No-Reflow Prediction in Acute Coronary Syndrome During Percutaneous Coronary Intervention: The NORPACS Risk Score

BACKGROUND

Suboptimal coronary reperfusion (no reflow) is common in acute coronary syndrome percutaneous coronary intervention (PCI) and is associated with poor outcomes. We aimed to develop and externally validate a clinical risk score for angiographic no reflow for use following angiography and before PCI.

METHODS

We developed and externally validated a logistic regression model for prediction of no reflow among adult patients undergoing PCI for acute coronary syndrome using data from the Melbourne Interventional Group PCI registry (2005-2020; development cohort) and the British Cardiovascular Interventional Society PCI registry (2006-2020; external validation cohort).

RESULTS

A total of 30 561 patients (mean age, 64.1 years; 24% women) were included in the Melbourne Interventional Group development cohort and 440 256 patients (mean age, 64.9 years; 27% women) in the British Cardiovascular Interventional Society external validation cohort. The primary outcome (no reflow) occurred in 4.1% (1249 patients) and 9.4% (41 222 patients) of the development and validation cohorts, respectively. From 33 candidate predictor variables, 6 final variables were selected by an adaptive least absolute shrinkage and selection operator regression model for inclusion (cardiogenic shock, ST-segment-elevation myocardial infarction with symptom onset >195 minutes pre-PCI, estimated stent length ≥20 mm, vessel diameter <2.5 mm, pre-PCI Thrombolysis in Myocardial Infarction flow <3, and lesion location). Model discrimination was very good (development C statistic, 0.808; validation C statistic, 0.741) with excellent calibration. Patients with a score of ≥8 points had a 22% and 27% risk of no reflow in the development and validation cohorts, respectively.

CONCLUSIONS

The no-reflow prediction in acute coronary syndrome risk score is a simple count-based scoring system based on 6 parameters available before PCI to predict the risk of no reflow. This score could be useful in guiding preventative treatment and future trials.

Sex Differences in Pharmacotherapy and Long-Term Outcomes in Patients With Ischaemic Heart Disease and Comorbid Left Ventricular Dysfunction

BACKGROUND

Left ventricular (LV) dysfunction and ischaemic heart disease (IHD) are common among women. However, women tend to present later and are less likely to receive guideline-directed medical therapy (GDMT) compared with men.

METHODS

We analysed prospectively collected data (2005-2018) from a multicentre registry on GDMT 30 days after percutaneous coronary intervention in 13,015 patients with LV ejection fraction <50%. Guideline-directed medical therapy was defined as beta blocker, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker±mineralocorticoid receptor antagonist. Long-term mortality was determined by linkage with the Australian National Death Index.

RESULTS

Women represented 20% (2,634) of the total cohort. Mean age was 65±12 years. Women were on average >5 years, with higher body mass index and higher rates of hypertension, diabetes, renal dysfunction, prior stroke, and rheumatoid arthritis. Guideline-directed medical therapy was similar between sexes (73% vs 72%; p=0.58), although women were less likely to be on an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (80% vs 82%; p=0.02). Women were less likely to be on statin therapy (p<0.001) or a second antiplatelet agent (p=0.007). Women had higher unadjusted long-term mortality (25% vs 19%; p<0.001); however, there were no differences in long-term mortality between sexes on adjusted analysis (hazard ratio 0.99; 95% confidence interval 0.87-1.14; p=0.94).

CONCLUSIONS

Rates of GDMT for LV dysfunction were high and similar between sexes; however, women were less likely to be on appropriate IHD secondary prevention. The increased unadjusted long-term mortality in women was attenuated in adjusted analysis, which highlights the need for optimisation of baseline risk to improve long-term outcomes of women with IHD and comorbid LV dysfunction.

Impact of Preprocedural Diastolic Blood Pressure on Outcomes in Patients Undergoing Percutaneous Coronary Intervention

BACKGROUND

Recent US guidelines recommend lower blood pressure (BP) targets in hypertension, but aggressive lowering of diastolic BP (DBP) can occur at the expense of myocardial perfusion, particularly in the presence of coronary artery disease. We sought to establish the long-term impact of low DBP on mortality among patients undergoing percutaneous coronary intervention with well-controlled systolic BP.

METHODS

We analyzed data from 12 965 patients undergoing percutaneous coronary intervention between 2009 and 2018 from the Melbourne Interventional Group registry who had a preprocedural systolic BP of ≤140 mm Hg. Patients with ST-elevation myocardial infarction, cardiogenic shock, and out-of-hospital arrest were excluded. Patients were stratified into 5 groups according to preprocedural DBP: <50, 50 to 59, 60 to 69, 70 to 79, and ≥80 mm Hg. The primary outcome was long-term, all-cause mortality. Mortality data were derived from the Australian National Death Index.

RESULTS

Patients with DBP<50 mm Hg were older with higher rates of diabetes, renal impairment, prior myocardial infarction, left ventricular dysfunction, peripheral and cerebrovascular disease (all P<0.001). Patients with DBP<50 mm Hg had higher 30-day (2.5% versus 0.7% for the other 4 quintiles; P<0.0001) and long-term mortality (median, 3.6 years; follow-up, 29% versus 11%; P<0.0001). Cox-regression analysis revealed that DBP<50 mm Hg was an independent predictor of long-term mortality (hazard ratio [HR], 1.55 [95% CI, 1.20-2.00]; P=0.001).

CONCLUSIONS

In patients with well-controlled systolic BP undergoing percutaneous coronary intervention, low DBP (<50 mm Hg) is an independent predictor of long-term mortality.

Outcomes of thrombus aspiration during primary percutaneous coronary intervention for ST-elevation myocardial infarction

BACKGROUND

Previous large multi-centre randomised controlled trials have not provided clear benefit with routine intracoronary thrombus aspiration (TA) as an adjunct to primary percutaneous coronary intervention (PCI) in patients with ST-elevation myocardial infarction (STEMI).

AIM

To determine whether there is a difference in outcomes with the use of manual TA prior to PCI, compared with PCI alone in a cohort of patients with STEMI.

METHODS

We analysed data from 6270 consecutive patients undergoing primary PCI for STEMI prospectively enrolled in the Melbourne Interventional Group registry between 2007 and 2018. Multivariable analysis was performed to determine predictors of 30-day major adverse cardiovascular and cerebrovascular events (MACCE) and long-term mortality.

RESULTS

We compared 1621 (26%) patients undergoing primary PCI with TA to 4649 (74%) patients undergoing PCI alone. Male gender (81% vs 78%; P < 0.01), younger age (61 vs 63 years; P = 0.03), GP-IIb/IIIa use (76% vs 58%, P < 0.01), and current smoking (40% vs 36%; P < 0.01) were more common in the TA group. TA was more likely to be used in patients with complex lesions (83% vs 66%; P < 0.01) with TIMI 0 flow (77% vs 56%; P < 0.01). No significant difference in post-procedural TIMI flow, stroke, 30-day mortality, or long-term mortality were identified. Multivariable analysis demonstrated a reduction in 30-day MACCE (hazard ratio (HR) 0.75; confidence interval (CI) 0.63-0.89; P < 0.01) in the TA group, but was not associated with long-term mortality (HR 0.98; CI 0.85-1.1; P = 0.73).

