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BACKGROUND: Whether revascularization by percutaneous coronary intervention (PCI) can improve event-free survival and left ventricular function in patients with severe ischemic left ventricular systolic dysfunction, as compared with optimal medical therapy (i.e., individually adjusted pharmacologic and device therapy for heart failure) alone, is unknown. METHODS: We randomly assigned patients with a left ventricular ejection fraction of 35% or less, extensive coronary artery disease amenable to PCI, and demonstrable myocardial viability to a strategy of either PCI plus optimal medical therapy (PCI group) or optimal medical therapy alone (optimal-medical-therapy group). The primary composite outcome was death from any cause or hospitalization for heart failure. Major secondary outcomes were left ventricular ejection fraction at 6 and 12 months and quality-of-life scores. RESULTS: A total of 700 patients underwent randomization - 347 were assigned to the PCI group and 353 to the optimal-medical-therapy group. Over a median of 41 months, a primary-outcome event occurred in 129 patients (37.2%) in the PCI group and in 134 patients (38.0%) in the optimal-medical-therapy group (hazard ratio, 0.99; 95% confidence interval [CI], 0.78 to 1.27; P = 0.96). The left ventricular ejection fraction was similar in the two groups at 6 months (mean difference, -1.6 percentage points; 95% CI, -3.7 to 0.5) and at 12 months (mean difference, 0.9 percentage points; 95% CI, -1.7 to 3.4). Quality-of-life scores at 6 and 12 months appeared to favor the PCI group, but the difference had diminished at 24 months. CONCLUSIONS: Among patients with severe ischemic left ventricular systolic dysfunction who received optimal medical therapy, revascularization by PCI did not result in a lower incidence of death from any cause or hospitalization for heart failure. (Funded by the National Institute for Health and Care Research Health Technology Assessment Program; REVIVED-BCIS2 ClinicalTrials.gov number, NCT01920048.).

Guidelines endorse a heart team (HT) approach to standardize the decision-making process for patients with complex coronary artery disease (CAD). With percutaneous treatment options for complex CAD increasing, we hypothesized that practice had changed over the past decade-and that more individuals, previously deemed too high risk for intervention, would now be referred for either surgical or percutaneous revascularization.This observational study was conducted at St Thomas' Hospital (London, United Kingdom). All patients discussed at HT meetings were recorded and treatment recommendations audited. A subset of historic cases was selected for blinded, repeat discussion.From April 2018 to 2019, a total of 52 HT meetings discussing 375 cases were held. Patients tended to be male, with a majority demonstrating multivessel CAD in the context of preserved left ventricular function. SYNTAX scores were balanced across the tertiles. Thirty-five percent of patients had at least 1 chronic total occlusion (mean J-CTO, 3 [interquartile range, 2-3]), affecting the right coronary artery in 60%. Fifteen historic patients with isolated CTOs were re-presented an average of 8 years later; only 3 patients received the same outcome, with 80% now receiving a recommendation for revascularization over medical therapy.A dedicated program supporting complex coronary intervention is associated with a change in treatment recommendations issued by the local HT. In line with international guidelines, this might indicate that any complex or multivessel CAD should be discussed at HT meetings with, ideally, the presence of CTO operators.

A new method is presented for the extraction of the complex index of refraction from the extinction efficiency, $$Q_{ext} {({\tilde{\nu }})}$$ Q ext ( ν ~ ) , of homogeneous and layered dielectric spheres that simultaneously removes scattering effects and corrects measured extinction spectra for systematic experimental errors such as baseline shifts, tilts, curvature, and scaling. No reference spectrum is required and fit functions may be used that automatically satisfy the Kramers–Kronig relations. Thus, the method yields the complex refractive index of a sample for unambiguous interpretation of the chemical information of the sample. In the case of homogeneous spheres, the method also determines the radius of the sphere. In the case of layered spheres, the method determines the substances within each layer. Only a single-element detector is required. Using numerically computed $$Q_{ext}({\tilde{\nu }})$$ Q ext ( ν ~ ) data of polymethyl-methacrylate and polystyrene homogeneous and layered spheres, we show that the new reconstruction algorithm is accurate and reliable. Reconstructing the complex refractive index from a published, experimentally measured raw absorbance spectrum shows that the new method simultaneously corrects spectra for scattering effects and, given shape information, corrects raw spectra for systematic errors that result in spectral distortions such as baseline shifts, tilts, curvature, and scaling.

Cardiologists and the cardiac catheter laboratory have key roles to play in the management of patients after out-of-hospital cardiac arrest (OHCA). Although immediate catheter laboratory activation is the standard of care in cardiogenic shock and ST elevation myocardial infarction, the majority of patients will present without these features and with an uncertain diagnosis. Even in the latter, early assessment and invasive management may be beneficial, but this is counterbalanced by significant resource utilization, potential to cause harm and the possibility that any diagnostic or therapeutic gains are offset by a poor neurological outcome. Past consensus on the management of the OHCA patient without ST elevation or cardiogenic shock is being challenged by emerging results from new trials in this field. Further randomized trials are ongoing, and are expected to deliver robust data from over 4,000 patients, allowing us to further refine the optimal management strategy in this challenging cohort. This article describes the benefits and pitfalls of a strategy of immediate coronary angiography in these patients, examines the recently published COACT and TOMAHAWK trials in detail, and describes a framework with which to approach the patient after resuscitated OHCA, based on the available evidence to date.

