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The study aimed to determine the predictors of procedural failure (coronary cannulation) in patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) from the transradial (TR) approach.We conducted an observational study of 20,315 consecutive patients undergoing TR angiography between 2016 and 2020. TR failure was described as inability to cannulate the coronary arteries. Univariate and multivariate analyses were performed to determine independent predictors of TR failure.Out of the study population, TR failure was observed in 365 (1.8%) patients, out of which 281 (77%) crossed over successfully to the transfemoral (TF) route and 84 (23%) to left radial access (LRA). Unsuccessful procedures were most likely seen in patients who were elderly, female, BAME background, short stature or with a history of hypertension, diabetes, and renal disease. On regression analysis, age (OR: 1.024; 95% Cl: 1.014-1.035), female gender (OR: 0.729; 95% Cl: 0.555-0.957), BAME (OR: 0.786; 95% Cl: 0.612-0.959), height (OR: 0.988; 95% Cl: 0.977-0.999), hypertension (OR: 1.510; 95% Cl: 1.147-1.987) and RRA (OR: 1.977; 95% Cl: 1.105-3.538) were independent predictors of TR failure. On further analysis, these predictors of failure were not seen from the LRA approach.This study identifies that rates of TR failure are low and that predictors of failure differ between the RRA and LRA. The difference in predictors between the 2 routes suggests that in patients when coronary cannulation is unsuccessful via the RRA then the LRA could be considered as a second access site. Further study is needed to see if in selected patient groups the LRA could be used as the first-choice access route.

The transradial access approach is a well-established route for coronary angiography and percutaneous intervention, given its lower complication rate over the transfemoral route. However, complications are still apparent, some of which can lead to serious injury. We report a case of delayed diagnosis of localized compartment syndrome , caused by haematoma and pseudoaneurysm formation following a radial procedure which resulted in long term disability. We emphasize the importance of early recognition and diagnosis of compartment syndrome to avoid long term sequalae.

BACKGROUND Mortality from alcohol-related liver disease has risen significantly for three decades. Transient elastography (TE) is a non-invasive test providing a numerical marker of liver disease. Preliminary evidence suggests that receiving TE can reduce alcohol consumption. The KLIFAD (Does knowledge of liver fibrosis affect high risk drinking behaviour?) study has developed a complex intervention in which people receiving alcohol treatment are provided with access to TE, accompanied by scripted feedback tailored to disease state, and access to video narratives describing alcohol misuse recovery after receiving TE. Recovery narratives are included due to preliminary evidence from mental health studies which suggest that access to digital narratives describing recovery from mental health problems can help people affected by mental health problems, including through mechanisms with potential to be transferable to an alcohol treatment setting, for example by increasing hope for the future, enabling learning from the experience of others, or promoting help-seeking behaviours. OBJECTIVE To develop the KLIFAD Intervention to the point that it could be delivered in a feasibility trial; to produce knowledge relevant to clinicians and researchers developing interventions making use of biomarkers of disease. METHODS In research activity one, standardised scripted feedback was developed by the study, and then iterated through focus groups with people who had experienced alcohol misuse and transient elastography, and key alcohol workers with experience of delivering transient elastography. We report critical design considerations identified through focus groups, in the form of sensitizing concepts. In research activity two, a video production guide was co-produced to enable the production of impactful video-based recovery narratives, and a PPI panel was consulted for recommendations on how best to integrated recovery narratives into an alcohol treatment setting. We report PPI recommendations and an overview of video form and content. RESULTS Through research activity one, we learnt that patient feedback has not been standardised in prior use of transient elastography, that receiving a numeric marker can provide an objective target that motivates and rewards recovery, and that key alcohol workers regularly tailor information to their clients. Through research activity two, we developed a video production guide asking narrators what recovery means to them, what helped their recovery, and what they have learned about recovery. We produced ten recovery narratives and collected PPI recommendations on maximising impact and safety. These led to the production of unplanned videos presenting carer and clinician perspectives, and a choice to limit narrative availability to alcohol treatment settings, where support is available around distressing content. These choices will be evaluated through a feasibility RCT [ISRCTN16922410]. CONCLUSIONS Providing an objective target that motivates and rewards recovery is a candidate change mechanism for complex interventions integrating biomarkers of disease. Recovery narratives can contain distressing content; intervention developers should attend to safe usage. INTERNATIONAL REGISTERED REPORT RR2-10.1136/bmjopen-2021-054954

Regional heart attack services have improved clinical outcomes following ST-segment elevation myocardial infarction (STEMI) by facilitating early reperfusion by primary percutaneous coronary intervention (PCI). Early discharge after primary PCI is welcomed by patients and increases efficiency of health care.This study aimed to assess the safety and feasibility of a novel early hospital discharge pathway for low-risk STEMI patients.Between March 2020 and June 2021, 600 patients who were deemed at low risk for early major adverse cardiovascular events (MACE) were selected for inclusion in the pathway and were successfully discharged in 48 hours. Patients were reviewed by a structured telephone follow-up at 48 hours after discharge by a cardiac rehabilitation nurse and underwent a virtual follow-up at 2, 6, and 8 weeks and at 3 months.The median length of hospital stay was 24.6 hours (interquartile range [IQR]: 22.7-30.0 hours) (prepathway median: 65.9 hours [IQR: 48.1-120.2 hours]). After discharge, all patients were contacted, with none lost to follow-up. During median follow-up of 271 days (IQR: 88-318 days), there were 2 deaths (0.33%), both caused by coronavirus disease 2019 (30 days after discharge), with 0% cardiovascular mortality and MACE rates of 1.2%. This finding compared favorably with a historical group of 700 patients meeting pathway criteria who remained in the hospital for48 hours (48-hour control group) (mortality, 0.7%; MACE, 1.9%) both in unadjusted and propensity-matched analyses.Selected low-risk patients can be discharged safely following successful primary PCI by using a pathway that is supported by a structured, multidisciplinary virtual follow-up schedule.