CONCLUSION

The use of TA in patients undergoing primary PCI for STEMI was not associated with improved short or long-term mortality when compared with PCI alone.

Trends in Intra-Aortic Balloon Pump Use in Cardiogenic Shock After the SHOCK-II Trial

Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularization. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the IABP-SHOCK-II (Intra-aortic Balloon Pump in Cardiogenic Shock-II study) trial found no survival benefit. We aimed to determine the trends in IABP use in patients who underwent percutaneous intervention over time. Data were taken from patients in the Melbourne Interventional Group registry (2005 to 2018) with MI-CS who underwent percutaneous intervention. The primary outcome was the trend in IABP use over time. The secondary outcomes included 30-day mortality and major adverse cardiovascular and cerebrovascular events (MACCEs). Of the 1,110 patients with MI-CS, IABP was used in 478 patients (43%). IABP was used more in patients with left main/left anterior descending culprit lesions (62% vs 46%), lower ejection fraction (<35%; 18% vs 11%), and preprocedural inotrope use (81% vs 73%, all p <0.05). IABP use was associated with higher bleeding (18% vs 13%) and 30-day MACCE (58% vs 51%, both p <0.05). The rate of MI-CS per year increased over time; however, after 2012, there was a decrease in IABP use (p <0.001). IABP use was a predictor of 30-day MACCE (odds ratio 1.6, 95% confidence interval 1.18 to 2.29, p = 0.003). However, IABP was not associated with in-hospital, 30-day, or long-term mortality (45% vs 47%, p = 0.44; 46% vs 50%, p = 0.25; 60% vs 62%, p = 0.39). In conclusion, IABP was not associated with reduced short- or long-term mortality and was associated with increased short-term adverse events. IABP use is decreasing but is predominately used in sicker patients with greater myocardium at risk.

Harmonising Individual Patient Level Cardiac Registry Data Across the Asia Pacific Region-A Feasibility Study of In-Hospital Outcomes of STEMI Patients From the Asia Pacific Evaluation of Cardiovascular Therapies (ASPECT) Network

OBJECTIVE

The Asia-Pacific Evaluation of Cardiovascular Therapies (ASPECT) collaboration was established to inform on percutaneous coronary intervention (PCI) in the Asia-Pacific Region. Our aims were to (i) determine the operational requirements to assemble an international individual patient dataset and validate the processes of governance, data quality and data security, and subsequently (ii) describe the characteristics and outcomes for ST-elevation myocardial infarction (STEMI) patients undergoing PCI in the ASPECT registry.

METHODS

Seven (7) ASPECT members were approached to provide a harmonised anonymised dataset from their local registry. Patient characteristics were summarised and associations between the characteristics and in-hospital outcomes for STEMI patients were analysed.

RESULTS

Six (6) participating sites (86%) provided governance approvals for the collation of individual anonymised patient data from 2015 to 2017. Five (5) sites (83%) provided >90% of agreed data elements and 68% of the collated elements had <10% missingness. From the registry (n=12,620), 84% were male. The mean age was 59.2±12.3 years. The Malaysian cohort had a high prevalence of previous myocardial infarction (34%), almost twice that of any other sites (p<0.001). Adverse in-hospital outcomes were the lowest in Hong Kong whilst in-hospital mortality varied from 2.7% in Vietnam to 7.9% in Singapore.

CONCLUSIONS

Governance approvals for the collation of individual patient anonymised data was achieved with a high level of data alignment. Secure data transfer process and repository were established. Patient characteristics and presentation varied significantly across the Asia-Pacific region with this likely to be a major predictor of variations in the clinical outcomes observed across the region.

Long-term mortality in asymptomatic patients with stable ischemic heart disease undergoing percutaneous coronary intervention

OBJECTIVES

Patients with stable ischemic heart disease (SIHD) may present with a variety of symptoms including typical angina, angina equivalents such as dyspnea or no symptoms. We sought to determine whether symptom status affects periprocedural safety and long-term mortality in patients undergoing PCI.

METHODS

Prospectively enrolled consecutive patients undergoing PCI for SIHD at six hospitals in Australia between 2005 to 2018 as part of the Melbourne Interventional Group registry. Symptom status was recorded at the time of PCI and patients undergoing staged PCI were excluded.

RESULTS

Overall, 11,730 patients with SIHD were followed up for a median period of 5 years (maximum 14.0 years, interquartile range 2.2-9.0 years) with 1,317 (11.2%) being asymptomatic. Asymptomatic patients were older, and more likely to be male, have triple-vessel disease, with multiple comorbidities including renal failure, diabetes and heart failure (all P < .01). These patients had significantly higher rates of periprocedural complications and major adverse cardiovascular events at 30-days. Long-term mortality was significantly higher in asymptomatic patients (27.2% vs 18.0%, P < .001). On cox regression for long-term mortality, after adjustment for more important clinical variables, asymptomatic status was an independent predictor (Hazard ratio (HR) 1.39 95% CI 1.16-1.66, P < .001).

CONCLUSIONS

In a real-world cohort of patients undergoing revascularization for SIHD, absence of symptoms was associated with higher rates of periprocedural complications and, after adjustment for more important clinical variables, was an independent predictor of long-term mortality. As the primary goal of revascularization in SIHD remains angina relief, the appropriateness of PCI in the absence of symptoms warrants justification.

Trends in intra-aortic balloon pump use in cardiogenic shock in the post-SHOCK II trial era

Background

Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularisation. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the SHOCK-II trial in 2012 found no survival benefit.

Purpose

This study aimed to determine the trends in IABP use in patients with MI-CS undergoing percutaneous intervention (PCI) over time and characteristics associated with use.

Methods

Between 2005–2018, patients presenting with MI-CS that underwent percutaneous coronary intervention (PCI) at a hospital participating in the Melbourne Interventional Group Registry were included. The primary outcome was the trend in IABP use over time. Secondary outcomes included mortality, 30-day MACCE (major adverse cardiovascular and cerebrovascular events) and predictors of outcome, determined via logistic regression.

Results

Of the 1,110 patients identified, IABP was used in 478 (43%). IABP was used more in patients with left main and left anterior descending culprit lesions (62% vs. 46%), lower ejection fraction (&lt;35%; 18% vs. 11%), and pre-procedural inotrope use (81% vs. 73%), all p&lt;0.05. IABP use was associated with higher inpatient bleeding (18% vs. 13%) and 30-day MACCE (58% vs. 51%), both p&lt;0.05. The rate of MI-CS increased over time, but after 2012 there was a decline in IABP use (Figure 1). IABP use was a predictor of 30-day MACCE (OR 1.6, 95% CI 1.18–2.29, p=0.003). However, IABP was not associated with in-hospital, 30-day or long-term mortality (45% vs. 47%, p=0.44; 46% vs. 50%, p=0.25; 60% vs. 62%, p=0.39).

