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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.).

Thrombus embolisation complicating primary percutaneous coronary intervention in ST-elevation myocardial infarction is associated with an increase in adverse outcomes. However, there are currently no proven recommendations for intervention in the setting of large thrombus burden. In this review, we discuss the clinical implications of thrombus embolisation and angiographic predictors of embolisation, and provide an update of current evidence for some preventative strategies, both pharmacological and mechanical, in this setting.

An 85-year-old male was admitted to our center with a non-ST elevation myocardial infarction. The patient had a dual-chamber pacemaker in situ with an atrial and His lead. A transient increase in His threshold and loss of nonselective capture occurred at the presentation of right coronary artery infarction, peaking during rotational atherectomy therapy causing loss of capture and complete atrioventricular block. A follow-up interrogation, 2 weeks postrevascularization, showed a return to a normal nonselective capture morphology and threshold measurements. Physicians should be aware of this complication in patients with His leads, particularly those with a history of coronary artery disease.

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

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

Background Acute myopericarditis can be caused by a myriad of infectious and non-infectious aetiologies, however, it is often considered to be due to self-limiting viral infection. Salmonella spp. myopericarditis is rare and the few cases in the literature suggest significant associated morbidity and mortality. Case summary A 44-year-old man presented with fever, dyspnoea, and chest pain. He was found to have a large pericardial effusion with clinical signs of tamponade and sepsis. Therapeutic pericardiocentesis was performed and ceftriaxone and levofloxacin were administered. Fully sensitive Salmonella enterica serovar Enteritidis (S. Enteritidis) was isolated in his pericardial fluid and he made a full recovery after a 4-week course of ciprofloxacin. A new diagnosis of type 2 diabetes mellitus was made on admission. A follow-up cardiac magnetic resonance (CMR) scan was suggestive of myocarditis which was unexpected given a normal Troponin T level on presentation. Discussion We report a rare case of S. Enteritidis myopericarditis. Our case is notable as the patient was immunocompetent apart from newly diagnosed diabetes. This case highlights the value of CMR imaging in assessing for myocarditis and ventricular function.

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

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

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

Introduction There has been an increasing focus on the development of scoring systems for patients admitted following resuscitation from out-of-hospital cardiac arrest (OHCA) to determine both prognosis and short-term management. One such system, the CREST score, has been shown to predict circulatory aetiology death in patients without ST-elevation myocardial infarction, however with an increasing number of OHCAs seen, general scoring systems to predict outcome in OHCA would be helpful. Aims We sought to determine whether the addition of an admission lactate ≥8 mmol/l to the existing CREST score was able to better predict in-hospital mortality in patients admitted with OHCA. Methods and results We retrospectively analysed the data of 500 patients admitted with an OHCA of presumed cardiac origin to our tertiary cardiac centre between June 2014 and Oct 2018. Mean age was 62.6y (±14.7), 379 (76%) were male and 250 (50%) were Caucasian. 313 (62.6%) were admitted with ST elevation myocardial infarction or equivalent. 48.6% (243/500) of patients died in hospital and of those that survived, 20.2% (52/257) were left with hypoxic brain injury (CPC score 3–4). When analysed independently, all individual factors other than history of Coronary artery disease (OR 1.47, p=0.084) significantly predicted in-hospital mortality: Admission lactate ≥8 mmol/l (OR 6.78, p25 minutes (OR 12.8, p When each factor was assigned one point and totalled, both increasing CREST and C-AREST scores were associated with increasing in-hospital mortality: CREST (0–5 points): 4.3%, 30.5%, 41.5%, 85.6%, 95.2%, 100% vs C-AREST (0–6 points): 9.1%, 28.3%, 41.9%, 62.8%, 97.6%, 96.4%, 100%. When analysed with stepwise logistic regression, the addition of admission lactate ≥8 mmol/l to the model improved the prediction of in-hospital mortality: CREST (40.8% of variance explained) vs C-AREST (43.3%), with admission lactate remaining an independently significant predictor (OR 3.67, p=0.002). Conclusion We describe a novel modification to the previously described CREST scoring system for OHCA: the C-AREST score. The addition of admission lactate ≥8 mmol/l may have a role in differentiating those in intermediate risk categories (score between 2 and 3) where the predicted in hospital mortality would otherwise vary greatly. Given the relative ease of obtaining admission lactate, this scoring system may further improve stratification of patients who may or may not benefit from invasive management.

Introduction European guidelines recommend a primary PCI strategy in patients following out-of-hospital cardiac arrest (OHCA) with ST-segment elevation on the ECG. In those without ST elevation the decision to proceed to urgent angiography is recommended if there a high index of suspicion of ischaemia. Predicting which patients are likely to have an acute coronary lesion utilising clinical characteristics available at the time of resuscitation may help inform decision making over which patients should proceed to emergent angiography. The ACS2 score has been shown in a registry of 247 patients to predict the presence of an acute coronary lesion in those resuscitated from an OHCA and hence those who may benefit from emergency coronary angiography. It includes: preceding Angina, Congestive heart failure symptoms, a Shockable rhythm and ST-elevation. We sought to validate this scoring system with an independent cohort of OHCA patients. Methods We retrospectively analysed patients admitted to our cardiac tertiary centre with an OHCA who underwent coronary angiography between 2014 and 2018 and followed them up until discharge or death in hospital. Baseline demographic characteristics and angiographic findings were recorded. Results 395 patients were analysed over a 4 year period. The average age was 61.7 years (SD±13.9). 76.7% of patients were found to have an acute (culprit) coronary lesion and 64.3% of patients had ST-elevation. There was no difference in mean age in those with vs without an acute lesion (62.3 vs 59.1 years, p=0.053). Likewise, the presence of an acute lesion was not associated with (percentage with acute lesion): male gender (76.9% vs 75.9%, p=0.840), existing coronary artery disease (72.4% vs 77.7%, p=0.329), diabetes (76.1% vs 77.8%, p=0.739), smoking (81.4% vs 77.8%, p=0.486), previous coronary intervention (71.8% vs 77.7%, p=0.411) or previous CABG (61.1% vs 78%, p=0.096). Similarly, there was no difference in mean downtime (23.6 min vs 22.5 min, p=0.071) or in-hospital mortality (35.8% vs 41.8%, p=0.302) in those with vs without an acute lesion. When the components of the ACS2 model were analysed independently, the presence of an acute lesion was associated with: preceding angina (87.2% vs 72.6%, p=0.002), a shockable rhythm (80.1% vs 62.5%, p=0.003) and ST-elevation (93.6% vs 46.4%, p=0.0001), but not with congestive heart failure symptoms (79.2% vs 74.9%, p=0.255). When analysed with stepwise logistic regression, the model as a whole correctly predicted 82.5% of cases and had good discrimination (C-statistic 0.832, 95% CI 0.747–0.858, Hosmer and Lemeshow p=0.902). The model was superior to the presence of ST-elevation alone (C-statistic 0.802, 95% CI 0.847–0.858, X2 difference in -2loglikelihood 18.8, p=0.001). When all factors were given one point, other than ST-elevation which was given two points, and scores were totalled, the percentage of patients found to have an acute coronary lesion was (0–5): 14.3%, 41.9%, 54.0%, 90.6%, 94.7% and 95.8%. Conclusion These results are the first to our knowledge to validate, using an independent contemporary cohort, the ACS2 scoring system for the prediction of an acute coronary lesion in those resuscitated from an OHCA. As such, our study supports the use of ACS2 to determine which OHCA patients should receive emergency coronary angiography. Conflict of Interest Nil