The effect of intra-aortic balloon counterpulsation (IABC) varies, and it is unknown whether this is due to a heterogeneous coronary physiological response. This study aimed to characterise the coronary and left ventricular (LV) effects of IABC and define responders in terms of their invasive physiology. Twenty-seven patients (LVEF 31 ± 9%) underwent coronary pressure and Doppler flow measurements in the target vessel and acquisition of LV pressure volume loops after IABC supported PCI, with and without IABC assistance. Through coronary wave intensity analysis, perfusion efficiency (PE) was calculated as the proportion of total wave energy comprised of accelerating waves, with responders defined as those with an increase in PE with IABC. The myocardial supply/demand ratio was defined as the ratio between coronary flow and LV pressure volume area (PVA). Responders (44.4%) were more likely to have undergone complex PCI (p = 0.03) with a higher pre-PCI disease burden (p = 0.02) and had lower unassisted mean arterial (87.4 ± 11.0 vs. 77.8 ± 11.6 mmHg, p = 0.04) and distal coronary pressures (88.0 ± 11.0 vs. 71.6 ± 12.4 mmHg, p < 0.001). There was no effect overall of IABC on the myocardial supply/demand ratio (p = 0.34). IABC has minimal effect on demand, but there is marked heterogeneity in the coronary response to IABC, with the greatest response observed in those patients with the most disordered autoregulation.

Objective This study aimed to assess the pathophysiological differences between saphenous vein grafts (SVG) and native coronary arteries (NCA) following presentation with non-ST elevated myocardial infarction (NSTEMI). Background There is accelerated pathogenesis of de novo coronary disease in harvested SVG following coronary artery bypass (CABG) surgery, which contributes to both early and late graft failure , and is also causal in adverse outcomes following vein graft PCI. However in vivo assessment, with OCT imaging, comparing the differences between vein grafts and NCAs has not previously been performed. Methods We performed a retrospective, observational, analysis in patients who underwent PCI with adjunctive OCT imaging following presentation with NSTEMI , where the infarct-related artery (IRA) was either in an SVG or NCA. Results A total of 1550 OCT segments was analysed from thirty patients with a mean age of 66.3 (±9.0) years were included. The mean graft age of 13.9 (±5.6) years in the SVG group. OCT imaging showed that the SVG group had evidence of increased lipid pool burden (lipid pool quadrants, 2.1 vs 2.7; p = 0.021), with a reduced fibro-atheroma cap-thickness in the SVG group (45.0 μm vs 38.5 μm; p = 0.05) and increased burden of calcification (calcified lesion length = 0.4 mm vs 1.8 mm; p = 0.007; calcified quadrants = 0.2 vs 0.9; p = 0.001; arc of superficial calcium deposits = 11.6° vs 50.9°; p = 0.007) when compared to NCA. Conclusion This OCT study has demonstrated that vein grafts have a uniquely atherogenic environment which leads to the development of calcified, lipogenic, thin-capped fibro-atheroma's, which may be pivotal in the increased, acute and chronic graft failure rate, and may underpin the increased adverse outcomes following vein graft PCI.

Percutaneous coronary intervention is the most common mode of revascularization and is increasingly undertaken in high-risk subsets, including the elderly. The presence of coronary artery calcification is increasingly observed and significantly limits technical success. The mechanisms for this are multi-factorial, including increased arterial wall stiffness and impaired delivery of devices, leading to suboptimal stent delivery, deployment, and expansion which are harbingers for increased risk of in-stent restenosis and stent thrombosis. Although conventional balloon pretreatment techniques aim to mitigate this risk by modifying the lesion before stent placement, many lesions remain resistant to conventional strategies, due to the severity of calcification. There have been several substantial technological advancements in calcium modification methods in recent years, which have allowed improved procedural success with low periprocedural complication rates. This review will summarize the current adjunctive modification technologies that can be employed to improve technical outcomes in percutaneous coronary intervention in calcific disease and the evidence supporting these tools.

Percutaneous coronary intervention (PCI) has undergone a rapid and adaptive evolution since its introduction into clinical practice more than 40 years ago. It is the most common mode of coronary revascularisation in use, with the scope, breadth and constellation of disease being treated increasing markedly over time. This has principally been driven by improvements in technology, engineering and training in the field, which has facilitated more complex PCI procedures to be undertaken safely. Robot-assisted PCI represents the next paradigm shift in contemporary PCI practice. It has the ability to enhance procedural accuracy for the patient while improving radiation safety and ergonomics for the operator. This state-of-the-art review outlines the current position and future potential of robot-assisted PCI.

