Sex inequities in the performance of the GRACE 2.0 score in non-ST-segment elevation acute coronary syndromes: a multinational observational study in contemporary cohorts from four European countries

Background

The Global Registry of Acute Coronary Events (GRACE) score was developed and validated in predominantly male patient populations. Growing evidence indicates distinct pathophysiologic and clinical characteristics of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) in women and men.

Purpose

We aimed to assess sex differences in the performance of the GRACE score in NSTE-ACS in contemporary populations.

Methods

We calculated GRACE 2.0 risk estimates for patients with NSTE-ACS in contemporary nation-wide ACS cohorts from England, Wales, and Northern Ireland (MINAP, 2005–2017, n=400,054) and from Switzerland (AMIS Plus, 2005–2020, n=20,727; SPUM-ACS, 2009–2017, n=2,239). Sex disaggregated analyses were stratified according to the mortality endpoint of the score (in-hospital death, death at 6 months, death at 1 year), the clinical setting (calculated at admission and calculated for hospital survivors, respectively), the geographic region (United Kingdom and Switzerland, respectively) and the level of care (all hospitals and PCI-capable university hospitals, respectively). The area under the receiver operating characteristic curve (AUC), the average prediction error (APE), and the misclassification rate (MCR) were compared between women and men.

Results

The discriminatory performance of GRACE 2.0 for in-hospital death was lower and the APE and MCR were higher in women as compared to men in the United Kingdom (AUC female: 80.4%, 95% confidence interval [CI], 80.0 to 80.8, AUC male: 84.7%, 95% CI, 84.4 to 85.1, p<0.001; APE female: 0.0512, 95% CI, 0.0501–0.0522, APE male: 0.0357, 95% CI, 0.0351 to 0.0363; MCR female: 5.81%, 95% CI, 5.68 to 5.94, MCR male: 3.96, 95% CI, 3.89 to 4.03) and in Switzerland (AUC female: 84.2%, 95% CI, 81.4 to 86.8, AUC male: 88.5%, 95% CI 87.1–89.7, p=0.003; APE female: 0.0420, 95% CI 0.0376 to 0.0465, APE male: 0.0312, 95% CI 0.0289 to 0.0335; MCR female: 4.98%, 95% CI 4.39 to 5.56, MCR male: 3.69%, 95% CI, 3.39 to 4.00). Similar results were obtained for 6-month death and 1-year death endpoints across clinical settings, geographic regions, and levels of care. The risk of in-hospital death relative to males was increased in females that GRACE 2.0 classified as low-to-intermediate risk (suggesting no early invasive management strategy) in the United Kingdom (relative risk [RR]: 1.61, 95% CI, 1.50 to 1.74, p<0.001) and in Switzerland (RR: 1.84, 95% CI, 1.28 to 2.64, p<0.001).

Conclusion

Thus far, this is the largest investigation on the GRACE risk score. We confirmed good overall score performance and found decreased performance in contemporary female patients with NSTE-ACS irrespective of the mortality endpoint, the clinical setting, the geographic region, and the level of care.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation

Collaterals and extent of myocardial injury in patients with acute coronary syndromes – an analysis of the prospective SPUM-ACS cohort

Introduction

The impact of collateral circulation in the presence of severe coronary artery disease such as chronic total occlusion (CTO) has been extensively studied, with results despite few discrepancies, supporting an overall benefit on preservation of myocardial tissue and left ventricular ejection fraction (LVEF). However, less is known about the protective effects of collaterals in the context of acute coronary syndromes (ACS). In the current study we sought to analyze the incidence, grade and impact of collateral circulation in a large prospectively recruited cohort of patients presenting with ACS with independent events adjudication.

Methods and results

4'546 ACS patients presenting with ACS, enrolled in the prospective Special Program University Medicine ACS (SPUM-ACS) cohort were included. The current analysis showed the presence of a collateralized culprit lesion in 12.9% (n=586) of patients, 84% (n=492) originating from the contralateral side and 16% (n=94) from the ipsilateral side. Of those 64.6% (n=378) were being graded as Rentrop 2 or more. There were no differences in baseline characteristics between the two groups including incidence of diabetes, coronary artery disease, age and gender. However, despite the presence of collaterals graded Rentrop 2 or more, those patients had a significantly lower LVEF mean 48,44% vs 51.6%, p=0.025 and higher creatinine Kinase levels, mean (CK) 981 U/I vs 957 UI, p<0.001 as compared to patients with absent collateral-circulation on admission. Interestingly a sub analysis of the STEMI population showed no significant differences in both LVEF and CK at presentation, while troponin (TNT) plasma levels were significantly lower in patients with collaterals (mean TNT 0.0031 ug/l vs 0.035 ug/l p=0.001). Additionally no differences in cardiovascular mortality, stent thrombosis or MI was seen at one year follow-up.

Conclusion

The current analysis highlights a possible protective impact of a pre-existing collateral circulation against myocardial injury in the setting of ACS and ST elevation myocardial infarction. However this was not translated into improvement in hard outcomes acutely and up to one year of follow up, but may be important in the long run.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Research Foundation - ZurichHeart House

Sex differences in acute coronary syndromes: a never ending same old story or sign for improvement

Introduction

We previously described sex differences in baseline characteristics, interventional therapy and mortality in patients admitted for acute coronary syndromes (ASC) in Swiss hospitals and enrolled in the AMIS Plus registry between 1997 and 2006 (1). This present analysis aimed to reassess whether anything changed over the last 15 years.

Method

All AMIS Plus patients enrolled between 2007 and 2021 were included. Baseline characteristics, therapy and outcome were analysed according to sex and age groups. Multivariate analyses were performed to assess independent predictors of in-hospital mortality.

Results

Among 42,471 patients, 10,825 (25.5%) were women. Women were still older (71.6±12.6y vs. 64.2±12.6y for men), had more comorbidities (Charlson Comorbidity Index>1: 26.5% vs. 21.7%), were less likely to receive drug therapy (e.g., P2Y12 inhibitors 83.3% vs. 89.2% or statins 73.0% vs. 78.5%) and underwent percutaneous coronary intervention (PCI) less frequently (OR 0.77; 95% CI 0.73–0.83). These findings paralleled our observations for the period 1997–2006. However, the increase in PCI use over the years, particularly in women, led to a marked decrease in differences between men and women with respect to revascularization, from 16.6% in 2006 down to 2.0% in 2020. Unadjusted in-hospital mortality was higher in women (OR 1.55; 95% CI 1.41–1.70), but this significance disappeared after adjustment for baseline differences (OR 1.07; (95% CI 0.96–1.20)). However, in women under the age of 50 years, crude mortality (3.1% versus 1.6%) was significantly higher than in same-aged men; adjusted OR 1.78 (95% CI 0.99–3.20).

Conclusions

Sex differences in the baseline characteristics of ACS patients and the use of evidence-based drugs persisted but the sex gap in PCI access slowly but surely diminished. Female sex per se was not an independent predictor of in-hospital mortality in the overall population but it showed a strong trend among patients younger than 50 years of age.

Funding Acknowledgement

Type of funding sources: None.

Heart rate and mortality in myocardial infarction: incremental or bimodal correlation?

Introduction

Risk prediction scores adopted in acute coronary syndromes use incremental models to estimate mortality for heart rate (HR) above 60 bpm. Nonetheless, a non-linear, bimodal relationship, with higher event rates at low or high HR, has been described, potentially hampering risk prediction accuracy.

Purpose

Our aim was to assess the prognostic impact of bradycardia, defined as admission HR <50 bpm, in myocardial infarction (MI) among patients enrolled in a large nationwide registry.

Methods

Data of patients enrolled between 1999 and 2021 stratified by admission HR were retrospectively analysed. The primary endpoint was in-hospital mortality. The secondary endpoint was a composite of death, cerebrovascular event, and reinfarction. Associations between HR and outcomes were assessed at univariate and multivariable logistic regression analyses, then verified after sequential propensity-score matchings among HR groups.

Results

51001 patients (median age 66 years, IQR 56–76) were included. Crude estimates showed a bimodal distribution of primary and secondary endpoints with peaks at low and high HR. Association of HR <50 bpm with mortality was recognised only at primary multivariable logistic regression analysis (OR 1.49; 95% CI 1.01–2.13 p=0.038) but not at multiple sensitivity analyses after exclusion of patients on negative chronotropic therapy. Three sequential propensity-score matching were performed among patients with HR <50 bpm at admission and those with HR 50–75 bpm, HR 76–100 bpm and HR >100 bpm at admission, identifying 1159, 1159 and 1158 matched pairs, respectively. After propensity-score matching, rates of primary and secondary endpoints equalled among groups with HR <100 bpm.

