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Up to 20% of patients in heart failure with reduced ejection fraction (HFrEF) trials are not taking diuretic agents at baseline, but little is known about them.The aim of this study was to examine outcomes in patients with HFrEF not taking diuretic medications and after diuretic medications are started.Patient characteristics and outcomes were compared between patients taking or not taking diuretic drugs at baseline in the ATMOSPHERE (Aliskiren Trial of Minimizing Outcomes for Patients With Heart Failure) and PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial) trials combined. Patients starting diuretic medications were also compared with those remaining off diuretic drugs during follow-up. Symptoms (Kansas City Cardiomyopathy Questionnaire Clinical Summary Score [KCCQ-CSS]), hospitalization for worsening heart failure (HF), mortality, and kidney function (estimated glomerular filtration rate slope) were examined.At baseline, the 3,079 of 15,415 patients (20%) not taking diuretic medications had a less severe HF profile, less neurohumoral activation, and better kidney function. They were less likely to experience the primary outcome (hospitalization for HF or cardiovascular death) than patients taking diuretic agents (adjusted HR: 0.77; 95% CI: 0.74-0.80; P 0.001) and death of any cause. Commencement of a diuretic drug was associated with higher subsequent risk for death (adjusted HR: 2.05; 95% CI: 1.99-2.11; P 0.001) and greater decreases in KCCQ-CSS and estimated glomerular filtration rate. The 5 strongest predictors of initiation of diuretic medications were higher N-terminal pro-B-type natriuretic peptide, higher body mass index, older age, history of diabetes, and worse KCCQ-CSS. In PARADIGM-HF, fewer patients who were treated with sacubitril/valsartan commenced diuretic agents (OR: 0.72; 95% CI: 0.58-0.88; P = 0.002).Patients with HFrEF not taking diuretic medications and those who remained off them had better outcomes than patients treated with diuretic agents or who commenced them.

Sudden death is a leading cause of mortality in heart failure with reduced ejection fraction (HFrEF). In PARADIGM-HF, sacubitril/valsartan reduced the incidence of sudden death. The purpose of this post hoc study was to analyse the effect of sacubitril/valsartan, compared to enalapril, on the incidence of ventricular arrhythmias.Adverse event reports related to ventricular arrhythmias were examined in PARADIGM-HF. The effect of randomized treatment on two arrhythmia outcomes was analysed: ventricular arrhythmias and the composite of a ventricular arrhythmia, implantable cardioverter defibrillator (ICD) shock or resuscitated cardiac arrest. The risk of death related to a ventricular arrhythmia was examined in time-updated models. The interaction between heart failure aetiology, or baseline ICD/cardiac resynchronization therapy-defibrillator (CRT-D) use, and the effect of sacubitril/valsartan was analysed. Of the 8399 participants, 333 (4.0%) reported a ventricular arrhythmia and 372 (4.4%) the composite arrhythmia outcome. Ventricular arrhythmias were associated with higher mortality. Compared with enalapril, sacubitril/valsartan reduced the risk of a ventricular arrhythmia (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.62-0.95; p = 0.015) and the composite arrhythmia outcome (HR 0.79, 95% CI 0.65-0.97; p = 0.025). The treatment effect was maintained after adjustment and accounting for the competing risk of death. Baseline ICD/CRT-D use did not modify the effect of sacubitril/valsartan, but aetiology did: HR in patients with an ischaemic aetiology 0.93 (95% CI 0.71-1.21) versus 0.53 (95% CI 0.37-0.78) in those without an ischaemic aetiology (p for interaction = 0.020).Sacubitril/valsartan reduced the incidence of investigator-reported ventricular arrhythmias in patients with HFrEF. This effect may have been greater in patients with a non-ischaemic aetiology.

