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BACKGROUND: While the blood pressure (BP)-lowering effect of renal denervation (RDN) has been established, long-term durability is a key prerequisite for a broader clinical implementation. AIMS: Our aims were to assess the long-term durability of the office BP (OBP)-lowering efficacy, antihypertensive medication (AHM) use, and safety of ultrasound RDN (uRDN). METHODS: Four weeks after withdrawal of AHM, patients with untreated daytime ambulatory BP ≥135/85 mmHg and 135/85 mmHg following primary endpoint ascertainment at 2 months. Patients and physicians were unblinded at 6 months. Results: Fifty-one of 74 patients (age: 53.9±11 years; 67% men) originally randomised to uRDN completed the 36-month follow-up. Initial screening OBP upon study entry was 145/92±14/10 mmHg on a mean of 1.2 AHM (range: 0-2.0). Baseline OBP after AHM washout was 154/99±13/8 mmHg. At 36 months, patients were on an average of 1.3 AHM (range: 0-3.0) with 8 patients on no AHM. OBP decreased by 18/11±15/9 mmHg from baseline to 36 months (p

International audience; Purpose: To assess the variability of renal artery (RA) anatomy and presence of RA-pathology in patients with mild-to-moderate hypertension enrolled in the RADIANCE-HTN SOLO trial.Background: RADIANCE-HTN SOLO was a multicenter, international, blinded, randomized, sham-controlled trial evaluating ultrasound-based endovascular renal denervation (RDN) in patients with mild-to-moderate hypertension while off antihypertensive medications.Methods: Eligible subjects had pre-randomization renal CT- or MR- angiography (CTA, MRA) to confirm anatomic suitability and to define RA ablation sites. All images were sent for independent review for evaluation of RA anatomy and other vascular pathology.Results: A total of 324 patients underwent RA imaging (282 CTA and 42 MRA). Of those, 178 had simple anatomy with a single left and single right RA with mean diameters of 5.4 ± 0.9 and 5.1 ± 0.8 mm and mean lengths of 40.0 ± 12.9 and 52.0 ± 13.1 mm, respectively. Twenty-seven patients (8.3%) had unilateral or bilateral dual RAs with mean diameters of 4.0 ± 0.9 mm on the left and 3.9 ± 0.9 mm on the right. Forty percent (129/324) of patients had at least 1 accessory RA, with mean accessory diameters of 2.4 ± 0.8 mm on the left and 2.3 ± 0.8 mm on the right. Twenty-eight patients (8.6%) had at least 1 short (

Objectives:\ud \ud This study aimed to assess the impact of stent optimization by NC‐balloon postdilatation (PD) during primary‐PCI for STEMI with the use of coronary physiology and intracoronary imaging.\ud \ud Methods:\ud \ud This was a prospective observational study (ClinicalTrials.gov:NCT02788396). Optical coherence tomography (OCT) and physiological measurements were performed immediately before and after PD with the operators blinded to all measurements. The index of microcirculatory resistance (IMR), coronary flow reserve (CFR) and fractional flow reserve (FFR) were measured. OCT analysis was performed for assessment of stent expansion, malapposition, in‐stent plaque‐thrombus prolapse (PTP) and stent‐edge dissections (SED). The change in IMR before and after PD as a measure of microvascular injury was the primary objective of the study.\ud \ud Results:\ud \ud Thirty‐two STEMI patients undergoing primary‐PCI had physiological measurements before and after PD. All patients received second‐generation DES (diameter 3.1 ± 0.5 mm, length 29.9 ± 10.7 mm) and postdilatation with NC‐balloons (diameter 3.6 ± 0.6 mm, inflation pressure 19.3 ± 2.0 atm). IMR (44.9 ± 25.6 vs. 48.8 ± 34.2, p = 0.26) and CFR (1.60 ± 0.89 vs. 1.58 ± 0.71, p = 0.87) did not change, while FFR increased after PD (0.91 ± 0.08 vs. 0.93 ± 0.06, p = 0.037). At an individual patient level, IMR increased in half of the cases. PD improved significantly absolute and relative stent expansion, reduced malapposition, and increased PTP. There was no difference in clinically relevant SED.\ud \ud Conclusion:\ud \ud In this exploratory, hypothesis‐generating study, postdilatation during primary‐PCI for STEMI improved stent expansion, apposition and post‐PCI FFR, without a significant effect on coronary microcirculation overall. Nevertheless, IMR increased in a group of patients and larger studies are warranted to explore predictors of microcirculatory response to postdilatation.