ObjectivesPersistently impaired culprit artery flow (MethodsIn T-TIME (trial of low-dose adjunctive alTeplase during primary PCI), patients ≤6 hours from onset of ST-elevation myocardial infarction (STEMI) were randomised to placebo, alteplase 10 mg or alteplase 20 mg, administered by infusion into the culprit artery, pre-stenting. In this prespecified, secondary analysis, coronary flow was assessed angiographically at the point immediately before drug administration. Microvascular obstruction, myocardial haemorrhage and infarct size were assessed by cardiovascular magnetic resonance (CMR) at 2–7 days and 3 months.ResultsTIMI flow was assessed after first treatment (balloon angioplasty/aspiration thrombectomy), immediately pre-drug administration, in 421 participants (mean age 61±10 years, 85% male) and was 3, 2 or 1 in 267, 134 and 19 participants respectively. In patients with TIMI flow ≤2 pre-drug, there was higher incidence of microvascular obstruction with alteplase (alteplase 20 mg (53.1%) and 10 mg (59.5%) combined versus placebo (34.1%); OR=2.47 (95% CI 1.16 to 5.22, p=0.018) interaction p=0.005) and higher incidence of myocardial haemorrhage (alteplase 20 mg (53.1%) and 10 mg (57.9%) combined vs placebo (27.5%); OR=3.26 (95% CI 1.44 to 7.36, p=0.004) interaction p=0.001). These effects were not observed in participants with TIMI 3 flow pre-drug. There were no interactions between TIMI flow pre-drug, alteplase and 3-month CMR findings.ConclusionIn patients with impaired culprit artery flow (Trial registration numberNCT02257294.

Objective We aimed to assess the use of enhanced stent visualisation (ESV) on outcomes, after PCI with overlapping stents, specifically using CLEARstent technology. Background Stent underexpansion and overlap are both significant risk factors for restenosis and stent thrombosis. Enhanced stent visualisation (e.g. CLEARstent) systems could provide important data to reduce under-expansion and stent overlap. Methods This was a cohort study based on this institution's percutaneous coronary intervention (PCI) registry. A total of 2614 patients who had PCI for stable angina or acute coronary syndromes (ACS, excluding cardiogenic shock) with overlapping 2nd generation drug eluting stents (DES) in the same vessel between May 2015 and January 2018 were included in the analysis. Patients were divided into ESV (n = 1354) and no ESV guided intervention (n = 1260). The primary end-point was major adverse cardiovascular events (MACE: target vessel revascularisation, target vessel myocardial infarction and all-cause mortality) recorded at a median follow up of 2.4 years. Results Groups were comparable for patient characteristics (age, diabetes mellitus, ACS presentation). A significant difference in MACE was observed between patients who underwent ESV-guided PCI (9.5%) compared with patients who underwent Standard PCI (14.4%, p = .018). This difference was mainly driven by reduced rates of target vessel revascularisation and recurrent myocardial infarction. Overall this difference persisted after multivariate Cox analysis (HR 0.86, 95% CI: 0.73–0.98) and propensity matching (HR = 0.88, 95% CI: 0.69–0.99). Conclusion We suggest that routine clinical use of ESV technology during PCI can be useful, and is associated with better medium-term angiographic and clinical outcomes. Further study is required to build on this promising signal.

OBJECTIVES: This study compared the prognostic value of a noncontrast CMR risk score for the composite of all-cause death, nonfatal myocardial infarction, and new congestive heart failure.BACKGROUND: A cardiovascular magnetic resonance (CMR) risk score including left ventricular ejection fraction (LVEF), myocardial infarct (MI) size, and microvascular obstruction (MVO) was recently proposed to risk-stratify patients with ST-segment elevation myocardial infarction (STEMI).METHODS: The Eitel CMR risk score and GRACE (Global Registry of Acute Coronary Events) score were used as a reference (Score 1: acute MI size ≥19% LV, LVEF ≤47%, MVO >1.4% LV and GRACE score). MVO was replaced by intramyocardial hemorrhage (IMH) in Score 2 (acute MI size ≥19% LV, LVEF ≤47%, IMH, and GRACE score). Score 3 included only LVEF ≤45%, IMH, and GRACE score.RESULTS: There were 370 patients in the derivation cohort and 234 patients in the validation cohort. In the derivation cohort, the 3 scores performed similarly and better than GRACE score to predict the 1-year composite endpoint with C-statistics of 0.83, 0.83, 0.82, and 0.74, respectively. In the validation cohort, there was good discrimination and calibration of score 3, with a C-statistic of 0.87 and P = 0.71 in a Hosmer-Lemeshow test for goodness of fit, on the 1-year composite outcome. Kaplan-Meier curves for 5-year composite outcome showed that those with LVEF ≤45% (high-risk) and LVEF >45% and IMH (intermediate-risk) had significantly higher cumulative events than those with LVEF >45% and no IMH (low-risk), log-rank tests: P = 0.02 and P = 0.03, respectively. The HR for the high-risk group was 2.3 (95% CI: 1.1-4.7) and for the intermediate-risk group was 2.0 (95% CI: 1.0-3.8), and these remained significant after adjusting for the GRACE score.CONCLUSIONS: This noncontrast CMR risk score has performance comparable to an established risk score, and patients with STEMI could be stratified into low risk (LVEF >45% and no IMH), intermediate risk (LVEF >45% and IMH), and high risk (LVEF ≤45%). (A Trial of Low-dose Adjunctive alTeplase During prIMary PCI [T-TIME]; NCT02257294) (Detection and Significance of Heart Injury in ST Elevation Myocardial Infarction [BHF MR-MI]; NCT02072850).