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

OBJECTIVES: This study aimed to determine the effect on long-term survival of using optical coherence tomography (OCT) during percutaneous coronary intervention (PCI). BACKGROUND: Angiographic guidance for PCI has substantial limitations. The superior spatial resolution of OCT could translate into meaningful clinical benefits, although limited data exist to date about their effect on clinical endpoints. METHODS: This was a cohort study based on the Pan-London (United Kingdom) PCI registry, which includes 123,764 patients who underwent PCI in National Health Service hospitals in London between 2005 and 2015. Patients undergoing primary PCI or pressure wire use were excluded leaving 87,166 patients in the study. The primary endpoint was all-cause mortality at a median of 4.8 years. RESULTS: OCT was used in 1,149 (1.3%) patients, intravascular ultrasound (IVUS) was used in 10,971 (12.6%) patients, and angiography alone in the remaining 75,046 patients. Overall OCT rates increased over time (p < 0.0001), with variation in rates between centers (p = 0.002). The mean stent length was shortest in the angiography-guided group, longer in the IVUS-guided group, and longest in the OCT-guided group. OCT-guided procedures were associated with greater procedural success rates and reduced in-hospital MACE rates. A significant difference in mortality was observed between patients who underwent OCT-guided PCI (7.7%) compared with patients who underwent either IVUS-guided (12.2%) or angiography-guided (15.7%; p < 0.0001) PCI, with differences seen for both elective (p < 0.0001) and acute coronary syndrome subgroups (p = 0.0024). Overall this difference persisted after multivariate Cox analysis (hazard ratio [HR]: 0.48; 95% confidence interval [CI]: 0.26 to 0.81; p = 0.001) and propensity matching (hazard ratio: 0.39; 95% CI: 0.21 to 0.77; p = 0.0008; OCT vs. angiography-alone cohort), with no difference in matched OCT and IVUS cohorts (HR: 0.88; 95% CI: 0.61 to 1.38; p = 0.43). CONCLUSIONS: In this large observational study, OCT-guided PCI was associated with improved procedural outcomes, in-hospital events, and long-term survival compared with standard angiography-guided PCI.

Summary Background Simulation training with manikin simulators for medical emergencies is increasingly used in medical training. The assessment of a manikin, in particular history and examination, is very different to that of a real patient. We sought to combine aspects of traditional simulation training with the assessment of real hospital in-patients. Study design In-patients who had recently experienced a cardiac emergency were asked to recall their symptoms as if they were still present. Medical students assessed these patients in the role of foundation year–1 (FY1) doctors, supervised by core medical trainee (CMT) doctors, and were encouraged to formulate a differential diagnosis and initial management plan. The students filled in a questionnaire prior to, immediately after and 1 week after each simulation session. This included a self-assessment of confidence in managing cardiac emergencies, as well as knowledge-based questions on aspects of assessment and management of cardiac emergencies. We sought to combine aspects of traditional simulation training with the assessment of real hospital in-patients Results Confidence in managing cardiac emergencies was initially low, but significantly increased after one simulation training session (p

Objectives This study aimed to assess the impact of thrombus aspiration on mortality in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI). Background The clinical effect of routine intracoronary thrombus aspiration before primary PCI in patients with ST-segment elevation myocardial infarction is uncertain. Methods We undertook an observational cohort study of 10,929 ST-segment elevation myocardial infarction patients from January 2005 to July 2011 at 8 centers across London, United Kingdom. Patients’ details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society PCI dataset. Primary outcome was all-cause mortality at a median follow-up of 3.0 years (interquartile range: 1.2 to 4.6 years). Results In our cohort, 3,572 patients (32.7%) underwent thrombus aspiration during primary PCI. Patients who had thrombus aspiration were younger, had lower rates of previous myocardial infarction but were more likely to have poor left ventricular function. Procedural success rates were higher (90.9% vs. 89.2%; p = 0.005) and in-hospital major adverse cardiac event rates were lower (4.4% vs. 5.5%; p = 0.012) in patients undergoing thrombus aspiration. However, Kaplan-Meier analysis demonstrated no significant difference in mortality rates between patients with and without thrombus aspiration (14.8% aspiration vs. 15.3% PCI only; p = 0.737) during the follow-up period. After multivariate Cox analysis (hazard ratio [HR]: 0.89, 95% confidence interval [CI]: 0.65 to 1.23) and the addition of propensity matching (HR: 0.85 95% CI: 0.60 to 1.20) thrombus aspiration was still not associated with decreased mortality. Conclusions In this cohort of nearly 11,000 patients, routine thrombus aspiration was not associated with a reduction in long-term mortality in patients undergoing primary PCI, although procedural success and in-hospital major adverse cardiac event rates were improved.