Conclusions

Consistent with the SHOCK II trial, IABP use is not associated with reduced short- or long-term mortality, but in this study was associated with increased short-term adverse events. IABP use is declining, but is still used in sicker patients with greater myocardium at risk, given limited alternatives.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Melbourne interventional group

Differences in outcome of percutaneous coronary intervention between Indigenous and non-Indigenous people in Victoria, Australia: a multicentre, prospective, observational, cohort study

BACKGROUND

Data on the patient characteristics and health outcomes of Indigenous Australians having revascularisation for treatment of coronary artery disease are scarce. The aim of this study was to assess differences in patient characteristics, presentations, and outcomes among Indigenous and non-Indigenous Australians having percutaneous coronary intervention (PCI) in urban and larger regional centres in Victoria, Australia.

METHODS

In this multicentre, prospective, observational cohort study, data were prospectively collected from six government-funded tertiary hospitals in the state of Victoria, Australia. The Melbourne Interventional Group PCI registry was used to identify patients having PCI at Victorian metropolitan and large regional hospitals between Jan 1, 2005, and Dec 31, 2018. The primary outcome was long-term mortality. Secondary outcomes were 30 day mortality and 30 day major adverse cardiovascular events (MACE), defined as a composite endpoint of death, myocardial infarction, and target-vessel revascularisation. Regression analyses, adjusted for clinically relevant covariates and geographical and socioeconomic indices, were used to establish the influence of Indigenous status on these study outcomes.

FINDINGS

41 146 patient procedures were entered into the registry, of whom 179 (0·4%) were recorded as identifying as Indigenous Australian, 39 855 (96·9%) were not Indigenous Australian, and 1112 (2·7%) had incomplete data regarding ethnicity and were excluded. Compared with their non-Indigenous counterparts, Indigenous patients were younger, more often women, and more likely to have comorbidities. Indigenous Australians were also more likely to live in a regional community and areas of socioeconomic disadvantage. Procedural success and complication rates were similar for Indigenous and non-Indigenous patients having PCI. At 30 day follow-up, Indigenous Australians were more likely to be taking optimal medical therapy, although overall follow-up rates were lower and prevalence of persistent smoking was higher. Multivariable analysis showed that Indigenous status was independently associated with increased risk of long-term mortality (hazard ratio 2·49, 95% CI 1·79-3·48; p<0·0001), 30 day mortality (odds ratio 2·78, 95% CI 1·09-7·12; p=0·033), and 30-day MACE (odds ratio 1·87, 95% CI 1·03-3·39; p=0·039).

INTERPRETATION

Indigenous Australians having PCI in urban and larger regional centres are at increased risk of mortality and adverse cardiac events. Clinically effective and culturally safe care pathways are urgently needed to improve health outcomes among Indigenous Australians who are having PCI.

FUNDING

National Health and Medical Research Council, National Heart Foundation.

The role of CHA2DS2-VASc score in evaluating patients with atrial fibrillation undergoing percutaneous coronary intervention

OBJECTIVE

The aim of the review was to assess whether CHA2DS2-VASc score is predictive of mortality in patients with atrial fibrillation undergoing percutaneous coronary intervention (PCI).

BACKGROUND

The CHA2DS2-VASc score is validated in predicting stroke risk in atrial fibrillation. The optimum management strategy for these patients undergoing PCI is still debated.

METHODS

The CHA2DS2-VASc score was calculated in consecutive patients with atrial fibrillation undergoing PCI in a large Australian registry between 2007 and 2013. Patients were divided into low (1-2), intermediate (3-4) and high (≥5) groups. Clinical and procedural data, 30-day, 1-year and long-term outcomes were compared between the groups.

RESULTS

A total of 564 patients were included in our analysis. Patients with high CHA2DS2-VASc scores had higher mortality rates at 1-year (2, 8, 15; P = 0.002) and long-term (6, 20, 37; P < 0.001). High-risk patients were more likely to have renal impairment and multivessel disease. Increasing CHA2DS2-VASc score was associated with increased risk of stroke (0, 2, 6; P = 0.03). However, only 41.9% received anticoagulation, with no difference across the risk groups. When compared to low-risk, intermediate [HR 3.57; 95% confidence interval (CI), 1.28-9.92; P = 0.015] and high (hazard ratio 7.82; 95% CI, 2.88-21.24; P < 0.001) CHA2DS2-VASc scores were significant predictors of long-term mortality.

CONCLUSIONS

Higher CHA2DS2-VASc scores in patients with atrial fibrillation undergoing PCI are associated with significantly worse outcomes. Despite being high-risk, the patients in this cohort are likely undertreated with anticoagulation. Close clinical follow-up with greater utilization of anticoagulation and optimal medical therapy has the potential to improve long-term outcomes.

Sex Disparity In Secondary Prevention Pharmacotherapy And Clinical Outcomes Following Acute Coronary Syndrome

Aims

We sought to investigate if sex disparity exists for secondary prevention pharmacotherapy following acute coronary syndrome (ACS) and impact on long-term clinical outcomes.

Methods and results

We analysed data on medical management 30-day post-percutaneous coronary intervention (PCI) for ACS in 20 976 patients within the multicentre Melbourne Interventional Group registry (2005–2017). Optimal medical therapy (OMT) was defined as five guideline-recommended medications, near-optimal medical therapy (NMT) as four medications, sub-optimal medical therapy (SMT) as ≤3 medications. Overall, 65% of patients received OMT, 27% NMT and 8% SMT. Mean age was 64 ± 12 years; 24% (4931) were female. Women were older (68 ± 12 vs. 62 ± 12 years) and had more comorbidities. Women were less likely to receive OMT (61% vs. 66%) and more likely to receive SMT (10% vs. 8%) compared to men, P &lt; 0.001. On long-term follow-up (median 5 years, interquartile range 2–8 years), women had higher unadjusted mortality (20% vs. 13%, P &lt; 0.001). However, after adjusting for medical therapy and baseline risk, women had lower long-term mortality [hazard ratio (HR) 0.88, 95% confidence interval (CI) 0.79–0.98; P = 0.02]. NMT (HR 1.17, 95% CI 1.05–1.31; P = 0.004) and SMT (HR 1.79, 95% CI 1.55–2.07; P &lt; 0.001) were found to be independent predictors of long-term mortality.

Conclusion

Women are less likely to be prescribed optimal secondary prevention medications following PCI for ACS. Lower adjusted long-term mortality amongst women suggests that as well as baseline differences between gender, optimization of secondary prevention medical therapy amongst women can lead to improved outcomes. This highlights the need to focus on minimizing the gap in secondary prevention pharmacotherapy between sexes following ACS.

Outcomes of Percutaneous Coronary Intervention in Patients With Rheumatoid Arthritis

Rheumatoid arthritis (RA) is the most common inflammatory arthritis and is associated with increased risk of cardiovascular events and mortality. Evidence regarding outcomes following PCI is limited. This study aimed to assess differences in outcomes following percutaneous coronary intervention (PCI) between patients with and without RA. The Melbourne Interventional Group PCI registry (2005 to 2018) was used to identify 756 patients with RA. Outcomes were compared with the remaining cohort (n = 38,579). Patients with RA were older, more often female, with higher rates of hypertension, previous stroke, peripheral vascular disease, obstructive sleep apnea, chronic lung disease, myocardial infarction, and renal impairment, whereas rates of dyslipidemia and current smoking were lower, all p <0.05. Lesions in patients with RA were more frequently complex (ACC/AHA type B2/C), requiring longer stents, with higher rates of no reflow, all p <0.05. Risk of long-term mortality, adjusted for potential confounders, was higher for patients with RA (hazard ratio 1.53, 95% confidence interval 1.30 to 1.80; median follow-up 5.0 years), whereas 30-day outcomes including mortality, major adverse cardiovascular events, bleeding, stroke, myocardial infarction, coronary artery bypass surgery, and target vessel revascularization were similar. In subgroup analysis, patients with RA and lower BMI (P_{for interaction} < 0.001) and/or acute coronary syndromes (P_{for interaction} = 0.05) had disproportionately higher risk of long-term mortality compared with patients without RA. In conclusion, patients with RA who underwent PCI had more co-morbidities and longer, complex coronary lesions. Risk of short-term adverse outcomes was similar, whereas risk of long-term mortality was higher, especially among patients with acute coronary syndromes and lower body mass index.