Background In the UK, the rapid access chest pain clinic (RACPC) is increasingly used as an open access resource for patients with chest pain presenting to GP surgeries or Emergency Departments. Patients are not uncommonly admitted for inpatient investigation and treatment from RACPC. This study aimed to assess the outcome of patients presenting to our RACPC and look for predictors of acute coronary syndrome and revascularisation. Methods Electronic notes of all patients assessed in our high-volume Rapid Access Chest Pain Clinic (RACPC) within a 12-month period (2018–19) were reviewed. Patients admitted directly from RACPC with ACS were compared to those felt to have typical anginal symptoms who were managed on an outpatient basis. Information on demographics, symptoms, initial investigations and management were obtained. Results 2416 patients were assessed in the RACPC during the study period. Of these, 378 (15.6%) presented with symptoms thought to represent typical anginal chest pain (CP), 1357 (56.2%) had atypical CP and 681 (28.2%) had non-anginal CP. Patients with typical angina had a median age of 68 years, 121 (22%) female, 216 (57%) had high cholesterol, 86 (23%) had diabetes, 220 (58%) had hypertension, 175 (46%) had a family history, and 218 (58%) were current or ex-smokers. The mean number of risk factors in those presenting with typical CP was 2.7. See Table 1. On univariate analysis regression, gender, ACS presentation, ischaemic ECG changes and regional wall motion abnormality on echocardiogram were predictors of revascularisation, however on multivariate analysis only gender (OR 2.447, CI 1.336-4.480, p= Conclusion The rapid access chest pain clinic is a valuable resource for prompt assessment of patients with suspected cardiac pain. Our experience suggests patients seen with typical angina represent a high-risk group with high rates of revascularisation, particularly in those with suspected ACS. Within our cohort, predictors of revascularisation were ACS presentation and male gender. Conflict of Interest None

Introduction Perioperative management of patients undergoing non-cardiac surgery (NCS) is complex and challenging. Whilst overall mortality is low, approximately 40% of post-operative deaths are due to myocardial infarction. Historic management of such patients has been driven by anaesthetic-led care with limited systematic cardiology input. We have developed a unique cardiology-anaesthetic multi-disciplinary (CA-MDT) forum to discuss how to optimally manage high-risk cardiovascular patients undergoing general anaesthesia for NCS. We present a qualitative description, and present the data, for one-year from this service. Method Data from all patients identified as having a high-risk cardiovascular profile via the anaesthetic led pre-operative assessment clinic (POAC), and discussed at the weekly CA-MDT during a one-year period (2019) are presented. Data collected in a consecutive cohort of patients awaiting NCS, include the proportion of cases discussed, nature of the discussion (Figure 1), the MDT outcome, the number and type of referrals for non-invasive imaging, ischaemia testing and/or angiography, and all-cause mortality. Results During the 2019 calendar year, n=2509 patients were screened in the POAC, with 7% (n=184) deemed high-risk requiring discussion at the CA-MDT. 67% (n=123) were deemed fit for surgery without further investigation. 12% (n=22) had non-invasive ischaemia testing prior to surgery, most commonly with exercise or dobutamine stress echocardiography and 7% (n=13) had invasive angiography +/-PCI prior to surgery (Figure 2). 3% (n=6) had percutaneous revascularization prior to NCS due to a high-grade angina and/or a large burden of ischaemia identified on stress imaging or invasive functional assessment with Fractional Flow Reserve (FFR). Of the revascularized group, 83% (n=5) had surgery, with one patient being subsequently deemed too high risk for operative management. There was no significant delay to the planned NCS with all undergoing this within the initially planned timeline. Mortality within the entire cohort was 3.8%, with no cardiovascular deaths observed. All deaths were due to disease progression from cancer. Conclusion The development of our CA-MDT demonstrates that a systematic and collaborative approach between cardiology and anaesthetics in the management of high-risk patients undergoing NCS is both feasible and time efficient; with no delay in intended surgical treatment seen in our initial observations. Moreover, this unique MDT forum streamlines and improves risk assessment of these complex patients. Finally, the increased cohesion between specialties may provide a more personalised approach to patient care, with the concept of precision medicine at the cornerstone of this strategy. Conflict of Interest None

Background The recently presented ISCHEMIA trial demonstrates that optimal medical therapy (OMT) is not inferior to an early interventional approach for patients with stable angina. These results have the potential to significantly impact on future care pathways. In the UK, the rapid access chest pain clinic (RACPC) is increasingly used as an open access resource. This study compared how the ISCHEMIA study may apply to real-world clinical services. Methods Electronic notes of patients assessed in our high-volume Rapid Access Chest Pain Clinic (RACPC) within a 12-month period (2018–19) were reviewed. Patients retrospectively meeting key inclusion criteria for the ISCHEMIA trial were selected. Information on demographics, symptoms, initial investigations and management were obtained. Results 2416 patients were assessed in the RACPC during the study period. Of these, 378 (15.6%) presented with symptoms thought to represent typical anginal chest pain (CP). Within this group, 158 patients (41.8%) were excluded (62 due to ACS, 91 due to known CAD, 3 due to known severe LV impairment, 2 due to eGFR From these 220 patients, 48 (21.8%) had a CT coronary angiogram (CTCA) as their first line investigation (42 completed). Of these patients, 1 (2.4%) patient had findings suggestive of significant left main stem (LMS) disease. 18 (8.2%) patients had stress echocardiography or stress perfusion CMR requested as their first line investigation (15 completed), 4 were positive for inducible ischaemia. 143 (65%) patients underwent invasive coronary angiogram (ICA) as their first line investigation (112 completed). In total 43 patients (19.5%) patients subsequently underwent revascularisation (8 patients for LMS disease, 11 patients due to multivessel disease, 24 patients treated with PCI). The median wait time for a CTCA was 55 days compared to 165.5days for ICA. See Table 1 for more details. Conclusion In the real-world, patients present with undifferentiated chest pain, consequently the outcomes of the ISCHEMIA trial must be considered cautiously. Within our cohort of 2416 patients, only 220 patients met key inclusion criteria for the trial. Our patients were younger, more frequently female and not diabetic. Referral for invasive tests was the most common pathway, however service pressures resulted in a significant delay to treatment. Ultimately, only 19.5% received revascularisation, compared to 80% of patients in the invasive arm of ISCHEMIA. It is unclear how the results of the ISCHEMIA trial will ultimately impact on UK practice, but it is clear that OMT plays a central role. References Hochman JS, Reynolds HR, Bangalore S, O’Brien SM, Alexander KP, Senior R, et al. Baseline characteristics and risk profiles of participants in the ISCHEMIA randomized clinical trial. JAMA Cardiol [Internet]. 2019 Mar 1;4(3):273–86. Available from: https://pubmed.ncbi.nlm.nih.gov/30810700 ISCHEMIA Research Group. ISCHEMIA Study Results [Internet]. 2020 [cited 2 Mar 2020]. Available from: https://www.ischemiatrial.org/ Conflict of Interest None

