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A multivariate risk score model was proposed by Sieira et al in 2017 for sudden death in Brugada syndrome; their validation in 150 patients was highly encouraging, with a C-index of 0.81; however, this score is yet to be validated by an independent group. A total of 192 records of patients with Brugada syndrome were collected from 2 centers in the United Kingdom and retrospectively scored according to a score model by Sieira et al. Data were compiled summatively over follow-up to mimic regular risk re-evaluation as per current guidelines. Sudden cardiac death survivor data were considered perievent to ascertain the utility of the score before cardiac arrest. Scores were compared with actual outcomes. Sensitivity in our cohort was 22.7%, specificity was 57.6%, and C-index was 0.58. In conclusion, up to 75% of cardiac arrest survivors in this cohort would not have been offered a defibrillator if evaluated before their event. This casts doubt on the utility of the score model for primary prevention of sudden death. Inherent issues with modern risk scoring strategies decrease the likelihood of success even in robustly designed tools such as the Sieira score model.

Acute myocarditis is an inflammatory condition that may herald the onset of dilated cardiomyopathy (DCM) or arrhythmogenic cardiomyopathy (ACM). We investigated the frequency and clinical consequences of DCM and ACM genetic variants in a population-based cohort of patients with acute myocarditis. This was a population-based cohort of 336 consecutive patients with acute myocarditis enrolled in London and Maastricht. All participants underwent targeted DNA sequencing for well-characterized cardiomyopathy-associated genes with comparison to healthy controls (n=1053) sequenced on the same platform. Case ascertainment in England was assessed against national hospital admission data. The primary outcome was all-cause mortality. Variants that would be considered pathogenic if found in a patient with DCM or ACM were identified in 8% of myocarditis cases compared with

Background: Myocarditis may predispose to dilated cardiomyopathy (DCM) and sudden cardiac death (SCD). Familial data indicate a potential genetic susceptibility shared with arrhythmogenic cardiomyopathy (ACM). We present the first large-scale genotype-phenotype study of adults with acute myocarditis. Methods: A cohort comprising 336 consecutive patients with acute myocarditis was enrolled in London and Maastricht. All participants underwent targeted DNA sequencing for well-characterised cardiomyopathy-associated genes. The burden of rare protein altering variants (PAV) in ACM genes, DCM genes, and TTN specifically, were compared with local healthy controls sequenced on the same platform (n=1053). Case ascertainment was assessed against national hospital admission data. Results: We identified rare protein-altering variants in 23% of cases compared to 16% in controls (Δ+6.8%; p=0.021), with rare truncating variants (tv) in 6% of cases compared to Conclusion: We identified enrichment of cardiomyopathy gene variants in acute myocarditis patients, dominated by DSP-tv in those with normal LVEF and TTN-tv in those with reduced LVEF. Incorporation of genetic testing may be beneficial to identify such high-risk individuals and guide family screening in acute myocarditis patients.

Morphine can delay absorption of P2Y12-inhibitors in ST-elevation myocardial infarction (STEMI) patients, which has the potential to expose these patients to increased stent thrombosis risk after primary percutaneous coronary intervention (PPCI). Limited evidence exists for pharmacotherapeutic strategies aiming to mitigate this risk. We evaluated the impact of guideline-driven 'routine' glycoprotein IIb/IIIa antagonist (GPI) use in morphine-treated patients undergoing PPCI. A total of 3224 consecutive STEMI patients undergoing PPCI at a large tertiary cardiac center between 2012 and 2017 were evaluated. GPI use and outcomes before and after introduction of a local guideline were compared, and rates of definite stent thrombosis were identified at 24 h and 30 days. GPI use increased from 42.4% to 69.9% after the introduction of the new guideline. Stent thrombosis occurred in 1.3% (26/1947) pre-guideline and 0.6% (7/1244) post-guideline (P = .037). Of the 33 stent thrombosis cases, 90% (27/30) had received morphine, of whom 85.2% (23/27) had not received adjunctive GPI. Complete records for assessing 30-day bleeding rates were only available in 374 patients and, in this subset, there was no significant difference in rates of GUSTO moderate or severe bleeding before vs. after introduction of the local guideline (1.7% vs 2.8%; P = .47) although, in both cohorts combined, any GUSTO bleeding was observed more frequently in GPI-treated patients (21.8%) compared to those not receiving a GPI (10.0%; P = .002). In conclusion, routine GPI use in morphine-treated STEMI patients undergoing PPCI appears to protect against stent thrombosis. Large-scale studies are needed to establish the overall risk-benefit of GPI therapy in morphine-treated PPCI patients and to assess alternative strategies for preventing acute stent thrombosis in these patients.