Background: Out-of-hospital cardiac arrest (OHCA) is a major cause of death worldwide. Recent guidelines recommend the centralisation of OHCA services in cardiac arrest centres to improve outcomes. In 2015, two major tertiary cardiac centres in London merged to form a large dedicated tertiary cardiac centre. This study aimed to compare the short-term mortality of patients admitted with an OHCA before-and-after the merger of services had taken place and admission criteria were relaxed, which led to managing OHCA in higher volume. Methods: We retrospectively analysed the data of OHCA patients pre- and post-merger. Baseline demographic and medical characteristics were recorded, along with factors relating to the cardiac arrest. The primary endpoint was in-hospital mortality. Results: OHCA patients (N =728; 267 pre- and 461 post-merger) between 2013 and 2018 were analysed. Patients admitted pre-merger were older (65.0 vs. 62.4 years, p=0.027), otherwise there were similar baseline demographic and peri-arrest characteristics. There was a greater proportion of non-acute coronary syndrome-related OHCA admission post-merger (10.1% vs. 23.4%, p=0.0001) and a corresponding decrease in those admitted with ST-elevation myocardial infarction (80.2% vs. 57.0%, p=0.0001) and those treated with percutaneous coronary intervention (78.8% vs. 54.0%, p=0.0001). Despite this, in-hospital mortality was lower post-merger (63.7% vs. 44.3%, p=0.0001), which persisted after adjustment for demographic and arrest-related characteristics using stepwise logistic regression (p=0.036) between the groups. Conclusion: Despite an increase in non-acute coronary syndrome-related OHCA cases, the formation of a centralised invasive heart centre was associated with improved survival in OHCA patients. This suggests there may be a benefit of a cardiac arrest centre model of care.

Background Patients with ischaemic heart disease and previous coronary artery bypass grafting (CABG) often need coronary evaluation by means of invasive coronary angiography (ICA). ICA in such patients is technically more challenging and carries a higher risk of complications including kidney damage, myocardial infarction, stroke and death. Improvements in Computed Tomography Cardiac Angiography (CTCA) technology have ensured its emergence as a useful clinical tool in CABG assessment, allowing for its potential use in planning interventional procedures in this patient group. Methods The BYPASS-CTCA study is a prospective, single centre, randomised controlled trial assessing the value of upfront CTCA in patients with previous surgical revascularisation undergoing ICA procedures. A total of 688 patients with previous CABG, requiring ICA for standard indications, will be recruited and randomised to receive ICA alone, or CTCA prior to angiography. Subjects will be followed up over a 12-month period post procedure. The primary endpoints are ICA procedural duration, incidence of contrast-induced nephropathy (CIN) and patient satisfaction scores post ICA. Secondary endpoints include contrast dose (mL) and radiation dose (mSv) during ICA, number of catheters used, angiography-related complications and cost-effectiveness of CTCA (QALY) over 12 months. Discussion The study will investigate the hypothesis that CTCA prior to ICA in patients with previous CABG can reduce procedural duration, post-procedural kidney damage and improve patient satisfaction, therefore strengthening its role in this group of patients. Trial registration The study is registered on ClinicalTrials.gov which is a resource maintained by the U.S. National Library of Medicine. Registration number NCT03736018.

Aims: The CREST tool was recently developed to stratify the risk of circulatory-aetiology death (CED) in out-of-hospital cardiac arrest (OHCA) patients without ST-elevation myocardial infarction (STEMI). We aimed to validate the CREST score using an external cohort and determine whether it could be improved by the addition of serum lactate on admission. Methods: The study involved the retrospective analysis of consecutive patients admitted to a single tertiary centre with OHCA of presumed cardiac origin over a 51-month period. The CREST score was calculated by attributing points to the following variables: Coronary artery disease (CAD), non-shockable Rhythm, Ejection fraction

The Nightingale Hospital London (NHL) was the first of seven new UK National Health Service (NHS) hospitals designed to address the potential shortfall in critical care capacity caused by the rapidly escalating first wave of the SARS-CoV-2 pandemic. When scenes of hospitals at risk of saturation were being broadcast internationally, the initial NHL mandate was to deliver a large-scale intensive care unit (ICU) for up to 4000 ventilated patients to increase the capacity of London’s existing hospitals. Before this, ICU bed capacity in London and England was 839 and 3766, respectively.1 Healthcare projects of this pace, scale or complexity are usually overseen by experienced teams over many years, and within specifically designed environments and timetables.2 However, the NHL was constructed in an events centre, and started accepting patients within weeks of conception. The newly formed NHL leadership team was redeployed from different hospitals across London at a time of unprecedented national uncertainty, before disease-modifying COVID-19 therapies were approved and when staff in existing hospitals were preparing ICU expansions of their own.3 This unique mandate resulted in the NHL being exposed to a level of potential risk and vulnerability to human error that healthcare services have worked to reduce in recent years.4 5 Fortunately, due to lockdown restrictions and ICU expansion in existing hospitals, only 54 patients were admitted to the NHL. Therefore, in comparison to forecasts, existing hospitals and its potential capacity, the overall contribution of the NHL to the ICU COVID-19 response in London was relatively small. Importantly, however, clinical outcomes were comparable to existing hospitals. NHL patient mortality was 48.1% compared with 47.7% nationally, and the requirements for, and duration of, organ support were also similar.6 Although its true potential was fortunately never reached, the NHL did fulfil its role in urgently providing …