Introduction Glycoprotein IIb/IIIa inhibitors are recommended by guidelines in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention. There are few studies directly comparing these agents. The aim of this study was to assess whether eptifibatide is a safe and cost-effective alternative to abciximab in the treatment of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction. Methods This was an observational cohort study of 3863 patients who received a GPIIb/IIIa inhibitor whilst undergoing primary percutaneous coronary intervention from 2007 to 2014. Patients who did not receive a GPIIb/IIIa inhibitor were excluded. Time to first major adverse cardiac event defined as death, non-fatal myocardial infarction, stroke or target vessel revascularization, and total hospital costs were compared between the groups. Results In all, 1741 patients received abciximab with 2122 receiving eptifibatide. Patients who received eptifibatide had higher rates of previous MI/percutaneous coronary intervention and were more likely to undergo a procedure from the radial route. Unadjusted Kaplan–Meier analysis revealed no significant difference in the 1-year event rates between patients given eptifibatide versus abciximab (p = 0.201). Age-adjusted Cox analysis demonstrated no difference in 1-year outcome between abciximab and eptifibatide (hazard ratio: 0.83; 95% confidence interval: 0.73–1.39), which persisted after multivariate adjustment (hazard ratio: 0.92; 95% confidence interval: 0.79–1.56) including the incorporation of a propensity score (hazard ratio: 0.88; 95% confidence interval: 0.71–1.44). Eptifbatide was associated with significant cost savings being 87% cheaper overall compared to abciximab (on average £650 cheaper per patient and saving approximately £950,000). Conclusion This observational data suggest that eptifibatide is associated with similar outcomes and significant cost savings compared to abciximab when used in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention.

AIMS We aimed to examine the prevalence, clinical outcomes and procedural characteristics of percutaneous coronary intervention (PCI) complicated by coronary artery perforation (CAP) in a contemporary patient population. METHODS AND RESULTS Procedural records of 39,115 patients undergoing PCI between 2005 and 2016 were reviewed. CAP affected 149 cases (0.37%). The prevalence of CAP increased from 0.31% in 2005 to 0.45% in 2016 (p=0.03), reflecting an increase in more complex PCI (from 14% in 2005 to 21% in 2016; p

Current recommendations are for primary percutaneous coronary intervention (pPCI) in ST-elevation myocardial infarction (STEMI) complicated by out of hospital cardiac arrest (OHCA). However, information about longer-term outcomes is sparse, particularly among high-risk patients who do not regain consciousness promptly after resuscitation.Of 1836 consecutive patients admitted with STEMI for pPCI between April 2008-October 2011, 132 (7.2%) who had suffered OHCA with recovery of spontaneous circulation (ROSC) form the study population. 101 patients survived to hospital discharge (76.5%) with only one further death in the first year. Prognosis was worse for the 62 patients who were unconscious on arrival and required admission to the intensive therapy unit (ITU), only 54% of whom survived. Every additional minute in the time to ROSC increased the hazard of death by 1.7% while alertness upon ROSC and successful reperfusion in response to pPCI reduced the hazard of death by 90% and 65% respectively. Full neurological recovery was recorded in 85.1% of those who survived to be discharged but in only 30.6% of the 34 survivors who were admitted unconscious and received ITU treatment. Every additional minute in the time to ROSC increased the odds of neurological deficit by 7.0%.In patients with STEMI who are conscious after OHCA, high rates of survival can be achieved with pPCI, depending in part on the time it takes for ROSC. Prognosis is less good in the subgroup brought to hospital unconscious but even in this high risk group neurologically intact survival can be achieved in about one-third of cases, suggesting the benefit of immediate pPCI in STEMI patients successfully resuscitated after OHCA.

Background Drug-eluting stents (DES) may be associated with an increased risk of late stent thrombosis (ST) compared with bare metal stents (BMS). We compared major adverse cardiac events (MACE) and long term all cause mortality in patients with isolated proximal LAD disease treated with DES or BMS. Method and Results This study of 1653 patients with isolated proximal LAD disease, includes 643 treated with BMS and 1010 treated with DES. All patients received standard dual antiplatelet treatment. MACE after 5 years were less frequent in DES compared with BMS (12.1% 95% CI 9.3–14.2 versus 21.3% 95% CI: 16.9–25.1, P < 0.0001), driven largely by a decreased rate of both target vessel and lesion revascularization (TVR: 6.3%, 95% CI 4.0–7.5% versus 14.7%, 95% CI 11.0–17.3%, P < 0.0001, TLR: (5.3%, 95% CI 3.2–7.1% versus 13.2%, 95% CI 9.8.0–15.4%, P < 0.0001). There was no difference in the rate of death, myocardial infarction, or CVA. Incidence of stent thrombosis was also comparable (1.2% 95% CI: 0.6–2.6% versus 1.1% 95% CI: 0.6–2.5%, P = 0.8). Adjusted Cox analysis confirmed a decreased risk of MACE for DES compared with BMS 0.55 (95% confidence intervals 0.41–0.73) with no difference in the hazard of all cause mortality (HR: 1.04 95% CI: 0.67–1.61). Conclusion When treating proximal LAD disease, use of DES was associated with a lower MACE rate than BMS, with no differences in the incidence of stent thrombosis, myocardial infarction or 5 year all cause mortality. Our data suggests that despite the adverse prognostic correlates of proximal LAD disease, DES deployment in this location is both safe and clinically more effective than BMS. © 2012 Wiley Periodicals, Inc.

The role of percutaneous balloon aortic valvuloplasty (BAV) in the management of severe symptomatic aortic stenosis has come under the spotlight following the development of the transcatheter aortic valve implantation (TAVI) technique. Previous indications for BAV were limited to symptom palliation and as a bridge to definitive therapy for patients undergoing conventional surgical aortic valve replacement (AVR). In the TAVI era, BAV may also be undertaken to assess the ‘therapeutic response’ of a reduction in aortic gradient in borderline patients often with multiple comorbidities, to assess symptomatic improvement prior to consideration of definitive TAVI intervention. This narrative review aims to update the reader on the current indications and practical techniques involved in undertaking a BAV procedure. In addition, a summary of the haemodynamic and clinical outcomes, as well as the frequently encountered procedural complications is presented for BAV procedures conducted during both the pre-TAVI and post-TAVI era.

Bioresorbable Vascular Scaffolds (BVS) are the newest generation of stents for use during Percutaneous Coronary Intervention. However, as history has demonstrated, each development in stent technology has been associated with its own specific complications. With BVS, there are reports that recoil is

ObjectivesThe electronic health record (EHR) is underused in the hospital setting. The aim of this service evaluation study was to respond to National Health Service (NHS) Digital’s ambition for a paperless NHS by capturing routinely collected cardiac outpatient data in the EHR to populate summary patient reports and provide a resource for audit and research.DesignA PowerForm template was developed within the Cerner EHR, for real-time entry of routine clinical data by clinicians attending a cardiac outpatient clinic. Data captured within the PowerForm automatically populated a SmartTemplate to generate a view-only report that was immediately available for the patient and for electronic transmission to the referring general practitioner (GP).ResultsDuring the first 8 months, the PowerForm template was used in 61% (360/594) of consecutive outpatient referrals increasing from 42% to 77% during the course of the study. Structured patient reports were available for immediate sharing with the referring GP using Cerner Health Information Exchange technology while electronic transmission was successfully developed in a substudy of 64 cases, with direct delivery by the NHS Data Transfer Service in 29 cases and NHS mail in the remainder. In feedback, the report’s immediate availability was considered very or extremely important by >80% of the patients and GPs who were surveyed. Both groups reported preference of the patient report to the conventional typed letter. Deidentified template data for all 360 patients were successfully captured within the Trust system, confirming availability of these routinely collected outpatient data for audit and research.ConclusionElectronic template development tailored to the requirements of a specialist outpatient clinic facilitates capture of routinely collected data within the Cerner EHR. These data can be made available for audit and research. They can also be used to enhance communication by populating structured reports for immediate delivery to patients and GPs.

