectively.Conclusions The CARDia (Coronary Artery Revascularization in Diabetes) trial is the first randomized trial of coronary revascularization in diabetic patients, but the 1-year results did not show that PCI is noninferior to CABG. However, the CARDia trial did show that multivessel PCI is feasible in patients with diabetes, but longer-term follow-up and data from other trials will be needed to provide a more precise comparison of the efficacy of these 2 revascularization strategies. (The Coronary Artery Revascularisation in Diabetes trial; ISRCTN19872154) (J Am Coll Cardiol 2010; 55: 432-40) (C) 2010 by the American College of Cardiology Foundation

Aims: To determine the clinical utility of 24 hour Holter monitoring by measuring the frequency of candidate arrhythmias recorded during the investigation of palpitations and altered consciousness. Methods: Of 9,729 Holter recordings, reports were available in 8,973 (92.2%) performed in the 7394 patients who comprise the study group. The mean age of the study group was 66 ± 19 years and 56.4% were women. Results: The most common indications were altered consciousness (41.7%) and palpitations (36.2%). Among patients with palpitations and sinus rhythm (n=2688), recordings were normal in 2247 (83.6%). Abnormalities included paroxysmal atrial fibrillation (PAF, 6.6%), narrow complex tachycardia (NCT, 2.8%) nonsustained or sustained ventricular tachycardia (NSVT/VT, 2.6%). Among patients with altered consciousness (n=3075), recordings were normal in 2589 (84.2%). Abnormalities included PAF (9.5%), NCT (2.6%), NSV/VT (0.2%), pause >2.8s (2.2%) and high degree AV block (1.3%). The diagnostic yield of Holter monitoring was particularly low in patients aged ≤50 years, of whom 93.1% had palpitations and 95.3% had altered consciousness had normal recordings. Conclusions: The diagnostic utility of Holter monitoring in patients being investigated for palpitations and altered consciousness is very limited, particularly in young patients for whom alternative diagnostic methods should be considered.

Diabetic patients are recognised as being at high risk of vascular complications in a variety of situations. Approximately 80% will die of a cardiovascular event. In recent years there has been increasing recognition of the diversity of mechanisms responsible for prevalence of adverse events, although there are still many aspects that are poorly understood. Coronary artery disease is the major cause of death among diabetics and tends to be more severe and diffuse in this group. The growth of the diabetic population combined with recent technological and pharmacological advances in both bypass surgery and angioplasty make choosing the optimum revascularisation strategy in this group one of the most challenging issues facing the cardiologist today. The exponential relation between the risk of developing diabetes mellitus (DM) and increasing body mass index ensures that the incidence of type 2 DM will rapidly increase if the current trend in western countries of increasing weight each succeeding generation continues. This is particularly relevant to immigrant communities moving to cultures enjoying a higher standard of living; not only do they have a higher incidence of diabetes, but their growth in population tends to be proportionately greater than the growth in the indigenous population. This statistic suggests that DM will continue to consume an increasing proportion of medical resources, not least the provisions set aside for the treatment of coronary artery disease. Not only do diabetics have a greater complexity and extent of vascular disease in general, but they also have the additional disadvantages of having multisystem dysfunction involving endothelium, platelets, and renal and neurological systems. The primary defect in type 2 DM is not fully understood, but the pathophysiology driving the disease process can be divided into four areas: endothelial dysfunction, platelet and clotting abnormalities, lipid abnormalities, and the consequences of hyperglycaemia, including protein and …

There are over 1.3 million known diabetic patients in the UK and a similar number who have the disease undiagnosed. Over 90% have non-insulin dependent diabetes mellitus usually characterised by insulin resistance and adult onset. Over half of all diabetic patients die of coronary disease and account for over a fifth of percutaneous coronary intervention (PCI) revascularisation procedures. Despite recent therapeutic advances such as new antiplatelet treatments and drug eluting stents, outcomes for diabetic patients after PCI are still significantly worse than for non-diabetic patients. This article summarises what is known about the pattern and severity of diabetic coronary disease, what mechanisms are responsible for these differences, and whether this information can help explain the poorer prognosis for these patients after PCI and form the basis of interventions to improve outcome.