Objectives: The clinical environment has been forced to adapt to meet the unprecedented challenges posed by the COVID-19 pandemic. Intensive care facilities were expanded in anticipation of the pandemic where the consequences include severe delays in elective procedures. Emergent procedures such as Percutaneous Coronary Intervention (PCI) in acute myocardial infarction (AMI) in which delays in timely delivery have well established adverse prognostic effects must also be explored in the context of changes in procedure and public behaviour associated with the COVID-19 pandemic. The aim for this single centre retrospective cohort study is to determine if door-to-balloon (D2B) times in PCI for ST Elevation Myocardial Infarction (STEMI) during the United Kingdom’s first wave of the COVID-19 pandemic differed from pre-COVID-19 populations. Methods: Data was extracted from our single centre PCI database for all patients that underwent pPCI for STEMI. The reference (Pre-COVID-19) cohort was collected over the period 01-03-2019 to 31-05-2019 and the exposure group (COVID-19) over the period 01-03-2020 to 31-05-2020. Baseline patient characteristics for both populations were extracted. The primary outcome measurement was D2B times. Secondary outcome measurements included: time of symptom onset to call for help, transfer time to first hospital, transfer time from non-PCI to PCI centre, time from call-to-help to PCI centre, time to table and onset of symptoms to balloon time. Categorical and continuous variables were assessed with Chi squared and Mann-Whitney U analysis respectively. Procedural times were calculated and compared in the context of heterogeneity findings. Results: 4 baseline patient characteristics were unbalanced between populations with statistical significance (P

Background In patients presenting with non ST-segment elevation acute coronary syndromes (NSTE-ACS) an invasive approach has been shown to be superior to conservative management. Purpose We aimed to investigate the optimal timing of invasive coronary angiography and subsequent intervention. Methods We examined the impact ofearly (≤24h) versus delayed (>24h) intervention in a large observational cohort of 20882 consecutive patients with acute NSTE myocardial infarction (NSTEMI) treated with PCI between 2005 and 2015 at 9 tertiary cardiac centers in London (UK) using Cox-regression analysis and propensity matching. Results Mean age was 64.5±12.7 years and 26.1% were females. A quarter (27.6%), were treated within 24h.Patients treated within 24h were slightly younger (62.8±12.8 vs. 65.2±12.6, p24h following their presentation (p Conclusions Notwithstanding the limitations of the retrospective design, this real-world cohort of NSTEMI patients suggests that an early intervention (≤24h) may improve mid term survival. Figure 1 Funding Acknowledgement Type of funding source: None

Background Microvascular obstruction commonly affects patients with acute ST-segment elevation myocardial infarction and is independently associated with adverse outcomes. Objective To determine whether or not a strategy involving low-dose intracoronary fibrinolytic therapy infused early after coronary reperfusion will reduce microvascular obstruction. Design This was a multicentre, randomised, double-blind, parallel-group, placebo-controlled, dose-ranging trial. Setting The trial took place at 11 hospitals in the UK between 17 March 2016 and 21 December 2017. Participants Patients with acute ST-segment elevation myocardial infarction and a symptom onset to reperfusion time of ≤ 6 hours were eligible for randomisation. Radial artery access was a requirement, and further angiographic criteria included a proximal-to-middle coronary artery occlusion or impaired coronary flow in the presence of a definite thrombus in the culprit coronary artery. Exclusion criteria included a functional coronary collateral supply to the infarct-related artery, any contraindication to fibrinolysis and lack of informed consent. Additional exclusion criteria for safety were (1) requirement for immunosuppressive drug therapy for ≤ 3 months and (2) treatment with an antimicrobial agent. Intervention A total of 440 participants were randomly assigned 1 : 1 : 1 to treatment with placebo (n = 151), 10 mg of alteplase (n = 144) or 20 mg of alteplase (n = 145) administered by manual infusion directly into the infarct-related coronary artery over 5–10 minutes. The intervention was scheduled to happen after reperfusion and before stent implantation. Outcomes The primary outcome was the amount of microvascular obstruction (percentage of left ventricular mass) demonstrated by contrast-enhanced cardiac magnetic resonance imaging at 2–7 days after enrolment. The primary analysis was the comparison between the 20 mg of alteplase group and the placebo group; if this comparison was not significant, the comparison of the 10 mg of alteplase group with the placebo group was considered as a secondary analysis. Sample size A total of 618 patients (minimum of 558 patients). Recruitment was halted on 21 December 2017 given that conditional power for the primary outcome based on a prespecified analysis of the first 267 randomised participants was Methods The primary outcome was compared between groups using a stratified Wilcoxon rank-sum test (van Elteren test), stratified by the location of the myocardial infarction. Results Among the 440 patients (mean age of 60.5 years; 15% women), the primary end point was measured in 396 (90%) patients, 17 (3.9%) withdrew, seven died and all other patients were followed up to 3 months. The amount (mean percentage of left ventricular mass) of microvascular obstruction was 2.3% versus 2.6% versus 3.5% in the placebo, 10 mg of alteplase and 20 mg of alteplase groups, respectively. In the primary analysis, microvascular obstruction did not differ between the 20 mg of alteplase group and the placebo group: 3.5% versus 2.3%, estimated difference 1.16% (95% confidence interval –0.08% to 2.41%; p = 0.32). In the secondary analysis, microvascular obstruction did not differ between the 10 mg of alteplase group and the placebo group: 2.6% versus 2.3%, estimated difference 0.29% (95% confidence interval –0.76% to 1.35%; p = 0.74). By 3 months, major adverse cardiac events (cardiac death, non-fatal myocardial infarction and unplanned hospitalisation for heart failure) had occurred in 15 (10.1%) patients in the placebo group, 18 (12.9%) in the 10 mg of alteplase group and 12 (8.2%) in the 20 mg of alteplase group. Conclusions Adjunctive low-dose intracoronary alteplase given during the primary percutaneous intervention did not reduce microvascular obstruction compared with placebo. Limitations Premature discontinuation of enrolment limited the power of the secondary and safety analyses. Future work Low-dose intracoronary alteplase or tenecteplase could be compared with placebo at the end of primary percutaneous coronary intervention in patients with an ischaemic time of Trial registration This trial is registered as ClinicalTrials.gov NCT02257294. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council (MRC) and National Institute for Health Research (NIHR) partnership. This will be published in full in Efficacy and Mechanism Evaluation; Vol. 7, No. 5. See the NIHR Journals Library website for further project information.