Aim: There is an association between heart failure with preserved ejection fraction (HFpEF) and insulin resistance, but less is known about the diabetic continuum, and in particular about pre-diabetes, in HFpEF. We examined characteristics and outcomes of participants with diabetes or pre-diabetes in PARAGON-HF.Methods and results: Patients aged ≥50 years with left ventricular ejection fraction ≥45%, structural heart disease and elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) were eligible. Patients were classified according to glycated haemoglobin (HbA1c): (i) normal HbA1c, Conclusion: Pre-diabetes is common in patients with HFpEF and is associated with worse clinical status and greater risk of HFH. Clinical Trial Registration: ClinicalTrials.gov Identifier NCT01920711.

No abstract available.

Aims: \ud Frailty, characterized by loss of homeostatic reserves and increased vulnerability to physiological decompensation, results from an aggregation of insults across multiple organ systems. Frailty can be quantified by counting the number of ‘health deficits’ across a range of domains. We assessed the frequency of, and outcomes related to, frailty in patients with heart failure and reduced ejection fraction (HFrEF).\ud \ud Methods and results: \ud Using a cumulative deficits approach, we constructed a 42‐item frailty index (FI) and applied it to identify frail patients enrolled in two HFrEF trials (PARADIGM‐HF and ATMOSPHERE). In keeping with previous studies, patients with FI ≤0.210 were classified as non‐frail and those with higher scores were divided into two categories using score increments of 0.100. Clinical outcomes were examined, adjusting for prognostic variables. Among 13 625 participants, mean (± standard deviation) FI was 0.250 (0.10) and 8383 patients (63%) were frail (FI >0.210). The frailest patients were older and had more symptoms and signs of heart failure. Women were frailer than men. All outcomes were worse in the frailest, with high rates of all‐cause death or all‐cause hospitalization: 40.7 (39.1–42.4) vs. 22.1 (21.2–23.0) per 100 person‐years in the non‐frail; adjusted hazard ratio 1.63 (1.53–1.75) (P

Background: Unlike heart failure with reduced ejection fraction, there is no approved treatment for heart failure with preserved ejection fraction, the predominant phenotype in women. Therefore, there is a greater heart failure therapeutic deficit in women compared with men. Methods: In a prespecified subgroup analysis, we examined outcomes according to sex in the PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction), which compared sacubitril-valsartan and valsartan in patients with heart failure with preserved ejection fraction. The primary outcome was a composite of first and recurrent hospitalizations for heart failure and death from cardiovascular causes. We also report secondary efficacy and safety outcomes. Results: Overall, 2479 women (51.7%) and 2317 men (48.3%) were randomized. Women were older and had more obesity, less coronary disease, and lower estimated glomerular filtration rate and NT-proBNP (N-terminal pro–B-type natriuretic peptide) levels than men. For the primary outcome, the rate ratio for sacubitril-valsartan versus valsartan was 0.73 (95% CI, 0.59–0.90) in women and 1.03 (95% CI, 0.84–1.25) in men ( P interaction = 0.017). The benefit from sacubitril-valsartan was attributable to reduction in heart failure hospitalization. The improvement in New York Heart Association class and renal function with sacubitril-valsartan was similar in women and men, whereas the improvement in Kansas City Cardiomyopathy Questionnaire clinical summary score was less in women than in men. The difference in adverse events between sacubitril-valsartan and valsartan was similar in women and men. Conclusions: As compared with valsartan, sacubitril-valsartan seemed to reduce the risk of heart failure hospitalization more in women than in men. Whereas the possible sex-related modification of the effect of treatment has several potential explanations, the present study does not provide a definite mechanistic basis for this finding. Clinical Trial Registration: https://www.clinicaltrials.gov . Unique identifier: NCT01920711.