Summary Background Endovascular renal denervation reduces blood pressure in patients with mild-to-moderate hypertension, but its efficacy in patients with true resistant hypertension has not been shown. We aimed to assess the efficacy and safety of endovascular ultrasound renal denervation in patients with hypertension resistant to three or more antihypertensive medications. Methods In a randomised, international, multicentre, single-blind, sham-controlled trial done at 28 tertiary centres in the USA and 25 in Europe, we included patients aged 18–75 years with office blood pressure of at least 140/90 mm Hg despite three or more antihypertensive medications including a diuretic. Eligible patients were switched to a once daily, fixed-dose, single-pill combination of a calcium channel blocker, an angiotensin receptor blocker, and a thiazide diuretic. After 4 weeks of standardised therapy, patients with daytime ambulatory blood pressure of at least 135/85 mm Hg were randomly assigned (1:1) by computer (stratified by centres) to ultrasound renal denervation or a sham procedure. Patients and outcome assessors were masked to randomisation. Addition of antihypertensive medications was allowed if specified blood pressure thresholds were exceeded. The primary endpoint was the change in daytime ambulatory systolic blood pressure at 2 months in the intention-to-treat population. Safety was also assessed in the intention-to-treat population. This study is registered with ClinicalTrials.gov , NCT02649426 . Findings Between March 11, 2016, and March 13, 2020, 989 participants were enrolled and 136 were randomly assigned to renal denervation (n=69) or a sham procedure (n=67). Full adherence to the combination medications at 2 months among patients with urine samples was similar in both groups (42 [82%] of 51 in the renal denervation group vs 47 [82%] of 57 in the sham procedure group; p=0·99). Renal denervation reduced daytime ambulatory systolic blood pressure more than the sham procedure (−8·0 mm Hg [IQR –16·4 to 0·0] vs –3·0 mm Hg [–10·3 to 1·8]; median between-group difference –4·5 mm Hg [95% CI –8·5 to –0·3]; adjusted p=0·022); the median between-group difference was –5·8 mm Hg (95% CI –9·7 to –1·6; adjusted p=0·0051) among patients with complete ambulatory blood pressure data. There were no differences in safety outcomes between the two groups. Interpretation Compared with a sham procedure, ultrasound renal denervation reduced blood pressure at 2 months in patients with hypertension resistant to a standardised triple combination pill. If the blood pressure lowering effect and safety of renal denervation are maintained in the long term, renal denervation might be an alternative to the addition of further antihypertensive medications in patients with resistant hypertension. Funding ReCor Medical.

Aim: \ud To determine the safety and feasibility of an early (12 h) waking and extubation protocol for out-of-hospital cardiac arrest (OHCA) patients receiving targeted temperature management (TTM).\ud \ud Methods: \ud This was a single-centre, prospective, non-randomised, observational, safety and feasibility pilot study which included successfully resuscitated OHCA patients, of presumed cardiac cause. Inclusion criteria were: OHCA patients aged over 18 years with a return of spontaneous circulation, who were going to receive TTM33 (TTM at 33 °C for 24 h and prevention of hyperthermia for 72 h) as part of their post cardiac arrest care. Clinical stability was measured against physiological and neurological parameters as well as clinical assessment.\ud \ud Results:\ud 50 consecutive patients were included (median age 65.5 years, 82% male) in the study. Four (8%) patients died within the first twelve hours and were excluded from the final cohort (n = 46). Twenty-three patients (46%) were considered clinically stable and suitable for early waking based on the intention to treat analysis; 12 patients were extubated early based on a variety of clinical factors (21.4 ± 8.6 h) whilst continuing to receive TTM33 with a mean core temperature of 34.2 °C when extubated. Of these, five patients were discharged from the intensive care unit (ICU)

Background: Fractional flow reserve (FFR) uses pressure-based measurements to assess the severity of a coronary stenosis. Distal pressure (Pd) is often at a different vertical height to that of the proximal aortic pressure (Pa). The difference in pressure between Pd and Pa due to hydrostatic pressure, may impact FFR calculation. Methods: One hundred computed tomography coronary angiographies were used to measure height differences between the coronary ostia and points in the coronary tree. Mean heights were used to calculate the hydrostatic pressure effect in each artery, using a correction factor of 0.8 mmHg/cm. This was tested in a simulation of intermediate coronary stenosis to give the “corrected FFR” (cFFR) and percentage of values, which crossed a threshold of 0.8. Results: The mean height from coronary ostium to distal left anterior descending (LAD) was +5.26 cm, distal circumflex (Cx) –3.35 cm, distal right coronary artery-posterior left ventricular artery (RCA-PLV) –5.74 cm and distal RCA-posterior descending artery (PDA) +1.83 cm. For LAD, correction resulted in a mean change in FFR of +0.042, –0.027 in the Cx, –0.046 in the PLV and +0.015 in the PDA. Using 200 random FFR values between 0.75 and 0.85, the resulting cFFR crossed the clinical treatment threshold of 0.8 in 43% of LAD, 27% of Cx, 47% of PLV and 15% of PDA cases. Conclusions: There are significant vertical height differences between the distal artery (Pd) and its point of normalization (Pa). This is likely to have a modest effect on FFR, and correcting for this results in a proportion of values crossing treatment thresholds. Operators should be mindful of this phenomenon when interpreting FFR values.

Objectives This study reports the 12-month results of the RADIANCE-HTN (A Study of the ReCor Medical Paradise System in Clinical Hypertension) SOLO trial following unblinding of patients at 6 months. Background The blood pressure (BP)–lowering efficacy and safety of endovascular ultrasound renal denervation (RDN) in the absence (2 months) and presence (6 months) of antihypertensive medications were previously reported. Methods Patients with daytime ambulatory BP ≥135/85 mm Hg after 4 weeks off medication were randomized to RDN (n = 74) or sham (n = 72) and maintained off medication for 2 months. A standardized medication escalation protocol was instituted between 2 and 5 months (blinded phase). Between 6 and 12 months (unblinded phase), patients received antihypertensive medications at physicians’ discretion. Outcomes at 12 months included medication burden, change in daytime ambulatory systolic BP (dASBP) and office or home systolic BP (SBP), visit-to-visit variability in SBP, and safety. Results Sixty-five of 74 RDN patients and 67 of 72 sham patients had 12-month dASBP measurements. The proportion of patients on ≥2 medications (27.7% vs. 44.8%; p = 0.041), the number of medications (1.0 vs. 1.4; p = 0.015), and defined daily dose (1.4 vs. 2.2; p = 0.007) were less with RDN versus sham. The decrease in dASBP from baseline in the RDN group (−16.5 ± 12.9 mm Hg) remained stable at 12 months. The RDN versus sham adjusted difference at 12 months was −2.3 mm Hg (95% confidence interval [CI]: −5.9 to 1.3 mm Hg; p = 0.201) for dASBP, −6.3 mm Hg (95% CI: −11.1 to −1.5 mm Hg; p = 0.010) for office SBP, and −3.4 mm Hg (95% CI: −6.9 to 0.1 mm Hg; p = 0.062) for home SBP. Visit-to-visit variability in SBP was smaller in the RDN group. No renal artery injury was detected on computed tomographic or magnetic resonance angiography. Conclusions Despite unblinding, the BP-lowering effect of RDN was maintained at 12 months with fewer prescribed medications compared with sham.