Diabetes mellitus (diabetes), in particular type 2 diabetes, constitutes one of the largest emerging threats to health in the 21st century. It is estimated that by 2030 as many as 360 million people world wide will be affected.1 The cause of death in those with diabetes is dominated by coronary heart disease, accompanied by increased rates of stroke and peripheral vascular disease: so called macrovascular complications. At least two‐thirds of deaths are attributable to these cardiovascular diseases and their sequelae.2 A true picture of the extent of macrovascular complications is obscured, however, by inaccurate death certification3 and diagnostic criteria4 based on the development of microvascular complications (retinopathy, neuropathy, nephropathy). The Euro Heart5 Survey demonstrated that if one applied oral glucose tolerance tests to those presenting with all forms of acute coronary syndrome, two‐thirds display impaired glucose regulation. In the USA, although the overall mortality rate associated with coronary heart disease has declined over the past 20 years, this trend has not been reflected in a decline of mortality rates in patients with diabetes.6 Results published in this issue of Heart from the Swedish registry on coronary care (RIKS‐HIA) confirm this trend (see article on page 1577).7 After a myocardial infarction (MI), patients with diabetes had an increased mortality rate compared with non‐diabetic patients. Moreover, despite the existence of treatments which may benefit diabetic patients disproportionately, the relative hazard of mortality in diabetic patients has improved little compared with non‐diabetic patients between the time periods 1995–8 and 1999–2002. These observations give us a glimpse of the vast epidemic that is approaching, if not upon us.

People with type 2 diabetes are more likely to develop cardiovascular disease (CVD), and are more likely to have adverse outcomes following acute myocardial infarction (AMI). There is considerable uncertainty about the management of hyperglycaemia following AMI, due to the inconsistent findings of the Diabetes Insulin Glucose Acute Myocardial Infarction (DIGAMI) studies.1,2 A number of recent randomized controlled trials (RCTs) also suggest that certain hyperglycaemic therapies may increase cardiovascular risk in diabetes subjects with known CVD.3 Moreover, some studies have raised concerns that tight glycaemic control may be deleterious in older patients with established or subclinical CVD.4

ObjectivesThis study investigated the impact of procedural success on mortality following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a large cohort of patients in the drug-eluting stent era.BackgroundDespite advances in expertise and technologies, many patients with CTO are not offered PCI.MethodsA total of 6,996 patients underwent elective PCI for stable angina at a single center (2003 to 2010), 836 (11.9%) for CTO. All-cause mortality was obtained to 5 years (median: 3.8 years; interquartile range: 2.0 to 5.4 years) and stratified according to successful chronic total occlusion (sCTO) or unsuccessful chronic total occlusion (uCTO) recanalization. Major adverse cardiac events (MACE) included myocardial infarction (MI), urgent revascularization, stroke, or death.ResultsA total of 582 (69.6%) procedures were successful. Stents were implanted in 97.0% of successful procedures (mean: 2.3 ± 0.1 stents per patient, 73% drug-eluting). Prior revascularization was more frequent among uCTO patients: coronary artery bypass grafting (CABG) (16.5% vs. 7.4%; p < 0.0001), PCI (36.0% vs. 21.2%; p < 0.0001). Baseline characteristics were otherwise similar. Intraprocedural complications, including coronary dissection, were more frequent in unsuccessful cases (20.5% vs. 4.9%; p < 0.0001), but did not affect in-hospital MACE (3% vs. 2.1%; p = NS). All-cause mortality was 17.2% for uCTO and 4.5% for sCTO at 5 years (p < 0.0001). The need for CABG was reduced following sCTO (3.1% vs. 22.1%; p < 0.0001). Multivariate analysis demonstrated that procedural success was independently predictive of mortality (hazard ratio [HR]: 0.32 [95% confidence interval (CI): 0.18 to 0.58]), which persisted when incorporating a propensity score (HR: 0.28 [95% CI: 0.15 to 0.52]).ConclusionsSuccessful CTO PCI is associated with improved survival out to 5 years. Adoption of techniques and technologies to improve procedural success may have an impact on prognosis.

Diabetes is occurring in epidemic proportions. In the general population in the developed world, approximately 8% of adults have diabetes. The prevalence of diabetes will double over the next 15 years or so to an estimated 300 million people by the year 2025. This is due almost totally to an increase in type 2 diabetes mellitus (T2DM). These figures are likely to understate the size of the problem as it has been estimated that up to one-half of affected patients in the general population remain undiagnosed. In addition up to double the number of patients who have diabetes have insulin resistance syndrome with a heightened risk of developing T2DM. This increase will be due mainly to an increasing prevalence of obesity, decreasing rates of physical activity, an increasing consumption of high calorie diets, and an ageing population.