Conclusions

Bradycardia (HR <50 bpm) at admission in patients with MI identified a group with higher crude rate of adverse events. Nonetheless, the signal supporting an independent association between bradycardia at admission and short-term mortality is weak and was not confirmed after correction for relevant baseline differences by propensity score matching. These findings support the hypothesis that lower HR might not be causative for the worse outcomes, but rather serves as a marker of underlying morbidity.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The AMIS Plus registry is funded by unrestricted grants from the Swiss Heart Foundation and from Abbot AG, Amgen AG, AstraZeneca AG, Bayer (Schweiz) AG, Biotronik AG, Boston Scientific AG, B. Braun Medical AG, Daiichi-Sankyo/Lilly AG, Cordis Cardinal Health GmbH, Medtronic AG, Novartis Pharma Schweiz AG, Sanofi-Aventis (Schweiz) AG, SIS Medical AG, Terumo AG, Vascular Medical GmbH, all in Switzerland, and the Swiss Working Group for Interventional Cardiology. The sponsors did not play any role in the design, data collection, analysis, or interpretation of data.

Treatment and outcome of patients with acute myocardial infarction and chronic lung disease: insights from the nationwide AMIS Plus registry

Introduction

Little is known about patients with acute myocardial infarction (AMI) and chronic lung disease (CLD). The aim of our study was to analyze risk factors, treatment, and outcome of AMI patients with CLD over the last 20 years using the nationwide AMIS Plus registry.

Methods

All AMI patients enrolled in the AMIS Plus registry with data on CLD between January 2002 and December 2021 were included. Chronic lung disease was determined according to the definition used in the Charlson Comorbidity Index. Data on baseline characteristics, regular medication, immediate therapy within 24 hours, in-hospital interventions and treatments, in-hospital outcome, complications and discharge medication were analyzed using descriptive statistics and logistic regression.

Results

Among 53,680 AMI patients, 5.8% had a CLD. The CLD group included 26.6% female and 73.4% male patients. Gender distribution was similar in patients with and without CLD. Patients with CLD were significantly older (71.2 vs. 65.8 y; p<0.001), more frequently diagnosed with NSTEMI, had more comorbidities and were less frequently never smokers (17.4% vs. 35.3%; p<0.001) compared to patients without CLD. In addition, CLD patients were less likely to receive aspirin, P2Y12 inhibitors, beta-blockers, ACE inhibitors and statins (all p<0.001), and were also less likely to undergo percutaneous coronary interventions (68.7% vs. 82.5%; p<0.001). Median length of stay was 2 days longer for CLD patients. Patients with CLD had more major adverse cardiac and cerebrovascular events in-hospital (10.3% vs. 5.9%; p<0.001) and higher crude in-hospital mortality (8.3% vs. 4.7%; p<0.001). However, multivariable regression analysis showed that CLD was not an independent predictor for in-hospital mortality (OR 1.19 (95% CI 0.98–1.45), p=0.081).

Conclusion

Patients with CLD were less likely to receive evidence-based medicine and had a worse in-hospital outcome compared to those without CLD. However, after adjustment, CLD was not an independent predictor of in-hospital mortality.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca AG, Biotronik (Schweiz) AG

Bleeding risk in patients hospitalized for non-ST-segment elevation acute coronary syndromes in Switzerland: performance of the CRUSADE score

Background

Evaluation of bleeding risk is critical to the management of patients with non-ST-segment elevation acute coronary syndromes (NSTE-ACS). The CRUSADE score is the most established tool to estimate major bleeding events following the index NSTE-ACS.

Purpose

We aimed to assess the performance of the CRUSADE score and the predictive utility of the individual score variables in contemporary European populations.

Methods

The CRUSADE score was studied in prospectively recruited Swiss patients with NSTE-ACS included in the multicentre SPUM-ACS study (n=4'787) and main findings were validated in the nation-wide AMIS Plus registry (n=46'939). Major bleeding during hospitalization was defined as Bleeding Academic Research Consortium (BARC) class IIIB, IIIC, IV, or V. Discrimination was evaluated by the area under the receiver operating characteristic curve (AUC). Multivariable-adjusted risk ratios (adj RR) were estimated for each of the 8 score variables. Hematocrit estimates were based on hemoglobin concentrations in AMIS Plus. Analyses were performed on complete and imputed data (multiple imputation using chained equations).

Results

CRUSADE showed poor discriminatory performance (SPUM-ACS: AUC, 0.65; 95% CI 0.57 to 0.72) and low balanced accuracy (SPUM-ACS: 0.50). Risk predicted by CRUSADE exceeded the observed risk across all predefined risk categories (very low, low, moderate, high, and very high). Decision curve analyses suggested little to no net benefit from using the score. Adjusting for other score variables, signs of heart failure (adj RR, 3.83; 95% CI, 1.93 to 7.37), low hematocrit (adj RR, 2.16; 95% CI, 0.55 to 7.70; <31% vs. >40%), and low systolic blood pressure (adj RR, 2.70; 95% CI, 1.14 to 6.16; <100 mmHg vs. >121 mmHg) were the strongest predictors of major in-hospital bleeds in SPUM-ACS. These findings were similarly observed in AMIS Plus.

Conclusion

The CRUSADE score overestimates bleeding risk in NSTE-ACS. Among all 8 score variables, signs of heart failure, low hematocrit, and low systolic blood pressure are the strongest predictors of major in-hospital bleeds in contemporary patients with NSTE-ACS.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Swiss National Science FoundationSwiss Heart Foundation

Acute myocardial infarction and work inability: insights from the AMIS Plus registry

Introduction

The impact of acute myocardial infarction (AMI) on the ability to pursue professional life is not well defined. Using a nationwide database, we aimed to describe the ability to return to work after AMI in Switzerland and identify factors associated therewith.

Methods

AMI patients of working-age enrolled in the AMIS Plus registry between 01/2006 and 09/2020 with data on self-reported work status before and 12 months after AMI were included. Using the Kruskal-Wallis rank sum test or Fisher's exact test we compared patient characteristics between those who did not reduce work hours, those who reduced, and those no longer working 12 months after the AMI.

Results

Of 4315 AMI patients (median (IQR) age 54 (49, 59)), 3204 (74.3%) did not reduce work, 592 (13.7%) reduced and 519 (12.0%) stopped working. Patients not reducing were youngest (median age (IQR)): 54y (49y, 58y), those who reduced: 56y (51y, 60y), those who stopped: 56y (51y, 61y), p<0.001) and more often men (no reduction: 90%, reduced: 80%, stopped: 82%, p<0.001). Patients who reduced showed worst cardiac function at AMI reflected in the highest rates of Killip class>2 (no reduction: 1.8%, reduced: 5.2%, stopped: 3.3%, p<0.001) and resuscitation before admission (no reduction: 4.1%, reduced: 6.9%, stopped: 4.0%, p=0.008). Patients who stopped work had the most comorbidities such as past AMI (no reduction: 8.6%, reduced: 10%, stopped: 13%, p=0.003), hypertension (no reduction: 45%, reduced: 50%, stopped: 54%, p<0.001), diabetes (no reduction: 10%, reduced: 13%, stopped: 16%, p<0.001) and cerebrovascular disease (no reduction: 0.8%, reduced: 1.2%, stopped: 2.3%, p=0.007). There was no significant difference for rehabilitation participation during follow up (no reduction: 84%, reduced: 86%, stopped: 84%, n.s. for all group comparisons). Multivariable regression showed that the reduction group had a higher proportion of women (OR 2.30; 95% CI 1.80–2.93 p<0.001) and were more likely to have a Killip class >2 at admission (OR 2.58; 95% CI 1.54–4.31 p<0.001) as compared to the no reduction group whereas the comparison between no reduction and work stop identified comorbidities (past MI (OR 1.46; 95% CI 1.07–1.94 p=0.016), diabetes (OR 1.59; 95% CI 1.21–2.09 p=0.001), cerebrovascular disease (OR 2.53; 95% CI 1.22–5.25 p=0.013)) and being female (OR 1.98; 95% CI 1.51–2.58 p<0.001) as major predictors for work stop.