Background: Biventricular pacing has been shown to increase both cardiac contractility and coronary flow acutely but the causal relationship is unclear. We hypothesised that changes in coronary flow are secondary to changes in cardiac contractility. We sought to examine this relationship by modulating coronary flow and cardiac contractility. Methods: Contractility and lusitropy were altered by varying the location of pacing in 8 patients. Coronary autoregulation was transiently disabled with intracoronary adenosine. Simultaneous coronary flow velocity, coronary pressure and left ventricular pressure data were measured in the different pacing settings with and without hyperaemia and wave intensity analysis performed. Results: Multisite pacing was effective at altering left ventricular contractility and lusitropy (pos. dp/dtmax −13% to +10% and neg. dp/dtmax −15% to +17% compared to baseline). Intracoronary adenosine decreased microvascular resistance (362.5 mm Hg/s/m to 156.7 mm Hg/s/m, p

How do we reduce cardiac death and myocardial infarction by percutaneous coronary intervention (PCI) in coronary heart disease? Although the interventional community continues to grapple with this question in stable angina, the benefits of PCI for non-culprit lesions found at ST-elevation myocardial infarction are established. Is it then wishful thinking that an index developed in stable coronary disease, for identifying lesions capable of causing ischaemia will show an incremental benefit over angiographically guided non-culprit PCI? This is the question posed by the recently published FLOW Evaluation to Guide Revascularization in Multi-vessel ST-elevation Myocardial Infarction (FLOWER-MI) trial. We examine the trial design and results; ask if there is any relationship between the baseline physiological significance of a non-culprit lesion and vulnerability to future myocardial infarction; and consider if more sophisticated methods can help guide or defer non-culprit revascularisation.

Learning objectives Rupture or erosion of a coronary artery atheroma exposes flowing blood to the prothrombotic contents of the plaque, resulting in platelet activation and subsequent thrombus formation. If this process results in reduced coronary blood flow, the patient may present with an acute coronary syndrome (ACS). Total thrombotic occlusion generally results in ST-segment elevation myocardial infarction (STEMI), whereas incomplete occlusion (or extensive collateralisation) is more likely to present as non-STEMI or unstable angina without evidence of myonecrosis (collectively non-ST-segment elevation ACS (NSTE-ACS)). Revascularisation, most commonly with percutaneous coronary intervention (PCI) is standard of care in ACS, as it restores myocardial perfusion by addressing both the thrombotic obstruction and the underlying coronary stenosis. However, adjunctive pharmacological treatment after revascularisation, or in patients managed conservatively, may be of equal importance in influencing prognosis.1–3 Contemporary adjunctive antithrombotic therapy in ACS includes potent antiplatelet and anticoagulant agents, each of which carries the risk of bleeding. The frequency and implications of haemorrhagic complications must be factored into the risk-benefit analysis for each patient since PCI is increasingly performed in complex subgroups such as those with renal dysfunction, underlying anaemia and the elderly, cohorts with inherently increased bleeding risk.4 ,5 Furthermore, although the absolute bleeding risk will vary according to individual patient characteristics, the overall relative bleeding risk increases with the number, potency and duration of agents co-administered. For example, those patients with ACS, already taking chronic oral anticoagulation (OAC) for stroke protection in atrial fibrillation, are then treated with dual antiplatelet therapy (DAPT) (so-called ‘triple therapy’).6 ,7 There is extensive evidence in the published literature that demonstrates major bleeding to …

A 69-year-old man with established coronary artery disease and left ventricular dysfunction (ejection fraction, 40%) with typical Canadian Cardiovascular Society class III angina underwent percutaneous coronary intervention (PCI) for severe diffuse calcific disease in the right coronary artery ([

The pathogenesis that underlies acute myocardial infarction (MI) is complex and multifactorial. One of the most important components, however, is the role of thrombus formation following atherosclerotic plaque rupture, leading to sudden coronary occlusion and subsequent ischemia and infarction. The management of the atherothrombotic cascade in the setting of acute MI, both ST-elevated and non-ST-elevated MI, is an evolving field that includes management with pharmacotherapy and also mechanical techniques to reduce thrombus burden and improve percutaneous coronary intervention results, with the aim of improving coronary and myocardial perfusion. This chapter will discuss the current methods of managing acute coronary syndrome patients who often present with angiographic evidence of thrombus, with particular insights into strategies that can be adopted to improve outcomes in this setting.