Role of beta blockers following percutaneous coronary intervention for acute coronary syndrome

AIMS

There is a paucity of evidence supporting routine beta blocker (BB) use in patients undergoing percutaneous coronary intervention (PCI) for acute coronary syndrome (ACS). The aim of this study was to evaluate BB use post PCI and its association with mortality. Furthermore, the study aimed to evaluate the association between BB and mortality in the subgroups of patients with left ventricular ejection fraction (LVEF) <35%, LVEF 35%-50% and LVEF >50%.

METHODS

Using a large PCI registry, data from patients with ACS between January 2005 and June 2017 who were alive at 30 days were analysed. Those patients taking BB at 30 days were compared with those who were not taking BB. The primary outcome was all-cause mortality. The mean follow-up was 5.3±3.5 years.

RESULTS

Of the 17 562 patients, 83.3% were on BB. Mortality was lower in the BB group (13.1% vs 19.5%, p=0.0001). Multivariable Cox proportional hazards model showed that BB use was associated with lower overall mortality (adjusted HR 0.87, 95% CI 0.78 to 0.97, p=0.014). In the subgroup analysis, BB use was associated with reduced mortality in LVEF <35% (adjusted HR 0.63, 95% CI 0.44 to 0.91, p=0.013), LVEF 35%-50% (adjusted HR 0.80, 95% CI 0.68 to 0.95, p=0.01), but not LVEF >50% (adjusted HR 1.03, 95% CI 0.87 to 1.21, p=0.74).

CONCLUSION

BB use remains high and is associated with reduced mortality. This reduction in mortality is primarily seen in those with reduced ejection fraction, but not in those with preserved ejection fraction.

Incidence and risk factors for stroke following percutaneous coronary intervention

BACKGROUND

Stroke rates and risk factors may change as percutaneous coronary intervention practice evolves and no data are available comparing stroke incidence after percutaneous coronary intervention to the general population.

AIMS

This study aimed to identify the incidence and risk factors for inpatient and subsequent stroke following percutaneous coronary intervention with comparison to age-matched controls.

METHODS

Data were prospectively collected from 22,618 patients undergoing percutaneous coronary intervention in the Melbourne Interventional Group registry (2005-2015). The cohort was compared to the North-East Melbourne Stroke Incidence Study population-based cohort (1997-1999) and predefined variables assessed for association with inpatient or outpatient stroke.

RESULTS

Inpatient stroke occurred in 0.33% (65.3% ischemic, 28.0% haemorrhagic, and 6.7% cause unknown), while outpatient stroke occurred in 0.55%. Inpatient and outpatient stroke were associated with higher rates of in-hospital major adverse cardiovascular outcomes (p < 0.0001) and mortality (p < 0.0001), as well as 12-month mortality (p < 0.0001). Factors independently associated with inpatient stroke were renal impairment, ST-elevation myocardial infarction, previous stroke, left ventricular ejection fraction 30-45%, and female sex, while those associated with outpatient stroke were previous stroke, chronic lung disease, previous myocardial infarction, rheumatoid arthritis, female sex, and older age. Compared to the age-standardized population-based cohort, stroke rates in the 12 months following discharge were higher for percutaneous coronary intervention patients <65 years old, but lower for percutaneous coronary intervention patients ≥65 years old.

CONCLUSIONS

Risk of inpatient stroke following percutaneous coronary intervention appears to be largely associated with clinical status at presentation, while outpatient stroke relates more to age and chronic disease. Compared to the general population, outpatient stroke rates following percutaneous coronary intervention are higher for younger, but not older, patients.

Short- and long-term outcomes of out-of-hospital cardiac arrest following ST-elevation myocardial infarction managed with percutaneous coronary intervention

AIM

Out-of-hospital cardiac arrest (OHCA) is frequently associated with ST-elevation myocardial infarction (STEMI) and has a high mortality. We aimed to identify differences in characteristics and very long-term outcomes for STEMI patients with and without OHCA managed with percutaneous coronary intervention (PCI).

METHODS

We analysed data from 12,637 PCI patient procedures for STEMI in the multi-centre Melbourne Interventional Group registry between January 2005 and December 2018. Multivariable models examined associations with OHCA presentation and 30-day mortality. Long-term outcomes were assessed through linkage with the Australian National Death Index.

RESULTS

Compared with patients without OHCA (N = 11,580), patients with OHCA (N = 1057) were younger, more often male, had less cardiovascular risk factors, and more often presented with cardiogenic shock. OHCA preceded an increasing proportion of STEMI PCI cases from 2005 to 2018 (2.4% vs. 9.2%). Factors independently associated with OHCA presentation were younger age, male gender, prior valve surgery, multi-vessel disease, LAD culprit, small vessel diameter, and renal impairment on presentation. Patients with OHCA had lower procedural success, higher rates of bleeding and stroke, larger infarct size (measured by peak CK), and higher 30-day mortality (37% vs. 5%; all p < 0.05). Cardiogenic shock, renal impairment and lower ejection fraction were independently associated with 30-day mortality. Long-term mortality was 44% vs. 20% (median follow-up 4.6 years), with Cox regression analysis demonstrating no difference in survival if patients survived beyond 30 days (HR 1.18, 95% CI 0.95-1.47).

CONCLUSIONS

OHCA has a high short-term mortality and precedes an increasing proportion of STEMI PCI cases. Thirty-day survivors have an excellent long-term prognosis.

The cost-effectiveness of guideline-driven use of drug-eluting stents: propensity-score matched analysis of a seven-year multicentre experience

Background: In routine clinical practice, the implantation of a drug-eluting stent (DES) versus a bare metal stent (BMS) for percutaneous coronary intervention (PCI) has been guided by criteria for appropriate use. The cost-effectiveness (CE) of adopting these guidelines, however, is not clear, and was investigated from the perspective of the Australian healthcare payer.Methods and results: Baseline and 12-month follow-up data of 12,710 PCI patients enrolled in the Melbourne Interventional Group (MIG) registry between 2004 and 2011 were analysed. Costs inputs were derived from a clinical costing database and published sources. Propensity-score-matching was performed for DES and BMS groups within sub-groups. Incremental cost-effectiveness ratios (ICERs) were evaluated for all patients, and sub-groups of patients with '0', 1, 2, or ≥3 indications for a DES. The incremental cost per target vessel revascularization avoided for the overall population was $24,683, and for patients with 0, 1, and 2 indications for a DES was $44,635, $33,335, and $23,788, respectively. However, for those with >3 indications, DES compared with BMS was associated with cost savings. At willingness to pay thresholds of $45,000-$75,000, the probability of cost-effectiveness of DES for the overall cohort was 71-91%, '0' indications, 49-67%, 1 indication, 56-82%, 2 indications, 70-90%, and ≥3 indications, 97-99%.Conclusions: The cost-effectiveness of DES compared with BMS increased with increasing risk profile of patients from those who had 1, 2, to ≥3 indications for a DES. When compared with BMS, DES was least cost effective among patients with '0' indications for a DES. Based on these results, selective use of DES implantation is supported. These findings may be useful for evidence-based clinical decision-making.