Aims Patients with heart failure and preserved ejection fraction (HFpEF) frequently have difficult-to-control hypertension. We examined the effect of neprilysin inhibition on ‘apparent resistant hypertension’ in patients with HFpEF in the PARAGON-HF trial, which compared the effect of sacubitril–valsartan with valsartan. Methods and results In this post hoc analysis, patients were categorized according to systolic blood pressure at the end of the valsartan run-in (n = 4795). ‘Apparent resistant hypertension’ was defined as systolic blood pressure ≥140 mmHg (≥135 mmHg if diabetes) despite treatment with valsartan, a calcium channel blocker, and a diuretic. ‘Apparent mineralocorticoid receptor antagonist (MRA)-resistant’ hypertension was defined as systolic blood pressure ≥140 mmHg (≥135 mmHg if diabetes) despite the above treatments and an MRA. The primary outcome in the PARAGON-HF trial was a composite of total hospitalizations for heart failure and death from cardiovascular causes. We examined clinical endpoints and the safety of sacubitril–valsartan according to the hypertension category. We also examined reductions in blood pressure from the end of valsartan run-in to Weeks 4 and 16 after randomization. Overall, 731 patients (15.2%) had apparent resistant hypertension and 135 (2.8%) had apparent MRA-resistant hypertension. The rate of the primary outcome was higher in patients with apparent resistant hypertension [17.3; 95% confidence interval (CI) 15.6–19.1 per 100 person-years] compared to those with a controlled systolic blood pressure (13.4; 12.7–14.3 per 100 person-years), with an adjusted rate ratio of 1.28 (95% CI 1.05–1.57). The reduction in systolic blood pressure at Weeks 4 and 16, respectively, was greater with sacubitril–valsartan vs. valsartan in patients with apparent resistant hypertension [−4.8 (−7.0 to −2.5) and 3.9 (−6.6 to −1.3) mmHg] and apparent MRA-resistant hypertension [−8.8 (−14.0 to −3.5) and −6.3 (−12.5 to −0.1) mmHg]. The proportion of patients with apparent resistant hypertension achieving a controlled systolic blood pressure by Week 16 was 47.9% in the sacubitril–valsartan group and 34.3% in the valsartan group [adjusted odds ratio (OR) 1.78, 95% CI 1.30–2.43]. In patients with apparent MRA-resistant hypertension, the respective proportions were 43.6% vs. 28.4% (adjusted OR 2.63, 95% CI 1.18–5.89). Conclusion Sacubitril–valsartan may be useful in treating apparent resistant hypertension in patients with HFpEF, even in those who continue to have an elevated blood pressure despite treatment with at least four antihypertensive drug classes, including an MRA. Clinical trial registration PARAGON-HF: ClinicalTrials.gov Identifier NCT01920711., Graphical Abstract Almost one in six patients with heart failure and preserved ejection fraction had apparent resistant hypertension in PARAGON-HF and this was associated with worse clinical outcomes; neprilysin inhibition reduced systolic blood pressure significantly in these patients.

Aims Hypertensive disorders occur in women with peripartum cardiomyopathy (PPCM). How often hypertensive disorders co-exist, and to what extent they impact outcomes, is less clear. We describe differences in phenotype and outcomes in women with PPCM with and without hypertensive disorders during pregnancy. Methods and results The European Society of Cardiology EURObservational Research Programme PPCM Registry enrolled women with PPCM from 2012-2018. Three groups were examined: (i) women without hypertension (PPCM-noHTN); (ii) women with hypertension but without pre-eclampsia (PPCM-HTN); (iii) women with pre-eclampsia (PPCM-PE). Maternal (6-month) and neonatal outcomes were compared. Of 735 women included, 452 (61.5%) had PPCM-noHTN, 99 (13.5%) had PPCM-HTN and 184 (25.0%) had PPCM-PE. Compared to women with PPCM-noHTN, women with PPCM-PE had more severe symptoms (New York Heart Association class IV in 44.4% vs. 29.9%, P < 0.001), more frequent signs of heart failure (pulmonary rales in 70.7% vs. 55.4%, P = 0.002), a higher baseline left ventricular ejection fraction (LVEF) (32.7% vs. 30.7%, P = 0.005) and a smaller left ventricular end-diastolic diameter (57.4 +/- 6.7 mm vs. 59.8 +/- 8.1 mm, P = 0.001). There were no differences in the frequencies of death from any cause, rehospitalization for any cause, stroke, or thromboembolic events. Compared to women with PPCM-noHTN, women with PPCM-PE had a greater likelihood of left ventricular recovery (LVEF >= 50%) (adjusted odds ratio 2.08, 95% confidence interval 1.21-3.57) and an adverse neonatal outcome (composite of termination, miscarriage, low birth weight or neonatal death) (adjusted odds ratio 2.84, 95% confidence interval 1.66-4.87). Conclusion Differences exist in phenotype, recovery of cardiac function and neonatal outcomes according to hypertensive status in women with PPCM.