The aim of the Bypass Angioplasty Revascularization in Type 1 and Type 2 Diabetes study was to assess percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) as treatments for multivessel coronary artery disease in diabetic patients.CABG is generally regarded as the treatment of choice for multivessel coronary artery disease in diabetes. PCI is an alternative therapy. The Bypass Angioplasty Revascularization in Type 1 and 2 Diabetes study compared long-term outcomes of CABG with PCI in diabetic patients treated during the bare-metal stent era.We collected data prospectively on consecutive diabetic patients undergoing index angiography in a single tertiary centre from January 1998 to December 2001. Multivessel coronary artery disease was defined as more than 50% luminal stenosis in two or more vessels. Exclusion criteria included left main stem disease and previous revascularization.Two hundred and thirty-five eligible patients underwent CABG and 237 PCI. Median follow-up was 5.4 years. There were 46 (19%) deaths in the CABG group and 43 (18%) deaths in the PCI group (P = 0.64). Cox regression analysis revealed baseline glomerular filtration rate (hazard ratio 0.979, P = 0.001), age (hazard ratio 1.034, P = 0.033), urgent procedure (hazard ratio 1.97, P = 0.008) and myocardial infarction within 4 weeks (hazard ratio 2.494, P = 0.041) to be important predictors of outcome. At 5 years, there was no mortality difference (hazard ratio 1.0) following adjustment for baseline characteristics, and the Kaplan-Meier survival curves were similar. A subanalysis of patients with three-vessel disease revealed similar outcomes with both PCI and CABG.In the Bypass Angioplasty Revascularization in Type 1 and Type 2 Diabetes study, diabetic patients with multivessel coronary artery disease had similar long-term mortality whether treated with CABG or PCI, the revascularization determined by the physician's choice. This was despite the frequent use of a strategy of selective revascularization in the PCI arm. Randomized trials comparing PCI and CABG specifically in diabetes, that is, Coronary Artery Revascularization in Diabetes and Future Revascularization Evaluation in Diabetes Mellitus: Optimal Management, will show whether drug-eluting stents further enhance PCI outcomes over the long term.

The purpose of this study was to compare the safety and efficacy of percutaneous coronary intervention (PCI) with stenting against coronary artery bypass grafting (CABG) in patients with diabetes and symptomatic multivessel coronary artery disease.CABG is the established method of revascularization in patients with diabetes and multivessel coronary disease, but with advances in PCI, there is uncertainty whether CABG remains the preferred method of revascularization.The primary outcome was a composite of all-cause mortality, myocardial infarction (MI), and stroke, and the main secondary outcome included the addition of repeat revascularization to the primary outcome events. A total of 510 diabetic patients with multivessel or complex single-vessel coronary disease from 24 centers were randomized to PCI plus stenting (and routine abciximab) or CABG. The primary comparison used a noninferiority method with the upper boundary of the 95% confidence interval (CI) not to exceed 1.3 to declare PCI noninferior. Bare-metal stents were used initially, but a switch to Cypher (sirolimus drug-eluting) stents (Cordis, JohnsonJohnson, Bridgewater, New Jersey) was made when these became available.At 1 year of follow-up, the composite rate of death, MI, and stroke was 10.5% in the CABG group and 13.0% in the PCI group (hazard ratio [HR]: 1.25, 95% CI: 0.75 to 2.09; p=0.39), all-cause mortality rates were 3.2% and 3.2%, and the rates of death, MI, stroke, or repeat revascularization were 11.3% and 19.3% (HR: 1.77, 95% CI: 1.11 to 2.82; p=0.02), respectively. When the patients who underwent CABG were compared with the subset of patients who received drug-eluting stents (69% of patients), the primary outcome rates were 12.4% and 11.6% (HR: 0.93, 95% CI: 0.51 to 1.71; p=0.82), respectively.The CARDia (Coronary Artery Revascularization in Diabetes) trial is the first randomized trial of coronary revascularization in diabetic patients, but the 1-year results did not show that PCI is noninferior to CABG. However, the CARDia trial did show that multivessel PCI is feasible in patients with diabetes, but longer-term follow-up and data from other trials will be needed to provide a more precise comparison of the efficacy of these 2 revascularization strategies. (The Coronary Artery Revascularisation in Diabetes trial; ISRCTN19872154).