Conclusion

Our data showed that 1:7 had reduced and 1:8 stopped professional activity 1 year after AMI. Younger age, being male and lower rates of comorbidities such as a past AMI, hypertension, diabetes and cerebrovascular disease were important factors associated with returning to work after AMI. Work reduction was significantly related with worse cardiac function whereas work stop was more related with comorbidities.

Funding Acknowledgement

Type of funding sources: None.

Patent foramen ovale closure: a comparison between two types of devices in a retrospective cohort

Background

Patent foramen ovale (PFO) closure has been shown to reduce the risk of recurrent stroke in selected patients. Different PFO occluding devices have been validated by the authorities and are used in the clinical practice.

Purpose

The main purpose of this study is to compare the use of two types of devices for PFO closure, the GORE CARDIOFORM Septal occluder and the AMPLATZER occluders (PFO or CRIBIFORM) in terms of major clinical safety and efficacy outcomes.

Methods

In this single-center retrospective study, the final cohort comprised 182 patients who underwent PFO closure between January 2012 and May 2019 (mean age 57±13 years, 34% males). The population was divided in two groups according to the device used (GORE CARDIOFORM Septal occluder [n=66, 36%] or the AMPLATZER occluders [n=116, 64%]). The endpoints assessed at 6 months, were the presence of a significant shunt (at least moderate [10–25 microbubbles] at rest or during the Valsalva manoeuvre), the incidence of supraventricular arrythmias, recurrent stroke, or serious device-related adverse events.

Results

At 6 months, a small percentage of patients with significant residual shunt was found in both the GORE and the AMPLATZER groups (7% vs 14% respectively, p=0.182). The incidence of supraventricular arrythmias was lower in the GORE as compared to the AMPLATZER group (9.1% vs 22.4% respectively, p=0.023). During the 6-month follow-up period there were 3 ischemic strokes, all of them in the AMPLATZER group, but this difference did not reach statistical significance (p=0.188). Finally, no serious device-related adverse events were noted in the total cohort.

Conclusion

PFO closure with a GORE device is related to lower incidence of supraventricular arrythmias at 6 months. The presence of a significant residual shunt and the incidence of recurrent stroke were comparable between both groups.

Funding Acknowledgement

Type of funding sources: None.

Long-term trends in treatment and outcomes of patients with diabetes and acute coronary syndromes: insights from the nationwide AMIS plus registry

Background

Although impressive advances in the treatment of patients with acute coronary syndromes (ACS) have been achieved over the last decades, morbidity and mortality of patients with diabetes and ACS remain substantial. This study aimed at investigating long-term trends in treatment and outcomes of patients with diabetes and ACS, using data from a large, prospective, nation-wide database.

Methods

Patients with ST segment elevation myocardial infarction (STEMI) or non-ST segment elevation myocardial infarction (NSTEMI) enrolled in the prospective AMIS Plus registry between 01/2003 and 12/2018 and available data on diabetes diagnosis were included in the analysis. Major adverse cardiovascular events (MACE), a composite of all-cause death, non-fatal myocardial infarction, and cerebrovascular events were assessed for each 3-year period.

Results

Out of 49'413 ACS patients, 10'200 (20.6%) had diabetes (29.4% women). In diabetic patients, the percentage of women decreased from 32.3% in 2002–2004 to 25.9% in 2017–2019 (p<0.001). Diabetic patients were older (p<0.001), more frequently women (p<0.001), and had a higher body mass index (p<0.001). They less often underwent percutaneous coronary intervention (p<0.001) and were more frequently treated by coronary artery bypass grafting (p<0.001). Over the 18-year period, the percentage of diabetic patients undergoing PCI or CABG increased (p<0.001). While treatment with glycoprotein IIb/IIIa inhibitors, low-molecular weight heparin, and beta blockers decreased over time, administration of aspirin, P2Y12 inhibitors, lipid-lowering drugs, and unfractionated heparin increased. Rates of MACE were 9.5% and 5.2% in diabetic and non-diabetic patients (p<0.001). Rates of mortality (7.7% versus 4.1%, p<0.001), recurrent myocardial infarction (1.5% versus 0.9%, p<0.001), and cerebrovascular events (1.2% versus 0.6%, p<0.001) were higher in diabetic as compared with non-diabetic patients, with highest rates of MACE, mortality, and myocardial infarction observed in diabetic women. Rates of MACE decreased from 11.8% in 2002–2004 to 7.5% in 2017–2019 in diabetic patients (p for trend <0.001). While rates of mortality (9.4% to 5.9%, p for trend =0.001) and rates of recurrent myocardial infarction (3.4% to 0.9%, p for trend <0.001) decreased over time, rates of cerebrovascular events remained stable (p for trend =0.34). Trends were the same in diabetic women and men.

Conclusions

Rates of MACE significantly decreased over the 18-year period in both diabetic women and men, with highest rates observed in diabetic women. Despite the observed improvements, rates of MACE remained 50% higher in diabetic as compared with non-diabetic patients. These findings emphasize that advanced strategies particularly targeting the vulnerable high-risk diabetic patient population are warranted to further improve quality of care in ACS.

Funding Acknowledgement

Type of funding sources: None.

Location and impact of the infarct-related artery in acute coronary syndrome: insight from the Swiss SPUM- ACS cohort

Background

Identifying the infarct-related artery (IRA) in patients with acute coronary syndromes (ACS) has prognostic and therapeutic implications.

Purpose

We aimed to evaluate the distribution, clinical presentation and impact of the culprit lesion location on long-term outcomes in ACS patients treated with primary percutaneous coronary intervention, medication and secondary prevention according to Guidelines.

Methods

Patients referred for ACS to one of the participating centres of the observational SPUM-ACS study between 2009 and 2017 with one year outcomes and independent events adjudication were included. The distribution of IRA, clinical presentation (STEMI/NSTEMI) and impact of IRA location on major adverse cardiac events (cardiac death, myocardial infarction, stent thrombosis, target vessel revascularisation) at one year were investigated.

Results

4'546 patients were included with 55% presenting as STEMI (mean age 62-years; 20% women), 42% as NSTEMI and 3% as unstable angina. The left anterior descending (LAD) artery was involved in 44.3%, the right coronary artery (RCA) and left circumflex artery (LCX) in 32.9% and 20%, respectively. Proximal and middle segments of the 3 main vessels were more often the culprit location compared to distal segments and side branches (78% versus. 22%). Left main (LM) and bypass graft were rarely involved (1.6% and 1.2% respectively), but most often responsible to overall cardiac dysfunction (higher NT-proBNP and hs troponin levels). Patients with an occluded IRA at angiography usually presented as STEMI on ECG (100% for LM, 90.5% for LAD territory, 83.8% for RCA territory, 56.6% for LCX territory). However 43.1% of patients with occluded LCX presented as NSTEMI. These patients were prone to extensive cardiac damage and significantly higher hs troponin levels as compared to those with patent LCX or STEMI presentation (626 ng/l vs 310 ng/l and 626 ng/l vs 580 ng/l respectively, p<0.001). Overall, 1-year MACE occurred in 11.8%. In native coronaries, the location of IRA had no impact on outcomes (20% LM, 10.9% LAD, 11.8% RCA, 11.8% LCX, p=0.112). However, in NSTEMI-ACS there were twice as many events when the LM was the IRA (MACE 20%, p=0.023) and 3-times higher when a bypass-graft was the IRA (33.9%, p=0.0001).

Conclusions

ST elevations are highly suggestive of an occluded IRA. However more than 40% of patients presenting with ACS involving an occluded LCX did not demonstrate ST-elevation and were prone to extensive cardiac damage, urging the necessity for early invasive measures in these patients. In native coronaries the IRA location did not affect outcomes except in NSTEMI with LM involvement or ACS with bypass grafts as IRA that had much worse outcomes.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): - Swiss National Research Foundation - Zurich Heart House

The impact of the COVID-19 pandemic on the management and outcomes of STEMI patients in Switzerland

Introduction

The COVID-19 pandemic has placed unprecedented strain on healthcare systems around the world, with potential repercussions on the quality of care of patients with other diseases. From a cardiological perspective, there have been concerns that the pandemic may have impacted the management of the most acute cardiovascular conditions.

Purpose

We evaluated the impact of the COVID-19 pandemic on the management of ST-elevation myocardial infarction (STEMI) in Switzerland by assessing a range of quality-of-care metrics during the first year of the pandemic, as compared with the preceding year.