Background: The multicenter, international, randomized, blinded, sham-controlled RADIANCE-HTN SOLO trial (A Study of the ReCor Medical Paradise System in Clinical Hypertension) demonstrated a 6.3 mm Hg greater reduction in daytime ambulatory systolic blood pressure (BP) at 2 months by endovascular ultrasound renal denervation (RDN) compared with a sham procedure among patients not treated with antihypertensive medications. We report 6-month results after the addition of a recommended standardized stepped-care antihypertensive treatment to the randomized endovascular procedure under continued blinding to initial treatment. Methods: Patients with a daytime ambulatory BP ≥135/85 mm Hg and Results: A total of 69/74 RDN patients and 71/72 sham patients completed the 6-month ambulatory BP measurement. At 6 months, 65.2% of patients in the RDN group were treated with the standardized stepped-care antihypertensive treatment versus 84.5% in the sham group ( P =0.008), and the average number of antihypertensive medications and defined daily dose were less in the RDN group than in the sham group (0.9±0.9 versus 1.3±0.9, P =0.010 and 1.4±1.5 versus 2.0±1.8, P =0.018; respectively). Despite less intensive standardized stepped-care antihypertensive treatment, RDN reduced daytime ambulatory systolic BP to a greater extent than sham (−18.1±12.2 versus −15.6±13.2 mm Hg, respectively; difference adjusted for baseline BP and number of medications: −4.3 mm Hg, 95% confidence interval, −7.9 to −0.6, P =0.024). There were no major adverse events in either group through 6 months. Conclusions: The BP-lowering effect of endovascular ultrasound RDN was maintained at 6 months with less prescribed antihypertensive medications compared with a sham control. Clinical Trial Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT02649426.

Summary Background Early studies suggest that radiofrequency-based renal denervation reduces blood pressure in patients with moderate hypertension. We investigated whether an alternative technology using endovascular ultrasound renal denervation reduces ambulatory blood pressure in patients with hypertension in the absence of antihypertensive medications. Methods RADIANCE-HTN SOLO was a multicentre, international, single-blind, randomised, sham-controlled trial done at 21 centres in the USA and 18 in Europe. Patients with combined systolic–diastolic hypertension aged 18–75 years were eligible if they had ambulatory blood pressure greater than or equal to 135/85 mm Hg and less than 170/105 mm Hg after a 4-week discontinuation of up to two antihypertensive medications and had suitable renal artery anatomy. Patients were randomised (1:1) to undergo renal denervation with the Paradise system (ReCor Medical, Palo Alto, CA, USA) or a sham procedure consisting of renal angiography only. The randomisation sequence was computer generated and stratified by centres with randomised blocks of four or six and permutation of treatments within each block. Patients and outcome assessors were blinded to randomisation. The primary effectiveness endpoint was the change in daytime ambulatory systolic blood pressure at 2 months in the intention-to-treat population. Patients were to remain off antihypertensive medications throughout the 2 months of follow-up unless specified blood pressure criteria were exceeded. Major adverse events included all-cause mortality, renal failure, an embolic event with end-organ damage, renal artery or other major vascular complications requiring intervention, or admission to hospital for hypertensive crisis within 30 days and new renal artery stenosis within 6 months. This study is registered with ClinicalTrials.gov, number NCT02649426. Findings Between March 28, 2016, and Dec 28, 2017, 803 patients were screened for eligibility and 146 were randomised to undergo renal denervation (n=74) or a sham procedure (n=72). The reduction in daytime ambulatory systolic blood pressure was greater with renal denervation (−8·5 mm Hg, SD 9·3) than with the sham procedure (−2·2 mm Hg, SD 10·0; baseline-adjusted difference between groups: −6·3 mm Hg, 95% CI −9·4 to −3·1, p=0·0001). No major adverse events were reported in either group. Interpretation Compared with a sham procedure, endovascular ultrasound renal denervation reduced ambulatory blood pressure at 2 months in patients with combined systolic–diastolic hypertension in the absence of medications. Funding ReCor Medical.

We present a case of a patient who presented with chest pain, and on diagnostic coronary angiography appeared to have a grossly angulated yet significant coronary stenosis. This was proven to be an artefactual appearance on further assessment with intravascular ultrasound imaging. We describe the causes and associations of coronary tortuosity with other arteriopathy, and highlight challenges in the interpretation of tortuous vessels to accurately assess luminal narrowing and suitability for coronary intervention. We describe a case of artefactual coronary stenosis, and its thorough assessment with intravascular ultrasound. A literature review describes the pathogenesis of coronary tortuosity, and links with other cardiovascular disease. Readers will gain an understanding of the challenge in determining the severity of luminal stenosis based on coronary angiography alone in tortuous coronary anatomy, the use of intravascular ultrasound in this setting, and the allied vasculopathies of interest.