Simultaneous multi-slice (SMS) balanced steady-state free precession (bSSFP) acquisition and iterative reconstruction can provide high spatial resolution and coverage for cardiac magnetic resonance (CMR) perfusion. However, respiratory motion remains a challenge for iterative reconstruction techniques employing temporal regularisation. The aim of this study is to evaluate an iterative reconstruction with integrated motion compensation for SMS-bSSFP first-pass myocardial stress perfusion in the presence of respiratory motion.Thirty-one patients with suspected coronary artery disease were prospectively recruited and imaged at 1.5 T. A SMS-bSSFP prototype myocardial perfusion sequence was acquired at stress in all patients. All datasets were reconstructed using an iterative reconstruction with temporal regularisation, once with and once without motion compensation (MC and NMC, respectively). Three readers scored each dataset in terms of: image quality (1:poor; 4:excellent), motion/blurring (1:severe motion/blurring; 3:no motion/blurring), and diagnostic confidence (1:poor confidence; 3:high confidence). Quantitative assessment of sharpness was performed. The number of uncorrupted first-pass dynamics was measured on the NMC datasets to classify patients into 'suboptimal breath-hold (BH)' and 'good BH' groups.Compared across all cases, MC performed better than NMC in terms of image quality (3.5 ± 0.5 vs. 3.0 ± 0.8, P = 0.002), motion/blurring (2.9 ± 0.1 vs. 2.2 ± 0.8, P 0.001), diagnostic confidence (2.9 ± 0.1 vs. 2.3 ± 0.7, P 0.001) and sharpness index (0.34 ± 0.05 vs. 0.31 ± 0.06, P 0.001). Fourteen patients with a suboptimal BH were identified. For the suboptimal BH group, MC performed better than NMC in terms of image quality (3.8 ± 0.4 vs. 2.6 ± 0.8, P 0.001), motion/blurring (3.0 ± 0.1 vs. 1.6 ± 0.7, P 0.001), diagnostic confidence (3.0 ± 0.1 vs. 1.9 ± 0.7, P 0.001) and sharpness index (0.34 ± 0.05 vs. 0.30 ± 0.06, P = 0.004). For the good BH group, sharpness index was higher for MC than NMC (0.34 ± 0.06 vs 0.31 ± 0.07, P = 0.03), while there were no significant differences observed for the other three metrics assessed (P 0.11). There were no significant differences between suboptimal BH MC and good BH MC for any of the reported metrics (P 0.06).Integrated motion compensation significantly reduces motion/blurring and improves image quality, diagnostic confidence and sharpness index of SMS-bSSFP perfusion with iterative reconstruction in the presence of motion.

Background: Acute myocarditis is a complex inflammatory disease increasingly associated with dilated cardiomyopathy (DCM) and arrhythmogenic ventricular cardiomyopathy (ACM), but its underlying genetic basis is unknown. We sought to determine if there is a genetic overlap between myocarditis and inherited forms of cardiomyopathy. Methods: Population-based cohort of 336 consecutive patients with acute myocarditis enrolled in London and Maastricht. All participants underwent targeted DNA-sequencing for well-characterised cardiomyopathy-associated genes with comparison to healthy controls (n=1053). Case ascertainment was assessed against national admission data. Findings: Variants of known or likely pathogenicity were identified in 6% of cases compared to

Three oral platelet P2Y

Background: Randomized controlled trials, notably PRAMI (Randomized trial of preventive angioplasty in myocardial infarction) demonstrated that immediate percutaneous coronary intervention (PCI) in significantly stenosed non-culprit vessels in patients with ST elevation myocardial infarction (STEMI) reduces adverse outcomes. However, the impact on clinical practice is unknown. Aims: To investigate whether the number of immediate and staged non-culprit PCIs has changed after the publication of PRAMI and the impact on mortality. Methods: A retrospective analysis of STEMI patients with significant multi-vessel disease presenting 1 year before and after PRAMI were included. Patients were divided into those who had immediate PCI, staged PCI or medical management of the non-culprit vessel. Mortality data for each patient group was analyzed. Results: Significant multi-vessel disease was present in 426 patients, with 202 patients in the pre-PRAMI group and 224 in the post-PRAMI group. The number of immediate non-culprit PCIs pre- PRAMI was 9.4% and increased to 12.5% post- PRAMI [p=ns]. Combining both groups, immediate PCI of the non-culprit vessel was associated with higher mortality than staged PCI [p=0.005]. There was no significant difference in all cause mortality in patients having non-culprit vessel PCI (immediate or staged) when compared to the medically managed cohort. Conclusion: Our center demonstrated a trend towards increased immediate PCI of the non-culprit vessel during the index procedure however, this practice was not widely adopted as recommended by PRAMI. Immediate PCI of non- culprit vessels was associated with increased mortality compared with staged PCI or medical management. However, given the small number of patients undergoing Immediate PCI, larger trials are required to confirm our results.

Background: We compared clopidogrel, prasugrel and ticagrelor, for mortality and stent thrombosis (ST) in patients with acute coronary syndromes (ACS). Methods: Data were collected for 10,793 consecutive ACS patients undergoing coronary angiography at Sheffield, UK (2009–2015). Clopidogrel and

Randomized-control trials, notably PRAMI, demonstrated that immediate percutaneous coronary intervention (PCI) in significantly stenosed, non-infarct vessels in ST elevation MI (STEMI) patients reduces adverse outcomes. However, the impact on clinical practice is unknown. To investigate if the