Methods

Data on STEMI patients hospitalised in Switzerland from 1st January 2019 to 31st December 2020 were obtained from the Acute Myocardial Infarction in Switzerland (AMIS) registry. Symptom-to-first-medical-contact (symptom-to-FMC) time, symptom-to-door time, and door-to-balloon (DTB) time were compared between 2020 and 2019 in an analysis by year and by month. Additionally, rates of in-hospital all-cause mortality and in-hospital major adverse cardiovascular events (MACE: all-cause mortality, MI, stroke) were compared.

Results

Data on 2192 STEMI patients were available. Compared with the preceding 12 months, the first year of the pandemic was not associated with a significant change in median symptom-to-FMC time (2020: 90 minutes vs 2019: 95 minutes, p=0.32) or median symptom-to-door time (2020: 145 min vs 2019: 157 min, p=0.51). In 2020, February (start of the pandemic) and March (start of national lockdown) were associated with increased DTB times as compared with the same months of 2019 (+7 minutes, +10 minutes, respectively). However, overall median door-to-balloon times remained stable (2020: 40 min vs 2019: 39 min, p=0.06). Furthermore, there was no significant difference in the proportion of patients undergoing percutaneous coronary intervention (2020: 95.6% vs 2019: 95.1%, p=0.54). Finally, there were no significant differences in median length of stay (2020: 4 days vs 2019: 157 min, p=0.51), in-hospital all-cause mortality (2020: 4.9% vs. 2019: 4.2%, p=0.41) or MACE (2020: 6.2% vs. 2019: 5.6%, p=0.52).

Conclusions

Although there are some limitations associated with the present study inherent to its retrospective observational design (for instance, a potentially important number of late comers may not have been included in the registry), the data suggest that despite the impact of COVID-19 on the healthcare system in Switzerland in 2020, STEMI management as defined by a range of quality-of-care metrics remained effective and efficient.

Funding Acknowledgement

Type of funding sources: None.

5-year outcomes in patients with acute coronary syndrome treated with biodegradable polymer sirolimus-eluting stents versus durable polymer everolimus-eluting stents

Background

Newest generation drug-eluting stents (DES) combining ultrathin cobalt chromium platforms with biodegradable polymers may reduce target lesion failure (TLF) as compared to second generation DES among patients with acute coronary syndrome (ACS). While previous studies indicated a potential benefit within the first two years after percutaneous coronary intervention (PCI), it remains uncertain whether the clinical benefit persists after complete degradation of the polymer coating.

Purpose

To compare the long-term effects of ultrathin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus thin-strut durable polymer everolimus-eluting stents (DP-EES) for PCI in patients with ACS.

Methods

We performed a subgroup analysis of ACS patients included into the BIOSCIENCE trial (NCT01443104), a randomized trial comparing BP-SES with DP-EES. The primary endpoint of the present post-hoc analysis was TLF, a composite of cardiac death, target vessel myocardial infarction (MI) and clinically indicated target lesion revascularization (TLR), at 5 years.

Results

Among 2,119 patients enrolled between March 2012 and May 2013, 1,131 (53%) presented with ACS (ST-segment elevation myocardial infarction, 36%). Compared to patients with stable CAD, ACS patients were younger, had a lower baseline cardiac risk profile, including a lower prevalence of hypertension, hypercholesterolaemia, diabetes mellitus, and peripheral artery disease, and had a greater incidence of previous revascularization procedures. At 5 years, TLF occurred similarly in 89 patients (cumulative incidence, 16.9%) treated with BP-SES and 85 patients (16.0%) treated with DP-EES (RR 1.04; 95% CI 0.78–1.41; p=0.78) in patients with ACS, and in 109 patients (24.1%) treated with BP-SES and 104 patients (21.8%) treated with DP-EES (RR 1.11; 95% CI 0.85–1.45; p=0.46) in stable CAD patients (p for interaction=0.77) (Figure 1, Panel A). Cumulative incidences of cardiac death (8% vs. 7%; p=0.66), target vessel MI (5.2% vs. 5.8%; p=0.66), clinically indicated TLR (8.9% vs. 8.3%; p=0.63) (Figure 1, Panel B-D), and definite thrombosis (1.4% vs. 1.0%; p=0.57) at 5 years were similar among ACS patients treated with ultrathin-strut BP-SES or thin-strut DP-EES. Overall, there was no interaction between clinical presentation and treatment effect of BP-SES versus DP-EES.

Conclusion

In a subgroup analysis of the BIOSCIENCE trial, we found no difference in long-term clinical outcomes between ACS patients treated with ultrathin-strut BP-SES or thin-strut DP-EES at five years.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Unrestricted research grant to the institution from Biotronik AG, Switzerland

Short and medium chain acylcarnitines as markers of outcome in diabetic and non-diabetic subjects with acute coronary syndromes

Background

Dietary carnitine that is not absorbed can serve as a precursor for gut microbiota-dependent generation of trimethylamine N-oxide (TMAO), a pro-atherogenic and pro-thrombosis promoting metabolite. Gut microbiome-derived metabolites of dietary carnitine, including TMAO and g-butyrobetaine, may accelerate atherosclerosis, increase platelet reactivity and in vivo thrombosis. Carnitine metabolism also produces numerous molecular species of short, medium and long chain acylcarnitines, which play important roles in energy metabolism and intracellular fatty acid transport.

Purpose

We sought to evaluate the differences between diabetics and non-diabetics presenting with ACS with respect to acylcarnitines, and to explore their relationship with incident cardiovascular outcomes.

Methods

Using a large, prospectively recruited cohort of patients presenting to the cardiac cath lab with suspected acute coronary syndromes, we measured levels of plasma acylcarnitines, carnitine and its gut microbial-derived metabolites to assess their relationship with independently adjudicated major adverse cardiac events (MACE = myocardial infarction, stroke or TIA, need for revascularization or all-cause mortality) amongst diabetics and non-diabetics.

Results

We analysed 1683 patients who presented with ACS, were treated according to current guidelines and had undergone acylcarnitine analysis. There were 294 diabetics and 1389 non-diabetics. Diabetics had significantly higher plasma levels of all acyl carnitine metabolites than non-diabetics (P<0.001), but not of carnitine itself. Baseline plasma levels of all gut microbiome derived carnitine metabolites (TMAO, g-butyrobetaine and crotonobetaine) were also significantly higher in those who subsequently experienced a MACE. All carnitine metabolites, apart from octenoylcarnitine, were significantly associated with MACE on univariate analysis, while acetylcarnitine and crotonobetaine were independently associated with MACE after multivariate adjustment.

Conclusion

Serum short- and medium- chain acylcarnitine levels are significantly higher in diabetic patients presenting with ACS and predict MACE. After multivariate adjustment, acetylcarnitine and crotonobetaine remained an independent predictor of MACE.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Zurich Heart House - Foundation for Cardiovascular Research

Prognostic value of intracoronary imaging-derived measures for non-infarct related vessel revascularization throughout 7 years among patients with ST-elevation myocardial infarction

Background

Underlying plaque characteristics that lead to future revascularization during long-term follow-up remain poorly understood.

Purpose

We aimed to explore intracoronary imaging-derived measures as assessed by intravascular ultrasound (IVUS) and optical coherence tomography (OCT) associated with non-infarct related vessel revascularization (non-TVR) arising from imaged segments during long-term (up to 7 years) follow-up among patients with ST-elevated myocardial infarction (STEMI).

Methods

A total of 94 STEMI patients enrolled into the IBIS-4 (Integrated Biomarker Imaging Study-4) study undergoing serial (baseline and 13 months) IVUS and OCT in 2 non-infarct-related coronary arteries under high-intensity statin therapy were analyzed in the present study. Patients were divided into 2 groups according to the occurrence of non-TVR within previously imaged vessel segments (non-TVR: n=14, no non-TVR: n=80).

Results

Baseline characteristics including LDL level were comparable between groups. At baseline, lesions with future non-TVR were associated with greater percent atheroma volume by IVUS (55.6±5.4% vs. 49.6±6.1%, P<0.001), minimum lumen area by OCT (3.4±1.7 mm2 vs. 6.0±3.3 mm2, P=0.004), and a higher prevalence of fibroatheroma (60.0% vs. 20.1%, P=0.007) by OCT compared with those without. Among patients with serial imaging, lesions with non-TVR had a trend towards a less reduction of percent atheroma volume (−0.2±3.8% vs. −2.4±4.2%, P=0.083).