Objectives: We sought to evaluate mortality predictors and the role of new-generation drug-eluting stents (NG-DES) in stent thrombosis (ST) management. Background: No data are available regarding the outcome of patients with ST after interventional management that includes exclusively NG-DES. Methods: Patients with definite ST of DES or BMS who underwent urgent/emergent angiography between 2015 and 2018 at our institution were considered for the study. After excluding patients who achieved TIMI-flow

Mild therapeutic hypothermia (MTH 33°C) post out-of-hospital cardiac arrest (OHCA) is widely accepted as standard of care. However, uncertainty remains around the dose and therapy duration. OHCA patients are usually kept sedated±paralyzed and ventilated for the first 24-36 hours, which allows for targeted temperature management, but makes neurological prognostication challenging. The aim of this study is to investigate the feasibility and safety of assessing the unconscious OHCA patient after 12 hours for early waking/extubation while continuing to provide MTH for 24 hours, and fever prevention for 72 hours by using an intravenous temperature management (IVTM) system and established conscious MTH anti-shiver regimens. This is a single-center, prospective, non-randomized observational study that will compare the results of early awakening (at 12 hours) with historical controls. A total of 50 consecutive unconscious survivors of OHCA, treated with MTH, who meet the Therapeutic Hypothermia and eArly Waking (THAW) inclusion criteria will be enrolled. The patient will receive MTH by using IVTM. After 12 hours of MTH, patients will be assessed by using strict clinical criteria to determine suitability for early waking and extubation. Once awake and extubated, MTH will continue for 24 hours with skin counter-warming and anti-shiver regimen followed fever prevention up to 72 hours. All patients will have serial electroencephalogram (EEG), somatic sensory potential, and neuro-biomarkers performed on admission to intensive care unit, 6 and 12 hours, then every 24 hours until 72 hours. The study has been approved by the National Research Ethics Service, Health Research Authority.

Introduction:\ud Trials demonstrate significant clinical benefit in patients receiving therapeutic hypothermia (TH) after cardiac arrest. However, incidence of mortality and morbidity remains high in this patient group. Rapid targeted brain hypothermia induction, together with prompt correction of the underlying cause may improve outcomes in these patients. This study investigates the efficacy of Rhinochill®, an intranasal cooling device over Blanketrol®, a surface cooling device in inducing TH in cardiac arrest patients within the cardiac catheter laboratory.\ud \ud Methods:\ud 70 patients were randomized to TH induction with either Rhinochill® or Blanketrol®. Primary outcome measures were time to reach tympanic ≤34 °C from randomisation as a surrogate for brain temperature and oesophageal ≤34 °C from randomisation as a measurement of core body temperature. Secondary outcomes included first hour temperature drop, length of stay in intensive care unit, hospital stay, neurological recovery and all-cause mortality at hospital discharge.\ud \ud Results:\ud There was no difference in time to reach ≤34 °C between Rhinochill® and Blanketrol® (Tympanic ≤34 °C, 75 vs. 107 mins; p = 0.101; Oesophageal ≤34 °C, 85 vs. 115 mins; p = 0.151). Tympanic temperature dropped significantly with Rhinochill® in the first hour (1.75 vs. 0.94 °C; p < 0.001). No difference was detected in any other secondary outcome measures. Catheter laboratory-based TH induction resulted in a survival to hospital discharge of 67.1%.\ud \ud Conclusion:\ud In this study, Rhinochill® was not found to be more efficient than Blanketrol® for TH induction, although there was a non-significant trend in favour of Rhinochill® that potentially warrants further investigation with a larger trial.

AIMS Recent studies have suggested that a low proportion of patients presenting with left bundle branch block (LBBB) require emergency intervention. In this study, we have compared baseline clinical characteristics, angiographic findings and subsequent outcomes in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for primary percutaneous coronary intervention (PCI). METHODS AND RESULTS A large retrospective observational study was performed involving 1875 consecutive patients presenting to our single tertiary cardiac centre for primary PCI over a 27-month period. Patients presenting with LBBB (n=155, 8.3%) were significantly older (P

Aim Takotsubo cardiomyopathy (TCM) is increasingly being recognised in patients admitted with suspected acute coronary syndrome, as access to angiography and echocardiography is much quicker than before. We aimed to analyse the prevalence of typical TCM in patients admitted for primary percutaneous coronary intervention (PPCI) with suspected ST elevation myocardial infarction (STEMI) to a single tertiary centre in United Kingdom. Methods All patients admitted to our unit with suspected STEMI from September 2009 to November 2011 were included for analysis. Results Of the 1875 patients admitted, 17 patients (all female) with mean age of 69 ± 11.9 yrs were identified to have clinical features of typical TCM, thus giving an overall prevalence of 0.9% in PPCI admissions (3.2% prevalence in women). The admission ECG showed ST elevation in 14 patients (82%) and 3 had LBBB (18%). In the 16 patients who had raised hs Troponin (normal range Conclusion This is the first observational study to report the prevalence of typical TCM in patients admitted for PPCI in “real-world” practice. Though this condition is not benign during the acute episode, there is a good survival outcome if managed appropriately during the acute phase.

The index of microcirculatory resistance (IMR) emerges as a valuable prognostic tool in ST elevation myocardial infarction (STEMI) patients undergoing primary percutaneous coronay intervention (PPCI). An IMR value more than 40 at the end of the procedure has been related with worse outcomes. In the

AIM Very few randomized trials have analysed the outcome of primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI) in very elderly patients (≥80 years). An observational study was performed to evaluate the outcome of PPCI in patients of at least 80 years of age who were admitted to our unit. METHODS We included all patients undergoing PPCI in our unit from September 2009 to November 2011. RESULTS Of the 1471 patients who underwent PPCI during the study period, 236 (16%) were at least 80 years of age. The mean age was 85 ± 4 years (range 80-99 years, median 85 years). There was a significant difference in in-hospital mortality [14.4 vs. 2.9%, odds ratio (OR) 5.6, 95% confidence interval (CI) 3.4-9.2, P