Currently a quarter of all patients treated with percutanous coronary intervention (PCI) are aged >75 years, with this proportion steadily growing. This subset of patients have a number of unique characteristics, such as a greater number of cardiovascular risk factors and frequently a larger burden of coronary artery disease, when compared to younger patients, therefore potentially deriving increased benefit from revascularization. Nonetheless this population are also more likely to experience procedural complications, secondary to age-related physiological alterations, increased frailty and increased prevalence of other co-morbidities. This article reviews the various aspects and data available to clinicians pertaining to and guiding revascularization in the elderly, including the use of adjuvant pharmacotherapy, specific considerations when considering age-related physiology, and revascularization in acute coronary syndromes.

Objectives This study sought to identify the effect of coronary autoregulation on myocardial perfusion during intra-aortic balloon pump (IABP) therapy. Background IABP is the most commonly used circulatory support device, although its efficacy in certain scenarios has been questioned. The impact of alterations in microvascular function on IABP efficacy has not previously been evaluated in humans. Methods Thirteen patients with ischemic cardiomyopathy (left ventricular ejection fraction: 34 ± 8%) undergoing percutaneous coronary intervention were recruited. Simultaneous intracoronary pressure and Doppler-flow measurements were undertaken in the target vessel following percutaneous coronary intervention, during unassisted and IABP-assisted conditions. Coronary autoregulation was modulated by the use of intracoronary adenosine, inducing maximal hyperemia. Wave intensity analysis characterized the coronary wave energies associated with balloon counterpulsation. Results Two unique diastolic coronary waves were temporally associated with IABP device use; a forward compression wave and a forward expansion wave caused by inflation and deflation, respectively. During basal conditions, IABP therapy increased distal coronary pressure (82.4 ± 16.1 vs. 88.7 ± 17.8 mm Hg, p = 0.03), as well as microvascular resistance (2.32 ± 0.52 vs. 3.27 ± 0.41 mm Hg cm s–1, p = 0.001), with no change in average peak velocity (30.6 ± 12.0 vs. 26.6 ± 11.3 cm s–1, p = 0.59). When autoregulation was disabled, counterpulsation caused an increase in average peak velocity (39.4 ± 10.5 vs. 44.7 ± 17.5 cm s–1, p = 0.002) that was linearly related with IABP–forward compression wave energy (R2 = 0.71, p = 0.001). Conclusions Autoregulation ameliorates the effect of IABP on coronary flow. However, during hyperemia, IABP augments myocardial perfusion, principally due to a diastolic forward compression wave caused by balloon inflation, suggesting IABP would be of greatest benefit when microcirculatory reserve is exhausted.

Percutaneous coronary intervention in the presence of impaired left ventricular function is associated with significant mortality and morbidity. Intra-aortic balloon counterpulsation simultaneously increases coronary blood flow, by augmenting the diastolic aortocoronary pressure gradient, and decreases myocardial oxygen demand, by reducing the end-diastolic pressure, and therefore the afterload. This makes it an attractive means of ameliorating ischaemia and consequently enhancing cardiac output. Although contemporary randomized control trials have demonstrated that routine placement of an intra-aortic balloon pump (IABP) is not mandatory, a standby approach is recommended, as an important minority of patients require bail-out IABP insertion in the event of haemodynamic compromise. IABP therapy remains the safest and most readily available mechanical assist device to deploy in the catheter laboratory setting, with deployment guided by salient haemodynamics and the individual clinical scenario.

We are grateful to Jin-shan and Xue-bin for their interest in our work, where we described the physiology of angina and its alleviation with nitroglycerin during physiological exercise in the catheter laboratory while simultaneously measuring intracoronary and aortic hemodynamics.1 It was also the subject of an insightful editorial.2 We agree entirely that understanding the physiological mechanisms by which other commonly used drugs alleviate angina is …

Background— There is conflicting evidence on the utility of elective intra-aortic balloon pump (IABP) use during high-risk percutaneous coronary intervention (PCI). Observational series have indicated a reduction in major in-hospital adverse events, although randomized trial evidence does not support this. A recent study has suggested a mortality benefit trend early after PCI, but there are currently no long-term outcome data from randomized trials in this setting. Methods and Results— Three hundred one patients with left ventricular impairment (ejection fraction P =0.039). Conclusions— In patients with severe ischemic cardiomyopathy treated with PCI, all-cause mortality was 33% at a median of 51 months. Elective IABP use during PCI was associated with a 34% relative reduction in all-cause mortality compared with unsupported PCI. Clinical Trial Registration— URL: http://www.isrctn.org . Unique identifier: ISRCTN40553718; and http://www.clinicaltrials.gov . Unique identifier: NCT00910481.