Conclusion

Greater plaque burden, smaller lumen area, and higher prevalence of OCT-detected fibroatheroma at baseline were associated with non-infarct related vessel revascularization. Lesions with non-TVR tend to have less-pronounced regression of coronary atheroma despite intensive statin therapy and achieved LDL levels.

Non-TVR 7 years after index PCI

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Swiss National Science Foundation

Heavy drinking habits are associated with worse in-hospital outcomes in patients with acute coronary syndrome

Introduction

The association between alcohol consumption and the occurrence of coronary heart disease is well described in literature. Data regarding the impact of regular alcohol consumption on in-hospital outcomes in the setting of acute coronary syndrome (ACS) are lacking.

Purpose

We aimed to evaluate the impact of self-reported alcohol consumption on in-hospital outcomes in patients with ACS.

Methods

Data derived from patients enrolled between 2007 and 2019 in the Acute Myocardial Infarction in Switzerland (AMIS) Plus registry were retrospectively analyzed. The primary endpoint was all-cause in-hospital mortality, while secondary endpoints were set as incidence of major adverse cardiac and cerebrovascular events (MACCEs). Outcomes comparisons according to quantity of daily alcohol intake were also performed.

Results

Records concerning alcohol consumption were available in 25707 patients; 5298 of them (21%) fulfilled the criteria of regular alcohol consumption. Daily alcohol intake was reported in 4059 (77%), of these patients (regular drinkers) with 2640 light drinkers (≤2 drinks/day) and 1419 heavy drinkers (>2 drinks/day). Regular drinkers were predominantly male, younger, smokers, more comorbid and with a worse clinical presentation as compared to abstainers/occasional drinkers.

In-hospital mortality and MACCEs of heavy drinkers were significantly higher compared to light drinkers (5.4% vs. 3.3% and 7.0% vs. 4.4%, both p=0.001). When tested together with GRACE risk score parameters, heavy alcohol consumption was independently associated to in-hospital mortality (p=0.004).

Conclusions

Heavy alcohol consumption is an additional independent predictor of in-hospital mortality in patients presenting with ACS.

Figure 1. Study flowchart.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): Swiss Heart Foundation

Regional differences in PCI practice and clinical outcomes among patients with diabetes mellitus enrolled in a contemporary world-wide registry

Background

Diabetes mellitus (DM) is a major risk factor for coronary artery disease (CAD) and PCI. Little is known about differences in PCI patterns and outcomes among DM patients across the globe.

Purpose

We aimed to determine differences in clinical outcomes and PCI practices among DM patients undergoing contemporary PCI across the continents.

Methods

e-Ultimaster is a prospective worldwide registry that enrolled 36; 671 patients and 1-year follow-up is currently available for 94,2% of the patients. All underwent PCI with a thin strut sirolimus-eluting stent with abluminal biodegradable polymer. This abstract focus on the DM population. Primary endpoint was target lesion failure (TLF) at 1-year (cardiac death, target vessel myocardial infarction (MI), clinically driven target lesion revascularization). A Clinical Event Committee adjudicated all endpoint-related adverse events. Patients were divided according to four regions of enrolment: Europe (EU), Asia (A), Africa/Middle East (A/ME), and Mexico/South America (M/SA).

Results

The prevalence of DM in e-Ultimaster ranged from 24.3% in E to 47.5% in A/ME. Among 9709 DM patients, 60% were enrolled in EU, 21% in A, 11% in A/ME and 8% in M/SA. Mean age ranged from 61.7 year in A as well as A/ME to 67.5 years in EU. The highest proportion of insulin requiring DM was found in A/ME (32.4%). Presentation with acute coronary syndromes ranged from 49% in A/ME to 55.6% in M/SA. The rate of primary endpoint (TLF) at one year was 4.2%. Definite/probable stent thrombosis (ST) occurred in 0.7% of at 1-year. Independent predictors of TLF included age, insulin-requiring DM, renal failure, previous PCI, number of lesions identified, presence of ACC/AHA type C lesions, treatment of left main lesions, treatment of bifurcation lesions, and number of stents implanted. Independent predictors of definite/probable ST included male gender, renal failure, history of MI, ST-elevated MI at presentation and number of lesions identified. TLF occurred in 2.1% in A/ME, 3.1% in A, 4.4% in M/SA and 5.0% in E. Definite/probable ST was lowest in A (0.3%) and A/ME (0.4%) and highest in M/SA and EU (both 0.9%).

Penetration of radial access ranged from 86.0% in EU to 56.9% in A/ME. The use of intravascular imaging ranged from 3.9% in EU to 30.3% in A. Use of dual antiplatelet therapy (DAPT), left at the discretion of the operator, was lowest in EU (92.9% at 3 months; 63.8% at 1 year) and highest in A (94.5% at 3 months; 82.6% at 1 year).

Conclusions

The analysis on more than 9000 DM patients treated with the same contemporary stent within a world-wide registry with defined inclusion/exclusion criteria and adjudicated clinical events showed favourable clinical outcomes at one year and detected major differences in patient characteristics, PCI pattern, DAPT prescription and clinical outcomes across continents. Data on the entire e-Ultimaster DM population will be available for ESC.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Terumo Europe

Quantitative flow ratio to predict non-target-vessel-related events at 5 years in STEMI patients undergoing angiography-guided revascularization

Background

In patients with ST-segment-elevation myocardial infarction (STEMI), angiography-based complete revascularization is associated with superior outcomes compared with culprit-lesion-only percutaneous coronary intervention (PCI). Quantitative Flow Ratio (QFR) is a novel, non-invasive, vasodilator-free method to assess the hemodynamic significance of coronary stenoses.

Purpose

To investigate the incremental value of QFR over angiography alone in the assessment of non-culprit lesions (NCL) in STEMI patients undergoing primary PCI.

Methods

In the randomized, multicenter COMFORTABLE AMI trial, STEMI patients underwent angiography-guided complete revascularization. QFR was determined in untreated non-target vessels by assessors blinded for clinical outcomes.

Results

Out of 1161 STEMI patients, 946 vessels in 617 patients could be analyzed by QFR. At 5-year follow-up, the rate of the primary endpoint cardiac death, non-target vessel myocardial infarction (non-TV-MI) and clinically indicated, non-target vessel revascularization (non-TVR) was significantly higher in patients with QFR ≤0.80 compared with QFR >0.80 (62.9% vs. 12.7%, HR 7.20, 95% CI 4.46–11.62, p<0.001), driven by higher rates of non-TV-MI (15.4% vs. 3.6%, HR 4.59, 95% CI 1.72–12.23, p=0.002) and non-TVR (58.6% vs. 7.7%, HR 10.99, 95% CI 6.39–18.91, p<0.001). No significant differences for cardiac death were observed. Multivariate analysis identified QFR ≤0.80, MI SYNTAX score and left ventricular function as independent predictors of the primary endpoint. QFR ≤0.80 showed an accuracy of 86.1%, sensitivity of 23.2%, specificity of 97.5%, positive predictive value of 62.9% and negative predictive value of 87.5% for the prediction of the primary endpoint.

Conclusions

Our study results suggest incremental value of QFR over angiography-guided PCI for NCL among STEMI patients undergoing primary PCI.

Kaplan-Meier curves of primary endpoint

Funding Acknowledgement

Type of funding source: None

Delay between symptom onset and hospital admission in patients with ST-elevation myocardial infarction: different trends in men and women

Introduction

The aim of this study was to analyse whether prehospital delay in ST-elevation myocardial infarction (STEMI) has changed in men and women since 2002.

Methods

We used data from the AMIS Plus registry of patients who were admitted for STEMI between 2002 and 2019. Patients who were transferred from another hospital or were resuscitated before admission were excluded. Patient delay was defined as the difference between symptom onset and hospital admission time. Trends in delay according to gender were depicted by medians per year with a 95% confidence interval. Differences between men and women were tested using the Mann-Whitney test. To analyse the adjusted effect of gender on delay, multivariable quantile regression was applied including the interaction between gender and admission year as well as the covariates age, diabetes, pain at presentation and myocardial infarction (MI) history.

Results

Among the 15,154 patients included (74.5% men), the overall median (IQR) delay between 2002 and 2019 was 150 (84; 345) minutes for men and 180 (100; 415) for women. Women were older (71.3y vs. 62.8y, p<0.001), had more often diabetes (20.0% vs. 16.9%, p<0.001), but less often MI history (11.2% vs. 14.9%, p<0.001) and less often pain at presentation (92.0% vs. 94.8%, p<0.001).

