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BACKGROUND: Disparities between weekend and weekday care, termed ‘the weekend effect’, have led to a UK government pledge to provide 7-day services. Despite this, poor outcomes have led to criticism of the programme. This study consequently sought to evaluate consultant-led virtual review as a model for 7-day cardiology services. METHODS: Over 4 weekends, cardiology patients underwent virtual review alongside in-person teams. Outcomes included length of stay, same-day discharge and 30-day mortality rates, as well as duration of ward rounds and change in patient management. Patients were surveyed on attitudes towards virtual review. RESULTS: Statistical analysis revealed no significant difference in clinical outcomes, while virtual review was noted to significantly decrease time taken (p

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.

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 Coronavirus disease-2019 (COVID-19) is thought to predispose patients to thrombotic disease. To date there are few reports of ST-segment elevation myocardial infarction (STEMI) caused by type 1 myocardial infarction in patients with COVID-19. Objectives The aim of this study was to describe the demographic, angiographic, and procedural characteristics alongside clinical outcomes of consecutive cases of COVID-19–positive patients with STEMI compared with COVID-19–negative patients. Methods This was a single-center, observational study of 115 consecutive patients admitted with confirmed STEMI treated with primary percutaneous coronary intervention at Barts Heart Centre between March 1, 2020, and May 20, 2020. Results Patients with STEMI presenting with concurrent COVID-19 infection had higher levels of troponin T and lower lymphocyte count, but elevated D-dimer and C-reactive protein. There were significantly higher rates of multivessel thrombosis, stent thrombosis, higher modified thrombus grade post first device with consequently higher use of glycoprotein IIb/IIIa inhibitors and thrombus aspiration. Myocardial blush grade and left ventricular function were significantly lower in patients with COVID-19 with STEMI. Higher doses of heparin to achieve therapeutic activated clotting times were also noted. Importantly, patients with STEMI presenting with COVID-19 infection had a longer in-patient admission and higher rates of intensive care admission. Conclusions In patients presenting with STEMI and concurrent COVID-19 infection, there is a strong signal toward higher thrombus burden and poorer outcomes. This supports the need for establishing COVID-19 status in all STEMI cases. Further work is required to understand the mechanism of increased thrombosis and the benefit of aggressive antithrombotic therapy in selected cases., Central Illustration

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 …

Purpose The purpose of this paper is to describe a gaming approach to making key theoretical ideas accessible, understandable and useful for security practitioners confronting “terrorism” in the real world. Design/methodology/approach The tool is instrumental “red-team” matrix gaming: a structured way to first build and then wargame instrumental “terrorist” attack plans. The working assumption is that “terrorist” violence is designed with purpose, and that it reflects Fromkin’s understanding that terrorism is a form of jujitsu to manipulate more powerful opponents into politically and ideologically self-destructive behaviours. By designing and gaming attack plans with political objectives as the focus, practitioners quickly gain a deeper understanding of the processes of violent influence and the role of responders and decision makers. The paper is structured to, first, provide a theoretical explanation of contemporary conflict, focussing on the public support and how violence can be differently designed to political ends. On this foundation, the methods for learning are explained. A “playing-card” technique for setting students objectives in terms of psychological levers, vulnerabilities, political purposes and influence targets is described and options for participants generating scenarios outlined. Then the matrix-gaming approach, where play progresses according to the result of a dice roll applied to a probability based on the merit of participants’ competing arguments is explained with an example. Findings The described method of creating and wargaming terrorist attack plans offers a new and engaging method of exploring and understanding the processes of terrorism while preparing practitioners by potentially developing both their decision making and resilience. Practical implications The method described has potential value for teaching about terrorism by generally improving student engagement, preparing practitioners to respond to terrorism and wider application (of matrix gaming) to other topics. Originality/value This is a novel application of matrix gaming in a simplified format suited for classrooms.