Objective We aimed to carry out a “real world” comparison of bivalirudin plus unfractionated heparin (UFH) versus abciximab plus UFH in patients undergoing primary percutaneous coronary intervention (PPCI) for ST elevation myocardial infarction (STEMI). Methods We included patients who had abciximab or bivalirudin during their PPCI in our unit between Sept 2009 and Nov 2011. Results The study included 516 and 484 patients in the bivalirudin and abciximab group respectively. There were more women in the bivalirudin group (29% vs 20%, p 0.001), while cardiogenic shock (6.4% vs 10.1%, p 0.04) and thrombectomy device use (76.6% vs 82%, p 0.04) were lower in the bivalirudin group. The primary composite end point of 30-day mortality, 30-day definite stent thrombosis or non-CABG major bleeding was similar between the bivalirudin and abciximab groups (7.8% vs 9.5%, OR 0.8, 95% CI 0.5 to 1.2, p 0.4). There was also no difference in in-hospital mortality (4.1% vs 4.3%, p 0.9), 30-day mortality (5.2% vs 6.4%, p 0.5), 1-year mortality (9.1% vs 9.9%, p 0.7), 30-day stent thrombosis (1% vs 0.4%, p 0.5) and non-CABG bleeding (2.7 vs 3.7%, p 0.4) between the bivalirudin and abciximab group respectively. On Cox proportional hazard analysis after adjusting for all the co-variates, the use of bivalirudin was not a predictor of 30-day mortality (HR 1.13, 95% CI 0.7–1.9, p 0.7). Conclusion In this “real-world” observational study, there was no significant difference in the clinical outcome of PPCI for patients who had abciximab or bivalirudin after initial pre-treatment with UFH.

Background: Mortality among emergency medical admissions has been reported to be higher when patients are admitted to hospital at nights and weekends. Aim: We studied the outcome of ST elevation myocardial infarction (STEMI) patients presenting at different times to our centre with 24/7 primary percutaneous coronary intervention (PPCI) service. Methods: We divided all patients who underwent PPCI between September 2009 and November 2011 into three groups according to the time of admission as group 1: in-hours (0800–1800 h weekdays), group 2: out-of-hours (1800– 0800 h weekdays) and group 3: weekends (Sat to Mon 0800–0800 h). Results: A total of 605 (41.1%), 397 (27%) and 469 (31.9%) were included in group 1, 2 and 3, respectively. Apart from cardiogenic shock (8.9%, 5.5% and 7.7%, P = 0.05) and door to balloon time (median 29, 33 and 36 min, P < 0.0001), there was no significant difference noted in the baseline and procedural characteristics between the groups. In-hospital mortality (4.6%, 4.3% and 5.3%, P = 0.5), 30-day mortality (6.4%, 6.3% and 7%, P = 0.7), 30-day stent thrombosis (0.8%, 0.8% and 0.2%, P = 0.1) and 1-year mortality (10.7%, 10.8% and 9.8%, P = 0.7) were no difference between the groups. On logistic regression analysis, out-of-hours and weekend admissions were not found to be a predictor of both 30-day and 1-year mortality. Conclusion: In this consecutive series of patients admitted to a high volume PPCI centre, there was no difference in mortality when patients were admitted at different times. The involvement of senior medical staff early in the patients’ admission may have contributed to these consistent outcomes.

Background:\ud \ud Contrast-induced acute kidney injury (CI-AKI) is a recognised complication during primary PCI that affects short and long term prognosis. The aim of this study was to assess the impact of point-of-care (POC) pre-PPCI creatinine and eGFR testing in STEMI patients.\ud Methods\ud \ud 160 STEMI patients (STATCREAT group) with pre-procedure POC testing of Cr and eGFR were compared with 294 consecutive retrospective STEMI patients (control group). Patients were further divided into subjects with or without pre-existing CKD.\ud \ud Results:\ud \ud The incidence of CI-AKI in the whole population was 14.5% and not different between the two overall groups. For patients with pre-procedure CKD, contrast dose was significantly reduced in the STATCREAT group (124.6 ml vs. 152.3 ml, p = 0.015). The incidence of CI-AKI was 5.9% (n = 2) in the STATCREAT group compared with 17.9% (n = 10) in the control group (p = 0.12). There was no difference in the number of lesions treated (1.118 vs. 1.196, p = 0.643) or stents used (1.176 vs. 1.250, p = 0.78). For non-CKD patients, there was no significant difference in contrast dose (172.4 ml vs. 158.4 ml, p = 0.067), CI-AKI incidence (16.7% vs. 13.4%, p = 0.4), treated lesions (1.167 vs. 1.164, p = 1.0) or stents used (1.214 vs. 1.168, p = 0.611) between the two groups.\ud \ud Conclusions:\ud \ud Pre-PPCI point-of-care renal function testing did not reduce the incidence of CI-AKI in the overall group of STEMI patients. In patients with CKD, contrast dose was significantly reduced, but a numerical reduction in CI-AKI was not found to be statistically significant. No significant differences were found in the non-CKD group.

In STEMI patients undergoing primary PCI, optimal stent deployment is challenging due to factors like thrombus formation and vasoconstriction. In this setting stent post-dilatation with non-compliant (NC) balloons could optimise acute results, but carries a risk of distal embolization and

Rotational atherectomy (rotablation) of coronary artery is relatively contraindicated in high thrombotic state such as acute ST-elevation myocardial infarction (STEMI) because of the risk of platelet activation by the rotablator. We present a case where rotablation was necessary to recanalize the right coronary artery in a patient presenting with acute STEMI complicated by cardiogenic shock, after unsuccessful attempts with balloon catheters. He improved remarkably after the procedure and was discharged after 4 days.