The unadjusted median delay decreased over the admission years. The decreasing trend was stronger in women than men: the unadjusted difference in delay between men and women decreased from 60 min in 2002 (p=0.003) to 15 min in 2019 (p=0.155) (Fig 1). The multivariable model confirmed a significant interaction between gender and admission year (p=0.042) indicating that the decrease in delay was stronger for women (−3.1 min per year) than for men (−1.4 min per year) even after adjustment. The adjusted difference between men and women decreased from 27.4 min in 2002 to −1.6 min for women in 2019. Additional independent predictors of longer delay were the covariates age (+1.6 min per additional year, p<0.001) and diabetes (+27.1 min, p<0.001). Conversely, pain at admission (−46.3 min, p<0.001) and MI history (−32.9 min, p<0.001) predicted a shorter delay.

Conclusions

The difference in delay between symptom onset and hospital admission in STEMI patients between men and women steadily diminished from 2002 to 2019. This might indicate that the public and health professionals' awareness of STEMI in women has ameliorated over time.

Unadjusted delay according to gender

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): AMIS Plus Foundation

Age-related clinical and hemodynamic outcome following transcatheter aortic valve replacement: a swiss TAVI registry analysis

Background

Transcatheter aortic valve implantation (TA) is the preferred treatment modality for patients with severe aortic valve disease at high surgical risk and is expanding into lower risk populations. Therefore age range of treated patients is increasing.

Purpose

The aim of this study is to analyze age-related clinical and hemodynamic outcome of patients following TAVI in a nationwide, prospective, multicentre cohort (Swiss TAVI registry).

Methods

We retrospectively analyzed prospectively collected data from all patients included in the Swiss TAVI registry between February 2011 and December 2018. In an adjusted analysis, in-hospital, 30-days and 1-year outcome between four age groups were compared.

Results

Overall, 7097 patients underwent TAVI (<70 years: n=324, 70–79 years: n=1913, 80–89 years: n=4353, 90–100 years n=507). Median STS risk score for mortality was 5.23±4.13% and differed significantly between age groups (3.46±4.10%, 3.97±3.73%, 5.57±3.97%, 8.22±4.74%; p=0.001). Valve predilatation was more often performed in older patients (54.3% vs. 54.3% vs. 60.7% vs. 69.6%; p≤0.001). Difference in hospital stay was statistically sigificant between age groups, numerically however not relevant (10.01±7.56 days vs. 9.25±6.38 days vs. 9.55±5.70 days vs 10.03±5.77 days; p=0.02). Post-procedural acute kidney injury stage 3 was highest in the youngest age group (3.4% vs. 1.6% vs. 1.1% vs. 1.0%; RR [95% CI] 0.65 (0.48–0.87); p=0,004) and rate of new pacemakers for conduction abnormalities increased significantly with age (10.2% vs. 13.7% vs. 17.1% vs. 18.7%; RR [95% CI] 1.22 (1.12–1.32); p<0.001). There was no significant difference in life threatening/major bleeding (p=0.288/0.197) or major vascular complications (p=0.083).

All-cause mortality and cardiovascular mortality in hospital, at 30 days and at 1 year were highest in nonagenarians and higher in the patients <70 years compared to patients of 70–79 years: in hospital all-cause mortality 2.2% vs. 1.6% vs. 2.9% vs. 5.5% (RR [95% CI] 1.64 (1.28–2.10), p<0.001); 30 day all-cause mortality 3.1% vs. 2.0% vs. 3.7% vs. 6.7%; (HR [95% CI] 1.59 (1.30–1.96); p<0.0001); 1-year all-cause mortality 10.9% vs. 10.4% vs. 12% vs. 19.5% (HR [95% CI] 1.27 (1.14–1.41); p<0.001); in hospital cardiovascular mortality 1.5% vs. 1.5% vs. 2.6% vs. 5.1% (RR [95% CI] 1.70 (1.31–2.20), p<0.001); 30 day cardiovascular mortality 2.2% vs. 1.9% vs. 3.3% vs. 6.3%; (HR [95% CI] 1.68 (1.35–2.09); p<0.001); 1-year cardiovascular mortality 7.2% vs. 6.9% vs. 8.3% vs. 15.3% (HR [95% CI] 1.36 (1.19–1.55); p<0.001). This held true, when hazard ratio was corrected for STS PROM score, femoral access vs other access and year of procedure.

Conclusion

In-hospital, 30-day and 1-year clinical outcome of nonagenarians undergoing TAVI are less favorable compared to lower age groups. Interestingly, clinical outcome of the patients group 70–79 years was the most favorable.

Mortality at 30 according to age

Funding Acknowledgement

Type of funding source: None

P1968Five-year outcomes in patients with diabetes mellitus treated with biodegradable polymer sirolimus-eluting stents versus durable polymer everolimus-eluting stents

Background

Patients with diabetes mellitus (DM) remain at higher risk for adverse events after percutaneous coronary intervention (PCI) compared with non-diabetic individuals. Among available drug-eluting stents (DES), thin-strut durable polymer everolimus-eluting stents (DP-EES) were shown to provide the best safety and efficacy profile in diabetics. Whether biodegradable polymer DES provide additional long-term clinical benefit compared with DP-EES among diabetic patients remains uncertain.

Purpose

To compare the long-term performance of ultrathin-strut biodegradable polymer sirolimus-eluting stents (BP-SES) versus DP-EES for PCI in patients with insulin-requiring and non-insulin-requiring DM.

Methods

We performed a prespecified subgroup analysis of the randomized, multicenter, non-inferiority BIOSCIENCE trial (NCT01443104). Patients with stable coronary artery disease or acute coronary syndrome were randomly assigned to treatment with ultrathin-strut BP-SES or thin-strut DP-EES. Patients were further divided according to diabetic status. The primary endpoint was target lesion failure (TLF), a composite of cardiac death, target-vessel myocardial infarction (MI) and clinically-indicated target lesion revascularization (TLR), within 12 months.

Results

Among 2'119 patients enrolled between March 2012 and May 2013, 486 (22.9%) presented with DM (insulin-requiring, 33.1%). Compared with non-diabetics, patients with DM were older and had a greater baseline cardiac risk profile, including higher prevalence of hypertension, hypercholesterolaemia, peripheral artery disease, chronic renal failure and prior PCI, coronary artery bypass graft surgery, or stroke. At 5 years, TLF occurred similarly in 74 patients (cumulative incidence, 31.0%) treated with BP-SES and 57 patients (25.8%) treated with DP-EES (RR 1.23; 95% CI 0.87–1.73; p=0.24) in diabetics, and in 124 patients (16.8%) treated with BP-SES and 132 patients (16.8%) treated with DP-EES (RR 0.98; 95% CI 0.77–1.26; p=0.90) in non-diabetics (p for interaction=0.31). Cumulative incidences of cardiac death (14.9% vs. 9.5%; p=0.10), target-vessel MI (11.4% vs. 11.0%; p=0.81), clinically-indicated TLR (16.9% vs. 15.8%; p=0.68), and definite thrombosis (3.0% vs. 2.5%; p=0.63) at 5 years were similar among diabetic patients treated with ultrathin-strut BP-SES or thin-strut DP-EES. Overall, there was no interaction between diabetic status and treatment effect of BP-SES versus DP-EES.

Conclusion

In a prespecified subgroup analysis of the BIOSCIENCE trial, we found no difference in clinical outcomes throughout five years between diabetic patients treated with ultrathin-strut BP-SES or thin-strut DP-EES.

Acknowledgement/Funding

BIOSCIENCE was an investigator-initiated trial supported by a dedicated research grant from Biotronik, Bülach, Switzerland

P3630Coronary angiography and percutaneous coronary intervention post implantation of a transcatheter aortic valve

When treating younger patients with longer life expectancy, the likelihood of having to perform a subsequent coronary angiogram and PCI during follow-up post transcatheter aortic valve implantation (TAVI) is increased. The aim of our study was to assess the feasibility and characteristics of the post TAVI coronary angiogram.

We interrogated our prospective single center TAVI database to analyze data from patients who underwent a coronary angiogram or PCI post TAVI. Between August 2008 and January 2019, 405 consecutive TAVI were performed in our institution with a 30-day, 6-month and yearly follow-up.