Item does not contain fulltext BACKGROUND: The Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) trial was a non-inferiority trial that compared percutaneous coronary intervention (PCI) using first-generation paclitaxel-eluting stents with coronary artery bypass grafting (CABG) in patients with de-novo three-vessel and left main coronary artery disease, and reported results up to 5 years. We now report 10-year all-cause death results. METHODS: The SYNTAX Extended Survival (SYNTAXES) study is an investigator-driven extension of follow-up of a multicentre, randomised controlled trial done in 85 hospitals across 18 North American and European countries. Patients with de-novo three-vessel and left main coronary artery disease were randomly assigned (1:1) to the PCI group or CABG group. Patients with a history of PCI or CABG, acute myocardial infarction, or an indication for concomitant cardiac surgery were excluded. The primary endpoint of the SYNTAXES study was 10-year all-cause death, which was assessed according to the intention-to-treat principle. Prespecified subgroup analyses were performed according to the presence or absence of left main coronary artery disease and diabetes, and according to coronary complexity defined by core laboratory SYNTAX score tertiles. This study is registered with ClinicalTrials.gov, NCT03417050. FINDINGS: From March, 2005, to April, 2007, 1800 patients were randomly assigned to the PCI (n=903) or CABG (n=897) group. Vital status information at 10 years was complete for 841 (93%) patients in the PCI group and 848 (95%) patients in the CABG group. At 10 years, 244 (27%) patients had died after PCI and 211 (24%) after CABG (hazard ratio 1.17 [95% CI 0.97-1.41], p=0.092). Among patients with three-vessel disease, 151 (28%) of 546 had died after PCI versus 113 (21%) of 549 after CABG (hazard ratio 1.41 [95% CI 1.10-1.80]), and among patients with left main coronary artery disease, 93 (26%) of 357 had died after PCI versus 98 (28%) of 348 after CABG (0.90 [0.68-1.20], pinteraction=0.019). There was no treatment-by-subgroup interaction with diabetes (pinteraction=0.66) and no linear trend across SYNTAX score tertiles (ptrend=0.30). INTERPRETATION: At 10 years, no significant difference existed in all-cause death between PCI using first-generation paclitaxel-eluting stents and CABG. However, CABG provided a significant survival benefit in patients with three-vessel disease, but not in patients with left main coronary artery disease. FUNDING: German Foundation of Heart Research (SYNTAXES study, 5-10-year follow-up) and Boston Scientific Corporation (SYNTAX study, 0-5-year follow-up).

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.

Pediatric missed appointments impact patient outcomes and the financial well-being of clinics. Our purpose was to implement the Six Sigma methodology at a pediatric clinic to (1) identify significant predictor factors of missed appointments and develop a prediction model and (2) implement interventions to reduce the missed appointment rate. Binary logistic regression identified historical no-show rate, high-risk visit types, lack of insurance, the number of provider visits, and appointment lead time as significant predictor factors. Interventions led to a significant drop in the missed appointment rate and the no-show rate.

Background: More than half of the patients undergoing primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) have multi-vessel coronary artery disease. This is associated with worse outcomes compared with single vessel disease. Whilst evidence now exists to support complete revascularisation for bystander disease the optimal timing is still debated. This study aimed to compare clinical outcomes in patients with STEMI and multi-vessel disease who underwent complete revascularisation as inpatients in comparison to patients who had staged PCI as early outpatients. Methods and results: We conducted an observational cohort study consisting of 1522 patients who underwent primary PCI with multi-vessel disease from 2012 to 2019. Exclusions included patients with cardiogenic shock and previous CABG. Patients were split into 2 groups depending on whether they had complete revascularisation performed as inpatients or as staged PCI at later outpatient dates. The primary outcome of this study was major adverse cardiac events (consisting of myocardial infarction, target vessel revascularisation and all-cause mortality). 834 (54.8%) patients underwent complete inpatient revascularisation and 688 patients (45.2%) had outpatient PCI (median 43 days post discharge). Of the inpatient group, 652 patients (78.2%) underwent complete revascularisation during the index procedure whilst 182 (21.8%) patients underwent inpatient bystander PCI in a second procedure. Overall, there were no significant differences between the groups with regards to their baseline or procedural characteristics. Over the follow-up period there was no significant difference in MACE between the cohorts ( P = .62), which persisted after multivariate adjustment (HR 1.21 [95% CI 0.72-1.96]). Furthermore, in propensity-matched analysis there was no significant difference in outcome between the groups (HR: 0.86 95% CI: 0.75-1.25). Conclusions: Our study demonstrated that the timing of bystander PCI after STEMI did not appear to have an effect on cardiovascular outcomes. We suggest that patients with multi-vessel disease can potentially be discharged promptly and undergo early outpatient bystander PCI. This could significantly reduce length of stay in hospital.

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 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.