Aims Ischaemic heart disease persists as the leading cause of death in both men and women in most countries and sex disparities, defined as differences in health outcomes and their determinants, may be relevant. We examined sex disparities in presenting characteristics, treatment and all-cause mortality in patients hospitalized with myocardial infarction (MI) or angina. Methods and results We conducted a cohort study of all patients admitted with MI or angina (01 October 2013 to 30 June 2016) from a secondary care acute coronary syndrome e-Registry in NHS Scotland linked with national registers of community drug dispensation and mortality data. A total of 7878 patients hospitalized for MI or angina were prospectively included; 3161 (40%) were women. Women were older, more deprived, had a greater burden of comorbidity, were more often treated with guideline-recommended therapy preadmission and less frequently received immediate invasive management. Men were more likely to receive coronary angiography [adjusted odds ratio (OR) 1.52, confidence interval (CI) 1.37–1.68] and percutaneous coronary intervention (adjusted OR 1.68, CI 1.52–1.86). Women were less comprehensively treated with evidence-based therapies post-MI. Women had worse crude survival, primarily those with ST-elevation myocardial infarction (14.3% vs. 8.0% at 1 year, P Conclusion After taking account of baseline risk factors, sex differences in treatment pathway, use of invasive management, and secondary prevention therapies indicate disparities in guideline-directed management of women hospitalized with MI or angina.

Background: Heart failure with preserved ejection fraction (HFpEF) is a global public health problem with important regional differences. We investigated these differences in the PARAGON-HF trial (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in HFpEF), the largest and most inclusive global HFpEF trial. Methods: We studied differences in clinical characteristics, outcomes, and treatment effects of sacubitril/valsartan in 4796 patients with HFpEF from the PARAGON-HF trial, grouped according to geographic region. Results: Regional differences in patient characteristics and comorbidities were observed: patients from Western Europe were oldest (mean 75±7 years) with the highest prevalence of atrial fibrillation/flutter (36%); Central/Eastern European patients were youngest (mean 71±8 years) with the highest prevalence of coronary artery disease (50%); North American patients had the highest prevalence of obesity (65%) and diabetes (49%); Latin American patients were younger (73±9 years) and had a high prevalence of obesity (53%); and Asia-Pacific patients had a high prevalence of diabetes (44%), despite a low prevalence of obesity (26%). Rates of the primary composite end point of total hospitalizations for HF and death from cardiovascular causes were lower in patients from Central Europe (9 per 100 patient-years) and highest in patients from North America (28 per 100 patient-years), which was primarily driven by a greater number of total hospitalizations for HF. The effect of treatment with sacubitril-valsartan was not modified by region (interaction P >0.05). Conclusions: Among patients with HFpEF recruited worldwide in PARAGON-HF, there were important regional differences in clinical characteristics and outcomes, which may have implications for the design of future clinical trials. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01920711.

This position paper focusses on the pathophysiology, diagnosis and management of women diagnosed with a cardiomyopathy, or at risk of heart failure (HF), who are planning to conceive or present with (de novo or previously unknown) HF during or after pregnancy. This includes the heterogeneous group of heart muscle diseases such as hypertrophic, dilated, arrhythmogenic right ventricular and non-classified cardiomyopathies, left ventricular non-compaction, peripartum cardiomyopathy, Takotsubo syndrome, adult congenital heart disease with HF, and patients with right HF. Also, patients with a history of chemo-/radiotherapy for cancer or haematological malignancies need specific pre-, during and post-pregnancy assessment and counselling. We summarize the current knowledge about pathophysiological mechanisms, including gene mutations, clinical presentation, diagnosis, and medical and device management, as well as risk stratification. Women with a known diagnosis of a cardiomyopathy will often require continuation of drug therapy, which has the potential to exert negative effects on the foetus. This position paper assists in balancing benefits and detrimental effects. ispartof: EUROPEAN JOURNAL OF HEART FAILURE vol:23 issue:4 pages:527-540 ispartof: location:England status: published