Prognostic significance of suboptimal secondary prevention pharmacotherapy after acute coronary syndromes

BACKGROUND

Optimal secondary prevention pharmacotherapy is the cornerstone of post-acute coronary syndrome (ACS) management. The prognostic impact of not receiving five guideline-recommended therapies is poorly described.

AIM

To ascertain the prognostic significance of suboptimal pharmacotherapy in ACS survivors.

METHODS

Consecutive patients with ACS from the Melbourne Interventional Group registry who were alive at 30 days following their index percutaneous coronary intervention were included. Patients were divided into three categories based on the number of secondary prevention medications prescribed. The optimal medical therapy (OMT), near-optimal medical therapy (NMT), suboptimal medical therapy (SMT) groups were prescribed 5, 4 and ≤ 3 medications, respectively. Primary endpoint was long-term mortality. Cox-proportional hazard modelling was undertaken to assess independent predictors of survival.

RESULTS

Of the 9375 patients included, 5678 (60.6%) received OMT, 2903 (31.0%) received NMT and 794 (8.5%) received SMT. Patients receiving SMT were older, more likely to be female and had higher burden of comorbidities (renal impairment, congestive heart failure, diabetes, peripheral vascular disease; P < 0.01 for all). SMT was associated with higher long-term mortality at 3.9 ± 2.2 years when compared to NMT and OMT (16.8% vs 10.5% vs 8.2%, P < 0.001). Compared to OMT, SMT was an independent predictor of long-term mortality (hazard ratio, HR 1.62, 95% confidence interval, CI 1.30-2.02, P < 0.01) while NMT was associated with a clinically significant 14% mortality hazard (HR 1.14, 95% CI 0.97-1.34, P = 0.11).

CONCLUSIONS

There is a graded long-term hazard associated with not receiving OMT after an ACS. Improvements in secondary prevention pharmacotherapy models of care are warranted to further decrease the long-term mortality.

Trends of Use and Outcomes Associated With Glycoprotein-IIb/IIIa Inhibitors in Patients With Acute Coronary Syndromes Undergoing Percutaneous Coronary Intervention

Background: Glycoprotein IIb/IIIa inhibitors (GPIs) are a treatment option in the management of acute coronary syndromes (ACSs). Evidence supporting the use of GPIs predates trials establishing the benefits of P2Y12 inhibitors, routine early invasive therapy, and thrombectomy devices in patients with ACS. Objective: The aim of this study was to determine trends in GPI use and their associated outcomes in contemporary practice. Methods: We assessed GPI use in patients with ACS undergoing percutaneous coronary intervention (PCI) from the Melbourne Interventional Group registry (2005-2013). The primary endpoint was the 30-day incidence of major adverse cardiovascular events (MACE). The safety endpoint was in-hospital major bleeding. Results: GPIs were used in 40.5% of 12 357 patients with ACS undergoing PCI. GPI use decreased over the study period (P for trend <0.0001). Patients were more likely to receive GPIs if they were younger, presented with a ST-elevation myocardial infarction (STEMI), had more complex (B2/C-type) lesions, and when thrombectomy devices were used (all P < 0.0001). MACE were higher in patients receiving GPI (4.9% vs 4.1%, P = 0.03). Propensity score matching revealed no difference in 30-day mortality and 30-day MACE (odds ratio [OR] = 1.00; 95% CI = 0.99-1.004 and OR = 1.01; 95% CI = 0.99-1.02, respectively). GPI use was associated with more bleeding complications (3.6% vs 1.8%, P < 0.0001). Conclusion and Relevance: GPI use in ACS patients undergoing PCI has declined, and use appears to be dictated by ACS type and lesion complexity, as opposed to high-risk comorbidities. GPI use was associated with a doubling in bleeding complications.

Impact of Gender and Door-to-Balloon Times on Long-Term Mortality in Patients Presenting With ST-Elevation Myocardial Infarction

Guidelines mandate emergent revascularization in patients presenting with ST-elevation myocardial infarction (STEMI) irrespective of gender. We sought to compare the door-to-balloon times and the impact of timely reperfusion on clinical outcomes in women compared with men presenting with STEMI undergoing primary percutaneous coronary intervention (PPCI). We analyzed data from 6,179 consecutive patients presenting with STEMI undergoing PPCI from the Melbourne Interventional Group registry (2005 to 2017). The primary outcome was long-term mortality. Of the 6,179 patients included 1,258 (20.3%) were female. Female patients were older (69 ± 13 vs 62 ± 12 years; p < 0.001), had more co-morbidities and had longer median symptom-to-balloon times (204 [interquartile range {IQR} 154 to 294] vs 181 [IQR 139 to 258] minutes; p < 0.001) and longer median door-to-balloon times (81 [IQR 55 to 102] vs 75 [IQR 51 to 102)] minutes; p < 0.001), while receiving less drug-eluting stents (39% vs 43%; p = 0.01) and having less radial access for PPCI (15% vs 21%; p < 0.001). Furthermore, female patients received less guideline-directed medical therapy than men with less prescription of aspirin (93.4% vs 95.4%; p = 0.02), statins (96.5% vs 97.6%; p < 0.05), and beta blockers (84.3% vs 89.4%; p < 0.001). Unadjusted in-hospital and 30-day mortality rates were higher in women (8.8% vs 6.2%, 9.8% vs 6.9%; p < 0.001). However, on Cox-proportional hazards modeling, gender was not an independent predictor of long-term mortality (hazards ratio 0.99, 95% confidence interval 0.83 to 1.18; p = 0.92) at a mean follow-up of 4.8 ± 3.5 years. In conclusion, in this large multicenter registry of patients with STEMI, women had longer ischemic times, higher risk profiles, and differing interventional approaches compared with men. Addressing these gender inequalities with early identification of symptoms, adherence to guideline-directed medical therapy, as well as higher rates of radial access and use of drug-eluting stents has the potential to further improve outcomes in women with STEMI.

Long-term clinical outcomes of transient and persistent no-reflow following percutaneous coronary intervention (PCI): a multicentre Australian registry

AIMS

The aim of the study was to evaluate long-term outcomes of transient versus persistent no-reflow.