Among 405 procedures, 18 coronary angiograms with 9 PCI (RCA 2; LM 3; LAD 3, LCX 1) were performed in 17 patients post TAVI. The mean age of patients was 78.1±7.5 years (3 women), with a mean STS score of 5.6±3.4%. Five patients had a history of prior CABG. The transcatheter heart valves implanted were 6 CoreValve, 8 Evolut R, 1 Evolut Pro and 2 Edwards Sapien. The valve sizes were 31mm (n=3), 29mm (n=6), 26mm (n=3) and 23mm (n=5). The indication for the coronary angiogram was acute coronary syndrome for 8 procedures (1 STEMI, 7 NSTEMI) and stable angina for the remaining 10 procedures. The mean time between TAVI and coronary angiogram was 519±332 days (189–1093 days). Femoral and radial approach was used in, respectively, 11 and 7 (right: 5, left: 2) procedures with one cross-over needed from right transradial to transfemoral. Out of 33 attempted ostia cannulations, there were 2 failures (both involving the RCA), and 31 successes classified as selective (RCA: 7, LM: 9), borderline selective (RCA: 3, LM: 2) and non-selective but sufficient for diagnosis (RCA: 3, LM: 7), using standard catheters (average number of catheter used to cannulate RCA: 1.2±0.8 and LM: 1.7±1.1 [min. 1 and max. 4]). All planned PCI were successful with the treatment of 11 stenosis including 2 multivessel lesions. In 44% of the treated arteries, the use of a GuideLiner catheter (Vascular Solutions Inc) was required to cannulate the ostium.

In conclusion, coronary angiogram post TAVI was needed in 4.2% of our cohort during follow-up. Overall, LM ostia cannulation was successful in 100% of the cases and we failed to cannulate 13.3% of RCA ostia. All PCI were successful with the need of a guiding cathteter extension in 44% of the procedures.

P4391Cardiovascular risk factor trends over two decades in patients presenting with acute myocardial infarction: a failure of smoking control, especially in women

Background

Hypertension, diabetes, dyslipidemia and smoking are established cardiovascular risk factors (CVRF). Little is known about the changes of risk factor profiles over time in patients presenting with acute myocardial infarction (AMI).

Purpose

To analyze the temporal trends of CVRF in patients presenting with AMI over the last 22 years in Switzerland.

Methods

We included data of all AMI patients enrolled between 1997 and 2018 in the Swiss nationwide AMIS Plus registry. The rates of hypertension, diabetes, dyslipidemia and smoking at presentation were descriptively analyzed dividing the data into 2-year periods. Trend analyses were performed using the CHI-square-test and ANOVA. A p-value of <0.005 was considered as statistically significant.

Results

A total of 57,995 patients were included in the analysis (73.6% male). The mean age was 66.0 years (males: 64.0 years, females 71.6 years) and did not differ over the study period. The mean CVRF rates over the study period were as follows: diabetes 20.5% (males: 19.4%, females: 23.6%), hypertension 60.2% (males: 57.0%, females: 69.0%), dyslipidemia 59.4% (males: 60.5%, females: 56.4%), and smoking 39.3% (males: 43.0%, females: 28.7%). While there was no significant change over time in the rates of diabetes for both genders, there were significant increases in the rates of hypertension and dyslipidemia for both males and females (p<0.001 for all comparisons). In terms of smoking, there was no significant trend for males while there was a significant increase in the rate of smoking for females (p<0.001). As a result, the gap in smoking rates between men and women decreased from 19.9% (45.3% vs. 25.4%) in 1997/98 to 7.9% (41.2% vs. 33.3%) in 2017/18.

Trends in the rate of smokers

Conclusions

Among patients presenting with AMI in Switzerland over two decades, the prevalence of hypertension and dyslipidemia increased in both men and women, while diabetes at presentation did not change over the years. We documented a failure of smoking control, with a lack of a reduction in the smoking prevalence among males and a striking increase among women.

[Role of percutaneous coronary intervention in diabetic patients]

Clinical outcomes after revascularization, both for surgery and percutaneous coronary intervention (PCI), is significantly worse in diabetic patients compared with non-diabetic patients. While in acute coronary syndrome, PCI is favored because of the increased risk of surgery performed during ongoing infarction, in stable patients assessment of clinical factors, such as coronary anatomy and comorbidities should guide decision of the revascularization modality (e.g., surgical, PCI, or conservative). Surgery should be favored in patients with multivessel coronary disease and acceptable surgical risk. Overall, the threshold for surgery compared to PCI should be lower in diabetic patients compared with non-diabetic ones.

Current concepts on the management of concomitant carotid and coronary disease

In the absence of randomized data, the optimal management of patients with severe carotid and coronary artery disease (CAD), especially those undergoing coronary bypass grafting (CABG), remains unsettled. As a general rule, in patients with multilevel atherosclerotic disease the symptomatic vascular discrict should be treated first. The entirely surgical approach with carotid endarterectomy (CEA) and CABG is associated with high event rates. Therefore, whenever in the work-up prior to cardiac surgery severe carotid disease is identified, the indication for CABG should be reassessed and the feasibility of percutaneous coronary intervention (PCI) as an alternative treatment should be explored. If PCI is not an option, carotid artery stenting (CAS) prior to open heart should be considered if the expertise is available. Although perioperative stroke is multifactorial and the value of revascularization of asymptomatic carotid disease prior to open heart surgery remains controversial, treatment of patients with severe bilateral carotid stenosis appears reasonable for perioperative stroke prevention. The aim of carotid revascularization in patient with unilateral severe carotid stenosis should more long-term stroke prevention than merely perioperative stroke reduction. The main advantage of CAS compared with CEA in patients with advanced CAD is the reduction of perioperative myocardial infarction, an event associated to long term mortality.

History of carotid artery stenting

The history of carotid artery stenting (CAS) was made by brave men and women who believed in a less invasive treatment modality than carotid endarterectomy (CEA) to treat carotid stenosis despite the risk--which was obviously present also with surgery--to cause a stroke, the very event that the procedure aimed to prevent. The bulky equipment, the lack of knowledge about the appropriate antithrombotic regimen, and the impossibility at early stage to influence distal embolization added to the pressure on the investigators. At times, the confrontation with the surgical community has been hard. The technique evolved with the inputs of multiple disciplines on both sides of the Atlantic including radiology, cardiology, neuroradiology and vascular surgery. Major breakthrough included the use of dual antiplatelet therapy, of self-expanding stents and of emboli protection devices. Unfortunately, randomized investigations against surgery started too early, in a phase in which the cas technique was not yet mature and the investigators lacked the necessary experience in terms of catheter skills and appropriate patient selection.

Influence of plaque volume on hemodynamic response and stress hormone release in patients undergoing carotid artery stenting

AIM

Carotid artery stenting (CAS) may cause bradycardia and hypotension due to barostimulation. The impact of periprocedural hypotension on CAS outcome remains controversial. The role of carotid plaque volume and catecholamine hormone release during CAS on hemodynamic changes has not been investigated so far. The aim of this prospective study was to evaluate if carotid artery plaque characteristics are predictive for stress hormone release or for postprocedural hemodynamic instability.

METHODS

In 26 patients undergoing CAS, carotid plaque volume and morphology were assessed by two- and three-dimensional (3D)-Duplex sonography prior to the procedure. Arterial plasma adrenaline, noradrenaline and renin concentrations were measured at the time of sheath insertion and 5 minutes after stent placement. ECG, heart rate, and invasive blood pressure were monitored throughout the procedure.

RESULTS

CAS caused no significant changes in hormone release, but increasing plaque volume was related to the degree of bradycardia following stent deployment (r=0.57; P=0.01). Plaque size was not associated with postprocedural hypotension. Plaque echogenicity (echolucent, heterogeneous or echogenic) did not correlate with changes in systolic blood pressure, heart rate or catecholamine hormone release.

CONCLUSION

CAS caused bradycardia in relation to plaque size, but did not cause catecholamine release which may indicate that the endovascular procedure is not associated with a relevant stress reaction.

[Mechanical complications of myocardial infarction]

Despite a marked reduction in mortality after myocardial infarction during the last decades thanks to heart monitoring and early reperfusion, there remains a significant rate of in-hospital mortality. This is a consequence of refractory ventricular dysfunction in most cases, or mechanical complications of myocardial infarction in the remaining cases. Mechanical complications include septal rupture with ventricular septal defect, tamponnade following rupture of the left ventricular free wall, and acute mitral regurgitation due to papillary muscle infarction and rupture. Although these complications are rare, their prognosis is very poor. An early detection of clinical signs of mechanical complications is crucial to urgently precise the diagnosis by echocardiography and subsequently plan the most appropriate medico-surgical management.