Aims: To determine the clinical utility of 24 hour Holter monitoring by measuring the frequency of candidate arrhythmias recorded during the investigation of palpitations and altered consciousness. Methods: Of 9,729 Holter recordings, reports were available in 8,973 (92.2%) performed in the 7394 patients who comprise the study group. The mean age of the study group was 66 ± 19 years and 56.4% were women. Results: The most common indications were altered consciousness (41.7%) and palpitations (36.2%). Among patients with palpitations and sinus rhythm (n=2688), recordings were normal in 2247 (83.6%). Abnormalities included paroxysmal atrial fibrillation (PAF, 6.6%), narrow complex tachycardia (NCT, 2.8%) nonsustained or sustained ventricular tachycardia (NSVT/VT, 2.6%). Among patients with altered consciousness (n=3075), recordings were normal in 2589 (84.2%). Abnormalities included PAF (9.5%), NCT (2.6%), NSV/VT (0.2%), pause >2.8s (2.2%) and high degree AV block (1.3%). The diagnostic yield of Holter monitoring was particularly low in patients aged ≤50 years, of whom 93.1% had palpitations and 95.3% had altered consciousness had normal recordings. Conclusions: The diagnostic utility of Holter monitoring in patients being investigated for palpitations and altered consciousness is very limited, particularly in young patients for whom alternative diagnostic methods should be considered.

Diabetic patients have an increased risk of coronary disease partly due to a higher frequency of associated risk factors including hypertension and hyperlipidemia but also from specific risks largely resulting from insulin resistance, hyperinsulinemia and hyperglycemia. This has resulted in a greater need for revascularization. Despite this there are few randomized data comparing surgery and angioplasty in patients with diabetes. The evidence to define the best operative strategy is limited, mainly confined to a subanalysis of the BARI trial suggesting the superiority of surgery in patients with multivessel disease. However there has been in Europe a wide increase in multivessel angioplasty, even in diabetic patients. This article discusses the higher risk of patients with diabetes, the data comparing surgery and angioplasty and outlines the advances in angioplasty since BARI.

There are no large studies available to guide the selection of thallium (Tl), methoxyisobutylisonitrile (MIBI) or tetrofosmin (Tf) for myocardial perfusion imaging. Our objective was to compare the technical and clinical performance of the three in routine clinical practice. We randomised 2,560 patients to receive Tl, MIBI or Tf. A 1-day stress/rest protocol was used for MIBI and Tf. Tracer uptake was scored using a 17-segment model, quality and artefact scores were assigned, and ratios of heart (H), liver (L), subdiaphragmatic (S) and lung activity were measured. Mean quality scores (stress/rest) were Tl 2.13/2.16, MIBI 2.18/2.39, Tf 2.18/2.42 ( P=ns stress and0.00001 rest). For attenuation artefact, TlMIBI=Tf ( P0.05) and for low-count artefact TlMIBITf ( P0.001). For H/S, TlMIBI=Tf, for H/L TlMIBI=Tf, and for H/lung TlMIBI=Tf. Stress defects in the patients with reversible or mixed perfusion defects were more severe for Tl than for the other tracers (mean summed score out of 68: Tl 52.3, MIBI 55.7, Tf 54.4, P0.01), but mean rest scores were more similar (Tl 58.7, MIBI 60.7, Tf 59.4, P=0.02). In the subset of 137 patients undergoing diagnostic perfusion studies without prior infarction, angiography or revascularisation, overall sensitivity for the detection of coronary disease defined by subsequent angiography was 91% with a specificity of 87%. There were no significant differences between the tracers with regard to sensitivity and specificity.There are technical differences between the tracers. Overall image quality score is superior using technetium, with less low-count artefact and less attenuation. Stress defect depth and extent are slightly greater using thallium, with no difference between MIBI and tetrofosmin. All three tracers perform well in clinical terms, with high sensitivity and specificity for angiographic stenosis and no differences in accuracy between the tracers.