METHODS AND RESULTS

A total of 17,547 patients with normal flow post percutaneous coronary intervention (PCI) were compared to 590 patients (3.2%) with transient no-reflow and 144 patients (0.8%) with persistent no-reflow. Long-term all-cause mortality was obtained by linkage with the National Death Index (NDI). No-reflow patients were more likely to have presented with ST-elevation myocardial infarction (STEMI), out-of-hospital cardiac arrest (OHCA) or cardiogenic shock (all p<0.01). Long-term NDI-linked all-cause mortality was highest in patients with persistent no-reflow (31%) followed by transient no-reflow (22%) and normal flow (14%) over a median follow-up of 5.2, 5.5 and 4.5 years, respectively (all p<0.0001). Kaplan-Meier survival estimates demonstrated a graded increase in all-cause mortality from normal flow, to transient to persistent no-reflow (p<0.01), with the highest mortality occurring early (<30 days) in the persistent no-reflow group (p<0.0001). Multivariate Cox proportional hazards modelling identified glomerular filtration rate <30 mL/min, ejection fraction <30%, persistent no-reflow and transient no-reflow as independent predictors of increased hazard for all-cause mortality (all p<0.05).

CONCLUSIONS

Transient and persistent no-reflow were associated with a stepwise reduction in long-term survival. The presence of even transient no-reflow appears to be an important predictor of adverse long-term outcome.

Late Post- Infarction Left Ventricular Pseudoaneurysm: A Case Report

We present a case of a 90 year-old-patient who presented with syncope. She had previous inferior acute myocardial infarction 10 years ago. Coronary angiography revealed left ventricular pseudoaneurysm, which was confirmed on cardiac computed tomography. The patient refused surgical repair and implantable cardioverter defibrillator insertion and was discharged from the hospital alive. This case demonstrates the possibility of long-term survival with left ventricular pseudoaneurysm and the increasing detection of 'incidental' left ventricular pseudoaneurysm with more frequent use of imaging.

One-Year Outcomes of Patients With Established Coronary Artery Disease Presenting With Acute Coronary Syndromes

The risk of major adverse cardiovascular events (MACE) remains high in patients with established coronary artery disease (CAD). The aim of this study was to assess the prognostic significance of established CAD in patients who present with acute coronary syndromes (ACS) using a large established multicenter registry. Consecutive patients from the Melbourne Interventional Group registry who presented with ACS and underwent percutaneous coronary intervention from 2005 to 2015 were included. Patients with a history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass graft surgery were included in the established CAD cohort. The primary end points were 12-month mortality and 12-month MACE. Of the 12,878 ACS patients included in our study, 3,542 (28%) patients had established CAD. Over the 10-year study period, the proportion of patients presenting with established CAD decreased (30.7% to 25.2%; p-for-overall-trend <0.001). Non-ST elevation myocardial infarction was the most prominent presentation in the established CAD cohort (45.1%) whereas ST-elevation myocardial infarction was the most prominent in the de novo CAD cohort (51%; p< 0.001). The patients in the established CAD cohort were older, had more co-morbidities and were more likely to present with high-risk features such as atrial fibrillation, left main disease, multivessel CAD and left ventricular dysfunction (all p < 0.001). Regarding revascularization in ST-elevation myocardial infarction presentations, symptom-to-door time was shorter, whereas door-to-balloon-time was longer in those with established CAD (p < 0.001). On multivariate analysis, established CAD was an independent risk factor for 12-month MACE (odds ratio 1.40, 95% confidence intervals 1.23 to 1.58, p < 0.001), but not for 12-month mortality (odds ratio 1.08, 95% confidence intervals 0.77 to 1.52, p = 0.66). In conclusion, patients with a history of myocardial infarction or previous revascularization have a higher rate of MACE at 12 months. Despite this they do not appear to suffer from higher mortality.

Heart Rate as a Predictor of Outcome Following Percutaneous Coronary Intervention

Data from previous studies of patients with heart failure and coronary artery disease suggest that those with higher resting heart rates (HRs) have worse cardiovascular outcomes. We sought to evaluate whether HR immediately before percutaneous coronary intervention (PCI) is an independent predictor for 30-day outcome. We analyzed the outcome of 3,720 patients who had HR recorded before PCI from the Melbourne Interventional Group registry. HR and outcomes were analyzed by quintiles, and secondarily by dichotomizing into <70 or ≥70 beats/min. Patients with cardiogenic shock, intra-aortic balloon pump or inotropic support, and out-of-hospital arrest were excluded. The mean ± SD HR was 70.9 ± 14.7 beats/min. HR by quintile was 55 ± 5, 64 ± 2, 70 ± 1, 77 ± 3, and 93 ± 13 beats/min, respectively. Patients with higher HR were more likely to be women, current smokers, have higher systolic and diastolic blood pressure, atrial fibrillation, recent heart failure, lower ejection fraction, and ST-elevation myocardial infarction as the indication for the PCI (all p ≤0.002). However, rates of treated hypertension, multivessel disease, previous myocardial infarction, PCI, and coronary bypass surgery were lower (all p ≤0.004). Increased HR was associated with higher 30-day mortality (p for trend = 0.04), target vessel revascularization (p for trend = 0.003), and 30-day major adverse cardiac events (MACE) (p for trend = 0.004). In a multivariable analysis, HR was an independent predictor of 30-day MACE (OR 1.21 per quintile; 95% confidence interval (CI): 1.06 to 1.39, p = 0.004). When dichotomized into <70 or ≥70 beats/min, HR independently predicted both 30-day MACE (OR 1.59, 95% CI 1.08 to 2.36, p = 0.02) and 30-day mortality (OR 2.80, 95% CI 1.10 to 7.08, p = 0.03). In conclusion, HR immediately before PCI is an independent predictor of adverse 30-day cardiovascular outcomes.

Pretreatment with dual antiplatelet therapy in patients with ST-elevation myocardial infarction

BACKGROUND

The optimal time to administer P2Y₁₂ inhibitors in patients with ST-elevation myocardial infarction (STEMI) remains to be defined. We sought to assess whether a pretreatment strategy was associated with improved coronary reperfusion and clinical outcomes.

METHODS

Consecutive patients from the Melbourne Interventional Group registry (2005-2014) who presented with STEMI and underwent primary PCI were included. Those who received any P2Y₁₂ inhibitor prior to arrival in the cardiac catheterisation laboratory were included in the pretreatment group. The primary endpoints were the proportion of patients with initial TIMI flow grade <3 and in-hospital bleeding. The secondary endpoints were 12-month mortality and major adverse cardiovascular events (MACE).

RESULTS

Of the 2,807 patients included, 892(31.8%) received pretreatment. Clopidogrel was the most common P2Y₁₂ inhibitor used (79.6%). Pretreatment was associated with less thromboaspiration and GPIIb/IIIa inhibitor use (both P < 0.01). Pretreatment was not associated with lower rates of TIMI flow <3 on initial angiogram (78.0% vs. 80.7%, P = 0.18) nor with increased in-hospital bleeding (3.6% vs. 3.9%, P = 0.67). Pretreatment was associated with lower 12-month mortality (4.7% vs. 7.0%, P = 0.02) but similar MACE rate (13.0% vs. 14.1%, P = 0.43). Multivariate analysis revealed pretreatment was not an independent predictor of 12-month mortality (OR 0.79; 95% CI 0.5-1.3, P = 0.32).