Embolization of athero-thrombotic material during primary percutaneous coronary intervention is a common cause of periprocedural complication. Methods developed to reduce embolization include thrombus aspiration, and distal protection. We report five cases of primary percutaneous intervention to coronary arteries that contain large amounts of thrombus, using a novel mesh covered stent. The mesh covering of the stent is designed such that it is theoretically able to ensnare thrombus and thus prevent distal migration of embolic material. In all cases, TIMI grade III flow was achieved at the end of the procedure, despite the extensive thrombus burden.

Background The electronic health record (EHR) is the major repository of clinical data in the NHS. It is a huge potential resource but remains severely under-utilised to the point that almost none of the UK’s audit and research output is based on routinely collected clinical data. The reasons are complex but ultimately reflect the fact that these data are rarely entered into the EHR in a form that allows for their organised storage and digital download. Methods We have developed a SNOMED-based electronic powerform comprising a user-friendly interface for real-time entry of clinical data into the hospital EHR during cardiac outpatient consultation. Our aim was to capture outpatient clinical data in a form that allows for automatic development of summary patient reports and for batch download of de-identified data for audit and research. Results During the first 4 months after installation of the powerform, consultant utilisation averaged 60% for the 327 new patients seen during that period. Presenting symptoms, examination findings, investigations, diagnosis, initial treatment and disposal (>120 fields) were entered in real time during consultation and a structured summary report was developed. This was made available for electronic transfer directly into the patients EMIS file in the primary care record, permitting same-day delivery of the report and obviating the need for a dictated clinic letter. Batched download of the digital data was successful, with sample analytic findings as follows: Patient ethnicity South Asian 44%, white 34%, black 15% Presenting symptom Chest pain 41%, dyspnoea 11%, palpitations 10%, dizzy attacks/syncope 8%, hypertension 7% Diagnosis Non-cardiac chest pain 24%, angina 11%, coronary disease 7% Disposal discharged to GP 74%, follow-up appointment 11%, cath lab waiting list 6%, referral to specialist clinic 9%. Ongoing are surveys of satisfaction with the power forms (cardiologists) and with the summary reports (GPs). Conclusion This is the first report of powerform development for entry of routinely collected cardiac outpatient data into the hospital EHR. The data are stored in a form that permits: (1) automatic generation of a summary report for same-day delivery into the primary care record and (2) batch download of de-identified digital data for audit. Integration of the system with programmes of generic patient consent will open up the EHR to real-world clinical research.

This study aimed to assess the impact of thrombus aspiration on mortality in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention (PCI).The clinical effect of routine intracoronary thrombus aspiration before primary PCI in patients with ST-segment elevation myocardial infarction is uncertain.We undertook an observational cohort study of 10,929 ST-segment elevation myocardial infarction patients from January 2005 to July 2011 at 8 centers across London, United Kingdom. Patients' details were recorded at the time of the procedure into local databases using the British Cardiac Intervention Society PCI dataset. Primary outcome was all-cause mortality at a median follow-up of 3.0 years (interquartile range: 1.2 to 4.6 years).In our cohort, 3,572 patients (32.7%) underwent thrombus aspiration during primary PCI. Patients who had thrombus aspiration were younger, had lower rates of previous myocardial infarction but were more likely to have poor left ventricular function. Procedural success rates were higher (90.9% vs. 89.2%; p=0.005) and in-hospital major adverse cardiac event rates were lower (4.4% vs. 5.5%; p=0.012) in patients undergoing thrombus aspiration. However, Kaplan-Meier analysis demonstrated no significant difference in mortality rates between patients with and without thrombus aspiration (14.8% aspiration vs. 15.3% PCI only; p=0.737) during the follow-up period. After multivariate Cox analysis (hazard ratio [HR]: 0.89, 95% confidence interval [CI]: 0.65 to 1.23) and the addition of propensity matching (HR: 0.85 95% CI: 0.60 to 1.20) thrombus aspiration was still not associated with decreased mortality.In this cohort of nearly 11,000 patients, routine thrombus aspiration was not associated with a reduction in long-term mortality in patients undergoing primary PCI, although procedural success and in-hospital major adverse cardiac event rates were improved.

Several studies have examined the relationship between age and clinical outcomes in patients with ST-elevation myocardial infarction (STEMI) treated by primary percutaneous coronary intervention (PPCI). The majority of studies have concentrated on describing elderly patients and there has been less focus on the profile and outcome of young patients suffering from STEMI. The aim of this study was to describe the clinical profile and outcomes of young patients compared with an older cohort and to establish what risk factors were associated with young patients having PPCI for STEMI.This was an observational cohort study of 3618 patients with STEMI treated by PPCI at a regional heart attack centre in London between January 2004 and September 2012. Clinical characteristics and outcomes in (young) patients aged ≤ 45 years were compared with those in (older) patients aged45 years. The primary and main secondary outcomes were all-cause mortality and major adverse cardiovascular event rates, respectively, at a median follow-up of 3.0 (interquartile range 1.2-4.6) years.Of the 3618 patients, 367 (10.1%) were aged ≤ 45 years and 3251 (89.9%) were aged45 years. The proportion of patients aged ≤ 45 years increased from 8.5% to 11.5% (p=0.04) during the study period. Compared with older patients, those aged ≤ 45 years were more likely to be male, smokers, of South Asian ethnicity and to have a family history of premature coronary artery disease. Young patients were less likely to have a history of hypertension, hypercholesterolaemia, diabetes mellitus, previous myocardial infarction, myocardial revascularisation, or to have left ventricular systolic impairment or renal impairment. Over the follow-up period, mortality (2.7% vs. 7.6%; p0.0001) and major adverse cardiovascular event rates (7.0% vs. 13.5%; p0.0001) were significantly lower in patients aged ≤ 45 years compared with older patients. After adjustment for potential confounding factors, young age remained a predictor of reduced all cause mortality when compared with older patients (hazard ratio 0.12 (95% confidence interval 0.04-0.38)), including after incorporation of a propensity score (hazard ratio: 0.14 (95% confidence interval 0.04-0.36)).In this cohort of patients with STEMI treated by PPCI there was an increasing incidence of young patients aged ≤ 45 years throughout the study period. These patients were more often male, smokers and of South Asian ethnicity. Outcomes in younger patients was good. Focusing preventative strategies on smokers and high risk ethnic groups may help reduce the incidence of premature coronary artery disease.