Contrast-induced acute kidney injury (CI-AKI) is a recognised complication during primary percutaneous coronary intervention (PPCI) that affects short and long term prognosis. Volume of contrast media used is a known predisposing factor for its development. The aim of this study was to determine the

Introduction Primary percutaneous coronary intervention (PPCI) has been established as standard therapy for ST elevation myocardial infarction (STEMI). Very few trials have looked at the outcome of PPCI in elderly patients. Even in trials which claimed to have looked at PPCI in elderly patients such as SENIOR PAMI (Grines, 2005) and TRIANA (Bueno, 2009) the minimum age for inclusion was 70 yrs and 75 yrs respectively. With an ageing population in the western world, about 20% of patients admitted for suspected STEMI are ≥80 yrs. We evaluated the outcome of PPCI in patients ≥80 yrs who were admitted to our unit with STEMI. Methods Our PPCI service was started in September 2009 and we analysed all the patients who were ≥80 yrs presenting to the PPCI service between September 2009 and September 2010 (13 months). Prospectively entered data were obtained from our dedicated cardiac service database system (Philips CVIS). Mortality data were obtained from the summary care record (SCR) database. Follow-up data were obtained from patients9 respective district general hospitals and general practitioners medical records. Results Of the 998 patients who were admitted to our unit for primary PCI for suspected STEMI during the study period, 183 (18.3%) were ≥80 yrs of age. After excluding 51 patients (27.9%) who did not undergo PPCI, we included 132 (70.1%) patients for analysis. Of those who were included in the study (n=132, 63 female), the mean age was 85±3.95 yrs (range 80–99 yrs, median 85 yrs). There were 20 diabetics (15.2%) and 39 (29.5%) had previous myocardial infarction. Ten patients (7.6%) were in cardiogenic shock on arrival of which 9 (90%) had an Intra aortic balloon pump (IABP). The infarct related vessel was the right coronary in 42.4% and left anterior descending in 37.1%. Drug eluting stents were used in 40.2% of patients. In-hospital and 30-day mortality was 14.4% and 19.7% respectively. There was a significant difference in the mortality between patients age Conclusion This study clearly demonstrates a significant mortality difference between patients aged

Introduction Mortality following ST-elevation myocardial infarction has declined significantly with the advent of primary PCI (PPCI). Concurrent use of antiplatelet agents has further decreased complication rates and mortality; however, these agents confer an increased bleeding risk, an independent risk factor for mortality. This retrospective study assesses the effect of blood loss on short- and long-term mortality and its association with clinical characteristics in a real world population of patients undergoing PPCI at a tertiary referral centre in the UK. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were eligible for inclusion in the study. Patient data were obtained from our Cardiac Services Database System (Phillips CVIS) and mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by one-way ANOVA. Categorical variables were compared using the chi-squared test. A P value of Results 1403 patients with recorded admission and discharge haemoglobin levels were included in this analysis. Characteristics and clinical outcomes were compared in three groups according to the degree of haemoglobin reduction (Table 1). Patients with a reduction in haemoglobin were more likely to be female, slightly older and have prior history of MI. Patients with a significant reduction in haemoglobin were more likely to have received abciximab. Thirty-day mortality was significantly higher in the group with a haemoglobin drop (Table 1) as was overall mortality (hazard ratio 1.8, 95% CI 1.2–2.5) during a mean follow-up period of 2.1 years (Figure 1). Conclusions Our retrospective analysis in a large cohort of patients confirms recent data suggesting an adverse association between a reduction in haemoglobin following PPCI and long-term mortality. Further work is required on strategies to reduce bleeding risk and hence improve clinical outcome following PPCI.

Purpose: Although the impact of inflammation on short-term clinical outcomes following Primary PCI (PPCI) in patients with STEMI is well described, there is little literature examining longer-term outcomes. This retrospective study assesses the association between C-Reactive Protein (CRP) levels following PPCI and clinical outcome in patients at our tertiary referral centre. Methods: All patients accepted for PPCI between September 2009 and November 2011 were eligible for inclusion. Patient data were obtained from Cardiac Services Database System (Phillips CVIS), and mortality data from the Summary Care Record (SCR) database. Patient characteristics and clinical outcomes were compared according to CRP groups: low (≤10 mg/L), intermediate (10-50 mg/L), and high (>50 mg/L). Continuous variables were compared using one-way ANOVA. Categorical variables were compared using the chi-squared test. A p-value of

Introduction Mortality amongst emergency medical admissions has been reported to be higher when patients are admitted to hospital at nights and weekends. We studied the mortality for STEMI patients presenting at different times to a large cardiothoracic centre in the UK with a 24/7 primary PCI (PPCI) service delivered by senior medical staff. Methods We included all patients who underwent PPCI from September 2009 to November 2011. We divided them into three groups according to the time of admission to our unit as group 1: in-hours (08:00–18: weekdays), group 2: out-of-hours (18:00–08:00 week nights) and group 3: weekend (Saturday 08:00 to Monday 08:00) and bank holidays. Results Of the 1471 patients who were admitted and underwent PPCI in our unit during the study period, 605 (41.1%), 397 (27%) and 469 (31.9%) were included in group 1, 2 and 3 respectively. Pre-procedure cardiogenic shock was significantly higher in group 1 compared to group 2 (8.9% vs 5.5%, p 0.05), but no other significant difference was noted in the baseline and procedural characteristics between the groups (table 1). When compared to group 1, door to balloon (DTB) time (median, IQR 29, 24–39 min) was significantly prolonged in group 2 (33, 24–36 min, p 0.004) and group 3 (36, 28–47 min, p Conclusions In this consecutive series of patients admitted to a high volume primary PCI centre, there was no difference in mortality when patients were admitted at night, at the weekend or during regular office hours. The involvement of senior medical staff early in the patients9 admission may have contributed to these consistent outcomes.