Simulations can produce large quantities of data. To reason about the results of simulations, machine-learning methods can be helpful. We explored a case-based reasoning approach to summarizing the results of a probabilistic simulation of naval combat involving missiles. We used a tree structure to index the data and showed that it gave good accuracy in estimating the results of this simulation with new parameters. We are now extending these ideas to a more complex military simulation.

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

Aim Current guidelines recommend the use of Vitamin K Antagonist (VKA) for up to 3–6 months for the treatment of LV thrombus post- acute myocardial infarction (AMI). However based on evidence supporting the non-inferiority and potential superiority of Direct Oral Anti-Coagulation's (DOAC) compared to VKA for other indications such as atrial fibrillation, DOACs are being increasingly used off licence for the treatment of left ventricular (LV) thrombus post AMI. In this study we investigated the effect of DOACs compared to VKA on LV thrombus resolution and their safety profile in patients presenting with AMI. Methods and results This was a prospective observational study of 2,328 consecutive patients undergoing Percutaneous Coronary Intervention (PCI) for AMI between 2015- 2018, at a UK cardiac centre. Patients' details were collected from the hospital electronic database. The primary end-point was the rate of resolution of LV thrombus with bleeding rates as a secondary outcome. Left ventricular (LV) thrombus was diagnosed by echocardiography, or cardiac magnetic resonance imaging in 98 (5.1%) patients. Sixty patients (61.2%) were started on VKA and 38 patients (38.8%) on DOAC therapy (Rivaroxaban: 57.9%, Apixaban, 36.8% and Edoxaban: 5.3%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous MI, PCI, CABG), and cardiovascular risk factors (Hypertension, Diabetes, Hypercholesterolaemia). Over the follow up period (median 1.8 years), overall rates of LV thrombus resolution were 86%. There was greater and earlier LV thrombus resolution in the DOAC group compared to patients treated with warfarin (75% vs 53%, p=0.0018, at 1 year), which persisted after adjusting for baseline variables (OR 1.8 95% CI 1.2–2.9). Major bleeding such as intracranial bleed, major GI bleed and bleed requiring hospital admission were lower in DOAC group, compared with VKA group (0% vs 5%, p=0.030) with no difference in rates of systemic thromboembolism (p=0.388). Conclusion This data suggests improved thrombus resolution in post ACS LV thrombosis in patient treated with DOACs compared to vitamin K antagonists. This improvement in thrombus resolution was accompanied with a better safety profile for the DOAC patients' vs VKA treated patients. This supports the need for randomised controlled trials to confirm this observational data. Acknowledgement/Funding None

Background Despite advances in technology, patients with Cardiogenic Shock (CS) presenting with ST-segment myocardial infarction (STEMI) still have a poor prognosis with high mortality rates. A large proportion of these patients have multi-vessel coronary artery disease, the treatment of which is still unclear. We aimed to assess the trends in management of CS patients with multi-vessel disease (MVD), particularly looking at the incidence and outcomes of complete revascularisation compared to culprit vessel only. Methods and results We undertook an observational cohort study of 21,210 STEMI patients treated between 2005 and 2015 at the 8 Heart Attack Centres in London, UK. Patients' details were recorded prospectively into local databases using the British Cardiac Intervention Society (BCIS) PCI dataset. 1058 patients presented with CS and MVD. Primary outcome was all-cause mortality. Patients were followed-up for a median of 4.1 years (IQR range: 2.2–5.8 years). 497 (47.0%) patients underwent complete revascularisation during primary PCI for CS with stable rates seen over time. These patients were more likely to be male, hypertensive and more likely to have poor LV function compared to the culprit vessel intervention group. Although crude, in hospital major adverse cardiac events (MACE) rates were similar (40.8% vs. 36.0%, p = 0.558) between the two groups. Kaplan-Meier analysis demonstrated no significant differences in mortality rates between the two groups (53.8% complete revascularisation vs. 46.8% culprit vessel intervention, p = 0.252) during the follow-up period. After multivariate cox analysis (HR 0.69 95% CI (0.44–0.98)) and the use of propensity matching (HR: 0.81 95% CI: 0.62–0.97) complete revascularisation was associated with reduced mortality. A number of co-variates were included in the model, including age, gender, diabetes, hypertension, hypercholesterolaemia, previous PCI, previous MI, chronic renal failure, Anterior infarct, number of treated vessels, pre-procedure TIMI flow, procedural success and GP IIb/IIIA use. Conclusion In a contemporary observational series of CS patients with MVD, complete revascularisation appears to be associated with better outcomes compared to culprit vessel only intervention. This supports on-going clinical trials in this area and provides further evidence of the association of complete revascularisation in STEMI with good outcomes.