Several coronary disease scoring systems have been developed to predict procedural risk during revascularization. Many vary in complexity, do not specifically account for myocardium at risk, and are not applicable across all patient subsets. The British Cardiovascular Intervention Society myocardial jeopardy score (BCIS-JS) addresses these limitations and is applicable to all patients, including those with coronary artery bypass grafts or left main stem disease. We assessed the prognostic relevance of the BCIS-JS in patients undergoing percutaneous coronary intervention (PCI). A total of 663 patients who underwent PCI with previous left ventricular function assessment were retrospectively assessed for inclusion, incorporating 221 with previous coronary artery bypass grafting. Blinded observers calculated the BCIS-JS, before (BCIS-JS(PRE)) and after (BCIS-JS(POST)) PCI, using the revascularization index (RI) (RI = [BCIS-JS(PRE) - BCIS-JS(POST)]/BCIS-JS(PRE)), quantifying the extent of revascularization, 1 indicating full revascularization and 0 indicating no revascularization. The primary end point all-cause mortality, tracked via the Office of National Statistics. A total of 660 patients were included (66 ± 10.7 years), with 43 deaths (6.5%) occurring during 2.6 ± 1.1 years after PCI. All-cause mortality was directly related to BCIS-JS(PRE) (hazard ratio [HR] 2.96, 95% confidence interval [CI] 1.71 to 5.15, p = 0.001) and BCIS-JS(POST) (HR 4.02, 95% CI 2.41 to 6.68, p = 0.001). A RI of0.67 was associated with increased mortality compared to a RI of ≥0.67 (HR 4.13, 95% CI 1.91 to 8.91, p = 0.0001). On multivariate analysis, a RI0.67 (HR 1.99, 95% CI 1.03 to 3.87, p = 0.04), left ventricular dysfunction (HR 2.03, 95% CI 1.25 to 3.30, p = 0.004) and renal impairment (HR 3.75, 95% CI 1.48 to 8.64, p = 0.005) were independent predictors of mortality. In conclusion, the BCIS-JS predicts mortality after PCI and can assess the degree of revascularization, with more complete revascularization conferring a survival advantage in the medium term.

This study assesses the relationship between classical anatomical jeopardy scores, functional jeopardy scores (combined anatomical and haemodynamic data), and the extent of ischaemia identified on cardiovascular magnetic resonance (CMR) perfusion imaging. In 42 patients with stable angina and suspected coronary artery disease (CAD), CMR perfusion imaging was performed. Fractional Flow Reserve (FFR) was measured in vessels with ≥50 % stenosis. The APPROACH and BCIS jeopardy scores were calculated based on QCA results with both a 70 % (APP70 and BCIS70) and a 50 % stenosis (APP50, and BCIS50) used as the threshold for significance, as well as after integration of FFR and compared with the extent of ischaemia identified on CMR. The correlation between the extent of ischaemia measured by CMR and the anatomical jeopardy scores was moderate (APPROACH: r = 0.58; BCIS: r = 0.48, p = 0.001). Integrating physiological information improved this significantly to r = 0.82, p = 0.0001 for APPROACH and r = 0.82, p = 0.0001 for BCIS scores (z-statistic = −2.04, p = 0.04; z-statistic = −2.63, p = 0.009). In relation to CMR, the APPROACH and BCIS scores overestimated the volume of ischaemic myocardium by 29.2 and 25.2 %, respectively, which was reduced to 12.8 and 12 % after integrating functional data. Anatomical and functional jeopardy scores overestimate ischaemic burden when compared to CMR. Integrating physiological information from FFR to generate a functional score improves ischaemic burden estimation.

The pathogenesis that underlies acute myocardial infarction is complex and multifactorial. One of the most important components, however, is the role of thrombus formation following atherosclerotic plaque rupture, leading to sudden coronary occlusion and subsequent ischemia and infarction. Thrombus aspiration provides the opportunity of intracoronary clot extraction with the aim to improve coronary and myocardial perfusion, by reducing the risk of no-reflow secondary to distal embolization of thrombus. The utility of thrombus aspiration during primary percutaneous coronary intervention has been assessed in an increasing number of observational and randomized studies. This article reviews the contemporary data and provides insights into the validity of thrombus aspiration in the setting of acute myocardial infarction.

Summary The recently described angiographic BCIS-1 Myocardial Jeopardy Score (BCIS-JS) provides a semi-quantitative estimate of the extent of coronary artery disease (CAD). It is simple to use and applicable to all patients including those with bypass grafts. Our objective was to validate the BCIS-JS by evaluating its correlation with myocardial ischaemic burden and its accuracy at predicting a prognostic ischaemic threshold. Seventy-five patients with angina and known or suspected CAD referred for coronary angiography prospectively underwent high-resolution CMR perfusion imaging. There was good correlation between the BCIS-JS and myocardial ischaemic burden: r = 0·75, P

Left ventricular (LV) dysfunction was associated with adverse outcome after percutaneous coronary intervention (PCI) in the balloon-angioplasty and bare-metal stent era. Technological advances have reduced complications after PCI. The impact of left ventricular ejection fraction (LVEF) on outcomes in current clinical practice is unknown, with commonly used risk stratification models not consistently incorporating preprocedural LVEF.A total of 2328 consecutive patients undergoing PCI in a single centre between April 2005 and July 2009 were analysed. Patients were eligible if LVEF had been categorized before PCI as good (LVEF ≥50%), moderate (LVEF 30-49%) or poor (LVEF30%). Those in cardiogenic shock were excluded. Mortality data were tracked using the UK Office of National statistics database. Logistic regression analysis was used to predict the risk of mortality at 30-day and long-term follow-up.Overall all-cause mortality was 1.0% at 30 days and 5% at long-term follow-up. Kaplan-Meier analysis revealed an early divergence in survival curves according to LVEF. Mortality rates stratified by LVEF category were 0.4, 1.3 and 6.3% at 30 days and 3.3, 5.7 and 12.0% in the long term (2.2±1.1 years) (P0.0001). Multiple regression analysis confirmed that impaired LVEF (≤50%) independently predicts 30-day [hazard ratio 4.20 (confidence interval 2.50-7.04), P=0.001] and long-term all-cause mortality [hazard ratio 1.67 (1.28-2.19), P=0.001].LV impairment remains a strong predictor of early and late mortality after PCI. LV function assessment is integral in risk stratification and patient optimization and should be recommended, wherever feasible, before PCI.