BackgroundThe response to COVID-19 has required cancellation of all but the most urgent procedures; there is therefore a need for the reintroduction of a safe elective pathway.MethodsThis was a study of a pilot pathway performed at Barts Heart Centre for the admission of patients requiring elective coronary and structural procedures during the COVID-19 pandemic (April–June 2020). All patients on coronary and structural waiting lists were screened for procedural indications, urgency and adverse features for COVID-19 prognosis and discussed at dedicated multidisciplinary teams. Dedicated admission pathways involving preadmission isolation, additional consent, COVID-19 PCR testing and dedicated clean areas were used.Results143 patients (101 coronary and 42 structural) underwent procedures (coronary angiography, percutaneous coronary intervention, transcatheter aortic valve intervention and MitralClip) during the study period. The average age was 68.2; 74% were male; and over 93% had one or more moderate COVID-19 risk factors. All patients were COVID-19 PCR negative on admission with (8.1%) COVID-19 antibody positive (swab negative). All procedures were performed successfully with low rates of procedural complications (9.8%). At 2-week follow-up, no patients had symptoms or confirmed COVID-19 infection with significant improvements in quality if life and symptoms.ConclusionWe demonstrated that patients undergoing coronary and structural procedures can be safely admitted during the COVID-19 pandemic, with no patients contracting COVID-19 during their admission. Reassuringly, patients reflective of typical practice, that is, those at moderate or higher risk, were treated successfully. This pilot provides important information applicable to other settings, specialties and areas to reintroduce services safely.

Non-invasive fractional flow reserve derived from CT coronary angiography (FFRCT) offers an amalgamation of both coronary anatomy and physiology. This review aims to provide a contemporary evaluation of the evidence for clinical use of FFRCT. The review article pays particular attention to the importance of patient preparation, anatomical features, scan quality and the overall interpretation of results that can lead to the best use of FFRCT analysis. Previous cost evaluations of the technology are compared and reviewed. Diagnostic accuracy of FFRCT in comparison with CTA has been established in several clinical studies previously. More recent studies for FFRCT use have focused on the clinical utility of the technology, in comparison with other non-invasive testing for coronary artery disease and the prognostic data of FFRCT. The registry data has demonstrated FFRCT as a comparable indicator of cardiac prognosis to invasive fractional flow reserve. Future research areas include the use of FFRCT to plan coronary revascularisation prior to procedures and even perhaps to predict future cardiac event using computational flow dynamic data. FFRCT is now an established technology for the diagnosis of coronary artery disease with increasing use in clinical practice. The potential of the technology to deliver cost savings, improved triage and more directed management will depend upon the manner of its use. Future applications of the principles of FFRCT have broad potential for improved understanding of coronary artery disease and superior management of patients afflicted with it.

Background: Recent studies have suggested that the routine use of aspiration thrombectomy catheters during primary percutaneous coronary intervention (PCI) do not result in improved mortality and may be associated with an increased stroke rate. This study sought to investigate this hypothesis. Methods: This was an observational study analysing data from a prospective database of 6366 patients undergoing primary PCI between August 2003 and May 2015 at a UK cardiac centre. Patients’ details were collected from the hospital electronic database. Primary outcome was thirty-day stroke rates. Results: 3989 (62.7%) patients underwent PCI alone and 2,377 (37.3%) patients underwent PCI with adjuctive thrombus aspiration. PCI alone group had an older demographic (63 (± 14) years vs 60.7 (± 14)), a lower proportion of male participants 75% vs 79% (P=0.001) and cardiovascular risk factors such as hypertension 22.4% vs 25.3% (P=0.007), hypercholesterolemia 18.5% vs 22.6% (P

Background Limited information exists regarding procedural success and clinical outcomes in patients with previous coronary artery bypass grafting (CABG) undergoing percutaneous coronary intervention ( PCI ). We sought to compare outcomes in patients undergoing PCI with or without CABG . Methods and Results This was an observational cohort study of 123 780 consecutive PCI procedures from the Pan‐London ( UK ) PCI registry from 2005 to 2015. The primary end point was all‐cause mortality at a median follow‐up of 3.0 years (interquartile range, 1.2–4.6 years). A total of 12 641(10.2%) patients had a history of previous CABG , of whom 29.3% (n=3703) underwent PCI to native vessels and 70.7% (n=8938) to bypass grafts. There were significant differences in the demographic, clinical, and procedural characteristics of these groups. The risk of mortality during follow‐up was significantly higher in patients with prior CABG (23.2%; P =0.0005) compared with patients with no prior CABG (12.1%) and was seen for patients who underwent either native vessel (20.1%) or bypass graft PCI (24.2%; P PCI was performed in native vessels in patients with previous CABG (hazard ratio [HR],1.02; 95% CI, 0.77–1.34; P =0.89), but a significantly higher mortality was seen among patients with PCI to bypass grafts (HR,1.33; 95% CI, 1.03–1.71; P =0.026). This was seen after multivariate adjustment and propensity matching. Conclusions Patients with prior CABG were older with greater comorbidities and more complex procedural characteristics, but after adjustment for these differences, the clinical outcomes were similar to the patients undergoing PCI without prior CABG . In these patients, native‐vessel PCI was associated with better outcomes compared with the treatment of vein grafts.