PPCM is a diagnosis of exclusion but should be suspected in any peripartum women with nonspecific or specific findings that could suggest an underlying cardiac condition. Diagnosis of PPCM is centered around electrocardiography, natriuretic peptide measurements, and echocardiography. In some centers, these can be supplemented with cardiac magnetic resonance imaging and genetic testing. This chapter summarizes the approach to investigating women with suspected PPCM.

Background Mortality from acute myocardial infarction (AMI) has declined, increasing the pool of survivors at risk of later development of heart failure (HF). However, coronary reperfusion limits infarct size and secondary prevention therapy has improved. In light of these competing influences on risk of HF, we have examined long-term trends in incident HF hospitalisation (HFH) after AMI in a long-term, nationwide study with a single healthcare provider. Purpose To describe temporal trends in the risk of HFH following first AMI occurring in Scotland over a 26 year period. Methods All patients in Scotland discharged alive after a first AMI between 1990 and 2015 were followed until a first HFH or death until the end of 2016 (minimum follow-up 1 year, maximum 27 years). The cumulative incidence of HF was estimated at 1, 5 and 10 years following MI, accounting for the competing risk of death, with adjustment for comorbidities, age, sex and socioeconomic deprivation. In a sensitivity analysis, rates of HFH by AMI type (ST elevation MI [STEMI], non-STEMI and unknown ST type) were calculated for the period 2012 to 2015. Results A total of 184,826 people with no prior history of HF were discharged alive after a first AMI during the period of study. 23,414 (12.7%) had a first HFH during a median follow-up time of 6.8 years. Accounting for the competing risk of death, the cumulative incidence of first HFH, at 1 year, fell between 1990 and 2015 from 5.0% to 2.9%; the 5 year risk fell from 10.4% to 5.8%; 10 year risk from 14.8% to 9.0% (Figure). The adjusted risk of HFH at 1 year after discharge fell by 55% (95% CI 49–60%). The adjusted 5 year risk of HFH fell by 57% (95% CI 53–60%) and 10 year risk fell by 53% (95% CI 50–57%). The adjusted risk of death after first MI fell at 1 year (44%; 95% CI 39–48%), 5 years (37%; 34–39%) and 10 years (34%; 31–36%). The 10 year risk of HF following AMI was higher in older individuals ( Figure 1 Conclusion Despite an increasing pool of survivors of AMI at risk of HF, the incidence of HF hospitalisation following AMI in Scotland has consistently decreased since 1990. This is despite changes in the treatment and definition of AMI. These trends suggest that better treatment of MI and secondary prevention are having an impact on the risk of HF at a population level. Acknowledgement/Funding This study was funded by an NHS Greater Glasgow and Clyde endowment fund award (GN17CA406)

Heart failure with reduced ejection fraction (HF-REF) is a common problem worldwide and its prevalence rises with age. It is associated with substantial morbidity and mortality. Development of the condition is driven by a number of haemodynamic and neurohumoral pathophysiological processes which, in turn, lead to adverse remodelling of the myocardium and worsening heart failure. In every case, there is an underlying aetiological factor which triggers this detrimental cascade. The mainstay of treatment is pharmacological, and in select patients this can be complemented by the use of implantable devices or other more approaches techniques. This chapter provides an overview of the pathophysiology of HF-REF, with a focus on the evidence-based treatments currently used.