Aims The CARDia trial randomised diabetic patients to coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) and concluded that PCI is a potentially safe and feasible alternative to CABG in selected patients with diabetes mellitus (DM) and multivessel coronary artery disease. The impact of insulin treatment on clinical outcomes after revascularisation is unclear. The present study is a sub group analysis of the CARDia trial comparing the cardiovascular outcomes at 12 months following revascularisation between the insulin treated (IT) and non-insulin treated (NIT) group. Methods 508 patients with an established diagnosis of DM and de novo coronary artery disease were identified and randomised to CABG or PCI. Of those, 316 patients were treated with oral antidiabetic medication and the rest were treated with additional subcutaneous insulin injections. Demographics, clinical presentation, history, haemodynamic parameters, anti diabetic therapy, concomitant medications, duration of DM and HBA1C were documented. Death, stroke and myocardial infarction were classified as the primary outcome events. The secondary outcome events included death, MI, Stroke, repeat revascularisation and TIMI major bleed. The clinical results of patients in the IT and NIT groups were compared. Results There were 192 patients in the IT group (37.8%). Asian patients constituted one fifth of the total population with a slightly higher representation (24.5% vs 21.6%) in the NIT. The clinical severity of dyspnoea, heart rate, systolic and diastolic BP, body mass index, risk factors for coronary artery disease appeared similar in the IT and NIT groups, but more patients in the IT group had a prior MI (30.7% vs 19.6%, p=0.004) and duration of diabetes was longer in the IT group (14 vs 6 yrs, p Conclusion Our data suggest that insulin treatment is a marker for higher risk for PCI when compared with CABG. Treatment with insulin rather than diabetic status alone should be considered when choosing the mode of revascularisation.

Background The incidence of contrast nephropathy (CIN) following coronary angiography or percutaneous coronary intervention (PCI) in patients with diabetes mellitus (DM) may be up to 30% and is associated with increased long term morbidity and mortality. Methods We recruited 208 consecutive patients undergoing elective or urgent coronary angiography or PCI with known DM and chronic kidney disease (CKD) (defined as eGFR 25% from baseline or an absolute rise of 44.5 μmol/l. Severity of coronary disease was assessed using the SYNTAX Score and risk of CIN using the Mehran risk score. We evaluated serum and urine neutrophil gelatinase-associated lipocalin (NGAL) and albuminuria for additional information about CIN risk. N-acetylcysteine and intravenous hydration were given to all patients with eGFR Results Baseline characteristics are summarised in table 1. 116 patients underwent coronary angiography and 92 underwent PCI. 39 patients (18.8%) developed CIN. Contrast dose was similar in the CIN and non-CIN group (p=0.249). The Mehran risk score was strongly predictive of CIN development (p Conclusions The current gold standard for measuring CIN is a rise in serum creatinine but this is of limited value as it does not increase until 48–72 h post renal injury. Neither the SYNTAX score, nor urinary albuminuria or proteinuria are predictive of CIN development. A rise in serum NGAL levels within the first 12 h following coronary angiography or PCI appears to be a very promising marker in the early diagnosis of CIN.

Aims Previous research has demonstrated that patients with diabetes mellitus (DM) have a worse prognosis than patients without diabetes following coronary artery bypass graft surgery (CABG). However, patients with insulin treated diabetes (ITD) may have a different prognosis when compared with non-insulin treated diabetic patients (NITD) after CABG. There is limited data investigating long term outcomes following CABG in patients with ITD and NITD patients. This study compared outcomes at 5 years following CABG in these two patient groups. Methods 7442 consecutive patients underwent CABG at a single cardiac centre between 2003 and 2011. We identified 2471 patients with DM within this group. Demographic and procedural data were collected at the time of intervention. All cause mortality data were obtained from the Office of National Statistics via the BCIS/CCAD national audit out to a median of 2.80 years (CI 2.08 to 3.56 years). Results Of 2471 patients with DM, 741 (30.0%) were ITD and 1730 (70.0%) were NITD. ITD patients had significantly higher rates of previous MI (65% vs 52%, p Conclusions Our data suggest that insulin treatment is an independent predictor of long term mortality for patients undergoing CABG. Treatment with insulin rather than diabetic status alone is an important factor affecting outcome in patients with coronary artery disease requiring surgical intervention. Furthermore, these differences in mortality appear after the first year. Hence there is a role for intensive medical therapy in ITD patients and further research is required to confirm these outcomes.