Aims. We investigate the effect of glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors on long-term outcomes following percutaneous coronary intervention (PCI) after non-ST elevation myocardial infarction (NSTEMI). Meta-analyses indicate that these agents are associated with improved short-term outcomes. However, many trials were undertaken before the routine use of P2Y12inhibitors. Recent studies yield conflicting results and registry data have suggested that GP IIb/IIIa inhibitors may cause more bleeding than what trials indicate.Methods and Results. This retrospective observational study involves 3047 patients receiving dual-antiplatelet therapy who underwent PCI for NSTEMI. Primary outcome was all-cause mortality. Major adverse cardiac events (MACE) were a secondary outcome. Mean follow-up was 4.6 years. Patients treated with GP IIb/IIIa inhibitors were younger with fewer comorbidities. Although the unadjusted Kaplan-Meier analysis suggested that GP IIb/IIIa inhibitor use was associated with improved outcomes, multivariate analysis (including propensity scoring) showed no benefit for either survival (P=0.136) or MACE (P=0.614). GP IIb/IIIa inhibitor use was associated with an increased risk of major bleeding (P=0.021).Conclusion. Although GP IIb/IIIa inhibitor use appeared to improve outcomes after PCI for NSTEMI, patients who received GP IIb/IIIa inhibitors tended to be at lower risk. After multivariate adjustment we observed no improvement in MACE or survival and an increased risk of major bleeding.

Background Research trials have shown improved short-term outcome with drug-eluting stents (DES) over bare metal stents (BMS) in saphenous vein graft (SVG) percutaneous coronary intervention (PCI), primarily by reducing target vessel revascularization (TVR) for in-stent restenosis. We compared the outcomes in patients undergoing SVG stent implantation treated with DES or BMS. In exploratory analyses we investigated the influence of stent generation and diameter. Methods Data were obtained from a prospective database of 657 patients who underwent PCI for SVG lesions between 2003 and 2011. A total of 344 patients had PCI with BMS and 313 with DES. Propensity scores were developed based on 15 observed baseline covariates in a logistic regression model with stent type as the dependent variable. The nearest-neighbour-matching algorithm with Greedy 5-1 Digit Matching was used to produce two patient cohorts of 313 patients each. We assessed major adverse cardiac events (MACE) out to a median of 3.3 years (interquartile range: 2.1-4.1). MACE was defined as all-cause mortality, myocardial infarction (MI), TVR and stroke. Results There was a significant difference in MACE between the two groups in favour of DES (17.9% DES vs. 31.2% BMS group; p = 0.0017) over the 5-year follow-up period. MACE was driven by increased TVR in the BMS group. There was no difference in death, MI or stroke. Adjusted Cox analysis confirmed a decreased risk of MACE for DES compared with BMS 0.75 (95% confidence interval (CI) 0.52-0.94), with no difference in the hazard of all-cause mortality (hazard ratio: 1.08; 95% CI: 0.77-1.68). However, when looking at stent diameters greater than 4 mm, no difference was seen in MACE rates between BMS and DES. Conclusions Overall in our cohort of patients who had PCI for SVG disease, DES use resulted in lower MACE rates compared with BMS over a 5-year follow-up period; however, for stent diameters over 4 mm no difference in MACE rates was seen.

Two advantages of transradial coronary procedures are an increased potential for same-day discharge and better resource management. This study assessed the impact of a dedicated "radial lounge" (1) on the rate of same-day discharge after elective percutaneous coronary intervention (PCI) and coronary angiography and (2) on bed utilization.We compared our unit's rates of same-day discharge in patients who underwent elective PCI or coronary angiography in the year before and in the year after the opening of a dedicated radial lounge for elective patients.In its first year of operation, 439 patients who underwent PCI and 1,109 patients who underwent angiography were managed in the radial lounge. Among these patients, the rate of same-day discharge was 84.7% after PCI and 97.0% after angiography. Requirement for overnight admission was significantly more common after femoral access compared with radial access for both angiography (4.1% vs 2.8%, P.05) and PCI (20.3% vs 14.2%, P.01). The unit's overall rate of same-day discharge increased from 2.3% to 51.2% after elective PCI (P.0005) and from 72.7% to 84.9% after elective angiography (P.005). An estimated 595 bed days were saved through reduced overnight admissions in elective patients.Our unit's overall rates of same-day discharge after elective PCI and coronary angiography increased dramatically in the year after the opening of a dedicated radial lounge. This was directly attributable to the high rates of same-day discharge in radial lounge patients. The radial lounge impacted favorably on in-patient bed capacity.

ObjectivesThis study investigated the impact of procedural success on mortality following chronic total occlusion (CTO) percutaneous coronary intervention (PCI) in a large cohort of patients in the drug-eluting stent era.BackgroundDespite advances in expertise and technologies, many patients with CTO are not offered PCI.MethodsA total of 6,996 patients underwent elective PCI for stable angina at a single center (2003 to 2010), 836 (11.9%) for CTO. All-cause mortality was obtained to 5 years (median: 3.8 years; interquartile range: 2.0 to 5.4 years) and stratified according to successful chronic total occlusion (sCTO) or unsuccessful chronic total occlusion (uCTO) recanalization. Major adverse cardiac events (MACE) included myocardial infarction (MI), urgent revascularization, stroke, or death.ResultsA total of 582 (69.6%) procedures were successful. Stents were implanted in 97.0% of successful procedures (mean: 2.3 ± 0.1 stents per patient, 73% drug-eluting). Prior revascularization was more frequent among uCTO patients: coronary artery bypass grafting (CABG) (16.5% vs. 7.4%; p < 0.0001), PCI (36.0% vs. 21.2%; p < 0.0001). Baseline characteristics were otherwise similar. Intraprocedural complications, including coronary dissection, were more frequent in unsuccessful cases (20.5% vs. 4.9%; p < 0.0001), but did not affect in-hospital MACE (3% vs. 2.1%; p = NS). All-cause mortality was 17.2% for uCTO and 4.5% for sCTO at 5 years (p < 0.0001). The need for CABG was reduced following sCTO (3.1% vs. 22.1%; p < 0.0001). Multivariate analysis demonstrated that procedural success was independently predictive of mortality (hazard ratio [HR]: 0.32 [95% confidence interval (CI): 0.18 to 0.58]), which persisted when incorporating a propensity score (HR: 0.28 [95% CI: 0.15 to 0.52]).ConclusionsSuccessful CTO PCI is associated with improved survival out to 5 years. Adoption of techniques and technologies to improve procedural success may have an impact on prognosis.