Peripartum cardiomyopathy (PPCM) is a potentially life-threatening condition typically presenting as heart failure with reduced ejection fraction (HFrEF) in the last month of pregnancy or in the months following delivery in women without another known cause of heart failure. This updated position statement summarizes the knowledge about pathophysiological mechanisms, risk factors, clinical presentation, diagnosis and management of PPCM. As shortness of breath, fatigue and leg oedema are common in the peripartum period, a high index of suspicion is required to not miss the diagnosis. Measurement of natriuretic peptides, electrocardiography and echocardiography are recommended to promptly diagnose or exclude heart failure/PPCM. Important differential diagnoses include pulmonary embolism, myocardial infarction, hypertensive heart disease during pregnancy, and pre-existing heart disease. A genetic contribution is present in up to 20% of PPCM, in particular titin truncating variant. PPCM is associated with high morbidity and mortality, but also with a high probability of partial and often full recovery. Use of guideline-directed pharmacological therapy for HFrEF is recommended in all patients respecting contraindications during pregnancy/lactation. The oxidative stress-mediated cleavage of the hormone prolactin into a cardiotoxic fragment has been identified as a driver of PPCM pathophysiology. Pharmacological blockade of prolactin release using bromocriptine as a disease-specific therapy in addition to standard therapy for heart failure treatment has shown promising results in two clinical trials. Thresholds for devices (implantable cardioverter-defibrillators, cardiac resynchronization therapy and implanted long-term ventricular assist devices) are higher in PPCM than in other conditions because of the high rate of recovery. The important role of education and counselling around contraception and future pregnancies is emphasised.

The aim of this paper is to investigate whether the methyl group of the adsorbed methoxy intermediate on industrial grade alumina catalysts undergoes rotational tunnelling on the wavenumber energy scale. The data show that this is clearly the case for a fraction of the methyl groups and potentially allows the subtle intermolecular interactions between adsorbed species and catalyst to be probed through the exponential dependence of the tunnel frequency on the rotational potential.

In DAPA-HF, dapagliflozin (10mg qd) compared with placebo, reduced the risk of worsening HF and CV death. It is important to understand whether the effects of dapagliflozin vary according to background HF therapy. Key inclusion criteria: 1) NYHA class II-IV, 2) LVEF ≤40%, and 3) elevated plasma

Peripartum cardiomyopathy is an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause for heart failure is identified. Outcome varies from full recovery to residual left ventricular systolic dysfunction and even death. Many women return to their physician to acquire information on their long- term prognosis, to seek medical advice regarding contraception, or when planning a subsequent pregnancy. This position paper summarizes current evidence for long-term outcome, risk stratification of further pregnancies and overall management. Based on the best available evidence, as well as the clinical experience of the European Society of Cardiology Study Group on Peripartum Cardiomyopathy members, a consensus on pre- and postpartum management algorithms for women undergoing a subsequent pregnancy is presented.

Learning objectives In 2010, the Heart Failure Association of the European Society of Cardiology Working Group on peripartum cardiomyopathy (PPCM) defined PPCM as ‘an idiopathic cardiomyopathy presenting with heart failure secondary to left ventricular (LV) systolic dysfunction towards the end of pregnancy or in the months following delivery, where no other cause of heart failure is found. It is a diagnosis of exclusion’1 (figure 1). It is important to appreciate that not all heart failure during pregnancy is due to PPCM. Other cardiovascular conditions can present during pregnancy; for example, pre-existing cardiomyopathies or previously undiagnosed congenital or valvular heart disease. Figure 1 European Society of Cardiology PPCM Working Group definition of peripartum cardiomyopathy. The incidence of PPCM varies between countries and between races within countries. In Africa, among predominantly black populations, the incidence is around 1 in 1000 live births.2 There are a few countries where PPCM appears to be much more common. For example, in Nigeria and Haiti, an incidence of 1 in 100 and 1 in 300 pregnancies respectively has been reported.3 4 In the USA, the incidence in predominantly white populations is between 1 in 1000 and 1 in 4000, but in African-American populations it is between 1 in 1000 and 1 in 2000.5–7 The incidence in Europe and Australasia is not well studied. The incidence does appear to be increasing—possibly due to increased awareness and diagnosis.8 It is striking that PPCM is often only recognised when patients are very sick with severe myocardial dysfunction. It seems likely that less severe forms of PPCM go undiagnosed, with symptoms being ascribed to the stresses around the arrival of a new child …