Introduction Contrast induced nephropathy (CIN) is associated with adverse clinical outcomes, including prolonged hospitalisation and increased morbidity and mortality following elective invasive cardiac procedures. The impact of CIN following primary PCI (PPCI) for ST segment elevation MI (STEMI) remains poorly defined. Aim To investigate the long-term prognostic implications of CIN following PPCI for STEMI. Methods This is a retrospective observational registry study. Data were available upon 2224 patients undergoing PPCI for STEMI at a tertiary Cardiac centre between October 2003 and May 2010. CIN was defined as an increase in serum creatinine (>25% or 44.2 mmol/l) within 2 days of PPCI. The primary outcome measure was all-cause mortality determined via Office of National Statistics data. Results CIN was observed in 317 patients (14.3%). Patients with CIN were older (69.3 vs 62.7, p 75 years (HR 1.81, CI 1.28 to 2.57), eGFR Conclusion CIN following PPCI for STEMI was associated with increased short and long-term mortality and increased length of hospital stay. Better strategies are needed to prevent CIN in high risk STEMI patients.

Background Renal impairment is associated with increased cardiovascular mortality following acute coronary syndromes (ACS), however there is limited data assessing this relationship in the context of primary PCI and whether it exists with other major adverse cardiovascular events. Methods Clinical information was analysed from a prospective data base on 2310 STEMI patients who underwent primary PCI between January 2004 and May 2010 at a London centre. Information was entered at the time of procedure and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS/CCAD national audit. Estimated glomerular filtration rate (eGFR) was calculated using the modified diet in renal disease equation and patients were divided into groups based on eGFR ( 60 ml/min/1.73 m 2 ). 3-year composite of MACE (death, reinfarction, stroke and target vessel revascularisation) were compared between groups. Results The average eGFR in all patients was 73.40±23.37 (95% CI 72.25 to 74.56) ml/min/1.73 m 2 . The prevalence of coexisting risk factors (hypertension, diabetes mellitus, hypercholesterolaemia), previous MI, previous CABG and cardiogenic shock were higher among patients with reduced eGFR. There was a progressive increase in MACE with declining eGFR (OR=4.84, 95% CI 2.94 to 7.96, for comparison between the highest and lowest eGFR groups). See Abstract 46 figure 1. After adjustment for baseline characteristics including age, diabetes and cardiogenic shock renal function based on the GFR at admission remained a strong independent predictor of outcome. Conclusion Baseline renal dysfunction in patients undergoing primary PCI is associated with an increased risk for combined death, re-infarction and recurrent angina. This risk increases linearly with declining eGFR.

Introduction Chronic total occlusion (CTO) remains a challenging lesion subset. Despite advances in equipment and expertise, many CTO patients may not be offered PCI as physicians perceive procedural success may be lower, and the anatomy is stable. The aim of this study was to investigate the impact of procedural success on mortality following CTO-PCI in a large cohort of patients in the drug eluting stent era. Methods 6122 consecutive patients underwent elective PCI at a single centre (October 2003–May 2010), 836 (13.7%) for CTO. Demographic and procedural data were collected at the time of intervention (Abstract 35 table 1). In-hospital MACE (myocardial infarction, urgent revascularisation, stroke or death) was documented at discharge. All cause mortality data was obtained from the Office of National Statistics via the BCIS/CCAD national audit out to 4 years (mean 2.9±1.6) and stratified according to successful or unsuccessful CTO recanalisation. Results 572 (68.4%) CTO procedures were successful. Coronary stents were implanted in 96.9% (mean 2.3±0.1 stents per patient, 70% drug eluting). Prior revascularisation was more frequent among patients with unsuccessful CTO-PCI than successful; prior CABG 16.5% unsuccessful vs 7.4% successful, (p Conclusion A successful angiographic outcome following CTO-PCI is associated with a survival advantage out to 4 years following intervention. These data suggest that the adoption of new techniques and technologies to improve procedural success may improve prognosis.

Background: Transthoracic echocardiography (TTE) is commonly performed in patients with ischaemic stroke or transient ischaemic attack (TIA). However, the diagnostic utility of echocardiography in this patient group has not been systematically evaluated. Methods: Data were collected prospectively from all patients undergoing echocardiography in a district general hospital from 1992 to 2006. …