[Transcatheter aortic valve implantations in 2011: the interventional cardiologist]

Since the first transcatheter aortic valve implantation 9 years ago, constant technological progress and simplification of the procedure have been observed. For two devices in particular (Edwards SAPIEN valve and CoreValve), considerable clinical experience has been gained, with over 17,000 implantations each. The safety and efficacy of this technique have recently been confirmed in the randomized trial Partner. Consequently, the end of 2010 saw the TAVI (Transcatheter aortic valve implantation) become the standard-of-care for selected patients deemed inoperable on the basis of age or co-morbidities and now is an acceptable alternative to surgery in selected high-risk operable patients. However, the selection of patients and the technique used (trans-arterial or trans-apical) require a multidisciplinary approach which remains essential for procedural success.

[Specificities of diabetes in acute coronary syndromes]

Contrary to the decline in the prevalence of several risk factors such as hypertension, hypercholesterolemia and smoking, diabetes is an expanding health burden in the western world. Because of the proatherosclerotic, proinflammatory, and prothrombotic states associated with diabetes, diabetic patients with acute coronary syndromes (ACS) are at high risk of subsequent cardiovascular events. However, they derive greater benefit from aggressive platelet inhibition and an early invasive strategy than non-diabetic individuals. Despite the documented efficacy, diabetic patients with ACS receive evidence-based treatments less frequently than non-diabetic individuals.

Endovascular stroke treatment today

The purpose of this study was to review current treatment options in acute ischemic stroke, focusing on the latest advances in the field of mechanical recanalization. These devices recently made available for endovascular intracranial thrombectomy show great potential in acute stroke treatments. Compelling evidence of their recanalization efficacy comes from current mechanical embolectomy trials. In addition to allowing an extension of the therapeutic time window, mechanical recanalization devices can be used without adjuvant thrombolytic therapy, thus diminishing the intracranial bleeding risk. Therefore, these devices are particularly suitable in patients in whom thrombolytic therapy is contraindicated. IV and IA thrombolysis and bridging therapy are viable options in acute stroke treatment. Mechanical recanalization devices can potentially have a clinically relevant impact in the interventional treatment of stroke, but at the present time, a randomized study would be beneficial.

[Paravalvular leak following surgical valve replacement: is there a role for percutaneous paravalvular leak reduction?]

After valve replacement, significant paravalvular leaks (PVL) may develop in up to 12.5% of the cases. Signs and symptoms include congestive heart failure and/or haemolysis and therefore may require reintervention. Redo valve surgery is considered the therapy of choice for symptomatic patients, either by valve replacement or leak repair. Considering the risk of morbidity and mortality associated with a surgical reintervention and the high post-surgical recurrence of PVL, the endovascular treatment represents an attractive alternative to surgery for high risk patients. The percutaneous approach aims at PVL reduction by implantation of certain occluder devices. The procedure is technically feasible in 60 to 90% of the cases according to different series. Technical success is associated with clinical improvement in 50 to 80% of the cases.

Diabetes and acute coronary syndrome

Contrary to the decline in the prevalence of several risk factors such as hypertension, hypercholesterolemia and smoking, diabetes is an expanding health burden in the Western world. Because of the proatherosclerotic, proinflammatory, and prothrombotic states associated with diabetes, diabetic patients with acute coronary syndromes (ACS) are at high risk of subsequent cardiovascular events. However, they derive at the same time greater benefit from evidence-based therapy than the non-diabetic individuals. The two mainstays of acute ACS therapy for diabetic patients are an aggressive platelet inhibition and an early invasive strategy. Aspirin should be administered in all patients and prasugrel is to be considered superior to clopidogrel in this setting. While the use of glycoprotein IIb/IIIa receptor inhibitors in the diabetic ACS population has been associated with a mortality reduction, the role of these agents in the prasugrel era remains to be elucidated. Importantly, the aggressiveness of anti-thrombotic therapy should be balanced in each individual patient with the risk of bleeding. The benefit of early coronary angiography and, if needed, revascularization, in the setting of non-ST-segment elevation ACS is more pronounced in diabetic than in non-diabetic individuals. All patients, diabetics and non-diabetics, qualify for primary percutaneous coronary intervention (PCI) as the therapy of choice for ST-segment elevation myocardial infarction. In order to reduce hemorrhagic complications related to vascular access for PCI, the radial approach should be favored. Additional important secondary preventive measures include high-dose statin therapy, ACE-Inhibition/angiotensin II receptor blockade, and adequate glucose metabolism control. Despite the documented efficacy, diabetic patients with ACS receive evidence-based treatments less frequently than non-diabetic individuals.

[Carotid stenting: an alternative to surgery?]

A stenosis of the internal carotid artery may cause 10-20% of all ischemic strokes. In symptomatic patients, carotid revascularization is indicated in the presence of a stenosis 50%. in asymptomatic patients, the indication for revascularization based on randomized trials is given at > or = 60% stenosis, as long as the estimated perioperative death or stroke risk is < 3%. In clinical practice however, asymptomatic stenoses are usually treated only if luminal narrowing exceeds 70-80%. The choice of the revascularization strategy (endarterectomy versus stenting) should be based on the surgical risk profile of the patient and on the locally available expertise. Carotid artery stenting is particularly beneficial in patients at high risk for surgery.

[Acute coronary syndrome: guidelines and geriatrics specificity]

Acute coronary syndrome (ACS) includes unstable angina pectoris, myocardial infarction without ST elevation and myocardial infarction with ST elevation. ACS is more frequent in the elderly than in the general population and is associated with very high morbidity and mortality. As older individuals are often excluded from clinical trials, the geriatrician needs to take care of these subjects without specific guidelines. Although older subjects (or very old subjects) represent a group at high risk of complications, they would benefit most of an aggressive coronary revascularisation procedure. Given the current state of knowledge, biological age itself should not be the only limiting criteria when considering an invasive coronary procedure, but the existing quality of life and physical conditions of the individual should also be taken into account in the global management strategy.

Thyrotoxicosis and the cardiovascular system

Thyrotoxicosis is associated with increased cardiovascular morbidity and mortality, primarily due to heart failure and thromboembolism. Palpitations, caused by sinus tachycardia and occasionally by atrial fibrillation, are the most frequent cardiovascular symptom. As atrial fibrillation may be the only manifestation of thyrotoxicosis, thyroid hormone excess should routinely be excluded in patients with this rhythm disturbance. Heart failure occurs mostly in the presence of underlying heart disease or tachycardia-induced cardiomyopathy in patients with long-standing atrial fibrillation. On occasion, long-standing hyperthyroidism may lead to heart failure even in the absence of concomitant cardiac conditions. Beta-blockers offer symptomatic relief and at the same time slow the ventricular response in patients with atrial fibrillation. Amiodarone, and occasionally iodinated contrast agents, may cause iodine-induced thyrotoxicosis. Clinical suspicion is essential in the diagnosis of amiodarone-induced thyrotoxicosis (AIT), because the antiadrenergic effect of the drug may conceal symptoms. AIT should be considered in any patient on amiodarone in the presence of new-onset or recurrent atrial arrhythmias or unexplained weight loss. Beyond discontinuation of amiodarone, treatment options include propylthiouracil or methimazole, potassium perchlorate, steroids, lithium and, if pharmacological treatment fails, surgery. Amiodarone may potentially be used less frequently in the future since recent studies have shown that this drug is inferior to implantable cardioverter defibrillators in prevention of sudden cardiac death in patients with severe heart failure. In addition, non-iodinated amiodarone analogues are currently in advanced phase of clinical testing.

[Cardiac indications for oral anticoagulation]

While considering long-term oral anticoagulation one should assess benefit (i.e., reduction in thromboembolic events) and risks (i.e., bleeding complications) associated with therapy for each individual patient. The classic cardiac indications for oral anticoagulation include chronic atrial fibrillation, prosthetic heart valves, and left ventricular thrombus formation following anterior myocardial infarction. The value of anticoagulation in patients with impaired left ventricular function in stable sinus rhythm and in secondary prevention of coronary artery disease remains controversial. For decades warfarin has been the only compound available. Currently, promising results have been achieved with the oral thrombin inhibitor ximelagatran. In the future, oral anticoagulants, which are administered in fixed dose with no need for monitoring of the anticoagulation level, may replace warfarin. Safety and efficacy of double antiplatelet therapy (aspirin and clopidogrel) in the secondary prevention of thromboembolic events in patients with atrial fibrillation are currently being addressed in large-scale clinical trials.