Although peripartum cardiomyopathy (PPCM) is associated with mortality and morbidity, improvement in cardiac function – termed myocardial recovery – can occur. No study has systematically reviewed myocardial recovery in PPCM and its independent predictors. A systematic review was performed of

Introduction Significant (>50%) left main stem stenosis (LMS) is found in 4–6% of patients undergoing diagnostic angiography. Unprotected LMS lesions are associated with a poor prognosis and the mortality for non-revascularised disease may be as high as 37% at 3 years. In order to reduce morbidity and mortality associated with delayed treatment, European guidelines recommend that all patients with LMS disease undergo revascularisation within 2 weeks. Aims We audited all patients in our high-volume tertiary centre that underwent revascularisation by coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) for significant LMS stenosis during a 6-month period. We sought to investigate timing between coronary angiography and revascularisation for stable and unstable presentations and compare our findings to the international guidelines. Methods Patients with significant LMS disease observed during invasive coronary angiography (Feb–Aug 2014) were retrospectively identified using the coronary intervention patient-database at the West of Scotland Regional Heart and Lung Centre (Golden Jubilee National Hospital). Data were collected from angiography reports and electronic patient records. Patients who did not undergo revascularisation or who had primary PCI were excluded from the analyses. Patients were considered unstable if the indication for angiography was acute coronary syndrome, including ST-elevation myocardial infarction without primary PCI. Results 207 patients were found to have significant LMS disease during the audit period, 42 were excluded (not revascularised or primary PCI). A total of 165 patients underwent non-emergency revascularisation. 103/165 (62%) patients were revascularised by CABG. A larger proportion of patients in the PCI group were female, older, had additional comorbidities and were unstable at presentation compared with the CABG group (Table 1). 102/165 (62%) patients waited >14 days for revascularisation. Figure 1 shows the distribution of timing of revascularisation by CABG and PCI, highlighting the stability of patients within each group. 16/93 (17%) stable patients and 47/72 (65%) unstable patients were revascularised within 14 days, with the majority undergoing PCI (43/64, 68%). The main reason for delay >14 days for CABG was the wait for outpatient surgery (Figure 2). In the PCI group waiting >14 days, 5/19 (26%) patients were referred back for PCI after being deemed unsuitable for surgery (Figure 3). Conclusion Huge service developments have been made in recent years to deliver timely revascularisation for patients, particularly those with unstable coronary disease. Despite this, we have found that patients with the highest risk coronary anatomy are experiencing significant delays to revascularisation, particularly by CABG. Further efforts to streamline the pathway to both surgical and percutaneous revascularisation for this patient group are needed.

Background NICE guidelines recommend CT coronary angiography (CTCA) as a first line investigation for patients with chest pain and an estimated likelihood of coronary artery disease (CAD) of 10–29%. These guidelines do not recommend exercise testing in this patient group. The recently published PROMISE and SCOT-HEART studies extended the use of CTCA to moderate and high risk patients. Neither study has shown clear clinical benefit for patient randomised to CTCA and there remains a divergence of opinion regarding the appropriateness of CTCA in these patient groups. In particular, there is a concern that CTCA may increase the number of future invasive coronary angiograms. We studied patients referred to the CTCA service in our centre and compared their predicted risk, prior stress testing and subsequent investigations to the NICE guidance and with data from the PROMISE and SCOT-Heart studies. Methods Data was collected prospectively for consecutive patients undergoing CTCA over a 3 month period. CTCA reports were retrospectively reviewed with details recorded of the scan protocol, scan quality and severity of coronary disease. Our cardiac catheterisation database was retrospectively interrogated 6 months after the final patient underwent CTCA to document any subsequent invasive coronary angiography, PCI or CABG. Results A total of 226 patients underwent CTCA during the 3 month study period (Table 1). The distribution of likelihood of CAD according the NICE guideline tables is shown in Figure 1. Only 34/226 (15%) had a pre-test probability of having significant CAD within the 10–29% category. Prior to CTCA, 153 patients (68%) had exercise ECG testing with 12/226 (5%) undergoing stress perfusion imaging. Overall, 164/226 (73%) patients had normal arteries or minimal CAD with 52 (23%) patients reported to have moderate/severe disease (Figure 2). 21/226 (9.3%) patients subsequently underwent invasive coronary angiography. 5 of these patients had pressure wire assessment (PWS) of coronary lesions with one of these patients subsequently undergoing revascularisation by CABG. An additional 4 patients underwent percutaneous revascularisation without PWS. Conclusion Only a minority of patients referred for CTCA to our centre were within the pre-test probability category recommended by NICE for this test. The majority of patients had undergone exercise testing prior to CTCA again suggesting limited adherence to the NICE guidelines. Despite the majority of patients having a pre-test probability > 30%, only 9.3% of patients underwent subsequent invasive angiography, less than in the patient group randomised to CTCA in both the PROMISE and SCOT-HEART studies (12%). Further studies are needed to better define the population that would most benefit from CTCA.