We aimed to investigate the optimal timing of invasive coronary angiography and subsequent intervention in non-ST-segment elevation acute myocardial infarction (NSTEMI) patients.We examined the impact of early (≤24 h) versus delayed (24 h) intervention in a large observational cohort of 20,882 consecutive NSTEMI patients treated with PCI between 2005 and 2015 at 8 tertiary cardiac centers in London (UK) using Cox-regression analysis and propensity matching.Mean age was 64.5 ± 12.7 years and 26.1% were females. A quarter (27.6%), were treated within 24 h. Patients treated within 24 h were slightly younger (62.8 ± 12.8 vs. 65.2 ± 12.6, p 0.001), most commonly male (76% vs. 72.9%, p 0.001) and were more frequently ventilated (2.3% vs. 1.4%, p 0.001) and in cardiogenic shock (3.6% vs. 1.4%, p 0.001) with dynamic changes on their ECG (84.5% vs. 76.1% p 0.001). At a median follow up of 4.2 years (interquartile range 1.8 to 7) 17.7% of patients had died. Estimated 5-year survival in patients treated within 24 h was 84.6% vs. 81% for those treated24 h following their presentation (p 0.001). This survival benefit remained following adjustment for confounders; HRNotwithstanding the limitations of the retrospective design, this real-world cohort of NSTEMI patients suggests that an early intervention (≤24 h) may improve mid-term survival.

Aim Current guidelines recommend the use of vitamin K antagonist (VKA) for up to 3–6 months for treatment of left ventricular (LV) thrombus post-acute myocardial infarction (AMI). However, based on evidence supporting non-inferiority of novel oral anticoagulants (NOAC) compared to VKA for other indications such as deep vein thrombosis, pulmonary embolism (PE), and thromboembolic prevention in atrial fibrillation, NOACs are being increasingly used off licence for the treatment of LV thrombus post-AMI. In this study, we investigated the safety and effect of NOACs compared to VKA on LV thrombus resolution in patients presenting with AMI. Methods and results This was an observational study of 2328 consecutive patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) for AMI between May 2015 and December 2018, at a UK cardiac centre. Patients’ details were collected from the hospital electronic database. The primary endpoint was rate of LV thrombus resolution with bleeding rates a secondary outcome. Left ventricular thrombus was diagnosed in 101 (4.3%) patients. Sixty patients (59.4%) were started on VKA and 41 patients (40.6%) on NOAC therapy (rivaroxaban: 58.5%, apixaban: 36.5%, and edoxaban: 5.0%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous myocardial infarction, PCI, coronary artery bypass grafting), and cardiovascular risk factors (hypertension, diabetes, hypercholesterolaemia). Over the follow-up period (median 2.2 years), overall rates of LV thrombus resolution were 86.1%. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin (82% vs. 64.4%, P = 0.0018, at 1 year), which persisted after adjusting for baseline variables (odds ratio 1.8, 95% confidence interval 1.2–2.9). Major bleeding events during the follow-up period were lower in the NOAC group, compared with VKA group (0% vs. 6.7%, P = 0.030) with no difference in rates of systemic thromboembolism (5% vs. 2.4%, P = 0.388). Conclusion These data suggest improved thrombus resolution in post-acute coronary syndrome (ACS) LV thrombosis in patients treated with NOACs compared to VKAs. This improvement in thrombus resolution was accompanied with a better safety profile for NOAC patients vs. VKA-treated patients. Thus, provides data to support a randomized trial to answer this question.

Background and aims: In patients with ST-segment elevation myocardial infarction (STEMI), mortality is directly related to time to reperfusion with guidelines recommending patients be delivered directly to centres for primary percutaneous coronary intervention (PCI). The aim of this study was to describe the impact of inter-hospital transfer on reperfusion time and to assess whether or not treatment delays influenced clinical outcomes in comparison with direct admission to a primary PCI centre in a large regional network. Method and results: We undertook an observational cohort study of patients with STEMI treated with primary PCI between 2005 and 2015 in London, UK. Patient details were recorded at the time of the procedure in databases using the British Cardiovascular Intervention Society PCI dataset. The primary end-point was all-cause mortality at a median of 4.1 years (interquartile range: 2.2–5.8 years). Secondary outcomes were in-hospital major adverse cardiac events. Of 25,315 patients, 17,560 (69.4%) were admitted directly to a primary PCI centre and 7755 (31.6%) were transferred from a non-primary PCI centre. Patients in the direct admission group were older and more likely to have left ventricular impairment compared with the inter-hospital transfer group. Median time from call for help to reperfusion in transferred patients was 52 minutes longer compared with patients admitted directly (p Conclusions: In this large registry of over 25,000 STEMI patients treated by primary PCI survival was better in patients admitted directly to a cardiac centre versus patients transferred for primary PCI, most likely due to longer call to balloon times in patient transferred from other hospitals.