Methods We identified 100 consecutive patients who underwent stress perfusion cardiac magnetic resonance scans between March 2008 and November 2008 and were reported as having normal perfusion scans. Patients were contacted via telephone to determine the endpoints of an adverse cardiac event identified as a composite of death from coronary heart disease or hospital admission with an acute coronary syndrome. Case notes were checked to confirm the endpoint when it occurred.

Results The mean age was 47 ± 15 years (range 21-79) and 25% were female. Serum troponin (Tn) was available in 46 (84%) and was elevated in 39 (85%). Urgent angiography was performed in 75% in whom 90% had unobstructed arteries. In the patients with abnormal angiography, epicardial or midwall focal fibrosis (FF) was detected in LV segments unrelated to the stenosed artery. The median interval from admission to CMR was 24 days (range 1685). LV systolic function was normal in 47% and preserved with regional hypokinesia in 27%. LV impairment (LVI) was mild in 13%, moderate in 13% and severe in none. FF was detected in 78%, and was subepicardial, mid-wall or patchy in all. T2 weighted oedema imaging was obtained in 27 (49%), and was abnormal in 48%. LVI was reported in 2/7 (29%) Tn-ve patients and 8/39 (21%) Tn+ve patients, FF was detected in 4/7 (57%) and 31/39 (79%) patients respectively (p = ns). Myocardial oedema was demonstrated in 12/22 (55%) Tn+ve patients and in no (0/3) Tn-ve patient (ns). In Tn+ve patients, oedema was demonstrated in 11/12 if the scan was performed < 2 weeks of symptom onset, and 1/7 if performed later (p < 0.005). Four patients were admitted with sustained (7%) and another patient died in hospital (2%); the LV dysfunction was mild in 4 and moderate in one.

ST elevation myocardial infarction (STEMI) complicated by out of hospital cardiac arrest (OOHCA) is associated with significant mortality. Small observational studies have shown survival benefit with primary percutaneous coronary intervention (pPCI) in this setting. We sought to investigate

Background Research trials have shown improved short-term outcome with DES over BMS in Saphenous vein graft (SVG) PCI, primarily by reducing target vessel revascularisation (TVR) for in-Stent Restenosis (ISR). Because of the high event rates in these patients it is not clear if these benefits are maintained long term. We compared the outcomes in patients undergoing SVG stent implantation treated with DES or BMS, over a prolonged follow-up period. Methods Clinical information was analysed from a prospective database on 512 patients who underwent PCI for SVG lesions between 2003 and 2010 at a London centre. Information was entered at the time of procedure and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS/CCAD national audit. The primary end point used was major adverse cardiac events (MACE), defined as death, myocardial infarction (MI), stroke and target vessel revascularisation (TVR). Results There were 293 patients who underwent PCI with BMS and 219 treated with DES. The mean follow-up period was 1086±418 days for the BMS group and 1046±390 days for the DES group. Baseline characteristics were the same between the groups other than diabetes, which was more common in the DES treated group (24% vs 15%, p Conclusions In our cohort of patients who had PCI for treatment of SVG disease the use of DES resulted in lower MACE rate compared to BMS over a 5-year follow-up.

Introduction The potential to achieve safe early mobilisation and same day discharge on a consistent basis after radial artery access has provided us with the opportunity to make a step change in the way we deliver elective care to patients undergoing percutaneous coronary procedures. We designed a dedicated “radial lounge” to accommodate patients before and after their procedure with the aim of minimising the feeling of “hospitalisation” that accompanies most encounters with health services. The lounge is a day case unit that has no beds, only chairs, and televisions but no cardiac monitors. Patients remain in their clothes throughout their hospital visit. Here we report our first year′s experience of this facility. Methods: The study population comprised all patients who attended the radial lounge between July 2009–June 2010 for coronary angiography or percutaneous coronary intervention (PCI). Patients were suitable for the radial lounge if they were elective cases who had a satisfactory radial pulse and no pre-procedure contraindication to same day discharge. Patients were excluded if they had any of the following: an unsuitable radial pulse, planned femoral access, prior coronary artery bypass surgery, or the requirement for an overnight hospital stay for planned complex/high risk PCI, renal impairment, or social reasons. The final decision regarding route of arterial access was left to the operator. Results In the one year study period, 1548 patients were managed in the radial lounge. 1109 patients underwent coronary angiography, 114 (10.2%) of whom also had a pressure wire or intravascular ultrasound, and 439 underwent PCI. This represented approximately 88% of our unit′s elective angiograms and 60% of our elective PCIs. Among the patients who underwent angiography, 938 (84.5%) were performed radially and 1076 (97.0%) were discharged from the radial lounge on the same day as their procedure. Among the PCI patients, 359 (81.8%) were performed radially and 372 (84.7%) were discharged the same day. The PCI group included 326 (74.3%) patients who had a single vessel treated, 105 (23.9%) who had two vessels or a bifurcation with a significant side branch treated, and 8 (1.8%) patients who had three vessels treated. There were no deaths or arrhythmias in the radial lounge. Requirement for overnight admission was significantly more common after femoral access compared with radial access for both angiography (4.1% vs 2.8%; p Conclusions A dedicated radial lounge free of cardiac monitors is a safe environment in which to manage most patients before and after elective coronary angiography and PCI. The lack of monitoring necessitates patient selection but this does not prevent the lounge being suitable for the majority of elective patients. Femoral access is associated with a significantly greater requirement for overnight admission.