Introduction The Eplerenone Post-Acute Myocardial Infarction Heart Failure Efficacy and Survival Study (EPHESUS) trial demonstrated that eplerenone reduces all-cause mortality and death or hospitalisation for cardiovascular events in patients with symptomatic left ventricular (LV) systolic dysfunction (ejection fraction ≤40%) or diabetes following ST-elevation myocardial infarction (STEMI). Current national and international guidelines recommend initiation of eplerenone in this patient group. We conducted a retrospective audit of assessment of LV systolic function and subsequent prescribing of eplerenone in eligible patients presenting with acute STEMI over a 4-month period. Aims and objectives 1. Establish what proportion of patients presenting with STEMI had in-patient assessment of LV systolic function 2. Identify whether LV systolic function assessment was performed qualitatively or quantitatively 3. Determine what proportion of eligible patients were prescribed eplerenone on hospital discharge Methods Patients from NHS Greater Glasgow and Clyde (GG&C) who underwent primary percutaneous coronary intervention (PPCI) for STEMI were retrospectively (01/08/13–30/11/13) identified using the coronary intervention patient-database at the West of Scotland Regional Heart and Lung Centre (Golden Jubilee National Hospital). Data were collected using electronic patient records and national radiology archive. Qualitative assessment was defined as a subjective description of LV systolic function (normal, mild, moderate or severe impairment). Quantitative assessment was defined as a documented ejection fraction (EF). Patients were considered eligible for eplerenone if they had a qualitative assessment of LV systolic function documented as moderately or severely impaired, or EF ≤ 40% on quantitative assessment, and symptomatic LV systolic dysfunction or diabetes. Results 172 patients were identified. 90% of the total population had in-patient assessment of LV systolic function ([Table 1][1]). All of these patients had qualitative assessment ([Table 1][1]). LV systolic function was quantitatively assessed in 27% (10% modified Simpson’s Biplane method, 11% estimated EF, 5% unspecified) ([Table 1][1]). 8% of patients were considered eligible for eplerenone ([Table 2][2]). Of those eligible, eplerenone was appropriately prescribed on discharge in 21% ([Table 2][2]). View this table: Abstract 22 Table 1 Assessment of LV systolic function View this table: Abstract 22 Table 2 Prescribing of eplerenone in eligible patients Conclusions This audit indicates that national and international guidelines for the assessment and management of LV systolic function post-STEMI are not being adhered to within this region. Identifying those with LV systolic dysfunction post-STEMI is not only of importance for the optimisation of drug therapy, but also for patient selection for implantable defibrillators. The wider implications of LV systolic dysfunction include DVLA-imposed restrictions on driving and critical illness policies. Potential barriers to compliance with guidelines include time-constraints, training and shorter inpatient stay since the adoption of PPCI. These factors may explain the low prescribing rate of eplerenone in eligible patients. [1]: #T1 [2]: #T2

G. James Fleming was a quiet, unassuming man who lived an exemplary life, made a big difference in society, and impacted on many lives across the country and abroad. A search of the archives reveals that very little written record on this impressive individual is readily available. In discussions with many that knew him, they had only kind words to say, but nothing in writing that could be shared. It is hoped that this paper will add to the written record and further memorialize a pioneer.