Aims Assessment of haemodynamically significant coronary artery disease (CAD) using cardiovascular magnetic resonance (CMR) imaging perfusion or dynamic stress myocardial perfusion imaging by computed tomography (CT perfusion) may aid patient selection for invasive coronary angiography (ICA). We evaluated the diagnostic performance and incremental value of qualitative CMR perfusion and quantitative CT perfusion complementary to cardiac computed tomography angiography (CCTA) for the diagnosis of haemodynamically significant CAD using fractional flow reserve (FFR) and quantitative coronary angiography (QCA) as reference standard. Methods and results CCTA, qualitative visual CMR perfusion, visual CT perfusion, and quantitative relative myocardial blood flow (CT-MBF) were performed in patients with stable angina pectoris. FFR was measured in coronary vessels with stenosis visually estimated between 30% and 90% diameter reduction on ICA. Haemodynamically significant CAD was defined as FFR Conclusion Visual CMR perfusion and relative CT-MBF outperformed visual CT perfusion and provided incremental discrimination compared with CCTA alone for the diagnosis of haemodynamically significant CAD.

No abstract available.

Chronic total occlusions (CTO) are commonly encountered in patients undergoing coronary angiography; however, percutaneous coronary intervention (PCI) is infrequently performed owing to technical difficulty, the perceived risk of complications and a lack of randomized data. The aim of this study was to analyse the frequency and outcomes of CTO-PCI procedures in a large contemporary cohort of successive patients.We undertook an observational cohort study of 48 234 patients with stable angina of which 5496 (11.4%) procedures were performed for CTOs between 2005 and 2015 at nine tertiary cardiac centres across London, UK. Outcome was assessed by in-hospital major adverse cardiac events and all-cause mortality at a median follow-up of 4.8 years (interquartile range: 2.2-6.4 years).Over time, there was an increase in the proportion of elective PCI procedures performed for CTOs, but no increase in the absolute number. Overall success rates increased over time (74.3% in 2005 to 81.5% in 2015; P=0.0003) despite an increase in case complexity (previous myocardial infarction, diabetes, renal failure, previous coronary artery bypass grafting, peripheral vascular disease and left ventricular impairment) that correlated with procedural advancements. Successful CTO PCI was associated with lower mortality [9.5%, 95% confidence interval (CI): 8.1-11.6 vs. 15.3%, 95% CI: 13.7-20.6, P0.0001] that persisted after multivariate cox analysis (hazard ratio: 0.37, 95% CI: 0.25-0.62) and propensity matching (hazard ratio=0.36, 95% CI: 0.18-0.73, P=0.0005).Successful procedures were associated with lower mortality suggesting that the greater uptake of CTO PCI may improve clinical outcomes in a wider population than are currently being offered therapy.

Introduction: Non-invasive fractional flow reserve derived from CT coronary angiography (FFRCT) represents a novel technology to investigate coronary artery disease. The application of computationa...

Background A large proportion of patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) present with multivessel disease (MVD). There is uncertainty in the role of complete coronary revascularization in this group of patients. Objectives The aim of this study was to investigate the outcomes of complete revascularization compared with culprit vessel–only intervention in a large contemporary cohort of patients undergoing percutaneous coronary intervention (PCI) for NSTEMI. Methods The authors undertook an observational cohort study of 37,491 NSTEMI patients treated between 2005 and 2015 at the 8 heart attack centers in London. Clinical details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. A total of 21,857 patients (58.3%) presented with NSTEMI and MVD. Primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2 to 5.8 years). Results A total of 11,737 (53.7%) patients underwent single-stage complete revascularization during PCI for NSTEMI, rates that significantly increased during the study period (p = 0.006). Those patients undergoing complete revascularization were older and more likely to be male, diabetic, have renal disease and a history of previous myocardial infarction/revascularization compared with the culprit-only revascularization group. Although crude, in-hospital major adverse cardiac event rates were similar (5.2% vs. 4.8%; p = 0.462) between the 2 groups. Kaplan-Meier analysis demonstrated significant differences in mortality rates between the 2 groups (22.5% complete revascularization vs. 25.9% culprit vessel intervention; p = 0.0005) during the follow-up period. After multivariate Cox analysis (hazard ratio: 0.90; 95% confidence interval: 0.85 to 0.97) and the use of propensity matching (hazard ratio: 0.89; 95% confidence interval: 0.76 to 0.98) complete revascularization was associated with reduced mortality. Conclusions In NSTEMI patients with MVD, despite higher initial (in-hospital) mortality rates, single-stage complete coronary revascularization appears to be superior to culprit-only vessel PCI in terms of long-term mortality rates. This supports the need for further randomized study to confirm these findings.

Objectives The introduction of the bioresorbable vascular scaffold (BVS) has led to new avenues of coronary intervention; however, there have been concerns raised regarding the mechanical properties of BVS and the resulting in-stent thrombosis. We aim to assess whether intracoronary imaging improves outcome in patients following BVS implantation. Patients and methods All patients undergoing percutaneous coronary intervention using BVS at a single centre between June 2013 and June 2016 were included in this study (n=79). Percutaneous coronary intervention with BVS was performed according to conventional practice: predilatation, postdilatation and intracoronary assessment with optical coherence tomography (OCT) according to operator's preferences. The primary endpoint was Major Adverse Cardiovascular Events (MACE), defined as all-cause mortality, myocardial infarction and revascularization, at 120 days. Results Forty-three (54.4%) patients underwent OCT assessment and 36 (45.6%) patients underwent angiography alone post-BVS insertion. There were no significant differences at baseline between both groups; a total of 13 (30.2%) patients who had intracoronary OCT imaging performed underwent further postdilatation after malapposed struts were identified. Although no deaths were observed, there was a significant difference seen in MACE over the follow-up period between OCT and angiography cohorts (4.7 vs. 19.4% respectively; P=0.042). There was a greater number of MACE in low-experienced operators. Conclusion As visual assessment with angiography has poor specificity for identifying strut malapposition, intracoronary OCT should be undertaken in all patients postinsertion of BVS stents in inexperienced operators to appropriately assess for stent malapposition, and reduce the subsequent risk of MACE.