Background The increase in global coronary flow seen with conventional biventricular pacing is mediated by an increase in the dominant backward expansion wave ( BEW ). Little is known about the determinants of flow in the left‐sided epicardial coronary arteries beyond this or the effect of endocardial pacing stimulation on coronary physiology. Methods and Results Eleven patients with a chronically implanted biventricular pacemaker underwent an acute hemodynamic and electrophysiological study. Five of 11 patients also took part in a left ventricular endocardial pacing protocol at the same time. Conventional biventricular pacing, delivered epicardially from the coronary sinus, resulted in a 9% increase in flow (average peak velocity) in the left anterior descending artery (LAD), mediated by a 13% increase in the area under the BEW ( P =0.004). Endocardial pacing resulted in a 27% increase in LAD flow, mediated by a 112% increase in the area under the forward compression wave (FCW) and a 43% increase in the area under the BEW ( P =0.048 and P =0.036, respectively). There were no significant changes in circumflex parameters. Conventional biventricular pacing resulted in homogenization of timing of coronary flow compared with baseline (mean difference in time to peak in the LAD versus circumflex artery: FCW 39 ms [baseline] versus 3 ms [conventional biventricular pacing], P =0.008; BEW 47 ms [baseline] versus 8 ms [conventional biventricular pacing], P =0.004). Conclusions Epicardial and endocardial pacing result in increased coronary flow in the left anterior descending artery and homogenization of the timing of waves that determine flow in the LAD and the circumflex artery. The increase in both the FCW and the BEW with endocardial pacing may be the result of a more physiological activation pattern than that of epicardial pacing, which resulted in an increase of only the BEW .

The effect of intra-aortic balloon counterpulsation (IABC) varies and it is unknown whether this is due to a heterogeneous coronary physiological response. This study aims to characterise the coronary effects of IABC and identify the determinants of an increase in coronary perfusion efficiency (PE

On average, a general practitioner, who works with an average practice list size of 6000 people, will look after 30 patients with chronic heart failure and suspect a new diagnosis of heart failure in approximately 10 patients annually.

Myocardial reperfusion injury has been identified as a key determinant of myocardial infarct size in patients undergoing percutaneous or surgical interventions. Although the molecular mechanisms underpinning reperfusion injury have been elucidated, attempts at translating this understanding into clinical benefit for patients undergoing cardiac interventions have produced mixed results. Ischemic conditioning has been applied before, during, or after an ischemic insult to the myocardium and has taken the form of local induction of ischemia or ischemia of distant tissues. Clinical studies have confirmed the safety of differing conditioning techniques, but the benefit of such techniques in reducing hard clinical event rates has produced mixed results. The aim of this article is to review the role of ischemic conditioning in patients undergoing percutaneous and surgical coronary revascularization.

Introduction Highest rates of exertion related cardiac death occur during cold air inhalation (CAI): e.g. shovelling snow, but the pathophysiology is unclear. Novel intracoronary wires that simultaneously measure arterial pressure (Pd) and blood flow (CBF) allow quantification of coronary micro-vascular resistance (MVR). A. We compared the accuracy of Doppler-derived hyperemic micro-vascular resistance (hMR) and thermodilution-derived index of microcirculatory resistance (IMR) at predicting micro-vascular dysfunction, as there is no current invasive gold-standard measurement of MVR. B. In coronary artery disease (CAD) patients we explored the effects of exercise with and without CAI on MVR (using the most accurate measure from A. ) and CBF. Methods A. 56 patients (61+/-10 years) undergoing cardiac catheterization for stable CAD or acute myocardial infarction (AMI) were recruited. Simultaneous intracoronary pressure, Doppler flow velocity and thermodilution were carried out in 74 unobstructed vessels, at rest and during hyperemia. Three independent measures of micro-vascular function were assessed, using predefined dichotomous thresholds: 1) CFRmean, the average value of Doppler- and thermodilution-derived coronary flow reserve (CFR), and cardiovascular magnetic resonance derived 2) Myocardial Perfusion Reserve Index (MPRI) and 3) Micro-vascular Obstruction (MVO). B. 35 CAD patients (61+/-9 years) undertook 5 min of either: 1. CAI (-15oC) 2. Exercise (Incremental supine ergometry) 3. Exercise with CAI. We measured baseline and peak MVR (Pd/CBF) and CBF, and calculated the proportional contribution of waves that accelerate versus decelerate CBF as a coronary perfusion efficiency index. Results A. hMR had better diagnostic accuracy than IMR to predict CFRmean (area under curve, (AUC) 0.82 vs. 0.58, p < 0.001, sensitivity/specificity 77/77% vs. 51/71%) and MPRI (AUC 0.85 vs. 0.72, p = 0.19, sensitivity/specificity 82/80% vs. 64/75%). In AMI patients, the AUCs of hMR and IMR at predicting MVO were 0.83 and 0.72 respectively (p = 0.22, sensitivity/specificity 78/74% vs. 44/91%). ![Abstract 30 Figure 1][1] Abstract 30 Figure 1 Defining best measure of microvascular resistance B. 47 datasets were obtained: 1. n = 10 2. n = 24 3. n = 13. (12 patients did both conditions 2 and 3, in randomized order). MVR increased during CAI alone (p = 0.04), and decreased during exercise (p < 0.0001). Exercise with CAI was associated with less decrease in MVR (NS). The increase in CBF was similarly 34% less during exercise with CAI (p = 0.04) versus without (p < 0.0001). Coronary perfusion efficiency increased during exercise (p < 0.05), but CAI during exercise abolished this. ![Abstract 30 Figure 2][1] Abstract 30 Figure 2 Simultaneous measurement of microvascular resistance during cold air inhalation and exercise Conclusions A. Doppler-derived hMR may have superior diagnostic accuracy than IMR at predicting invasive and non-invasive measures of micro-vascular function. B. CAI attenuates the reduction in MVR and the increases in CBF and coronary perfusion efficiency that normally occur during exercise. These suggest impedance of coronary vasodilatation and ventricular relaxation, rendering the heart more susceptible to ischaemia. [1]: pending:yes