AIMS: The effect of combined cytokine and cell therapy in ischaemic cardiomyopathy is unknown. Meta-analyses suggest improved cardiac function with cell therapy. The optimal cell delivery route remains unclear. We investigated whether granulocyte colony-stimulating factor (G-CSF) alone or in combination with intracoronary (i.c.) or intramyocardial (i.m.) injection of autologous bone marrow-derived cells (BMCs) improves cardiac function. METHODS AND RESULTS: Ninety patients with symptomatic ischaemic cardiomyopathy and no further treatment options were enrolled in the randomized, placebo-controlled, single-centre REGENERATE-IHD study. Randomization was to one of three arms: peripheral, i.c., or i.m. In each arm, patients were randomized to active treatment or placebo. All patients, apart from the peripheral placebo group (saline only) received G-CSF for 5 days. The i.c. and i.m. arms received either BMCs or serum (placebo). The primary endpoint was change in LVEF at 1 year assessed by cardiac magnetic resonance imaging/computed tomography. The i.m. BMC group showed a significant improvement in LVEF of 4.99% (95% confidence interval 0.33–9.6%; P = 0.038) at 1 year. This group also showed a reduction in NYHA class at 1 year and NT-proBNP at 6 months. No other group showed a significant change in LVEF. This finding is supported by post-hoc between-group comparisons. CONCLUSION: We have shown that G-CSF combined with autologous i.m. BMCs has a beneficial effect on cardiac function and symptoms. However, this result should be considered preliminary in support of a clinical benefit of i.m. stem cell infusion in ‘no option’ patients and needs further exploration in a larger study.

Hypertrophic cardiomyopathy (HCM) is a genetic disease occurring in up to 1 in 500 of the general population. HCM is often undiagnosed or misdiagnosed, and asymptomatic cases are often unrecognized. Asymmetric left ventricular hypertrophy (LVH) most often develops during the period of rapid body growth of adolescence, but it may be present in childhood or even before birth. Progressive LVH after age 20 is uncommon, but initial diagnosis even in old age is not. The hypertrophy predominantly involves the left ventricle, and is often more marked than in any other cardiac disease. Hypertrophy may involve the right ventricle, and an atrial myopathy may be progressive (left atrial enlargement and increased risks of atrial fibrillation). Right ventricle and left atrium involvement may be secondary to the left ventricular disease and/or a primary consequence of the basic molecular defect. The LVH represents hypertrophy and hyperplasia of several cell types, including cardiac myocytes, fibroblasts, and smooth muscle cells, along with excessive collagen and matrix deposition, and abnormalities of the microvasculature. The normal parallel arrangement of myocytes is often disturbed (fibre disarray).

Transradial access is increasingly used for coronary angiography and percutaneous coronary intervention, however, femoral access remains necessary for numerous procedures, including complex high-risk interventions, structural procedures, and procedures involving mechanical circulatory support. Optimising the safety of this approach is crucial to minimize costly and potentially life-threatening complications. We initiated a quality improvement project recommending routine fluoroscopic guidance (femoral head), and upfront femoral angiography should be performed to assess for location and immediate complications. We assessed the effect of these measures on the rate of vascular complications. Data were collected prospectively on 4534 consecutive patients undergoing femoral coronary angiographic procedures from 2015 to 2017. The primary end-point was any access complication. Outcomes were compared pre and post introduction including the use of an Interrupted Time-Series (ITS) analysis. 1890 patients underwent angiography prior to the introduction of routine fluoroscopy and upfront femoral angiography and 2644 post. All operators adopted these approaches. Baseline characteristics, including large sheath use, anticoagulant use and PCI rates were similar between the 2 groups. Fluoroscopy-enabled punctures were made in the ‘safe zone’ in over 91% of cases and upfront femoral angiography resulted in management changes i.e. procedural abandonment prior to heparin administration in 21 patients (1.1%). ITS analysis demonstrated evidence of a reduction in femoral complication rates after the introduction of the intervention, which was over and above the existing trend before the introduction (40% decrease RR 0.58; 95% CI: 0.25–0.87; P

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.