CONCLUSION

Pretreatment with a P2Y₁₂ inhibitor in patients with STEMI was not routine practice in our Australian cohort and was not associated with improved coronary reperfusion or clinical outcomes. Larger studies are required to definitively ascertain the risk/benefit ratio of dual antiplatelet therapy pretreatment in STEMI.

Temporal Changes in Characteristics, Treatment and Outcomes of Heart Failure Patients Undergoing Percutaneous Coronary Intervention Findings From Melbourne Interventional Group Registry

BACKGROUND

Limited data exist on whether outcomes of patients with heart failure (HF) undergoing percutaneous coronary intervention (PCI) have improved over time. The purpose of this study was to assess temporal trends in patient characteristics, treatment and outcomes of patients with HF undergoing PCI.

METHODS

Using data from the Melbourne Interventional Group (MIG), we evaluated temporal trends of procedure volume, major adverse cardiac events (MACE; a composite of all-cause mortality, myocardial infarction and target vessel revascularisation) and rates of cardiovascular readmission, all-cause death and cardiovascular death in consecutive patients with HF undergoing PCI. Change over time was assessed by Box-Jenkins autoregressive integrated moving average (ARIMA) models.

RESULTS

Data from 1,604 patients were analysed. In our cohort, there were no significant changes in the number of procedures performed annually and patient characteristics between January 2005 and December 2014. Optimal use of HF therapy has improved over the study period. Planned clopidogrel therapy of more than 12 months increased in tandem with increasing use of drug-eluting stents (DES). Procedural success was high (≥90%). However, the rates of MACE, cardiovascular readmission, all-cause death and cardiovascular death remained unchanged throughout the study period.

CONCLUSIONS

Clinical outcomes in HF patients undergoing PCI have remained unchanged despite improvement in medical technology and contemporary therapeutic measures.

Fibromyalgia has a high prevalence and impact in cardiac failure patients

Objective

Chronic cardiac failure (CCF) shares several clinical features with fibromyalgia (FM), a syndrome of increased central sensitivity and musculoskeletal pain. FM frequently coexists with other chronic illness. Musculoskeletal pain is reported in patients with CCF; however, the prevalence and impact of FM in patients with CCF is not known. This research aims to assess the prevalence and effects of concurrent FM in patients with CCF and to identify other coexisting central sensitivity syndromes.

Material and Methods

In a cross-sectional study, demographic, clinical, and functional information was gathered from participants with CCF from public and private clinics. Cardiac failure severity was rated using the New York Heart Association (NYHA) scale. FM diagnosis was determined using 2011 American College of Rheumatology (ACR) criteria. The short-form 36 (SF-36) assessed overall health function.

Results

Of the 57 CCF participants (63.2% male, mean age 70.3 years), 22.8% (n=13) met FM diagnostic criteria. CCF patients with FM had poorer outcomes across multiple SF-36 domains (p<0.05), compared to those without, despite having comparable CCF severity. Those with FM were more likely to report other central sensitivity syndromes, especially temporomandibular joint dysfunction (mean Δ=23%, p<0.05), headache (mean Δ=28.8%, p<0.05), and irritable bladder (mean Δ=14%, p<0.05).

Conclusion

High prevalence of FM was found in patients with CCF. This was associated with increased likelihood of other comorbid central sensitivity syndromes and with poorer clinical outcomes. The recognition of coexisting FM in patients with CCF provides an important opportunity to improve health outcomes by managing FM-related symptoms, in addition to symptoms that relate specifically to CCF.

The prognostic significance of smoking cessation after acute coronary syndromes: an observational, multicentre study from the Melbourne interventional group registry

OBJECTIVE

We aim to ascertain the prognostic significance of persistent smoking and smoking cessation after an acute coronary syndrome (ACS) in the era of percutaneous coronary intervention (PCI) and optimal secondary prevention pharmacotherapy.

METHODS

Consecutive patients from the Melbourne Interventional Group registry (2005-2013) who were alive at 30 days post-ACS presentation were included in our observational cohort study. Patients were divided into four categories based on their smoking status: non-smoker; ex-smoker (quit >1 month before ACS); recent quitter (smoker at presentation but quit by 30 days) and persistent smoker (smoker at presentation and at 30 days). The primary endpoint was survival ascertained through the Australian National Death Index linkage. A Cox-proportional hazards model was used to estimate the adjusted HR and 95% CI for survival.

RESULTS

Of the 9375 patients included, 2728 (29.1%) never smoked, 3712 (39.6%) were ex-smokers, 1612 (17.2%) were recent quitters and 1323 (14.1%) were persistent smokers. Cox-proportional hazard modelling revealed, compared with those who had never smoked, that persistent smoking (HR 1.78, 95% CI 1.36 to 2.32, p<0.001) was an independent predictor of increased hazard (mean follow-up 3.9±2.2 years) while being a recent quitter (HR 1.27, 95% CI 0.96 to 1.68, p=0.10) or an ex-smoker (HR 1.03, 95% CI 0.87 to 1.22, p=0.72) were not.

CONCLUSIONS

In a contemporary cohort of patients with ACS, those who continued to smoke had an 80% risk of lower survival while those who quit had comparable survival to lifelong non-smokers. This underscores the importance of smoking cessation in secondary prevention despite the improvement in management of ACS with PCI and pharmacotherapy.

Clopidogrel, prasugrel or ticagrelor in patients with acute coronary syndromes undergoing percutaneous coronary intervention

BACKGROUND

Guidelines recommend prasugrel or ticagrelor instead of clopidogrel in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary interventions (PCI).

AIM

We sought to describe the trends in uptake of the newer agents and analyse the clinical characteristics and short-term outcomes of patients treated with clopidogrel, prasugrel or ticagrelor.

METHODS

We analysed the temporal trends of antiplatelet use since the availability of prasugrel (2009-2013) in patients with ACS from the Melbourne Interventional Group registry. To assess clinical characteristics and outcomes, we included 1850 patients from 2012 to 2013, corresponding to the time all three agents were available. The primary outcome was major adverse cardiovascular events (MACE). The safety end-point was in-hospital bleeding.

RESULTS

For the period of 2009-2013, the majority of patients were treated with clopidogrel (72%) compared with prasugrel (14%) or ticagrelor (14%). There was a clear trend towards ticagrelor by the end of 2013. Patients treated with clopidogrel were more likely to present with non-ST-elevation ACS, be older, and have more comorbidities. There was no difference in unadjusted 30-day mortality (0.9 vs 0.5 vs 1.0%, P = 0.76), myocardial infarction (2 vs 1 vs 2%, P = 0.52) or MACE (3 vs 3 vs 4%, P = 0.57) between the three agents. There was no difference in in-hospital bleeding (3 vs 2 vs 2%, P = 0.64).

CONCLUSION

Prasugrel and ticagrelor are increasingly used in ACS patients treated with PCI, predominantly in a younger cohort with less comorbidity. Although antiplatelet therapy should still be individualised based on the thrombotic and bleeding risk, our study highlights the safety of the new P2Y12 inhibitors in contemporary Australian practice.