Introduction Randomised trials have questioned the benefit of intra-aortic balloon pump (IABP) counterpulsation in high-risk PCI and shock. A larger capacity balloon has been introduced into routine clinical practice that has been shown to provide greater systolic unloading and diastolic augmentation compared with the standard balloon. Our aim was to investigate whether larger capacity balloons provide a greater augmentation in coronary flow compared with standard capacity balloons. Methods Seven patients with severe ischaemic cardiomyopathy were studied using a two-treatment, single sequence crossover protocol at the time of elective percutaneous coronary intervention (PCI). Simultaneous coronary pressure and Doppler measurements were undertaken in the target vessel after PCI using a Volcano Combowire, during unassisted and assisted IABP conditions, first with a 40cc IABP and then, five minutes later, with a 50cc IABP. Measurements were taken with intact autoregulation and with autoregulation temporarily disabled by administration of intracoronary adenosine. Coronary wave intensity analysis was performed to characterise the wave energies associated with balloon counterpulsation. Data are presented as mean ± SD. Results Patients were 65 (±12) years old (75% male). Left ventricular ejection fraction was 29% (±11%) with a coronary jeopardy score of 11 (±2) (maximum possible score=12). There was no difference between the 40cc and 50cc IABP balloons in average peak velocity (50.3±33.6 vs. 49.7±24.2 cm s−1 p=0.916), mean distal coronary pressure (83.4±16 vs. 85.2±20 mmHg, p=0.549) (see Figure 1), or microvascular resistance (181.6±52.9 vs. 207.5±83.4 mmHgcm−1s, p=0.218) when autoregulation was disabled. Results were similar during basal assisted conditions. On wave intensity analysis, a late diastolic forward compression wave was identified during IABP support that was not seen during unassisted conditions. The magnitude of the IABP-forward compression wave was numerically greater with the 50cc balloon during basal conditions, which did not reach statistical significance (1.7±1.7 vs. 2.8±3.1, W m−2 s−2 × 105, p=0.155) (see Figure 2). Conclusions The larger capacity balloon does not provide greater augmentation in coronary flow or reduction in microvascular resistance compared with the standard balloon during basal or hyperaemic conditions. We did not measure left ventricular afterload or myocardial oxygen demand in this study and cannot exclude a differential effect of the 50cc balloon on myocardial oxygen supply and demand.

Background— The extent and severity of ischemia on myocardial perfusion scintigraphy (MPS) is commonly used to risk-stratify patients with coronary artery disease. Estimation of ischemic burden by cardiovascular magnetic resonance (CMR) with conventional 2-dimensional myocardial perfusion methods is limited by incomplete cardiac coverage. More recently developed 3-dimensional (3D) myocardial perfusion CMR, however, provides whole-heart coverage. The aim of this study was to compare ischemic burden on 3D myocardial perfusion CMR with 99m Tc-tetrofosmin MPS. Methods and Results— Forty-five patients who had undergone clinically indicated MPS underwent rest and adenosine stress 3D myocardial perfusion and late gadolinium enhancement CMR. Summed stress and rest scores were calculated for MPS and CMR using a 17-segment model and expressed as a percentage of the maximal possible score. Ischemic burden was defined as the difference between stress and rest scores. 3D myocardial perfusion CMR and MPS agreed in 38 of the 45 patients for the detection of any inducible ischemia. The mean ischemic burden for MPS and CMR was similar (7.5±8.9% versus 6.8±9.5%, respectively, P =0.82) with a strong correlation between techniques (rs=0.70, P P =0.45). Conclusions— 3D myocardial perfusion CMR is an alternative to MPS for detecting the presence and rating the severity of ischemia.

Wave intensity analysis and wave separation are powerful tools for interrogating coronary, myocardial and microvascular physiology. Wave speed is integral to these calculations and is usually estimated by the single-point technique (SPc), a feasible but as yet unvalidated approach in coronary vessels. We aimed to directly measure wave speed in human coronary arteries and assess the impact of adenosine and nitrate administration. In 14 patients, the transit time Delta t between two pressure signals was measured in angiographically normal coronary arteries using a microcatheter equipped with two high-fidelity pressure sensors located Delta s = 5 cm apart. Simultaneously, intracoronary pressure and flow velocity were measured with a dual-sensor wire to derive SPc. Actual wave speed was calculated as DNc = Delta s/Delta t. Hemodynamic signals were recorded at baseline and during adenosine-induced hyperemia, before and after nitroglycerin administration. The energy of separated wave intensity components was assessed using SPc and DNc. At baseline, DNc equaled SPc (15.9 +/- 1.8 vs. 16.6 +/- 1.5 m/s). Adenosine-induced hyperemia lowered SPc by 40 % (p