Background: Cardiogenic shock remains a major cause of morbidity and mortality in patients with ST-segment elevation myocardial infarction. We aimed to assess the current trends in cardiogenic shock management, looking specifically at the incidence, use of intra-aortic balloon pump therapy and outcomes in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. Methods and results: We undertook an observational cohort study of 21,210 ST-segment elevation myocardial infarction patients treated between 2005–2015 at the eight Heart Attack Centres in London, UK. Patients’ details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society percutaneous coronary intervention dataset. There were 1890 patients who presented with cardiogenic shock. The primary outcome was all-cause mortality at a median follow-up of 4.1 years (interquartile range: 2.2–5.8 years). Increasing rates of cardiogenic shock were seen over the course of the study with consistently high mortality rates of 45–70%. A total of 685 patients underwent intra-aortic balloon pump insertion during primary percutaneous coronary intervention for cardiogenic shock with decreasing rates over time. Those patients undergoing intra-aortic balloon pump therapy were younger, more likely to have poor left ventricular function and less likely to have had previous percutaneous coronary intervention compared to the control group. Procedural success rates were similar (86.0% vs 87.1%, p=0.292) although crude, in-hospital major adverse cardiac event rates were higher (43.8% vs 33.7%, pConclusion: Cardiogenic shock treated by percutaneous coronary intervention is increasing in incidence and remains a condition associated with high mortality and limited treatment options. Intra-aortic balloon pump therapy was not associated with a long-term survival benefit in this cohort and may be associated with increased early morbidity.

Aims: Clinical trials suggest that intracoronary delivery of autologous bone marrow-derived cells (BMCs) 1-7 days post-Acute myocardial infarction (AMI) may improve left ventricular (LV) function. Earlier time points have not been evaluated. We sought to determine the effect of intracoronary autologous BMC on LV function when delivered within 24 h of successful reperfusion therapy. Methods and results: A multi-centre phase II randomized, double-blind, and placebo-controlled trial. One hundred patients with anterior AMI and significant regional wall motion abnormality were randomized to receive either intracoronary infusion of BMC or placebo (1:1) within 24 h of successful primary percutaneous intervention (PPCI). The primary endpoint was the change in left ventricular ejection fraction (LVEF) between baseline and 1 year as determined by advanced cardiac imaging. At 1 year, although LVEF increased compared with baseline in both groups, the between-group difference favouring BMC was small (2.2%; 95% confidence interval, CI: -0.5 to 5.0; P = 0.10). However, there was a significantly greater myocardial salvage index in the BMC-treated group compared with placebo (0.1%; 95% CI: 0.0-0.20; P = 0.048). Major adverse events were rare in both treatment groups. Conclusion: The early infusion of intracoronary BMC following PPCI for patients with AMI and regional wall motion abnormality leads to a small non-significant improvement in LVEF when compared with placebo; however, it may play an important role in infarct remodelling and myocardial salvage. Clinical trial registration: Clinicaltrials.gov NCT00765453 and EudraCT 2007-002144-16.

Aims The REGENERATE-DCM trial is the first phase II randomized, placebo-controlled trial aiming to assess if granulocyte colony-stimulating factor (G-CSF) administration with or without adjunctive intracoronary (IC) delivery of autologous bone marrow-derived cells (BMCs) improves global left ventricular (LV) function in patients with dilated cardiomyopathy (DCM) and significant cardiac dysfunction. Methods and results Sixty patients with DCM and left ventricular ejection fraction (LVEF) at referral of ≤45%, New York Heart Association (NYHA) classification ≥2 and no secondary cause for the cardiomyopathy were randomized equally into four groups: peripheral placebo (saline), peripheral G-CSF, peripheral G-CSF and IC serum, and peripheral G-CSF and IC BMC. All patients, except the peripheral placebo group, received 5 days of G-CSF. In the IC groups, this was followed by bone marrow harvest and IC infusion of cells or serum on Day 6. The primary endpoint was LVEF change from baseline to 3 months, determined by advanced cardiac imaging. At 3 months, peripheral G-CSF combined with IC BMC therapy was associated with a 5.37% point increase in LVEF (38.30% ± 12.97 from 32.93% ± 16.46 P = 0.0138), which was maintained to 1 year. This was associated with a decrease in NYHA classification, reduced NT-pro BNP, and improved exercise capacity and quality of life. No significant change in LVEF was seen in the remaining treatment groups. Conclusion This is the first randomized, placebo-controlled trial with a novel combination of G-CSF and IC cell therapy that demonstrates an improvement in cardiac function, symptoms, and biochemical parameters in patients with DCM.