Management and outcomes of significant non-culprit coronary artery lesions in STEMI: a retrospective cohort study

<p>BACKGROUND<br /> In the setting of ST-elevation myocardial infarction (STEMI) and multi-vessel disease (MVD), guidelines recommend revascularization of the culprit lesion (CL) only, due to poor evidence supporting intervention in non-culprit lesions (non-CLs) during the same index procedure. Debate over management for significant non-CLs is of interest i.e. medical management vs. percutaneous revascularization. We describe a cohort of patients with STEMI and MVD and compare the occurrence of major adverse cardiac events (MACE) by therapeutic strategies for non-CLs with regard to follow-up outcomes.</p><p>METHODS<br /> 86 patients with STEMI and MVD were identified from a database of STEMI presentations to the University Hospital Limerick from Jan 2011 to April 2013. The occurrence of MACE was established by follow up with patients’ general practitioners.</p><p>RESULTS<br /> 48% of presentations had MVD. Predominant management for non-CLs was medical therapy alone comprising 58% (n=50) of patients, while 23% (n=20) of patients underwent PCI for non-CL, and 19% (n=16) had CABG.</p><p>Median follow up was 1.8 years (range 9–36 months).  We found no significant difference in the occurrence of MACE  between medical management of non-CLs and PCI of non-CLs (OR 1.10 95%CI 0.34, 3.56; p= 0.88). CABG however does show a trend to be superior to both PCI (OR 3.10 95%CI 0.54, 17.88; p= 0.21) and medical management (OR 2.83 95%CI 0.65, 12.27; P= 0.17) in non-CLs.</p><p>CONCLUSIONS<br /> CABG appears superior to both PCI or medical management in preventing MACE over time, and PCI is not superior to medical management alone.</p>

Pre-treatment with dual antiplatelet therapy in patients with non-ST-segment elevation acute coronary syndromes undergoing percutaneous coronary intervention

BACKGROUND

Although dual antiplatelet therapy is the standard of care in non-ST-segment elevation acute coronary syndromes (NSTEACS), it remains unclear when a second antiplatelet agent should be initiated. We sought to assess the safety and efficacy of pre-treatment with clopidogrel in patients with NSTEACS undergoing percutaneous coronary intervention (PCI).

METHODS

We analysed baseline clinical and procedural characteristics of 6817 patients with NSTEACS who underwent PCI from the Melbourne Interventional Group registry from 2005 to 2012. Patients were included in the pre-treatment group if clopidogrel was administered prior to cardiac catheterisation. We assessed 30-day mortality, myocardial infarction (MI) and major adverse cardiovascular events. The safety endpoint was in-hospital bleeding.

RESULTS

Of the 6817 patients, only 2951 (43%) received pre-treatment with clopidogrel. Patients in the pre-treatment group were more likely to present with unstable angina (70.8% vs 68.2%, P = 0.02) and have a history of MI (35.6% vs 23.6%, P < 0.01) but were less likely to have PCI within 24 h of admission (17.2% vs 25.2%, P < 0.01). There was no difference between the groups in 30-day mortality (0.9% vs 1.4%, P = 0.06), MI (2.0% vs 2.2%, P = 0.52) or major adverse cardiovascular event (3.7% vs 4.2%, P = 0.25). There was no difference in bleeding complications (1.9% vs 1.9%, P = 0.94).

CONCLUSIONS

Pre-treatment with dual antiplatelet therapy in NSTEACS is not routine clinical practice in Australia. Pre-treatment appears safe but is not associated with improved short-term clinical outcomes.

Trends in door-to-balloon time and outcomes following primary percutaneous coronary intervention for ST-elevation myocardial infarction: an Australian perspective

BACKGROUND

Guidelines for patients with ST-elevation myocardial infarction include a door-to-balloon time (DTBT) of ≤90 min for primary percutaneous coronary intervention.

AIM

The aim of this study was to assess temporal trends (2006-2010) in DTBT and determine if a reduction in DTBT was associated with improved clinical outcomes.

METHODS

We compared annual median DTBT in 1926 STEMI patients undergoing primary percutaneous coronary intervention from the Melbourne Interventional Group registry. ST-elevation myocardial infarction presenting >12 h and rescue percutaneous coronary intervention was excluded. Major adverse cardiac events were analysed according to DTBT (dichotomised as ≤90 min vs >90 min). A multivariable analysis for predictors of mortality (including DTBT) was performed.

RESULTS

Baseline demographics, clinical and procedural characteristics were similar in the STEMI cohort across the 5 years, apart from an increase in out-of-hospital cardiac arrest (3.6% in 2006 vs 9.4% in 2010, P < 0.0001) and cardiogenic shock (7.7-9.6%, P = 0.07). The median DTBT (interquartile range) was reduced from 95 (74-130) min in 2006 to 75 (51-100) min in 2010 (P < 0.01). In this period, the proportion of patients achieving a DTBT of ≤90 min increased from 45% to 67% (P < 0.01). Lower mortality and major adverse cardiac event rates were observed with DTBT ≤90 min (all P < 0.01). Multivariable analysis showed that a DTBT of ≤90 min was associated with improved clinical outcomes at 12 months (odds ratio 0.48; 95% confidence interval 0.33-0.73, P < 0.01).

CONCLUSION

There has been a decline in median DTBT in the Melbourne Interventional Group registry over 5 years. DTBT of ≤90 min is associated with improved clinical outcomes at 12 months.

Impact of renal function in patients with multi-vessel coronary disease on long-term mortality following coronary artery bypass grafting compared with percutaneous coronary intervention

BACKGROUND

Comorbidities, such as diabetes, affect revascularization strategy for coronary disease. We sought to determine if the degree of renal impairment affected long-term mortality after percutaneous coronary intervention (PCI) compared to coronary artery bypass grafting (CABG) in patients with multi-vessel coronary disease (MVD).

METHODS AND RESULTS

8970 patients with MVD undergoing revascularization between 2004 and 2008, in two multi-center parallel PCI and CABG Australian registries were assigned to three groups based on their estimated glomerular filtration rate (eGFR)≥60 mL/min/1.73 m2 (n=1678:839), 30-59 mL/min/1.73 m2 (n=452:226) and <30 mL/min/1.73 m2 (n=74:37). We used 2:1 propensity matching to compare 3306 patients undergoing primary CABG versus PCI. Shock, myocardial infarction (MI)<24 h, previous CABG, valve surgery or PCI were exclusions. Long-term mortality (mean 3.1 years) was compared with Cox-proportional hazard-adjusted modeling. Observed long-term mortality rates (CABG vs. PCI) were 4.5% vs. 4.3% p=0.84, 12.8% vs. 17.3% p=0.12, and 23.0% vs. 40.5% p=0.05 in the three strata, respectively. In patients with eGFR≥60 mL/min/1.73 m2, long-term mortality between PCI and CABG (HR 0.99, 95% CI 0.65-1.49, p=0.95) was similar. However, amongst patients with eGFR 30-59 mL/min/1.73 m2, there was a significant mortality hazard with PCI (HR 2.00, 95% CI 1.32-3.04, p=0.001). In patients with eGFR<30 mL/min/1.73 m2, there was a trend for hazard with PCI (HR 1.66, 95% CI 0.80-3.46, p=0.17).

CONCLUSION

Long-term mortality in MVD patients with preserved renal function was very low and similar between PCI and CABG. However there was a long-term mortality hazard associated with PCI amongst patients with moderate renal impairment.