Aims Current national and international guidelines continue to recommend activation of the primary percutaneous coronary intervention (PPCI) pathway in patients presenting with chest pain and presumed new-onset left bundle branch block (LBBB). Previous research has suggested that a lower proportion of patients presenting with LBBB require emergency intervention. In this study we have compared baseline clinical characteristics, angiographic findings and subsequent outcome in patients with LBBB versus ST-elevation myocardial infarction (STEMI) referred to our tertiary centre for PPCI. Methods All patients accepted for PPCI within the period of September 2009 to November 2011 were included in the study. Patient data obtained from our Cardiac Services Database System (Phillips CVIS) were analysed and angiographic images reviewed on our Cardiac Image Database (McKesson Horizon). Mortality data were gathered from the Summary Care Record (SCR) database. Statistical comparisons of continuous variables were made by an unpaired t test. Categorical variables were compared using the χ 2 test. A p value of Results During the study period, 1875 patients were referred for PPCI of whom 155 (8.3%) had LBBB. Compared with STEMI, patients with LBBB were significantly older, more likely to be female and have prior history of MI and CABG (table 1). Patients with LBBB had similar door-to-balloon (DTB) and call-to-balloon (CTB) times. PCI was performed in 40 (26%) patients with LBBB although an acutely occluded culprit vessel was found in only 19 (12.2%) patients (table 2). Furthermore, 85 (54.8%) patients had non-flow limiting coronary artery disease and of those with significant disease 12 (7.7%) patients required CABG (figure 1). Overall, an acute coronary syndrome (defined as ischaemic chest pain with positive troponin) was confirmed in only 67 (43.2%) of patients presenting with LBBB. 30-day mortality was similar between LBBB and STEMI patients (table 2). However, during a mean follow-up period of 2.1 years, overall mortality was significantly higher in the LBBB group compared to STEMI (HR 2.01, 95% CI 1.26 to 3.20) (figure 2). Conclusions Our study shows that, in contrast to STEMI, only a small proportion of patients presenting with chest pain and LBBB had an acutely occluded coronary artery. Although short-term mortality was similar between the two groups, long-term outcome was significantly worse in patients with LBBB. Further work is needed to identify those patients presenting with LBBB who are most likely to have an acute coronary occlusion, in order to facilitate the appropriate use of emergency coronary angiography and PPCI.

Introduction Adjunct anti-thrombotic therapies (ATT) such as Glycoprotein 2b3a inhibitors (GPI) and bivalirudin are shown to improve clinical outcome in primary percutaneous coronary intervention (PPCI). However, most of the studies related to this were done prior to high dose loading of clopidogrel (600 mg) and without the routine use of thrombectomy device. We aimed to compare the outcome between patients who had thrombectomy and parenteral ATT with those who had thrombectomy with no ATT during PPCI in our unit. Methods We included all patients undergoing PPCI in our unit from September 2009 to November 2011. All patients during the study period were loaded with Aspirin 300 mg and Clopidogrel 600 mg prior to angiography. Unfractionated Heparin (UFH) is used routinely for all PPCI in our unit immediately after angiography, irrespective of whether GPI or bivalirudin is used as ATT. This is in response to the HORIZONS AMI study analysis, which showed use of UFH reduced the risk of stent thrombosis in both arms of the study. Operators used ATT at their own discretion. We defined non-CABG bleeding as anyone requiring at least one unit of red cell transfusion. Results Of the 1471 patients who underwent PPCI during the study period, we excluded 408 (27.7%) patients who did not have thrombus aspiration (TA) during their procedure. The remaining patients (n=1063) were divided into two groups according to whether they had ATT or not (ATT grp: TA+UFH+ATT and UFH grp: TA+UFH). In the ATT group 397 (48.6%), 395 (48.4%) and 25 (3.4%) patients had abciximab, bivalirudin and combination therapy of both respectively. There were more elderly patients and women in the UFH group when compared to ATT group, but all other baseline and procedural characteristics were similar in both groups (table 1). In-hospital mortality, 30-day mortality, non-CABG major bleeding and stent thrombosis rates were similar in both groups (UFH vs ATT) (table 2). On logistic regression analysis of all 1063 patients, there was no effect of ATT on 30-day mortality (OR 0.8, 95% CI 0.4 to 1.6, p 0.5). The positive predictors of 30-day mortality were age >75 years (OR 4.8, 95% CI 2.6 to 8.8, p Conclusions This single centre study shows no significant mortality difference in patients receiving ATT when compared to UFH alone, despite the fact that patients receiving UFH alone were of higher risk. This suggests that the operators9 decision to avoid ATT was justified in some patients who had TA. Bleeding risk between the groups was also similar, but this could be related to the definition used in our study. Further studies are needed to clarify the benefit of ATT in PPCI at the present time, with the routine use of more potent or high dose anti-platelet agents and TA.