BACKGROUND: Elevated high-sensitivity troponin (hsTnT) after noncardiac surgery is associated with higher mortality, but the temporal relationship between early elevated troponin and the later development of noncardiac morbidity remains unclear. METHODS: Prospective observational study of patients aged ≥45 yr undergoing major noncardiac surgery at four UK hospitals (two masked to hsTnT). The exposure of interest was early elevated troponin, as defined by hsTnT >99th centile (≥15 ng L(−1)) within 24 h after surgery. The primary outcome was morbidity 72 h after surgery, defined by the Postoperative Morbidity Survey (POMS). Secondary outcomes were time to become morbidity-free and Clavien–Dindo ≥grade 3 complications. RESULTS: Early elevated troponin (median 21 ng L(−1) [16–32]) occurred in 992 of 4335 (22.9%) patients undergoing elective noncardiac surgery (mean [standard deviation, sd] age, 65 [11] yr; 2385 [54.9%] male). Noncardiac morbidity was more frequent in 494/992 (49.8%) patients with early elevated troponin compared with 1127/3343 (33.7%) patients with hsTnT

ObjectiveTo document UK rates of exercise treadmill testing, functional stress testing and CT coronary angiography (CTCA). Specific aims were to determine how rates have changed in the context of changing guideline recommendations within the UK and to identify regional inequalities in the utilisation of testing modalities. Secondary objectives were to compare these trends with national data on revascularisation.Methods159 acute National Health Service trusts were served Freedom of Information (FOI) requests to provide total numbers of CTCA and functional imaging tests for each financial year from 2011–2012 to 2016–2017.ResultsThe FOI requests yielded data from 88% of Trusts, increasing from 81.9% in 2011–2012% to 92.1% in 2016–2017. Exercise treadmill tests (ETTs) were performed by over 97% of Trusts. ETT was the most commonly performed diagnostic test in the UK across the study period despite declining by 8.4%. Utilisation of non-invasive stress imaging tests increased by 80.9% during the same period. Myocardial perfusion scintigraphy and stress echocardiography increased by 25.8% and 73.9%, respectively. The 268% increase in CTCA scans was yet greater. Trends in test utilisation during the study period showed important regional differences between devolved nations. Comparably, only small changes in rates of invasive coronary angiography and revascularisation have been reported during the study period.ConclusionNon-invasive imaging in UK Trusts has increased substantially since 2010 with only a small decline in use of the ETT and minimal changes in rates of invasive coronary angiography and revascularisation in the same time period.

Objectives: This study aimed to determine the effect on long-term survival of using optical coherence tomography (OCT) during percutaneous coronary intervention (PCI).Background: Angiograph...

To investigate the hypothesis that persistence of apical contraction into diastole is linked to reduced myocardial perfusion and chest pain.Apical hypertrophic cardiomyopathy (HCM) is defined by left ventricular (LV) hypertrophy predominantly of the apex. Hyperdynamic contractility resulting in obliteration of the apical cavity is often present. Apical HCM can lead to drug-refractory chest pain.We retrospectively studied 126 subjects; 76 with apical HCM and 50 controls (31 with asymmetrical septal hypertrophy (ASH) and 19 with non-cardiac chest pain and culprit free angiograms and structurally normal hearts). Perfusion cardiac magnetic resonance imaging (CMR) scans were assessed for myocardial perfusion reserve index (MPRi), late gadolinium enhancement (LGE), LV volumes (muscle and cavity) and regional contractile persistence (apex, mid and basal LV).In apical HCM, apical MPRi was lower than in normal and ASH controls (p0.05). In apical HCM, duration of contractile persistence was associated with lower MPRi (p0.01) and chest pain (p0.05). In multivariate regression, contractile persistence was independently associated with chest pain (p0.01) and reduced MPRi (p0.001).In apical HCM, regional contractile persistence is associated with impaired myocardial perfusion and chest pain. As apical myocardium makes limited contributions to stroke volume, apical contractility is also largely ineffective. Interventions to reduce apical contraction and/or muscle mass are potential therapies for improving symptoms without reducing cardiac output.

Aims To use the Global Registry of Acute Coronary Events (GRACE) and Can Rapid risk stratification of Unstable angina patients Suppress ADverse outcomes with Early implementation of the ACC/AHA guidelines (CRUSADE) scores to risk stratify antiplatelet treatment post-acute coronary syndrome (ACS). Methods and results This was a prospective registry of 3374 patients undergoing percutaneous coronary intervention for ACS between 2013 and 2015 at a UK cardiac centre. Patients with either low GRACE or high CRUSADE risk scores were stratified either to clopidogrel therapy or ticagrelor was used. The primary endpoint was major adverse cardiac events (MACE) defined as death, non-fatal myocardial infarction, stroke, or target vessel revascularization with bleeding rates as a secondary outcome, assessed at a median follow-up of 1.8 years (interquartile range 0.8-3.4 years). A total of 1723 (51.1%) patients were risk stratified to either clopidogrel (n = 520) or ticagrelor treatment (n = 1203), with the remaining 1651 not risk scored and treated with clopidogrel therapy. Patients in the risk score stratified group were older than the control group otherwise the groups were similar. Over the follow-up period, a significant reduction in MACE rates between the patients' risk score stratified and control (clopidogrel therapy) (13.7% vs. 19.7%, P