Background Multi-vessel disease occurs in 40%–65% of patients undergoing Primary PCI for STEMI and is associated with adverse prognosis. Contemporary guidelines recommend treating the infarct related artery alone (culprit) during the urgent procedure. There is limited data comparing outcomes of complete with infarct-related artery (IRA)-only revascularisation in primary PCI for STEMI with few studies including the option of later date elective procedures for the other lesions (staged revascularisation). We therefore sought to clarify the outcome of patients with multi-vessel disease undergoing primary PCI dependent on management strategy. Methods Clinical information was analysed from a prospective data base on 2131 STEMI patients who underwent Primary PCI between January 2004 and May 2010 at a London centre. Patients with previous CABG were excluded. Information was entered at the time of procedure and outcome assessed by all-cause mortality information provided by the Office of National Statistics via the BCIS/CCAD national audit. Patients were split into three different treatment groups: culprit vessel angioplasty-only (COR group); staged revascularisation (SR group) and simultaneous treatment of non-IRA (CR group). The primary end point used was major adverse cardiac events (MACE), defined as death, myocardial infarction (MI), stroke and target vessel revascularisation (TVR). Results There were 963 (45%) consecutive patients with STEMI and multivessel CAD undergoing primary angioplasty. There were similar baseline characteristics between the 3 groups, aside from cardiogenic shock, which was significantly higher in the complete revascularisation group. See Abstract 19 table 1. At 30-days of follow-up, 23/263 (9%) patients in the CR group experienced at least one major adverse cardiac event (MACE), 1 (1%) in the SR group and 35 (5%) in the COR group, p=0.01. This trend continued up to 1-year of follow-up with the lowest rates of events in the SR group. However after 3 years MACE rates are significantly increased in the COR group (24%) but were similar in the CR (18%) and SR (17%) groups. See Abstract figure 1. MACE rates were driven mainly by death in the CR with high rates of TVR in the COR and SR groups. See Abstract figure 2. Conclusions Culprit vessel-only angioplasty was associated with the highest rate of long-term MACE compared with multivessel treatment. Patients scheduled for staged revascularisation experienced a similar rate of MACE to patients undergoing complete simultaneous treatment of non-IRA.

Introduction: Anticoagulation in atrial fibrillation (AF) is strongly recommended in view of the fivefold increased risk of stroke. Current guidelines do not specify the timing of anticoagulation in patients admitted with new onset AF. There is no data comparing the effectiveness of inpatient vs. outpatient initiation of anticoagulation. Method: This was a single center, retrospective, observational study including patients admitted with new onset AF during 2013 (ICD-10 I48). We interrogated health records to identify patient characteristics, CHA2DS2VASc scores and contacted health care physicians to determine if anticoagulation was considered and the setting in which it was initiated. Results: We identified 234 patients admitted with a new diagnosis of AF (table 1). Anticoagulation was indicated in 201 patients (86%) but was considered in only 179 patients (89%) and no reason documented for the remaining 22 patients. 64 out of 179 patients had recognised contraindications. The remaining 115 patients were referred for inpatient (n=56) or outpatient anticoagulation (n=59, 32 anticoagulation clinic, 11 primary care and 16 secondary care) In the outpatient setting, only 69% were anticoagulated (29/32 anticoagulation clinic, 6/11 primary care and 6/16 secondary care). In those with (n-25) and without (n-7) scheduled anticoagulation clinic appointments on discharge, the mean delay was 6 vs. 37 days. In the primary and secondary care groups the time delay was 121 and 79 days respectively. This delay resulted in two patients, who were not anticoagulated as planned, suffering a stroke within 6 months of discharge. CHA2DS2VASc score (OR 0.72 95% 0.39-1.34, p- 0.31) or specialty team (cardiac vs. noncardiac) (OR 1.08 95% CI 0.58-2.00, p- 0.81) did not influence setting of anticoagulation. Conclusion: Anticoagulation is still not considered in all patients admitted with new onset AF. Outpatient referral for anticoagulation is associated with lack of uptake, significant delays and cerebrovascular events. Patient pathways need to be developed to minimise these delays; options include inpatient initiation, regulating clinic appointments and considering newer agents like NOACS. | | Total | Outpatient | Inpatient | | ------------------------------- | ---------- | ---------- | ---------- | | Mean Age (range) | 75 (22-99) | 77 (32-94) | 73 (45-97) | | M:F ratio | 1:1.2 | 1.1:1 | 1:1.5 | | Diabetes (%) | 57 (24) | 22 (37) | 13 (23) | | Hypertension (%) | 169 (72) | 51 (86) | 46 (82) | | Congestive heart failure (%) | 90 (39) | 24 (41) | 26 (46) | | Stroke (%) | 37 (16) | 13 (22) | 11 (20) | | Peripheral vascular disease (%) | 9 (4) | 2 (3) | 1 (2) | | Mean CHA2DS2VASc score (SD) | 3.6 (2) | 4 (2) | 3.7 (2) | | Mean hospital stay in days (SD) | 10 (11) | 8 (6) | 12 (11) | Table 1 Patients baseline characteristics

Purpose: European guidelines state that with the exception of cardiogenic shock, percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) should be limited to the culprit artery. Although there is no robust randomized controlled trial data available there is a general consensus that non culprit coronary artery lesions identified at the time of STEMI should be treated in a staged manner. Whilst there is general consensus on the above; currently neither guidelines nor evidence exist regarding the optimal time for staged PCI. Our aim was to compare outcomes in patients who underwent staged PCI either as an inpatient or as an outpatient within six weeks time. Methods: This was an observational cohort study of 983 patients with multi-vessel disease who underwent PPCI from 2007 to 2011. Patients with previous CABG, cardiogenic shock were excluded. 102 patients were managed with staged intervention. The primary outcome was major adverse cardiac events (all cause mortality, myocardial infarction, target vessel revascularisation and stroke). Follow-up was for a median of 3.2 years (IQR range 2.0-4.4 years). Results: 24 (23.5%) patients underwent inpatient staged PCI with 78 (76.5%) patients undergoing their intervention within 6 weeks of hospital discharge. Patients who underwent inpatient staged PCI were older compared to those having 6 week staged procedures. (66.1±10.4 vs 59.2±10.6, P=0.02). Otherwise there were no other differences in baseline characteristics. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 3-year event rates between patients undergoing in-patient and 6 week staged procedures. Un-adjusted Cox analysis demonstrated no difference in 3 year outcomes between inpatient and 6 week procedures (HR 0.84 [95% CI 0.27-2.61)), which persisted after multivariate adjustment ((HR 0.60 [95% CI 0.12-2.96)) (factors corrected for: previous MI, DM, access, age, EF, eGFR, DES use, gender, previous CVA, PVD). Conclusion: This observational data suggests that staged procedures performed as an in-patient or at 6 weeks post discharge are associated with similar outcomes in STEMI patients with MVD undergoing primary PCI.