Introduction Tako-tsubo cardiomyopathy (TCM) is increasingly being recognised in patients admitted with suspected acute coronary syndrome, as access to angiography and echocardiography are much quicker than before. Typically, patients with TCM present to the primary PCI service (PPCI) with chest pain and ST elevation on their electrocardiogram mimicking ST elevation myocardial infarction (STEMI). However, there is no ‘real-world’ data about the prevalence of this condition in PPCI admissions for suspected STEMI. Therefore we aimed to analyse the prevalence of TCM in a high volume regional PPCI service in UK. Methods All patients admitted with suspected STEMI between Sept 2009 and Nov 2011 to our centre were included. After excluding those who underwent PPCI, We analysed the echocardiogram and/or left ventriculogram of those patients who did not undergo PPCI to identify patients with typical TCM features of apical akinesia with basal hyperkinesia. Their coronary angiograms were reviewed and the inclusion criteria to identify TCM was the absence of significant coronary disease with no artery having >50% stenosis. Results Of the 1875 patients admitted, 17 (0.9%) patients (0 m, 17 f) with the mean age of 70±10.7 years (range 56–94 years) were identified to have typical TCM features. The prevalence of TCM in female PPCI admission was 3.1% (17/560) (figure 1). The admission ECG showed ST elevation in 14 patients (82%) and three had LBBB (18%). In those who had positive hsTroponin (n=16, 94.1%), the mean level was 921±668 (median 778, range 110–2550). Two patients had cardiac arrest prior to hospital admission with successful resuscitation. Left ventricular function was severely impaired (EF≤30%) in 2 patients whilst all others had moderately impaired LV function (EF 31–50%) (table 1). Aspirin, β-blocker, Angiotensin converter enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) was given to 13 (76.5%), 13 (76.5%) and 15 (88.2%) patients respectively on their discharge. All the 15 patients who had repeat echocardiogram within 3 months of their index admission showed complete recovery of their LV function. During a mean follow up period of 22±7 months (median 21, range 8–36 months), there was no mortality. Conclusions This first ‘real-world’ observational study of TCM in STEMI patients admitted for PPCI to a single centre showed an overall prevalence of 0.9% with 3% prevalence in female population. Although TCM is not benign during the acute episode, there is an excellent survival outcome if managed appropriately during the acute phase.

Aims Octogenarians constitute a fast growing group of patients referred for percutaneous coronary intervention (PCI) for stable angina and acute coronary syndromes (ACS). However, there are limited outcome data for PCI in this group. We evaluated the outcome of PCI in patients aged ≥80 years and compared them with younger patients treated in our centre. Methods We analysed all patients aged ≥80 years who underwent PCI in our unit between September 2009 and December 2010. Prospectively entered data were obtained from our dedicated cardiac service database system (Philips CVIS). Mortality data were obtained from the summary care record (SCR) database. Follow-up data were obtained from patients9 respective district general hospitals and general practitioners9 medical records. We defined major bleeding as anyone requiring at-least one unit of red cell transfusion. Results Of the 2931 patients who underwent PCI in our unit during the study period, 401 (13.7%) patients were ≥80 years of age. Out of this 163 (40.6%) had primary PCI (PPCI) for STEMI, 120 (29.9%) had PCI for non-ST elevation ACS (NSTEACS) and 118 (29.4%) had PCI for stable angina. Of the 2530 patients in the younger cohort ( Conclusion In this consecutive series from a high volume tertiary centre, patients aged ≥80 years undergoing PCI have 30-day mortality rates comparable with younger patients treated for stable angina or NSTEACS. Further studies are required to refine treatment strategies in unselected patients aged ≥80 years undergoing PPCI for STEMI.

Introduction Primary percutaneous coronary intervention (PPCI) has been established as a standard therapy for ST elevation myocardial infarction (STEMI). In addition to thrombectomy and unfractionated heparin (UFH), thrombus burden in STEMI may require use of more potent antithrombotic agents. Bivalirudin is shown to be superior to abciximab in reducing the net adverse clinical events and major bleeding in STEMI in the HORIZONS-AMI trial (Stone et al NEJM , 2008). We aimed to carry out a “real world” comparison of different anti-thrombotic regimes in patients undergoing PPCI in our unit. Methods Our PPCI service started in September 2009 and we included all patients undergoing PPCI between September 2009 and September 2010. Prospectively entered data were obtained from our dedicated cardiac service database system (Philips CVIS). Mortality data were obtained from the summary care record (SCR) database. We used Fisher′s exact test to compare clinical outcomes between the groups. Results Of the 998 patients admitted with suspected STEMI to our unit during the study period, 776 (77.8%) underwent PPCI. After excluding patients who had both bivalirudin and abciximab during their procedure (n=15), we divided the others (n=761) into 3 groups according to the anti-thrombotic regime used (Grp 1- Abciximab+UFH, Grp 2- Bivairudin+UFH and Grp 3- “UFH only”). Patient demographics and procedural information are given in Abstract 30 table 1. Continuous data are presented as mean± SD. Clinical outcomes are shown in Abstract 30 table 2. In-hospital and 30-day mortality did not differ between patients who had bivalirudin vs abciximab (5.6% vs 3.8%, p=0.35 and 6.8% vs 5.2% p=0.53 respectively). Both acute and 30 day stent thrombosis rates were also similar in the two groups (0.6% vs none, p=0.3, 0.6% vs 0.9%, p=1.0 respectively). Even though the bleeding risk was higher in the abciximab group when compared with bivalirudin, this was not significant (5.8% vs 3.1%, p=0.27). There was also no difference in the outcomes between the bivalirudin and “UFH only” groups for mortality, stent thromboses (acute and 30-day) and major bleeding. The abciximab group had significantly higher major bleeding rates than the “UFH only” group (5.8% vs 2.4%, p=0.04); all other outcomes were similar. Conclusion These “real-world” data do not show any significant difference in the clinical outcome for patients who had bivalirudin or abciximab. There was no advantage seen with the more expensive agent (abciximab) in keeping with previous trial data. Therefore bivalirudin should be considered as a non-inferior alternative to abciximab. This would have considerable economic benefits in the present situation. The “UFH only” group had similar outcomes to both bivalirudin and abciximab, which suggests that this may be a viable alternative in its own right. However, our study is clearly limited by not being randomised and those patients treated with UFH alone may have been a lower risk group.