Introduction During Primary Percutaneous Coronary Intervention (PPCI) post ST-Segment Myocardial Infarction (STEMI), distal embolisation of thrombus may lead to failure to re-establish normal flow in the infarct-related artery. Manual thrombus aspiration has been shown to improve coronary perfusion as assessed by time to ST-segment resolution and myocardial blush grade. Evidence supporting the benefit of thrombus aspiration on clinical outcomes, however, is limited and inconsistent. We aimed to assess the impact of manual thrombectomy on mortality in patients presenting with STEMI across all PPCI centres in London over a 5 year period from 2007 until 2012. Methods This was an observational cohort study of 9935 consecutive patients with STEMI treated with PPCI between 2007 and 2012 at eight tertiary cardiac centres across London, UK. Patient9s details were recorded at the time of the procedure into the British Cardiac Intervention Society (BCIS) database. Outcome was assessed by all-cause mortality. Anonymous datasets from the eight centres were merged for analysis. The primary end-point was all-cause mortality at a median follow-up of 2.0 years (IQR range 1.1–3.1 years). Results Of the 9935 consecutive STEMI patients presenting for PPCI, 2859 had mechanical thrombectomy. Patients who had manual thrombectomy were significantly younger (average age 60.6 vs 62.9) and were less likely to have had a previous myocardial infarction (11.9% of thrombectomy patients vs 14.7% of non-thrombectomy patients). Patients receiving manual thromectomy were found to be significantly more likely to have had PPCI via a radial approach (33.1% in thrombectomy patients vs 19.9% in non-thromectomy patients). Procedural success (defined as TIMI 3 flow at the end of procedure) was found to be significantly more likely in patients receiving manual thrombectomy (89.5% vs 86.7%) (table 1). Patients with thrombectomy use had similar unadjusted all-cause mortality rates to those without thrombectomy use (12.7% vs 16.5%, p=NS) during the 5-year follow-up period (figure 1). After multivariable adjustment thrombectomy use was associated with significantly decreased mortality rates (HR: 0.82, 95% CI 0.68 to 0.9, p=0.04). Conclusion Mechanical thrombectomy use appears to be associated with improved outcome, in the form of decreased mortality, in this large observational trial.

Background The superiority of stress CMR imaging for the detection of coronary artery disease has been demonstrated in recent studies. The identification of perfusion defects has been correlated with adverse outcomes. The percutaneous coronary intervention (PCI) treatment of proximal LAD lesions has been shown to be associated with improved outcome. Patients with previous proximal LAD stenting presenting with chest pain symptoms have often observed to have basal septal perfusion defects which do not propagate beyond the basal segments. This is likely related to compromised flow in the septal perforators in the presence of the stent scaffold. However, the significance of basal septal perfusion defects identified in patients presenting with chest pain symptoms in the presence of angiographically unobstructed proximal LAD stents is unclear. We studied the outcome of patients with previous proximal LAD stenting presenting with chest pain symptoms with or without a basal septal perfusion defect. Methods Retrospective analysis of 326 patients presenting with stable angina, who had undergone PCI to the proximal LAD at our institution between January 2005 and November 2011 was performed. All patients were investigated with a standard stress CMR protocol utilising vasodilator stress with adenosine. Patients were divided into two cohorts—234 patients with no basal septal perfusion defect and 92 patients with a basal septal perfusion defect. The primary outcome was all-cause mortality. The mean follow-up after stent implantation was 3.0±1.7 years for no basal septal perfusion defect group and 2.7±1.7 years for basal septal perfusion defect group. Results The two groups of patients were well matched in terms of age and gender. Among patients with a basal septal perfusion defect, there was a higher rate of Asian ethnicity and diabetes but this was not statistically significant. There was no significant difference in the use of drug eluting stents (DES) or the number of stents used. There was no significant difference between the two cohorts with regards to indication of PCI and the time elapsed from stenting to CMR scan. On long term follow-up, there was no significant difference in all-cause mortality between the two groups. Conclusions The presence of a basal septal perfusion defect in patients with proximal LAD stent is not associated with adverse outcome. The increasing observation of these defects may be related to superior spatial resolution of CMR imaging. However, if these perfusion defects are causing patients9 symptoms, our data does point to the safety of conservative management of these cases. Although there was higher rate of female gender, Asian ethnicity and diabetes among patients with a basal septal perfusion defect, there was no significant patient or procedural factors associated with the identification of perfusion defects in the presence of proximal LAD stent.

Background European guidelines state that with the exception of cardiogenic shock, percutaneous coronary intervention (PCI) for ST elevation myocardial infarction (STEMI) should be limited to the culprit artery. Although there is no robust randomised controlled trial data available there is a general consensus that non-culprit coronary artery lesions identified at the time of STEMI should be treated in a staged manner. Whilst there is general consensus on the above; currently neither guidelines nor evidence exist regarding the optimal time for staged PCI. Our aim was to compare outcomes in patients who underwent staged PCI either as an in-patient or as an out-patient within 6 weeks time following a STEMI. Methods This was an observational cohort study of 983 patients with multi-vessel disease who underwent primary PCI from 2007 to 2011. Patients with previous CABG, cardiogenic shock were excluded. 102 patients were managed with staged intervention. The primary outcome was major adverse cardiac events (all cause mortality, myocardial infarction, target vessel revascularisation and stroke). Follow-up was for a median of 3.2 years (IQR range 2.0–4.4 years). Results 24 (23.5%) patients underwent in-patient staged PCI with 78 (76.5%) patients undergoing their intervention within 6 weeks of hospital discharge. Differences in baseline characteristics are outlined in table 1. Patients who underwent in-patient staged PCI were older compared to those having 6 week staged procedures. (66.1±10.4 vs 59.2±10.6, p=0.02). Otherwise there were no other differences in baseline characteristics. Unadjusted Kaplan-Meier analysis revealed no significant difference in the 3-year event rates between patients undergoing in-patient and 6 week staged procedures (figure 1). Un-adjusted Cox analysis demonstrated no difference in 3 year outcomes between in-patient and 6 week procedures (HR 0.84 (95% CI 0.27 to 2.61)), which persisted after multivariate adjustment ((HR 0.60 (95% CI 0.12 to 2.96)) (factors corrected for: previous MI, DM, access, age, EF, eGFR, DES use, gender, previous CVA, PVD). Conclusions This observational data suggests that staged procedures performed as an in-patient or at 6 weeks post discharge are associated with similar outcomes in STEMI patients with multi-vessel disease undergoing primary PCI.